Quality Improvement Implementation Research Articles

Reconciling discordance between PI-RADS 4 lesions and targeted biopsy: Early experience of a multidisciplinary quality improvement protocol with PI-RADS 4 subcategorization

PurposePI-RADS 4 lesions are considered to have a “high” likelihood of clinically-significant prostate cancer (csPCa). However, patients undergoing targeted biopsy have a range of histologic findings. Understanding discordant cases is critical to improve diagnostic accuracy and inform subsequent management. We studied early findings from implementation of a multidisciplinary Quality Improvement (QI) protocol for reconciling discordance and evaluate the potential heterogeneity of PI-RADS 4. MethodsPatients with mpMRI PI-RADS 4 lesions undergoing fusion-targeted biopsy from January 2017 to May 2021 were retrospectively reviewed. The discordant targeted biopsy pathology (benign/GG1) was evaluated utilizing a QI protocol and all lesions were subcategorized based on ADC values. Positive Predictive Value (PPV) for PI-RADS 4 lesions overall and the Cancer Detection Rate (CDR) for subcategorized lesions were calculated. Results248 patients with 286 lesions were reviewed. Prior to re-review, PI-RADS 4 PPV for ≥ GG1 and ≥ GG2 lesions were 0.55 and 0.34, increasing to 0.67 and 0.43 following reconciliation. Lesion subcategorization based on ADC value as higher suspicion (4+) and lower suspicion (4-) resulted in 158 and 117 lesions, with reverse-fusion analysis revealing that 61% and 17% of lesions contained csPCa, respectively. Subgroup analysis among PI-RADS 4+ lesions led to an increase in the CDR to 75% and 61% for ≥ GG1 and ≥ GG2. ConclusionUse of multidisciplinary QI protocol to review discordance cases of PI-RADS 4 improves diagnostic accuracy and guides subsequent management. Our findings highlight the known heterogeneity of this category with reference to csPCa CDR, suggesting the potential value of PI-RADS 4 subcategorization.

Understanding Quality Improvement and Continuing Professional Mentorship: A Needs Assessment Study to Inform the Development of a Community of Practice.

Quality improvement (QI) programming attempts to bridge the gap between patient care and standards of care. Mentorship could be a means through which QI is fostered, developed, and incorporated into continuing professional development (CPD) programs. The current study examined (1) models of implementation for mentorship within the Department of Psychiatry of a large Canadian academic center; (2) mentorship as a potential vehicle for alignment of QI practices and CPD; and (3) needs for the implementation of QI and CPD mentorship programs. Qualitative interviews were conducted with 14 individuals associated with the university's Department of Psychiatry. The data were analyzed through thematic analyses with two independent coders using COREQ guidelines. Our results identified uncertainty among the participants regarding the conceptualization of QI and CPD, illustrating difficulties in determining whether mentorship could be used to align these practices. Three major themes were identified in our analyses: sharing of QI work through communities of practices; the need for organizational support; and relational experiences of QI mentoring. A greater understanding of QI is necessary before psychiatry departments can implement mentorship to enhance QI practices. However, models of mentorship and needs for mentorship have been made clear and include a good mentorship fit, organizational support, and opportunities for both formal and informal mentorship. Changing organizational culture and providing appropriate training is necessary for enhancing QI.

Participation in a multidisciplinary institutional committee, “RQUEST,” to enhance quality improvement education, project design, and implementation for hematology/oncology fellows.

