Improvement Science Methodology Research Articles

Incidence of infections associated with the use of invasive devices in an ICU after application of the Improvement Science Method

Objective: To reduce the incidence density of ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI) in the intensive care unit (ICU) using the Improvement Science method. Methods: This was a single-center retrospective cohort study. A collaborative quality improvement team developed and implemented local changes to HAI-related processes and protocols. Pre-intervention, intervention, and post-intervention periods were compared. The study was conducted at the Adult ICU of a hospital in southern Brazil. Variables were analyzed using interrupted time series analysis with segmented linear regression, simple correlation, and hypothesis testing. Results: There was a reduction in the incidence density of all infections. VAP was reduced from 27.2% to 7.2% (p < 0.001), CLABSI from 3.0% to 0.9% (p = 0.017), and CAUTI from 8.3% to 1.8% (p < 0.001). The ICU stay was also reduced from 6.7 to 6 days (p = 0.018). Conclusion: There was an improvement in all the evaluated parameters. Ongoing monitoring of related indicators and adherence to implemented measures are essential to sustain improvements. Applying the Improvement Science methodology can reduce the incidence of HAIs in the ICU.

Screening for traumatic stress in children and adolescents with congenital heart disease

BackgroundPrevious research has indicated that up to one-third of children undergoing cardiac surgery develop posttraumatic stress disorder (PTSD) following cardiac surgery. Despite the potential long term implications for mental health from this finding, there is no uniform screening procedure for traumatic stress that exists within pediatric cardiac care. ObjectivesA quality improvement initiative was developed to improve standards of care to better identify, manage, and prevent traumatic stress in pediatric cardiology patients. MethodsQuality improvement science methodology was utilized to develop, implement, study, and adopt changes in clinical practice within a pediatric cardiac outpatient clinic. Specifically, children who had undergone cardiac surgery, interventional cardiac catheterization, or heart transplant were offered screening for symptoms of traumatic stress using the Children's Revised Impact of Events Scale. Chi-Square tests and logistic regression were used to analyze differences associated with sociodemographic variables, type of surgical repair, and version of the traumatic stress symptom screener that was utilized. ResultsSuccessful implementation to improve quality of care occurred during a 24-month period as screening of eligible patients for traumatic stress increased from 0 % to 95 %. At risk scores for traumatic stress were found in 14 % of patients who were then subsequently referred to social work for further assessment and triage to mental and behavioral health services. Access to education about traumatic stress increased for patients, parents, and the medical team via the use of informational teaching sheets and increased dialogues among staff. ConclusionA multidisciplinary quality improvement intervention was effective in screening children at risk for traumatic stress who had experienced cardiac surgery, interventional cardiac catheterization, or heart transplant. Administering a screening tool for traumatic stress appears to be an effective means of identifying patients at risk for traumatic stress.

The emergence noise reduction quality improvement initiative to enhance patient safety and quality of care.

Operating room noise levels may hinder staff communication and cause distractions for providers, endangering patient safety. Owing to concerns of unacceptable noise levels during emergence from general anesthesia, our institution developed a quality improvement project. The SMART aim of this initiative was to decrease the average decibel noise level measured during emergence from general anesthesia in our operating rooms from 65.65 to 63 decibels and the maximum decibel noise level from 81.64 to 75 decibels over approximately 3months. A multidisciplinary team completed this project utilizing improvement science methodology from The Model for Improvement, including interventions tested via Plan-Do-Study-Act cycles. Data were measured, collected manually, and entered in an Excel spreadsheet. Data were analyzed using statistical process control methods, including a Run Chart. Our measures were the average and maximum decibel noise levels during emergence from general anesthesia. Several interventions were associated with a decrease in the average and maximum decibel noise levels. Interventions included educational presentations to perioperative staff; the operating room nurse taking the role of pausing any music; and the utilization of an audible and visual decibel alarm meter to sound and blink lights when the noise level is too high. During the initiative, the average (and maximum) decibel noise levels during emergence from general anesthesia in our operating rooms decreased from 65.65 (81.84) to 61.5 (76.44). This improvement project was associated with a decrease in decibel noise levels during emergence. We enhanced a process and encouraged culture change at an academic pediatric hospital to enhance the safety of our care.

