Quality Improvement Research Articles

Through the patients’ eyes: psychometric evaluation of the 64-item version of the Experienced Patient-Centeredness Questionnaire (EPAT-64)

BackgroundPatient-reported experience measures (PREMs) are valuable tools to evaluate patient-centredness (PC) from the patients’ perspective. Despite their utility, a comprehensive PREM addressing PC has been lacking. To bridge this gap,...

Enhancing Basic Education Quality through the Implementation of the Regional Medium-Term Development Plan in Oil-Rich Areas

This study investigates the implementation of basic education quality improvement policies in Balikpapan City, a region known for its pivotal role in Indonesia’s oil industry, often referred to as an oil-rich area. The research aims to assess the effectiveness of the Regional Medium-Term Development Plan (2021-2026) in addressing educational quality, considering the city's economic dependence on oil. Adopting a qualitative approach, the study focuses on the Department of Education and Culture in Balikpapan, engaging key informants to evaluate the efficacy of policy implementation. The analysis framework encompasses an evaluation of policy standards, resources, inter-organisational communication, and the characteristics of the implementing agencies. The findings reveal that, while considerable progress has been made in enhancing educational facilities and teacher competencies, challenges persist due to the city’s heavy reliance on the oil sector and its impact on local resources. Furthermore, the study explores the relationship between these challenges and Sustainable Development Goal (SDG) 4 (quality education) by addressing disparities in resource allocation and the city's limited capacity for economic diversification. The research recommends the integration of more diverse data sources, continuous monitoring, and deeper analysis of the social and economic impacts to further improve educational outcomes. Balikpapan's economic context, as an oil-dependent city, significantly influences its ability to implement and sustain effective educational policies, highlighting the necessity for balanced development strategies aligned with broader SDGs.

Impact of methane and other precursor emission reductions on surface ozone in Europe: scenario analysis using the European Monitoring and Evaluation Programme (EMEP) Meteorological Synthesizing Centre – West (MSC-W) model

Abstract. The impacts of future methane (CH4) and other precursor emission changes are investigated for surface ozone (O3) in the United Nations Economic Commission for Europe (UNECE) region excluding North America and Israel (the EMEP region, for European Monitoring and Evaluation Programme) for the year 2050. The analysis includes a current legislation (CLE) and maximum feasible technical reduction (MFR) scenario, as well as a scenario that combines MFRs with an additional dietary shift that also meets the Paris Agreement objectives with respect to greenhouse gas emissions (LOW). For each scenario, background CH4 concentrations are calculated using a probabilistic Earth system model emulator and combined with other precursor emissions in a three-dimensional Eulerian chemistry-transport model. While focus is placed on peak season maximum daily 8 h average (MDA8) O3 concentrations, a range of other indicators for health and vegetation impacts are also discussed. Our analysis shows that roughly one-third of the total peak season MDA8 reduction achieved between the 2050 CLE and MFR scenarios is attributable to CH4 reductions, resulting predominantly from CH4 emission reductions outside of the EMEP region. The impact of other precursor emission reductions is split nearly evenly between the reductions inside and outside of the EMEP region. However, the relative importance of CH4 and other precursor emission reductions is shown to depend on the choice of O3 indicator, though indicators sensitive to peak O3 show generally consistent results. The analysis also highlights the synergistic impacts of CH4 mitigation as reducing solely CH4 achieves, beyond air quality improvement, nearly two-thirds of the total global warming reduction calculated for the LOW scenario compared to the CLE case.

Improving access to syphilis screening among unhoused people in Yolo County

Background: This study aimed to increase syphilis screening rates amongst unhoused residents of Yolo County, California, through the implementation of plan-do-study-act (PDSA) cycles. Yolo County has a strategic goal to eliminate congenital syphilis cases. Homelessness is a known risk factor for syphilis. Methods: The primary researcher was embedded in a street medicine team. Using quality improvement tools like stakeholder interviews, workflow diagrams, and best practices from literature, we outlined the team's workflow for syphilis screening and developed ideas to improve uptake and expand capacity. The most effective cycle implemented gift card incentives for syphilis screening. During the patient intake we offered the option to receive a syphilis test, informing the patient of the gift card incentive. Results: Prior to gift card incentives, the team screened 1.6 patients on average per clinic for a total of 30 patients screened in April to June of 2022. After the gift card incentive was implemented, the team screened 3.0 patients on average per clinic, screening a total of 223 patients from July 2022 to May 2023. The intervention produced an 87.5% increase in screening rates (P=0.0094). The data showed a significant increase in syphilis testing upon implementing the gift card incentive program. Conclusion: These findings contribute to evidence supporting the use of patient incentives for public health prevention measures. This model could be applied to other populations to increase health screening participation. More research is needed on the effect of gift card incentives on confirmatory testing and treatment rates for syphilis.

