Integrated Quality Improvement Research Articles

Integrating Quality Improvement With Graduate Medical Education: Lessons Learned From the AIAMC National Initiatives.

Quality and safety initiatives (QI) are national priorities for health care, yet the role of residents in QI has not always been clear. In academic medical centers, residents and fellows play a critical role in patient care and, as such, their integration into QI presents a unique opportunity to affect change. The Alliance for Independent Academic Medical Centers (AIAMC) began a national campaign in 2007 to harness the potential of infusing graduate medical education (GME) with QI, through their AIAMC National Initiative: Improving Patient Care Through Medical Education. This article describes the National Initiatives (NIs) and the reflections of NI participants, including their reflections on the goals they set for integrating GME with QI, the barriers they encountered along the way, and their advice to others beginning the challenge. These reflections provide some insight into the pathways of promoting organizational change and offer practical insight and inspiring advice for others embarking on the journey.

Biting into integrated quality improvement: medical student and staff blinded taste test for sodium reduction improving medical education and care?

Over 90 % of Americans consume an excessive amount of sodium as a key salt ingredient, despite its contribution to morbidity and mortality. No known studies have analyzed the optimal salt reduction level for medical students and staff in characteristic restaurant recipes. Increased studies linking such quality improvement in medical education and care through lifestyle-based modifications with medical professionals in training may provide a promising model for competency-based medical education in the age of healthcare reform. A volunteer sample (n = 105) of medical students and staff was recruited over 3 weeks to test three-course meal components from representative restaurants prepared under a trained chef’s supervision. Subjects were not informed that sodium levels were decreased in three samples by 15, 25, and 35 % with the fourth sample being the control of 0 % reduction. The largest sub-group of subjects identified the 15 % reduced sample as the optimal saltiness sample compared to the 0, 25, and 35 % reduced samples overall among the shrimp, jambalaya, and gumbo dishes (29.23 % vs. 23.59 %, 22.56 %, 24.62 %, p = 0.567). The Kruskal–Wallis test with post hoc analysis with the Wilcoxon-Mann–Whitney test revealed that sodium-reduced samples had a significantly higher rank sum than the zero-reduced sample for favorite dish (p < 0.001). Our results suggest chefs may reduce sodium while still preserving consumer preference. Future studies are needed to investigate the impact of first-hand nutrition study participation on medical students and staff improving their own nutrition education for their future patients.

Hospitals' readiness to implement clinical governance.

Quality of health services is one of the most important factors for delivery of these services. Regarding the importance and vital role of quality in the health sector, a concept known as "Clinical Governance" (CG) has been introduced into the health area which aims to enhance quality of health services. Thus, this study aimed to assess private and public hospitals' readiness to implement CG in Iran. This descriptive and cross-sectional study was carried out in 2012. Four hundred thirty participants including doctors, nurses, diagnostic departments personnel, and support staff were chosen randomly from four hospitals (equally divided into private and public hospitals). Clinical Governance Climate Questionnaire (CGCQ) was used for data collection. Finally, data were entered into the SPSS 18 and were analyzed using statistical methods. Among the CG dimensions, "organizational learning" and "planned and integrated quality improvement program" scored the highest and the lowest respectively for both types of hospitals. Hospitals demonstrated the worst condition with regard to the latter dimension. Furthermore, both types of hospitals had positive picture regarding "training and development opportunities". Private hospitals scored better than public ones in all dimensions but there was only a significant difference in "proactive risk management" dimension between both types of hospitals (P< 0.05). Hospitals' readiness for CG implementation was "average or weak". In order to implement CG successfully, it is essential to have a quality-centered culture, a culture specified by less paperwork, more self-sufficiency, and flexibility in hospitals' affairs as well as centring on shared vision and goals with an emphasis on continuous improvement and innovation.

Educational system factors that engage resident physicians in an integrated quality improvement curriculum at a VA hospital: a realist evaluation.