Implementation of a gastrostomy care bundle reduces dislodgements and length of stay

PurposePediatric gastrostomy tubes (G-tubes) are associated with considerable utilization of healthcare resources. G-tube dislodgement can result in tract disruption and abdominal sepsis. We aimed to reduce early G-tube dislodgement by 25%. MethodsAn interdisciplinary team convened to identify key drivers of G-tube dislodgement and implement initiatives to reduce this complication. A G-tube care bundle was implemented in 2018. Rates of early G-tube dislodgement (within 90 days of insertion) were tracked. 15 months of cases after bundle implementation were compared to 20 months of cases before implementation. Length of stay (LOS, balancing measure) and bundle compliance (process measure) were tracked. ResultsG-tube dislodgements decreased 47% after bundle implementation. Overall, dislodgements after G-tube insertion decreased from 43% to 19% dislodgements per tube inserted, p = 0.004. Reductions were observed for dislodgements occurring in both the inpatient (14% vs. 1.5%) and outpatient (29% vs. 18%) settings. Median LOS was reduced from 15.3 to 7.1 days following implementation, p = 0.004. Process measures demonstrated 75% or greater compliance one year after implementation. ConclusionAn interdisciplinary team using quality improvement science methodology can significantly reduce G-tube dislodgement and improve value after pediatric gastrostomy tube insertion. Type of studyLongitudinal cohort study. Level of evidenceIII.

A coordinated approach to improving pediatric heart transplant waitlist outcomes: A summary of the ACTION November 2019 waitlist outcomes committee meeting

The number of children needing heart transplantation continues to rise. Although improvements in heart failure therapy, particularly durable mechanical support, have reduced waitlist mortality, the number of children who die while waiting for a suitable donor organ remains unacceptably high. Roughly, 13% of children and 25% of infants on the heart transplant waitlist will not survive to transplantation. With this in mind, the Advanced Cardiac Therapies Improving Outcomes Collaborative Learning Network (ACTION), through its Waitlist Outcomes Committee, convened a 2-day symposium in Ann Arbor, Michigan, from 2-3 November 2019, to better understand the factors that contribute to pediatric heart transplant waitlist mortality and to focus future efforts on improving the organ allocation rates for children needing heart transplantation. Using improvement science methodology, the heart failure-transplant trajectory was broken down into six key steps, after which modes of failure and opportunities for improvement at each step were discussed. As a result, several projects aimed at reducing waitlist mortality were initiated.

A Framework of System Level Measures Promotes Alliancing and System Integration

Introduction: The New Zealand health system is organised by 20 District Health Boards (DHB) and 30 Primary Healthcare Organisations (PHO). In 2012, every DHB was required to enter into a district alliance with the PHOs serving their resident population. The NZ Ministry of Health has co-designed with health sector clinicians, analysts and managers a framework of System Level Measures (SLM) for continuous quality improvement and system integration. Method: Basic underlying principles for SLM were established to determine selection, principally that they were outcomes with a clear focus on health equity. Data had to be available, feasible and timely. Using a collaborative approach engaging Ministry of Health and sector clinicians, data analysts and managers, and consumers a set of six measures has been implemented: ASH rates in 0-4 year old children; Proportion of babies living in a smoke-free home; Patient experience of care; Acute hospital bed days per capita; Amenable mortality; and a Youth Health composite SLM. The SLMs are underpinned by a large set of contributory measures of health processes and activities. A measures library was established as a repository of data definitions and sources in order to standardise measurement nationally and allow comparative analysis. The Ministry of Health has made patient identifiable data held in national collections available down to practice level via secure servers, for local managers and clinicians to use for quality improvement. Each district alliance is required to develop a quality improvement plan based on their analysis of local data on SLM, service configuration and the needs of their local population. The alliance must set an improvement milestone for each SLM and detail the improvement activities it will implement using improvement science methodology. The plan also details the contributory measures that will be used to track local progress and contains signatures of all parties in the alliance. The Ministry of Health releases funding to PHOs for capacity and capability development as seed funding and on approval of the plans. A small incentive funding pool is applied to achievement of SLM milestones. Results: In the first year of implementation, all twenty district alliances submitted a plan by the due date setting improvement milestones for four SLMs. The framework stimulated primary and secondary care clinicians, PHO senior managers and DHB chairs to collaborate on quality improvement. The Ministry gained knowledge about the maturity of alliances and their capability and capacity for improvement science methodology and analytics. This was found highly variable between districts. In the second year, two developmental SLMs were added and the quality of plans improved. Conclusion: New Zealand has developed and implemented a framework of system level health outcome measures to stimulate alliances between primary healthcare and secondary care to engage in quality improvement activities taking a co-design and patient-centred approach. Early indications are promising that the framework can deliver improved outcomes both for the system and the patients.