e18733 Background: Participation in quality improvement (QI) projects allows medical trainees to develop an essential skillset to systematically analyze practice and implement changes with the goal of practice improvement. The ACGME designates QI education and participation as a core competency for all fellows. Training programs and institutions can vary significantly in QI educational format, participation, and direct support for project design and implementation. Here we present a description of the Resident Quality, Experience, and Safety Team (RQUEST) committee, which is being utilized by Hematology and Oncology fellows for QI project design and implementation at our institution. Methods: The first RQUEST committee was convened in August of 2021. RQUEST holds formal monthly meetings from August to June of each academic year. At the initial meetings, committee members are introduced to quality, safety, and patient experience structures and receive introductory training in QI tools and techniques. RQUEST members are then split into smaller project groups and work to select a QI project, perform current state analysis and baseline data collection, design and implement improvement interventions, and re-measure to determine the impact of the chosen interventions. The year concludes with each team presenting their project at a joint session to a larger audience of program directors, quality officers, service line directors, department chairs, graduate medical education staff, and hospital leadership RQUEST participation provides fellows with direct access to a multidisciplinary team and resources throughout project design and implementation. The timeline of monthly meetings provides both accountability and productive feedback. This facilitates the identification of system-specific opportunities for improvement and the most practical points of contact within the hospital, clinic, or EMR to design and apply quality interventions promptly and effectively. Results: We sent a voluntary survey to RQUEST participants, and 40% of participants responded to the survey. 100% of those who responded said participating in RQUEST has been beneficial in developing and implementing a QI project, and 100% said they would recommend participating in RQUEST to other medical trainees. The most common benefits listed were: · Structured approach/guidance · Institutional support and resources · A collaborative environment with a team of members from various departments, including IT. Conclusions: Fellow participation in a multidisciplinary QI committee at our institution has improved fellow QI education, participation, and project implementation. This engagement model has proven valuable to fellows and faculty in enhancing QI competency and clinical practice.

Abstract 1: A Learning Collaborative Model to Empower Rural Rwandan Health Centers to Improve the Quality of Screening for Women’s Cancers

Abstract Purpose: Screening and early detection initiatives for breast and cervical cancer are public health priorities in sub-Saharan Africa, but sustainable strategies to monitor screening quality in rural health facilities are not well-described. We sought to empower rural primary care clinicians to monitor and improve screening quality and integrate quality improvement (QI) into routine practice through a learning collaborative in 8 health facilities participating in a breast and cervical cancer screening initiative in Burera district, Rwanda. We evaluated the model’s impact on participant knowledge/attitudes and QI projects’ success. Methods: Two-day didactic sessions in March 2022 addressed quality measurement and QI implementation. QI knowledge/attitudes were assessed before and after training using a brief written survey and compared using paired t-tests. Participants (all nurses) then identified a cancer screening problem at their health facility that could be solved using QI methods and planned projects. All health center (HC) trainees focused on increasing the proportion of eligible women screened for cervical cancer in their sectors, via educational campaigns. District hospital (DH) team members aimed to reduce missed referral visits. At subsequent meetings, teams discussed projects and next steps. Results: Three clinicians from each of 7 HCs and 2 from the DH (n=23) participated in training; 22 took pre- and post-training surveys. Baseline mean knowledge scores (66.5%,SD 11.8) improved following training (82.4%,SD 12.0,p<0.001). After training, 22(100%) reported interest in being more engaged in QI. In the 6 months following project implementation, HCs saw a 4.8-fold increase in the mean number of patients screened across 7 HCs (35.4,SD 17.1) compared to 6 months prior (7.5,SD 2.6). Efforts to reduce missed visits could not be assessed due to inability of the cancer screening electronic medical record to track patients across facilities. Conclusion: A learning collaborative model engaged rural primary care clinicians in evaluating and improving cancer screening practices. QI knowledge improved and HCs met initial project goals. Though projects focused on patient volume, future initiatives should examine other critical quality measures i.e., referral completion and time to cancer diagnosis. Improving data collection systems is essential to facilitate availability of follow-up data and patient tracking and empower clinicians to monitor care quality. Citation Format: Jean-Marie Vianney Dusengimana, Jean de Dieu Uwihaye, Amanda Fata, David Tuyisenge, Aphrodis Ndayisaba, Vestine Rugema, Marie Louise Uwineza, Lawrence N. Shulman, Cyprien Shyirambere, Lydia E. Pace. A Learning Collaborative Model to Empower Rural Rwandan Health Centers to Improve the Quality of Screening for Women’s Cancers [abstract]. In: Proceedings of the 11th Annual Symposium on Global Cancer Research; Closing the Research-to-Implementation Gap; 2023 Apr 4-6. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(6_Suppl):Abstract nr 1.