Learning about quality improvement (QI) in resident physician training is often relegated to elective or noncore clinical activities. The authors integrated teaching, learning, and doing QI into the routine clinical work of inpatient internal medicine teams at a Veterans Affairs (VA) hospital. This study describes the design factors that facilitated and inhibited the integration of a QI curriculum-including real QI work-into the routine work of inpatient internal medicine teams. A realist evaluation framework used three data sources: field notes from QI faculty; semistructured interviews with resident physicians; and a group interview with QI faculty and staff. From April 2011 to July 2012, resident physician teams at the White River Junction VA Medical Center used the Model for Improvement for their QI work and analyzed data using statistical process control charts. Three domains affected the delivery of the QI curriculum and engagement of residents in QI work: setting, learner, and teacher. The constant presence of the QI material on a public space in the team workroom was a facilitating mechanism in the setting. Explicit sign-out of QI work to the next resident team formalized the handoff in the learner domain. QI teachers who were respected clinical leaders with QI expertise provided role modeling and local system knowledge. Integrating QI teaching into the routine clinical and educational systems of an inpatient service is challenging. Identifiable, concrete strategies in the setting, learner, and teacher domains helped integrate QI into the clinical and educational systems.

Creating a sustainable culture of quality through the SLMTA programme in a district hospital laboratory in Kenya.

BackgroundBungoma District Hospital Laboratory (BDHL), which supports a 200-bed referral facility, began its Strengthening Laboratory Management Toward Accreditation (SLMTA) journey in 2011 together with eight other laboratories in the second round of SLMTA rollout in Kenya.ObjectivesTo describe how the SLMTA programme and enhanced quality interventions changed the culture and management style at BDHL and instilled a quality system designed to sustain progress for years to come.MethodsSLMTA implementation followed the standard three-workshop series, mentorship site visits and audits. In order to build sustainability of progress, BDHL integrated quality improvement processes into its daily operations. The lab undertook a process of changing its internal culture to align all hospital stakeholders – including upper management, clinicians, laboratory staff and maintenance staff – to the mission of sustainable quality practices at BDHL.ResultsAfter 16 months in the SLMTA programme, BDHL improved from zero stars (38%) to four stars (89%). Over a period of two to three years, external quality assessment results improved from 47% to 87%; staff punctuality increased from 49% to 82%; clinician complaints decreased from 83% to 16; rejection rates decreased from 12% to 3%; and annual equipment repairs decreased from 40 to 15. Twelve months later the laboratory scored three stars (81%) in an external surveillance audit conducted by Kenya Accreditation Service (KENAS).ConclusionManagement buy-in, staff participation, use of progress-monitoring tools and feedback systems, as well as incorporation of improvement processes into routine daily activities, were vital in developing and sustaining a culture of quality improvement.

Integrating Quality Improvement and Translational Research Models to Increase Exclusive Breastfeeding

Exclusive breastfeeding (EBF), a perinatal core measure, is associated with a longer duration of breastfeeding. The purpose of this quality improvement project was to increase the percent of healthy term singleton newborns who were exclusively breastfed at an academic medical center in the Midwest. Implementation of skin-to-skin contact between mother and newborn immediately following birth resulted in an increase in the percent of healthy term singleton newborns who were EBF from 55% to 64%.

The utah beacon experience: integrating quality improvement, health information technology, and practice facilitation to improve diabetes outcomes in small health care facilities.