Postoperative outcomes in minimally invasive total versus supracervical hysterectomy for endometriosis: a NSQIP study.

To study the rate and odds of 30day postoperative complications among patients undergoing minimally invasive total (TLH) compared to supracervical (LSCH) hysterectomy for endometriosis. A cohort study of patients with a diagnosis of endometriosis undergoing hysterectomy. We used prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2020. We compared short-term (30day) complications, following minimally invasive TLH and LSCH for endometriosis. The primary outcome was the risk of any postoperative complications according to the surgical approach. A total of 5,278 patients were included, 4,952 (93.8%) underwent TLH and 326 (6.2%) underwent LSCH. The incidence of any complication was significantly lower in the LSCH group compared to the TLH group (3.7% vs. 8.5%, p = .001). Both major complications (1.5% vs. 3.7%, p = 0.043) and minor complications (2.8% vs. 5.4%, p = .039) were less frequent in the LSCH group compared to the TLH group. In multivariable regression analysis, patients undergoing LSCH had significantly lower odds of any complication [aOR 95%CI 0.40 (0.22-0.72)], and of minor complications [aOR 95%CI 0.47 (0.24-0.92)] compared to TLH. LSCH is associated with a lower odd of short-term postoperative complications compared to TLH for patients with endometriosis.

Identifying potential outcomes of patient engagement in primary care quality improvement: a modified Delphi study.

A barrier to dedicating resources towards patient engagement in primary care quality improvement is the lack of clearly identified outcomes that might result from these initiatives. We sought to identify these potential outcomes at three healthcare levels as defined by the Institute of Medicine: 1) Micro/Direct Care; 2) Meso/Microsystem; and 3) Macro/Clinic/System using a Modified Delphi technique. Two focus groups of patients and primary care clinician leaders generated a first set of outcomes. These outcomes were then vetted and expanded through three web-based surveys sent to twelve national experts. Experts indicated the level of agreement with prior elicited outcomes and generated potential new outcomes. Included outcomes achieved at least 80% agreement. The final list of 46 consensus-derived outcomes was categorized across levels. 22 were at the Micro-level, 9 were at the Meso-level, and 15 were at the Macro-level. Our findings suggest outcomes across all health system levels have the potential for progress when patients are engaged in primary care quality improvement initiatives. Future programs should consider validating and measuring these outcomes as part of their interventions.

Mitigating overuse of antinuclear antibody (ANA) testing through educational intervention: a study in internal medicine and neurology departments.

Overuse of antinuclear antibody (ANA) tests leads to increased costs, false positives, and unnecessary treatments. This study evaluated ANA overuse in internal medicine and neurology departments and assessed the impact of an educational intervention. This quality improvement educational intervention study examined ANA test overuse in five internal medicine departments and one neurology department at a university-affiliated medical center. The educational intervention included a session focusing on ANA testing appropriateness. Outcome measures comprised the ANA/new patient ratio (APR) and the percentage of positive ANA test results. Outcomes were compared between the pre- and post-intervention periods (both 6months). The intervention took place in December 2021. The APR decreased from 43% in the pre-educational intervention period to 27% in the post-intervention period in the neurology department (odds ratio [OR] 0.49, confidence interval [95% CI] 0.37-0.63, P < 0.0001) and from 2.6% to 2.2% in the internal medicine departments (OR 0.89, 95% CI 0.73-1.10, P = 0.28). The percentage of positive ANA tests increased from 43% pre-intervention to 53% in the post-intervention period (OR 1.49, 95% CI 0.90-2.46, P = 0.12) in the neurology department and from 48% to 59% (OR 1.56, 95% CI 0.99-2.44, P = 0.0543) in the internal medicine departments. A simple educational intervention reduced unnecessary ANA testing in the neurology department but not in internal medicine departments, improving patient selection and potential cost savings. The results underscore the importance of targeted education to promote evidence-based behavior among healthcare professionals. Further research with longer follow-up is needed to assess the sustainability of these improvements.