Potential social marketing applications for knowledge translation in healthcare: a scoping review protocol

IntroductionKnowledge translation has emerged as a practice and a science to bridge the gap between evidence and practice in healthcare. While the field has appropriately borrowed from other related fields...

Quality improvement approach for surgical-site infection prevention in a Philippine provincial hospital

Background: Globally, the 30-day cumulative incidence of surgical-site infections (SSI) was 11% (95% CI, 10%–13%) based on the systematic review and meta-analysis derived from 57 studies. SSIs are poorly studied in the Philippines. Americares and its hospital partner, Camarines Norte Provincial Hospital, Philippines, sought to reduce SSIs through (1) establishing SSI surveillance in the hospitals’ surgical departments, (2) implementing quality improvement processes, and (3) developing and implementing an SSI prevention care bundle. Methods: A quality improvement methodology was used to introduce SSI surveillance and care-bundle checklist in partnership with Americares. Using paired t tests, pre- and posttest scores of the SSI care bundle training were analyzed. SSI surveillance was established based on the adapted CDC criteria. All clean surgeries were monitored except orthopedic surgeries. The number of surgeries performed, monitored, and SSIs identified were documented using the surveillance forms and plotted using Microsoft Excel software. A care bundle based on WHO evidence-based interventions for SSI prevention was designed and implemented. Compliance with the SSI care bundle was documented using Microsoft Excel. The relationship between the use of a care bundle and SSIs was analyzed using the Pearson correlation coefficient. Results: An online SSI care bundle training session was conducted. Overall, 150 participants had a mean pretraining test score of +6.46. After the training was conducted, the same participants had a mean posttraining test score of + 1.76). a statistically significant increase of 5.29 (95% CI). Thereby, the mean score difference after training showed that knowledge increased overall. These findings show an average of 90.43% compliance with the SSI care-bundle checklist over the 18-month window from May 2021 to November 2022. From a baseline of 0%, compliance increased from 80% upon its introduction in May 2021. Lastly, the SSI incidence rate from May 2021to November 2022 averaged 1.89%. The days between reported SSIs averaged 16.85. No baseline was available for comparison prior to the introduction of the surveillance and care bundle. A Pearson r data analysis (n = 1,850) was used to determine the relationship between the use of the care bundle and SSIs. The data illustrated a moderate negative correlation (r = −.31). Therefore, higher care-bundle compliance yielded fewer SSI cases. Conclusions: The use of an evidence-based care bundle paired with a local quality improvement process significantly improved SSI prevention and surveillance. Future studies are needed that include clean-contaminated, contaminated, and dirty surgical cases to test the degree of SSI reduction possible.Disclosures: None

Improving and Sustaining Interpreter Use Over 5 Years in a Pediatric Emergency Department.

Patients with a language for care other than English (LOE) face communication barriers and inequitable outcomes in health care. Professional interpretation can improve outcomes but is underutilized. Our pediatric emergency department (ED) implemented quality improvement (QI) interventions over a 5-year period with an aim to increase interpreter use to 80% of patient encounters with LOE. Overall interpreter use for ED encounters was measured over time, with a baseline period of October 2015 to December 2016 and during 5 years of QI interventions from January 2017 to August 2021. Interventions included staff education, data feedback, reducing barriers to interpreter use, and improving identification of language for care with plan-do-study-act cycles. Outcomes were analyzed by using statistical process control charts and standard rules for special cause variation. We analyzed a total of 277 309 ED encounters during the study period, 12.2% with LOE. The overall use of interpretation increased from a baseline of 53% to 82% of encounters. Interpretation throughout the ED visit and the number of interpreted interactions per hour also increased. There was improvement across language types, patient age groups, acuity levels, and during different times of day. Special cause variation was associated with multiple QI interventions. We reached our primary aim of providing professional interpretation for 80% of patient encounters with LOE. There were several QI interventions associated with improvements, including staff education, data feedback, improved access to interpretation, and improved identification and visualization of language for care. Efforts to improve interpreter use may benefit from a similar multifaceted approach.