Purpose:The Utah Improving Care through Connectivity and Collaboration (IC3) Beacon community (2010–2013) was spearheaded by HealthInsight, a nonprofit, community-based organization. One of the main objectives of IC3 was to improve health care provided to patients with diabetes in three Utah counties, collaborating with 21 independent smaller clinics and two large health care enterprises. This paper will focus on the use of health information technology (HIT) and practice facilitation to develop and implement new care processes to improve clinic workflow and ultimately improve patients’ diabetes outcomes at 21 participating smaller, independent clinics.Innovation:Early in the project, we learned that most of the 21 clinics did not have the resources needed to successfully implement quality improvement (QI) initiatives. IC3 helped clinics effectively use data generated from their electronic health records (EHRs) to design and implement interventions to improve patients’ diabetes outcomes. This close coupling of HIT, expert practice facilitation, and Learning Collaboratives was found to be especially valuable in clinics with limited resources.Findings:Through this process we learned that (1) an extensive readiness assessment improved clinic retention, (2) clinic champions were important for a successful collaboration, and (3) current EHR systems have limited functionality to assist in QI initiatives. In general, smaller, independent clinics lack knowledge and experience with QI and have limited HIT experience to improve patient care using electronic clinical data. Additionally, future projects like IC3 Beacon will be instrumental in changing clinic culture so that QI is integrated into routine workflow.Conclusion and Discussion:Our efforts led to significant changes in how practice staff optimized their EHRs to manage and improve diabetes care, while establishing the framework for sustainability. Some of the IC3 Beacon practices are currently smoothly transitioning to new models of care such as Patient-Centered Medical Homes. Thus, IC3 Beacon has been instrumental in creating a strong community partnership among various organizations to meet the shared vision of better health and lower costs, and the experience over the last few years has helped the community prepare for the changing health care landscape.

Hospitals' readiness for clinical governance implementation in educational hospitals of yazd, iran.

Background:Clinical governance is a systematic approach to maintaining and improving the quality of patient care. This study aimed to assess some Iranian educational hospitals’ readiness for clinical governance implementation through the organizational climate.Methods:It was a cross-sectional study that used the Clinical Governance Climate Questionnaire (CGCQ) in three educational hospitals in Yazd, a city in central Iran, in 2012. A total of 186 personnel contributed to the study. Data were analyzed using SPSS version 16. Descriptive statistics and the Kruskal-Wallis test were used for data analyses.Results:The mean scores of the clinical governance climate in Shahid Sadoughi, Shahid Rahnemoon and Afshar hospitals were 2.63±0.29, 2.58±0.32, and 2.68±0.29. The mean scores of quality improvement planning and change, quality improvement integration and motivation, clinical risk management and climate of blame and punishment, organizational learning, and training and development (T&D) opportunities for learning in the studied hospitals were 2.21±0.49, 2.80±0.40, 2.76±0.40, 2.91±0.54 and 3.06±0.72, respectively.Conclusion:The results of this study showed that the educational hospitals’ climate should be more supportive for successful implementation of clinical governance.

Integrated inventory model for single-vendor single-buyer with imperfect production process

In this paper, we develop an integrated inventory model for a single-vendor single-buyer system considering an imperfect production process under stochastic demand and variable lead time. The model takes into account the deterioration of the vendor’s production process. The lead time varies linearly with the production lot size. The proposed model jointly determines the optimal safety factor, ordering quantity, production batch, frequency of deliveries, and process quality, simultaneously. An algorithm is suggested to find the solution and a numerical example is presented to illustrate the benefit of a proposed model. The results from this study show that integrating quality improvement into production-inventory decisions can reduce expected integrated cost significantly.

Impact of Relaxation and Group Psycho-Education on Health Outcomes Using Integrated Care Models and Quality Improvement

The purpose of this Integrated Care Practice Change and Quality Improvement (ICPCQI) initiative was to evaluate the impact of wellness and relaxation and group psycho-education on health out-comes in an integrated care setting. Individuals diagnosed with mental illness and a co-occurring chronic medical condition participated in the ICPCQI initiatives which were run by peer support and wellness experts in an integrated care setting over the one-year project implementation period. Evaluation of outcome measures revealed an overall decline of 8.3% (p < 0.0001) and 7.3% (p < 0.0001) in the average systolic and diastolic blood pressure respectively. There was a 12.3% (p = 0.02) reduction on the average PHQ-9 scores. GAD-7 (p = 0.9) scores had a mean reduction of 1.5%. These preliminary results suggest that the evidence-based ICPCQI initiatives positively impact health outcomes among individuals with mental illness and chronic medical conditions.