Improving Compliance With Valid Oxygen Prescriptions for Surgical Inpatients in a District General Hospital: A Single-Centre Quality Improvement Study

Improving Compliance With Valid Oxygen Prescriptions for Surgical Inpatients in a District General Hospital: A Single-Centre Quality Improvement Study

School Nurse-Led Health Assessment for Students Experiencing Homelessness: A Quality Improvement Project.

Childhood homelessness is increasing and is associated with negative health and academic outcomes. The goal of this quality improvement project was to improve access to healthcare and health outcomes for students experiencing homelessness through a school nurse-led comprehensive health assessment. The multilevel intervention included identifying students experiencing homelessness, conducting a standardized health assessment, and making referrals to care. This 8-month project was conducted in an urban school district. Feasibility and acceptability data were collected to guide sustainability. Student health and referral data were analyzed using descriptive statistics. At the project start, 688 students were identified as experiencing homelessness. More than half (67%) had a partial or fully completed health assessment during the project. Of the students assessed, most had a primary care provider, some had a health condition, and half had a dental home. Students experiencing homelessness would benefit from systematic school-based health assessments to identify unmet health needs.

Integrating Universal Hepatitis C Screening into Adolescent Well Visits is a "Win-Win" Scenario: Rationale and Demonstration of Real-World Feasibility and Implementation.

Hepatitis C virus (HCV) testing is recommended for all adults 18 years and older to increase identification of those with infection and facilitate prompt referral for curative antiviral therapy. While critical to promote elimination, this strategy excludes a key demographic group who are clearly at risk of undetected HCV infection and who could benefit from early treatment: adolescents. In this paper, we review the available data on the burden of HCV and the close association with injection drug use, discuss the rationale of universal testing in adolescents and, finally, present data from a quality improvement project implementing HCV testing into routine adolescent health visits.

Deep Learning-Based Approximated Observation Sparse SAR Imaging via Complex-Valued Convolutional Neural Network

Sparse synthetic aperture radar (SAR) imaging has demonstrated excellent potential in image quality improvement and data compression. However, conventional observation matrix-based methods suffer from high computational overhead, which is hard to use for real data processing. The approximated observation sparse SAR imaging method relieves the computation pressure, but it needs to manually set the parameters to solve the optimization problem. Thus, several deep learning (DL) SAR imaging methods have been used for scene recovery, but many of them employ dual-path networks. To better leverage the complex-valued characteristics of echo data, in this paper, we present a novel complex-valued convolutional neural network (CNN)-based approximated observation sparse SAR imaging method, which is a single-path DL network. Firstly, we present the approximated observation-based model via the chirp-scaling algorithm (CSA). Next, we map the process of the iterative soft thresholding (IST) algorithm into the deep network form, and design the symmetric complex-valued CNN block to achieve the sparse recovery of large-scale scenes. In comparison to matched filtering (MF), the approximated observation sparse imaging method, and the existing DL SAR imaging methods, our complex-valued network model shows excellent performance in image quality improvement especially when the used data are down-sampled.

Developing a large-scale quality improvement program for thyroid cancer surgery.