572 Trace Element Supplementation in Burn Patients: A Quality Improvement Project

Abstract Introduction Patients with major burns suffer deficiencies in trace elements (TE), which can affect their clinical course. We established a quality improvement (QI) project to supplement TE (multivitamins with TE, vitamin C, and zinc). Herein, we assessed the impact of QI implementation on outcomes. Methods We queried the burn registry for burn patients admitted from 8/1/2019-5/31/2022 who weighed > 40 Kg and stayed >14 days. Demographics; comorbidities; injury, and hospital course information were collected. Post-implementation, TE levels (zinc, copper, and selenium) as well as C reactive protein levels were measured at 2 weeks. Analyses were performed to assess differences between the pre- and post-groups and post-group patients with major burns (≥20%TBSA) and smaller burns (< 20%TBSA). P < 0.05 was considered significant. Results We included 111 patients, 45 in the pre- and 66 in the post-group. Overall, the population was male (79.3%) with a median age of 53 years. Age and sex were not significantly different between the pre- and post-groups. The post-group had higher TBSA (p = 0.005). They were more likely to smoke (p =0.018) and have an alcohol use disorder (p = 0.035). There was no significant difference observed in mortality, complications, or LOS/TBSA (2.1 days [1.2-5.5] vs. 1.7 days [1.2-3.1], p = 0.300) between the groups. Focusing on the post-group, 37 presented with smaller burns and 29 with major burns. Patients with major burns were younger (p =0.003) and healthier than patients with smaller burns. At 14 days, 81.5% and 33.3% of patients with major burns were deficient in zinc and copper, respectively. Zinc (47.6 µg/dL vs.79.2 µg/dL p < 0.001), copper (80.2 µg/dL vs.121.9 µg/dL p < 0.001), and selenium (98.7 µg/L vs.135.5 µg/L, p = 0.003) levels were significantly lower in patients with major burns. C-reactive protein levels were high in both groups but significantly higher in patients with major burns (p < 0.001). Patients with major burns were more likely to have infectious complications (p = 0.004); however their LOS/TBSA was significantly lower than that of patients with smaller burns (1.21 days vs. 2.43 days, p < 0.001). Zinc levels of patients with major burns significantly increased overtime from 47.6 µg/dL at 14 days post-admission to 73.5 µg/dL at 53 ± 16 days (p < 0.01). Conclusions Our data show that TE supplementation was efficient in bringing zinc levels close to the normal range in patients with burns ≥20%TBSA who stayed up to 50 days in hospital. Controlled for TBSA burned, supplementation of TE significantly decreased LOS of patients with major burns compared to patients with smaller burns. Applicability of Research to Practice Further studies are needed to evaluate the correlation between supplementation of TE and improvement of patient LOS.

O172 Room for improvement: a multi-centre audit of our current compliance with surgical antibiotic prophylaxis guidelines in Ireland