A systems-based partnership learning model for strengthening primary healthcare

BackgroundStrengthening primary healthcare systems is vital to improving health outcomes and reducing inequity. However, there are few tools and models available in published literature showing how primary care system strengthening can be achieved on a large scale. Challenges to strengthening primary healthcare (PHC) systems include the dispersion, diversity and relative independence of primary care providers; the scope and complexity of PHC; limited infrastructure available to support population health approaches; and the generally poor and fragmented state of PHC information systems.Drawing on concepts of comprehensive PHC, integrated quality improvement (IQI) methods, system-based research networks, and system-based participatory action research, we describe a learning model for strengthening PHC that addresses these challenges. We describe the evolution of this model within the Australian Aboriginal and Torres Strait Islander primary healthcare context, successes and challenges in its application, and key issues for further research.DiscussionIQI approaches combined with system-based participatory action research and system-based research networks offer potential to support program implementation and ongoing learning across a wide scope of primary healthcare practice and on a large scale. The Partnership Learning Model (PLM) can be seen as an integrated model for large-scale knowledge translation across the scope of priority aspects of PHC. With appropriate engagement of relevant stakeholders, the model may be applicable to a wide range of settings. In IQI, and in the PLM specifically, there is a clear role for research in contributing to refining and evaluating existing tools and processes, and in developing and trialling innovations. Achieving an appropriate balance between funding IQI activity as part of routine service delivery and funding IQI related research will be vital to developing and sustaining this type of PLM.SummaryThis paper draws together several different previously described concepts and extends the understanding of how PHC systems can be strengthened through systematic and partnership-based approaches. We describe a model developed from these concepts and its application in the Australian Indigenous primary healthcare context, and raise questions about sustainability and wider relevance of the model.

Quality-driven workforce performance evaluation based on robust regression and ANOMR/ANOMRV chart

The integration of quality improvement and manufacturing system management has emerged as a promising research topic in recent years. Since operators’ performance variation can be reflected in product quality, workforce performance evaluation should be conducted with quality-based metrics to improve product quality as well as manufacturing system productivity. In this article, a methodology incorporating regression modeling and multiple comparisons is proposed to aid the performance evaluation. The effects of other impacting factors that contribute to operators’ performance variation are quantified with a robust zero-inflated Poisson regression model. The model coefficients are analyzed with multiple hypothesis tests to identify underperforming machines. Two statistical charts used in multiple comparisons are adopted for identifying underperforming operators. A case study with data from a real-world production system and a simulation experiment are presented to demonstrate the proposed methodology.

Integrating quality improvement into pre-registration education

Healthcare organisations around the world are adopting new strategies to improve the quality of patient care in response to reports of negative patient outcomes and cuts to public service expenditure. However, many nurses lack the knowledge, skills and attitude to improve the systems within which they work, calling for a radical redesign of nursing education to integrate quality improvement science. This article describes the integration of quality improvement education within undergraduate nursing education programmes in Wales through collaboration between higher education institutions, NHS Wales and the UK Institute for Healthcare Improvement Open School.

Abstract WP347: Telestroke Practice With Integrated Quality Improvement Strategy Increases Use of IV tPA in Rural Minnesota.

Background: In Minnesota, stroke is the cause of 2000 deaths, 12,000 hospitalizations with 1 in 3 presenting first to a rural hospital where resources for stroke care are limited. Nationally the percent of all acute ischemic stroke (AIS) patients presenting to acute care hospitals receiving IV tPA remains low with long times to treatment (4.3% and mean DTD time 79 min - GWTG data 2003-2009). This review supports the hypothesis that a stroke system utilizing telestroke with an integrated approach to the team process and quality review will increase the percentage of AIS patients treated and foster short door-to-drug times. Methods: The HealthEast Telestroke Network began in 2006, currently there are five hospitals within the system. During the implementation, team meetings occur with spoke hospital staff to collaboratively develop the stroke code process which includes a door to drug goal of 30 minutes. Components of this process include use of aggressive triage plan for ambulatory arrivals, partnering with EMS for pre-alerts, specific team member assignments and time goals, early stroke neurology involvement and leadership of the code. This integrated team approach continues into the quarterly quality review with cooperative hub and spoke meetings to address barriers and effect continuous improvement of the process. Results: Currently, our rate of all ischemic stroke discharges treated across our telestroke network hospitals is 24%. Comparisons between each of the five network hospital’s rates of all ischemic stroke treated is 17% to 34%. Mean door to drug time across the network is 58 minutes, with a range across sites of 46 to 67 minutes and sixty percent of patients receiving IV tPA within 60 minutes or less. Conclusion: Use of telestroke combined with an integrated approach to the team process and quality review resulted in a sustained high percentage of AIS patients treated with reperfusion therapies with door- to- drug times comparing favorably to nationally reported data.