Surgical quality improvement (QI) plays a critical role in optimizing patient outcomes and reducing healthcare costs. QI programs focusing specifically on thyroid cancer surgical care are lacking. This study aimed to (a) select and introduce surgical quality indicators for thyroid cancer and (b) identify areas for QI at the state-level. A multidisciplinary team of thyroid cancer and QI experts selected 10 thyroid cancer-specific quality indicators and assessed the quality of thyroid cancer surgical care compared to current national guidelines. Analysis of the first year (January-December 2023) of data collection was performed using descriptive statistics. The thyroid cancer quality indicators included preoperative cytology, postoperative pathology, staging, cancer size, margin status, extrathyroidal extension, lymph nodes, postoperative complications within 30days, documented follow-up treatment, and documented surveillance plans. 112 surgeons performed 360 thyroidectomies for thyroid cancer at 51 hospitals. Preoperative cytology was not performed in 34.3% (n=103) of cases with thyroid cancer on final pathology. When the extent of surgery was evaluated by papillary cancer size, 50.0% (n=38) of patients with <1cm cancers underwent total thyroidectomy, and 13.8% (n=4) with >4cm underwent thyroid lobectomy. Positive margins were found in 16.2% (n=53). Postoperatively, 19.2% (n=69) of patients lacked documented follow-up, and 18.6% (n=67) lacked thyroid cancer surveillance plans. Establishing a dedicated QI program for thyroid cancer provides a previously unharnessed opportunity to enhance the quality of thyroid cancer surgical care. Statewide surgical quality collaboratives offer a model for establishing thyroid cancer QI initiatives across diverse healthcare settings in other states and countries.

Quality Improvement Assessment of Massive Transfusion Protocol (MTP) Utilization and Blood Component Return to Blood Bank in a Level 1 Trauma Center

Abstract Introduction/Objective The goal of MTP in management of patients with hemorrhage is to restore coagulation factors, oxygen carrying capacity, and platelets by transfusing equal amount of plasma, RBC, and platelets. Upon activation of MTP, blood components are released in rounds until deactivation. This quality improvement study was initiated to assess blood products transfused versus returned during MTP activation at our Level1 Trauma Medical Center. Methods/Case Report Upon MTP activation, the Blood Bank (BB) prepares first round of cooler with components at 5:5:1 ratio of plasma, RBC, apheresis platelets. We reviewed retrospective MTP data of eleven-month, from 10/2022- 08/2023. We analyzed patterns of blood component usage by service line, number of MTP rounds issued, and number of units transfused versus returned. Results (if a Case Study enter NA) MTP data was reviewed for 195 patients. MTP activation by service line included emergency department 58.5%, medical ICU (MICU) 14.4%, and surgical ICU (SICU) 11.8%. In many MTP activations, only one round of components was released. Overall, an average of 1.5 rounds were issued. Data of units transfused and returned by component type showed more RBC (43.1%) units were transfused than plasma (39.4%) suggesting MTP transfusion did not follow 1:1:1 ratio. Out of all issued blood units 58% were returned. The high fraction of returned blood components suggests MTP activation may not always truly indicate massive hemorrhage. This finding, and the notable frequency of MTP activation for MICU and SICU patients suggests that individual component order on an emergency-release basis may have been the appropriate option. Conclusion In general, the data suggests implementation of a quality improvement initiative focused on increasing awareness of criteria for MTP activation, and training of staff surrounding MTP is essential. We recently implemented an electronic emergency transfusion order set that allows providers to order individual components for non-massively bleeding patients.

Culture failure and suboptimal analysis in cytogenetics: A data review as a quality improvement metric from a resource-limited country

Abstract Introduction/Objective Conventional cytogenetic failures can affect hematological cancer diagnosis and prognosis. Resource-constrained regions without contemporary genetic testing facilities may experience this impact more. The effectiveness of this technique is contingent on cultural success, availability of metaphases, and morphological adequacy. The results can be influenced by the underlying diagnosis, inherent biological features of the leukemic clone, sample conditions, and transit time. Culture failure (CF) and suboptimal analysis (SOA) data can identify problems and set standards. Thus, we designed a cohort to find areas of improvement and reduce negative contributing factors, making this cytogenetic technique more accessible and cost-effective. Methods/Case Report A retrospective study was conducted at Cytogenetics laboratory at Indus hospital, Karachi. From January 2021 to March 2023, 1234 blood and bone marrow samples were processed. CF was defined as no growth, whereas suboptimal cases showed a low mitotic index or poor morphology. Data analysis included collection and processing time, sample volume, cell count, specimen type, in-house or out-reach sample, and diagnosis. Armonk, NY-based IBM SPSS 24.0 used to analyze the data. Chi-square used to find association of various factors with karyotyping. A p-value &amp;lt; 0.05 indicated significance. Results (if a Case Study enter NA) Of 1234 samples, 1110 (90%) were bone marrow and 124 (10%) were peripheral blood. There were 32/1234 (2.6%) CF cases. Each CF case was found in bone marrow samples, making the true incidence 32/1110 (2.9%). Constitutional blood tests found no CF in 124 samples. Additionally, chromosomal analysis quality was assessed. SOA occurred in 105/1234 (8.5%) instances, with 58% having poor morphology and 31% having a low mitotic index. Among 137 CF and SOA patients, 134/1110 (12%) were found in marrow and 3/124 (2.4%) in blood. Conclusion Lower CF rates suggest that appropriate standards and quality management may reduce cytogenetic failure rates despite resource constraints and newly established services.