Abstract Introduction In 2017, a national point prevalence study in Ireland showed low compliance with Surgical Antibiotic Prophylaxis (SAP) duration, with 70% of prescriptions exceeding recommended duration. We hypothesise that there has been little improvement since then and we aim to define our compliance issues more broadly than duration alone. Methods To assess compliance with SAP guidelines at a locally, a multi-site audit was conducted over a 14-day period in July 2022. Data was collected at one major, public hospital and one private hospital, both in the Dublin region. Procedures performed in an operating theatre from all surgical specialties were audited. Results A total of 303 procedures were audited across both sites with 165 public and 138 private included. Overall, compliance with local SAP guidance, according to indication, duration and agent was present in 72 patients (23.7%). Performance in both centres was similar (22% public versus 26% private). Of patients in whom SAP was indicated, all 182 (100%) received it. 91 patients (30%), had no indication for SAP. 19 patients (21.1%) still received SAP despite having no indication. Antibiotic duration surpassed 48 h in 58 (25%) procedures, with 40 (17.5%) receiving antibiotic prophylaxis for more than 6 days. Compliance with appropriate agent recommendation was 43.5%. Conclusion Compliance with SAP guidance is low. Despite contrasting work processes in public versus private settings, compliance with SAP guidelines are similar. Work is currently underway to identify barriers to compliance in order to implement quality improvement initiatives and to address this.

Facilitators of palliative care quality improvement team cohesion: Lessons from a seven-site implementation project in India.

The Palliative Care: Promoting Access and Improvement of the Cancer Experience (PC-PAICE) initiative is a team-based, palliative care (PC) quality improvement (QI) project working to promote high-quality PC in India. As a PC QI initiative, PC-PAICE implementation relied upon building interdisciplinary teams, providing the ideal context for understanding facilitators of team cohesion that compelled clinical, organizational, and administrative team members to work together. There is an opportunity to leverage the intersection between QI implementation and organizational theory to inform and improve implementation science. As a subaim of a larger implementation evaluation, we aimed to identify facilitators of team cohesion within QI implementation context. A quota sampling approach captured the perspectives of 44 stakeholders across three strata (organizational leaders, clinical leaders, and clinical team members) from all seven sites through a semistructured interview guide informed by the Consolidated Framework for Implementation Research (CFIR). We used a combination of inductive and deductive approaches informed by organizational theory to identify facilitators. We identified three facilitators of PC team cohesion: (a) balancing formalization and flexibility around team roles, (b) establishing widespread awareness of the QI project, and (c) prioritizing a nonhierarchical organizational culture. Leveraging CFIR to analyze PC-PAICE stakeholder interviews created a data set conducive to understanding complex multisite implementation. Layering role and team theory to our implementation analysis helped us identify facilitators of team cohesion across levels within the team (bounded team), beyond the team (teaming), and surrounding the team (culture). These insights demonstrate the value of team and role theories in implementation evaluation efforts.

Digital radiography retake rates and effect on patient dose

Multiple exposures to ionizing radiation subject patients to a greater risk of exposure to unsafe levels of radiation, resulting in the later development of malignancies. This study analyzed the digital radiography retake rates and the effective dose for patients at a general public hospital in Saudi Arabia. This retrospective study, conducted at the Public Hospital Radiological Department between October and November 2021, sought to determine the causes of repeated or rejected radiographic images to maximize patient safety in terms of excess or unwarranted radiation doses. Positioning errors, machine-related issues, anatomy cutoff, artifacts, and body movements were the causes of repeated or rejected radiographic procedures. During this study, 4158 images were collected; among these, 217 were rejected. Most errors in the radiologic department were related to the lack of experience of the staff. Junior and senior staff were directly or indirectly responsible for 87.5% of repeated radiographic procedures, whereas expert-level staff were responsible for 12.4% of the repeated or rejected procedures. Based on these findings, this study proposes a heightened implementation of quality control measures and improvement in staff training to bolster staff skills to actively comply with “as low as reasonably achievable” radiation exposure to patients.

Editorial introductions.

Editorial introductions.

Interstate Practice Variation and Factors Associated with Antibiotic Use for Suspected Neonatal Sepsis in the United States.