Integrating Quality Improvement Into Continuing Medical Education Activities Within a Community Hospital System

The integration of the Mercy Health System's quality improvement (QI) and continuing medical educational (CME) activities is described. With the implementation of computerized medical data, the opportunities for QI-focused CME are growing. The authors reviewed their regularly scheduled series and special CME programs to assess their impact on quality care processes. Clinical improvements were affected by combining national guidelines and advancements with local clinical data and interactions with physicians within interdisciplinary as well as specialty conferences. Case-based, multidisciplinary conferences lent themselves to this process to a greater extent than didactic conferences. The latter also could lead to QI when the topics were focused on specific quality initiatives that often are part of a national QI initiative. Although the authors consider these efforts to be at an intermediate stage of development, they have observed several QI/patient safety process improvements.

Developing a Practice-Based Research Network by Integrating Quality Improvement: Challenges and Ingredients for Success

Improving patient outcomes in community-based settings is the goal of both the Clinical Translational Science Award program and practice-based quality improvement (QI) programs. Given this common goal, integrating QI and outcomes research is a promising strategy for developing, implementing, and evaluating clinical interventions. This article describes the challenges and strengths illuminated by the conduct of a combined research/QI study in a nascent practice-based research network. Challenges include research's exclusion of clinic patients who might benefit from the intervention; QI programs' less uniform approach to intervention implementation; and the need for both academic and clinically relevant products and publications. A major strength is the increased likelihood of both engaging clinical practices in research and developing successful clinical interventions. Required elements for success include identification of enthusiastic clinical research "champions," involvement of researchers with clinical experience, and adequate funding to support both research and clinical resources and dissemination. Combined Ql/research projects in the practice-based research environment have the potential to improve and shorten the cycle from good idea to improved clinical outcomes in real-world settings.

A National Model for Developing, Implementing, and Evaluating Evidence‐based Guidelines for Prehospital Care

In 2007, the Institute of Medicine's (IOM's) Committee on the Future of Emergency Care recommended that a multidisciplinary panel establish a model for developing evidence-based protocols for the treatment of emergency medical systems (EMS) patients. In response, the National EMS Advisory Council (NEMSAC) and the Federal Interagency Committee on EMS (FICEMS) convened a panel of multidisciplinary experts to review current strategies for developing evidence-based guidelines (EBGs) and to propose a model for developing such guidelines for the prehospital milieu. This paper describes the eight-step model endorsed by FICEMS, NEMSAC, and a panel of EMS and evidence-based medicine experts. According to the model, prehospital EBG development would begin with the input of evidence from various external sources. Potential EBG topics would be suggested following a preliminary evidentiary review; those topics with sufficient extant foundational evidence would be selected for development. Next, the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology would be used to determine a quality-of-evidence rating and a strength of recommendation related to the patient care guidelines. More specific, contextualized patient care protocols would then be generated and disseminated to the EMS community. After educating EMS professionals using targeted teaching materials, the protocols would be implemented in local EMS systems. Finally, effectiveness and uptake would be measured with integrated quality improvement and outcomes monitoring systems. The constituencies and experts involved in the model development process concluded that the use of such transparent, objective, and scientifically rigorous guidelines could significantly increase the quality of EMS care in the future.