Combinatorial Method for Quality Improvement of the Thrust Plate – A Case Study

Aim: This research aims to mitigate defects in the turning operation of thrust plates used in fighter jet fuel tank assemblies, thereby reducing the rejection rate and improving overall quality. This aligns with the aerospace industry's reliability goals. Background: The thrust plate is a critical component in fighter jet fuel tank assembly, transmitting engine thrust to the airframe. Quality compromises in this component can impair jet performance. It was observed that the thrust plate had a rejection rate of about 2.9% due to various defects. This real- world scenario underscores the importance of our study on the thrust plate and its potential impact on the aerospace industry. The rejection rate underscores its significance and potential for patent by quality improvement in turning of the thrust plate. Objective: The objective is to mitigate turning operation defects on the thrust plate to reduce rejection rates, aligning with aerospace industry reliability goals. Methods: Experimentation encompassed four pivotal factors: turning speed, feed rate, cutting depth, and tool inserts, implemented through Taguchi's Orthogonal Array technique. Grey Relational Analysis was utilized to optimize parameters in thrust plate turning. Specifically, this paper targeted the enhancement of its diameter, surface roughness, and tool life. Results: A single coefficient for the multiple responses, i.e., grey relational grade, has been determined, and optimum levels for the parameters have been identified. Confirmation experiments with the optimal factor level combination were carried out on a sample of thrust plates, and no rejections were observed. Conclusion: An experimental design based on Taguchi’s orthogonal array approach was used to conduct the experiments. The Grey Relational Analysis has been applied to analyze the experimental results and optimize the turning operation process parameters for the responses thrust plate diameter, tool life, and surface roughness. With this, the rejection of the thrust plate has been considerably reduced.

Micro-Coring: A Novel Approach to Perioral Rejuvenation.

A long philtrum and poor perioral skin quality are stigmata of the aging face. Micro-Coring is a novel technology that allows for scarless skin removal. In this study we aimed to determine whether micro-coring can shorten the philtrum and improve perioral skin quality. A retrospective cohort study was performed on patients who underwent facelift with perioral micro-coring and age- and BMI-matched controls who underwent facelift alone. Preoperative and postoperative 3-dimensional facial imaging was performed. Standard perioral distances and percentage of change were calculated. Perioral skin quality was evaluated by blinded raters with the Scientific Assessment Scale of Skin Quality (SASSQ) and Global Aesthetic Improvement Scale (GAIS). Thirteen patients and 13 controls were included, with a mean follow-up of 8.9 months (range 3.0-21.5). Patients had significantly shorter mean philtrum length postoperatively compared to preoperatively, with an average decrease of 6.18% (±2.25%; P < .05). Controls did not experience significant changes in philtrum length (P > .05). There were no significant changes in other perioral measurements. Perioral skin elasticity and wrinkles significantly improved in patients compared to controls and patients had significantly greater GAIS scores (P < .05). Micro-Coring can achieve perioral rejuvenation through measurable shortening of the philtrum and observable improvement in skin quality. Nonsurgical techniques continue to find new ways to achieve aesthetic goals without significant recovery or scarring and offer value to patients and clinicians.