This study aimed to estimate national time trends of overall and statewise antibiotic utilization (AU) rates for suspected neonatal sepsis (SNS) in the United States. In this cross-sectional study, we used retrospective linked birth cohort and vital records data from the Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research database for the years 2016 to 2020 and analyzed data containing antibiotic use for SNS. The primary outcome was proportional national and state-specific AU rates per 1,000 live births during the birth hospitalization. Secondary outcomes included overall trends and association between maternal education, race, sex, chorioamnionitis, mode of delivery, gestational age at birth, Apgar's scores, and insurance status with antibiotics exposure for SNS among newborns. Contingency tables, two-tailed t-test, and chi-square for independence tests were performed with statistical significance set at p < 0.05. For a birth cohort of >18 million, 2.2% of infants received antibiotics during birth hospitalization nationwide. There were wide variations in AU among U.S. states and territories, whereas overall treatment rates decreased by 16.1% (95% confidence interval [CI]: 15.2-17.0; p < 0.001). Compared with White newborns, Black newborns had higher AU rates (odds ratio [OR]: 1.33; 95% CI: 1.32-1.34), and Asians had the lowest rates (OR: 0.96; 95% CI: 0.95-0.97). There was a significant difference in mean AU rates by race (p < 0.001). Chorioamnionitis at birth significantly increased the odds for AU (OR: 14.5 ;95% CI: 14.4-14.6), although AU rates for chorioamnionitis showed a significant downward trend (OR: 0.52; 95% CI: 0.50-0.53) during the study period. Our findings suggest that there has been a gradual decline in AU for SNS in more than a third of states in last 5 years. While risk-based management approaches achieve widespread implementation, state- and nationwide quality improvement collaborates might have contributed to the relative decline in antibiotic use in newborns. Further studies are warranted to understand factors related to practice variation in the management of SNS in the United States KEY POINTS: · Early and prolonged use of antibiotics can lead to altered gut microbiome and adverse long-term neonatal outcomes.. · There is considerable clinical practice variation in antibiotic-prescribing practices for suspected neonatal sepsis.. · This cross-sectional study reports the differences in neonatal antibiotic usage patterns by region and maternal factors.. · Antibiotic use should be limited to newborns at high risk of infection and proven sepsis.. · Judicious use of antibiotics can be promoted by following evidence-based approaches to sepsis risk assessment..

“Quality teaches you how to use water. It doesn’t provide a water pump”: a qualitative study of context and mechanisms of action in an Ethiopian quality improvement program

BackgroundQuality improvement collaboratives are a common approach to bridging the quality-of-care gap, but little is known about implementation in low-income settings. Implementers rarely consider mechanisms of change or the role of context, which may explain collaboratives’ varied impacts.MethodsTo understand mechanisms and contextual influences we conducted 55 in-depth interviews with staff from four health centres and two hospitals involved in quality improvement collaboratives in Ethiopia. We also generated control charts for selected indicators to explore any impacts of the collaboratives.ResultsThe cross facility learning sessions increased the prominence and focus on quality, allowed learning from experts and peers and were motivational through public recognition of success or a desire to emulate peers. Within facilities, new structures and processes were created. These were fragile and sometimes alienating to those outside the improvement team. The trusted and respected mentors were important for support, motivation and accountability. Where mentor visits were infrequent or mentors less skilled, team function was impacted. These mechanisms were more prominent, and quality improvement more functional, in facilities with strong leadership and pre-existing good teamwork; as staff had shared goals, an active approach to problems and were more willing and able to be flexible to implement change ideas. Quality improvement structures and processes were more likely to be internally driven and knowledge transferred to other staff in these facilities, which reduced the impact of staff turnover and increased buy-in. In facilities which lacked essential inputs, staff struggled to see how the collaborative could meaningfully improve quality and were less likely to have functioning quality improvement. The unexpected civil unrest in one region strongly disrupted the health system and the collaborative. These contextual issues were fluid, with multiple interactions and linkages.ConclusionsThe study confirms the need to carefully consider context in the implementation of quality improvement collaboratives. Facilities that implement quality improvement successfully may be those that already have characteristics that foster quality. Quality improvement may be alienating to those outside of the improvement team and implementers should not assume the organic spread or transfer of quality improvement knowledge.