Performance measures for improving the prevention of venous thromboembolism: achievement in clinical practice

Venous thromboembolism (VTE) is a common complication during and after hospitalization for acute medical illness or surgery. Despite the existence of evidence-based guidelines for VTE prevention, real-world prescribing practices are frequently suboptimal. Specific performance measures relating to VTE prevention and treatment have been developed by US health care organizations to increase adherence with best-practice recommendations and ultimately reduce the number of preventable VTE events. Two measures developed by the Surgical Care Improvement Project have been endorsed by the National Quality Forum (NQF) and focus on VTE prevention. In addition, six measures have been developed recently by The Joint Commission in collaboration with the NQF; three measures relate to VTE prevention and three focus on treatment. To attain widespread achievement of these performance goals, it is essential to raise awareness of their existence and specifications. It is also imperative that hospitals develop and implement effective VTE protocols. The use of multiple, active strategies, such as computer decision support systems with regular audit and feedback, may be particularly valuable approaches to improve current practices within an integrated quality improvement program. During practical implementation of VTE protocols at Norton Healthcare (Kentucky's largest healthcare system), strong leadership, physician engagement, and caregiver accountability were identified as key factors influencing the process. As such, more hospitals may be able to increase adherence with guidelines, improve achievement of quality goals, and help to reduce the substantial burden associated with avoidable VTE.

Improved Clinical Outcomes Combining House Staff Self-Assessment with an Audit-Based Quality Improvement Program

There is a focus on integrating quality improvement with medical education and advancement of the American College of Graduate Medical Education (ACGME) core competencies. To determine if audits of patients with unexpected admission to the medical intensive care unit using a self-assessment tool and a focused Morbidity and Mortality (M&M) conference improves patient care. Charts from patients transferred from the general medical floor (GMF) to the medical intensive care unit (ICU) were reviewed by a multidisciplinary team. Physician and nursing self-assessment tools and a targeted monthly M&M conference were part of the educational component. Physicians and nurses participated in root cause analysis. Records of all patients transferred from a general medical floor (GMF) to the ICU were audited. One hundred ninety-four cases were reviewed over a 10-month period. New policies regarding vital signs and house staff escalation of care were initiated. The percentage of calls for patients who met medical emergency response team/critical care consult criteria increased from 53% to 73%, nurse notification of a change in a patient's condition increased from 65% to 100%, nursing documentation of the change in the patients condition and follow-up actions increased from 65% percent to a high of 90%, the number of cardiac arrests on a GMF decreased from 3.1/1,000 discharges to 0.6/1,000 discharges (p = 0.002), and deaths on the Medicine Service decreased from 34/1,000 discharges to 24/1,000 discharges (p = 0.024). We describe an audit-based program that involves nurses, house staff, a self-assessment tool and a focused M&M conference. The program resulted in significant policy changes, more rapid assessment of unstable patients and improved hospital outcomes.

Integrating Quality Improvement and Residency Education: Insights From the AIAMC National Initiative About the Roles of the Designated Institutional Official and Program Director

Active engagement of both the designated institutional official (DIO) and the program director (PD) is essential to implement any change in graduate medical education (GME). Strategies that are established by the Accreditation Council for Graduate Medical Education or other entities are, in the end, effective only as implemented at the individual program level. The interpretation of national standards or guidelines, and the specific adaptation to the vagaries of individual institutions and programs, can lead to significant variability in implementation and potentially in outcomes. Variability occurs between programs within the same institution and between some specialty programs at different institutions. The National Initiative, sponsored by the Alliance of Independent Academic Medical Centers, was launched in 2007 to demonstrate the effectiveness of GME as a key driver to improve quality, patient safety, and cost-effectiveness of care. This report addresses (1) the key roles of both the DIO and the PD in achieving the goals of the National Initiative, (2) the challenges these goals presented to each role, and (3) some of the tactics drawn from the experiences of the National Initiative in overcoming those challenges. The experience of the National Initiative underscored the synergies of the DIO and PD roles to improve patient care while simultaneously fulfilling their critical responsibilities as institutional and program leaders in GME with even greater effectiveness.