Analysis of the Efficacy and Prospects for Application of Olorparib and Dabrafenib in Liver Cancer Treatment

Abstract Introduction/Objective To evaluate the effectiveness of Olaparib and Dabrafenib in the treatment of liver cancer and explore their potential prospects for future applications. Methods/Case Report A comprehensive analysis of relevant literature on Olaparib and Dabrafenib in the treatment of liver cancer was conducted, including clinical trials, case studies, and previous meta-analyses. Key indicators such as treatment efficacy, adverse reactions, and patient survival rates were examined. Results (if a Case Study enter NA) In patients treated with the two drugs, the proportion of AFP decreased was 60.24% and 65.87%, the proportion of serum ferritin decreased was 50.25% and 53.39%, the proportion of CT tumor abbreviations was 52.13% and 58.89%, and the effective rate was 38.14% and 40.02%, respectively. There was no significant difference between the two drugs (P &amp;gt; 0.05). Survival analysis showed that the median progression-free survival was 10.7 and 12.3 months, respectively, and the median overall survival was 17.6 and 20.1 months, respectively. The incidence of adverse events including fever, fatigue, chills, nausea and rash was 23.14% and 28.56%, respectively, and there was no significant difference between the two drugs (P &amp;gt; 0.05). Conclusion Olaparib and Dabrafenib demonstrate significant efficacy in the treatment of liver cancer, offering new therapeutic options for patients. The application prospects of these drugs are promising, and they are expected to become crucial components in liver cancer treatment. Further research and clinical practice will contribute to a more comprehensive understanding of their mechanisms of action, optimization of treatment regimens, and improvement of the overall quality of life for liver cancer patients.

Retraction Note: A model predictive controller for improvement in power quality from a hybrid renewable energy system

Retraction Note: A model predictive controller for improvement in power quality from a hybrid renewable energy system

Improvement of water quality through coordinated multi-trophic level biomanipulations: Application to a subtropical emergency water supply lake

Artificial emergency water source lakes have been built in most cities in the middle and lower reaches of the Yangtze River, China, to ensure water safety for residents. However, these new ecosystems are prone to algal blooms or other degraded water quality conditions. A newly built water supply lake in the lower reaches of the Yangtze River was selected as a model system to test whether the coordinated manipulation of fish and submerged macrophyte communities could enhance ecosystem function and quality. The coordinated manipulations spanned a five-year period, aiming to enhance both top-down and bottom-up control of phytoplankton. As a result of these manipulations, the catch per unit effort of small-bodied zooplanktivorous fishes decreased by >95 % from year two and remained low. The coverage and biomass of submerged macrophytes increased year by year. Water transparency increased from 1.07 to 3.33 m. Total phosphorus and total nitrogen showed a decreasing trend (not significant though). The annual mean biomass of Cyanophyta, Chlorophyta and Bacillariophyta decreased from 2.99 to 0.03 mg/L, 3.90 to 0.16 mg/L, and 3.50 to 0.3 mg/L, respectively. The biomass of phytoplankton in different groups decreased in all four seasons. The annual mean biomass of Cladocera and Copepoda remained low. The biomass of Cladocera and Copepoda decreased in summer, fall, and winter. The Ecosystem Health Index - increased from 15.9 to 32.0. The pros and cons of the various top-down and bottom-up control measures employed are discussed. This research presents a valuable case study on the enhancement of ecosystem structure and function in newly constructed emergency water supply lakes and offers insights into the restoration of other subtropical shallow lakes.

Assessing Subseasonal Forecasts of Dry Spells and Heatwaves at the Regional Scale in Brazil

This study evaluates the performance of subseasonal forecasts for dry spells and heatwaves at a regional scale in Brazil. The forecasts’ verification was designed to provide end-users with relevant information about the forecasts’ quality. The U.K. Met Office model was assessed using a significant sample of weekly forecasts: 552 for dry spells and 240 for heatwaves. The analysis reveals that the overall performance of the forecasts is low, with a chance of detecting an event close to 0.2, indicating that only one out of five observed dry spells is accurately predicted on average. The application of quantile mapping corrections demonstrates improvements in predicting shorter dry spells (up to 5 days) and longer lead times, although the timing of these forecasts often remains inaccurate, leading to increased false alarms. A significant improvement in the forecast quality occurs when categorization by duration is disregarded. The detection chances increase to 0.5−0.7 for dry spells and 0.5 for heatwaves. The Brier Score indicates that the probabilistic forecasts issued by the model are equivalent or less skilful than climatological probabilities. Overall, the findings underscore the challenges in forecasting dry spells and heatwaves in Brazil and highlight the need for ongoing improvements in forecasting methodologies to enhance their reliability and utility for regional decision-making. This research contributes to understanding subseasonal climate forecasting and its implications for managing climate-related risks in Brazil.