Nationwide consensus on quality indicators to assess glaucoma care: A modified Delphi approach.

Performance assessments are essential to tracking and improving quality in health care systems. Key aspects of the care process that act as indicators must be measured in order to gain an in-depth understanding of a care unit's operation. Without standardized quality indicators (QIs), it is difficult to characterize and compare the abilities of institutions to achieve excellence. The aim of this study is to reach a consensus among glaucoma specialists concerning the development of a set of QIs to assess the performance of glaucoma care units. A two-round Delphi technique was performed among glaucoma specialists in Portugal, using a 7-point Likert scale. Fifty-three initial statements (comprising process, structure, and outcome indicators) were evaluated and participants had to agree on which ones would be part of the final set of QIs. By the end of both rounds, 28 glaucoma specialists reached consensus on 30/53 (57%) statements, including 19 (63%) process indicators (mainly relating to the proper implementation of complementary exams and the setting of follow-up intervals), 6 (20%) structure indicators, and 5 (17%) outcome indicators. Of the indicators that were part of the final list, functional and structural aspects of glaucoma progression and the availability of surgical/laser procedures were the most prevalent. A set of 30 QIs for measuring the performance of glaucoma units was developed using a consensus methodology involving experts in the field. Their use as measurement standards would provide important information about unit operations and allow further implementation of quality improvements.

Implementation of standardized cystic fibrosis care algorithm to improve the center data-quality improvement project international collaboration

BackgroundA collaboration between the University of Michigan (U of M) Cystic Fibrosis Center (CFC) and Marmara University (MU) CFC was initiated to improve the health status of people with cystic fibrosis (pwCF) at MU through implementing Quality Improvement (QI) initiatives. The main aim was to improve lung function in children with FEV1pp <80. The secondary aim was to assess the changes in health related quality of life. MethodsIncluded in the project were pwCF who received cystic fibrosis (CF) care at the MU CFC and were 6–18 years of age with an FEV1pp <80. Flow charts were created and a standardized CF care algorithm was implemented. Weekly case review were done to develop individualized treatment plans. Appropriate intervention was applied and patient data were assessed at baseline, 3, 6, 9 and 12 months. The Cystic Fibrosis Revised Questionnaire (CFQ-R) was completed. Results55 pwCF were included (mean age:11.8 ± 3.3 years). Mean FEV1pp (SD) at baseline, 6 and 12 month was 63.7 (14.6), 66.9 (16.6), 70.4 (19.2), respectively, with a relative increase of 5.0% in 6 months (p:0.002) and 10.5% in 12 months compared to baseline (p<0.001). Physical functioning, eating problems and respiratory symptoms domains of the CFQ-R questionnaire were improved at the end of the one year for 6–13 (p = 0.024, p = 0.009, p = 0.002) and 13–18 year olds (p = 0.013, p = 0.002, p = 0.038). ConclusionThere was significant improvement in pwCF with FEV1<80%pp after implementing this QI project. The processes and assessments used can be adopted by other low-middle income countries to improve similar measures.

A Quality Improvement Pilot Project for Noise Reduction in the NICU.

Increased noxious noise leads to adverse short-term and long-term effects on the growing neonate. The American Academy of Pediatrics recommends maintaining a noise level of less than 45 decibels (dBA). The average baseline noise level in an open-pod neonatal intensive care unit (NICU) was 62.6 dBA. The purpose of this pilot project was to reduce the average noise levels by 39% at the end of an 11-week period. The location of the project was in a large, high-acuity level IV open-pod layout NICU that consisted of 4 pods, one of which was cardiac-focused. The average baseline noise level in the cardiac pod was 62.6 dBA in a 24-hour period. Noise levels were not monitored before this pilot project. This project was implemented over an 11-week period. Several modes of education were used for parents and staff. Post-education, Quiet Times were implemented at set times twice daily. Noise levels were monitored for 4 weeks during Quiet Times, with weekly noise level updates for staff. General noise levels were collected a final time to evaluate the overall change in the average noise levels. At the end of the project, noise levels decreased from 62.6 dBA to 54 dBA, a 13.7% reduction. At the end of this pilot project it was noted that: Online modules were the best way to educate staff. Parents should be included in the implementation of quality improvement. Healthcare providers need to know and understand that they can make preventative changes to improve the outcomes of the population.