Impact of a Successful Speaking Up Program on Health-Care Worker Hand Hygiene Behavior.

Background:Health-care worker (HCW) hand hygiene (HH) is the cornerstone of efforts to reduce hospital infections but remains low. Real-time mitigation of failures can increase process reliability to > 95% but has been challenging to implement for HH.Objective:To sustainably improve HCW HH to > 95%.Methods:A hospital-wide quality improvement initiative to improve HH was initiated in February 2012. HCW HH behavior was measured by covert direct observation utilizing multiple-trained HCW volunteers. HH compliance was defined as correct HH performed before and after contact with the patient or the patient’s care area. Interventions focusing on leadership support, HCW knowledge, supply availability, and culture change were implemented using quality improvement science methodology. In February 2014, the hospital began the Speaking Up for Safety Program, which trained all HCWs to identify and mitigate HH failures at the moment of occurrence and addressed known barriers to speaking up.Results:Between January 1, 2012, and January 31, 2016, there were 30,514 HH observations, averaging 627 observations per month (9% attending physicians, 12% resident physicians, 46% nurses, 33% other HCW types). HCW HH gradually increased from 75% to > 90% by December 2014. After the Speaking Up for Safety Program, HCW HH has been > 95% for 20 months. Physician HH compliance has been above 90% for over a year.Conclusion:Creating a specific process for staff to speak up and prevent HH failures, as part of a multimodal improvement effort, can sustainably increase HCW HH above 95%.

Simulation in mental health nurse education: The development, implementation and evaluation of an educational innovation.

Simulation is an important learning approach for the development of skills for healthcare practice. However, it remains under used in the education of mental health practitioners. This article examines the development, implementation and evaluation of a simulated learning experience for final year undergraduate BSc mental health nursing students in the UK. Scenarios involving managing care in an acute in patient ward and community older persons' team were designed to enable students to develop their complex decision making skills. An evaluation of the simulation experience was undertaken. This was informed by the principles of improvement science methodology and data was collected from the student participants using questionnaires. The findings indicated that simulation provided a realistic environment in which students were able to develop skills and manage clinical situations autonomously without fear of being assessed or making mistakes. Reflecting Dieckmann etal.'s (2007) position that simulation is a social situation in itself, the learning approach enabled mental health students to both experience the safety of the Higher Education setting and also the reality of clinical practice. Simulation may therefore provide an important tool to prepare students for the responsibilities of a qualified nurse.

Quality Improvement Targeting Adherence During the Transition from a Pediatric to Adult Liver Transplant Clinic.

The transition from pediatric to adult transplant care is a high risk period for non-adherence and poor health outcomes. This article describes a quality improvement initiative integrated into a pediatric liver transplant program that focused on improving outcomes following the transfer from pediatric to adult liver transplant care. Using improvement science methodology, we evaluated the impact of our center's transition readiness skills (TRS) program by conducting a chart review of 45 pediatric liver transplant recipients who transferred to adult transplant care. Medication adherence, clinic attendance, and health status variables were examined for the year pre-transfer and first year post-transfer. 19 recipients transferred without participating in the TRS program (control group) and 26 recipients participated in the program prior to transferring to the adult clinic (TRS group). The TRS group was significantly older at the time of transfer, more adherent with medications, and more likely to attend their first adult clinic visit compared to the control group. Among the TRS group, better adolescent and parent regimen knowledge were associated with greater adherence to post-transfer clinic appointments. Transition planning should focus on the gradual shift in responsibility for health management tasks, including clinic attendance, from parent to adolescent. There may be support for extending transition support for at least 1year post-transfer to promote adherence.