Authentic leadership, organizational culture and the effects of hospital quality management practices on quality of care and patient satisfaction.

To examine the influence of hospital culture and authentic leadership on the effects of quality improvement practices on patient satisfaction. Nurses in formal leadership roles shape and are shaped by organizational culture to achieve high performance standards to influence quality of care. Using structural equation modelling, we tested a model on quality improvement practices across three participant groups that differed based on authentic leadership and hospital culture. We used survey data from a cross-sectional study conducted in 2015 measuring nurse. Managers' perceptions of authentic leadership, implementation of quality improvement, and organizational culture in Canadian hospitals. 226 nurse managers participated. Our model estimations fit for the high-relational group and mixed group. Our model explained 50.7% and 39.5% variance in our outcome variable of patient satisfaction for the high-relational group and mixed group, respectively. Our model failed to fit the low-relational group. Authentic leadership and developmental/group hospital cultures improve quality management practices, quality of care and patient satisfaction. In organizations with low authentic leadership and hierarchical/rational cultures, strategies should target increasing authentic leadership and shifting to developmental cultures. Organizations with high authentic leadership and/or developmental/group cultures should target employee engagement, autonomy and teamwork. We examined how different combinations of authentic leadership and hospital culture influence the effects of quality management practices on quality improvement and patient satisfaction. Findings demonstrate that having both high authentic leadership and developmental or group hospital cultures are essential for quality improvement practices to enhance the quality of care and patient satisfaction. These organizations would benefit the most from systemic programs aimed at standardizing quality management practices as they have the culture and leadership to support these practices. For hospitals with hierarchical/rational cultures and/or low authentic leadership, enhancing hospital culture and leadership through leadership training and accreditation programs is critically needed. The College and Association of Registered Nurses of Alberta contributed to this study by facilitating data collection and supporting the conduct of the study through messaging to its members.

Implementing Quality Improvement Management in Madrasah Aliyah

Implementing Quality Improvement Management in Madrasah Aliyah

The Impact of Healthcare Delivery Complexity on Practices for Clinical Quality Improvement: A Case of Healthcare Workers’ Hand Hygiene Compliance

Healthcare providers often implement quality improvement (QI) practices to improve clinical quality, which may be measured as the extent to which healthcare workers (HCWs) comply with standardized procedures designed for ensuring patient safety. Unfortunately, the effectiveness of QI practices to improve clinical quality varies from facility to facility because of healthcare delivery complexity. In this paper, we consider the contextual complexity and the provider complexity arising from healthcare delivery processes, and we propose an exploratory study based on discrete choice experiments to examine their roles in the relationship between QI practices and clinical quality. By collecting and analyzing data from 320 HCWs at a university hospital in Taiwan, we found that healthcare delivery complexity significantly moderated the effectiveness of QI practices and how they improved clinical quality. We found that the contextual complexity influenced the level of effectiveness of the QI practices, whereas the provider complexity influenced whether a QI practice may be effective or not. We also studied the effect of implementing multiple QI practices simultaneously to counter the provider complexity. We found that implementing more QI practices does not necessarily lead to better outcomes, but implementing the right ones would. Our findings provide healthcare facilities with ex ante insights for designing QI practices to improve clinical quality. Funding: W. Chen was supported by the National Natural Science Foundation of China [Grant 71902017], and C.-L. Tseng was supported by the University of New South Wales UNOVA Knowledge Hub. Supplemental Material: The online appendix is available at https://doi.org/10.1287/serv.2023.0323 .