Breast Cancer Patient Stories Project

It is estimated that there are almost half a million women living with or beyond a breast cancer diagnosis in the UK, often referred to as the breast cancer survivor population. We report on the setting up of a dedicated breast cancer and menopause symptoms service (BCMS), and present results from research undertaken with breast cancer survivors with the aim of obtaining their perspectives on the BCMS service. An action-oriented approach incorporating improvement science methodology has been used to help develop and drive changes to support a high standard of NHS patient care delivery for women with breast cancer within the BCMS setting. Evaluation was undertaken of this innovative service using qualitative methodology, and included discussion within a focus group setting, patient consent to record discussion, followed by thematic analysis of transcription. Women who have survived breast cancer identified a need for specialist support to help improve their quality of life, which is also affected by menopause type symptomology. This support can be provided within the BCMS service setting. Our recommendations are that the BCMS service model is incorporated into any regional or national breast cancer patient pathway and service redesign work in place. Breast cancer survivors would support the setting up of a BCMS service, and would actively help raise awareness and market this service.

A Hospital-wide Quality-Improvement Collaborative to Reduce Catheter-Associated Bloodstream Infections

Catheter-associated bloodstream infections (CA BSIs) are associated with increased hospital length of stay, total hospital costs, and mortality. Quality-improvement collaboratives (QICs) are frequently used to improve health care quality. Our PICU was previously involved in a successful national QIC to reduce the incidence of CA BSI in critically ill children. We hypothesized that the formation of a hospital-wide QIC would reduce the incidence of CA BSI throughout our institution. We retrospectively reviewed the incidence of CA BSI from March 2006 to March 2010. The collaborative approach included hospital-wide implementation of central-line insertion and maintenance bundles that emphasized full sterile barrier precautions and chlorhexidine skin preparation during line insertion, daily discussion of catheter necessity, and meticulous site and tubing care. The hospital units involved were our 3 critical care units, the oncology unit, the bone marrow transplant unit, and wards. Each individual unit was responsible for collecting unit-specific data and performing event-cause analysis within 48 hours of identifying a CA BSI. These results were shared with the other hospital units during monthly meetings. Compliance with the insertion and maintenance bundles was monitored and reported to each unit monthly. The hospital-wide CA-BSI rate decreased from a baseline of 3.0 to <1.0 CA BSI per 1000 line-days after implementation of the QIC. Our hospital-wide QIC resulted in a significant reduction in the incidence of CA BSI at our children's hospital. A collaborative model based on improvement science methodology is both feasible and effective in reducing the incidence of CA BSI.

Using Quality Improvement Science to Implement a Multidisciplinary Behavioral Intervention Targeting Pediatric Inpatient Airway Clearance

The objective of this study was to use quality improvement science methodology to develop a multidisciplinary intervention improving occurrence of best-practice airway clearance therapy (ACT) in inpatient adolescents with cystic fibrosis during routine clinical care. The model for improvement was used to develop and implement interventions. Primary outcomes were quality of ACT (% ACT meeting criteria for best practice) and quantity of ACT (% of hospital days patients received ACT four times/day). Annotated control charts were used to document the impact of the interventions. Quality of ACT significantly improved from 21% best practice ACT at baseline to 73%. Quantity of ACT significantly improved from 41% days with ACT four times/day at baseline to 64%. A multidisciplinary, evidence-based intervention was effective for improving occurrence of best-practice ACT. Pediatric psychology can make valuable contributions to improving the quality of care provided in the medical setting.

Applying Quality Improvement Methods to Implement a Measurement System for Chronic Pain-Related Disability

This article describes the application of quality improvement methodology to implement a measurement tool for the assessment of functional status in pediatric patients with chronic pain referred for behavioral intervention. The Functional Disability Inventory (FDI), a validated instrument for assessment of pain-related disability, was chosen as the primary clinical outcome measure. Using improvement science methodology, PDSA (Plan-Do-Study-Act) cycles were run to evaluate: (a) regular FDI administration, (b) two administration methods, (c) regular patient feedback, and (d) documentation methods. Within 1 month, psychologists were administering the FDI at least 80% of the time to patients. A high level of reliability using two administration methods (92.8%) was demonstrated. The FDI was feasible to integrate into clinical practice. Modifications to electronic records further enhanced clinician reliability of documentation. Quality improvement methods are an innovative way to make process changes in pediatric psychology settings to dependably gather and document evidence-based patient outcomes.