Quality Improvement Model Research Articles

Using a Quality Improvement Model to Implement Distress Screening in a Community Cancer Setting

BackgroundQuality cancer care includes routine screening for psychosocial distress. This quality improvement project focused on the implementation of distress screening at a licensed affiliate of Cancer Support Community, a community-based non-profit organization that provides professionally led cancer support.MethodsAn advanced practice oncology nurse assisted the staff in implementing and evaluating the process of distress screening. CancerSupportSource (CSS), a validated web-based distress screening program developed by Cancer Support Community for use in community cancer settings, was employed to screen for distress, identify potential resources, and improve in-house and community referrals. For purposes of this quality improvement project, CSS was administered in interview format by staff. The Plan-Do-Study-Act (PDSA) quality improvement approach was used to implement CSS.ResultsTo implement the practice of distress screening, 21 patient participants were initially screened and evaluated for distress, including risk for clinically significant levels of depression, using CSS. The tool identified participant concerns and flagged thirteen persons as at risk for depression. After implementation and evaluation of distress screening using PDSA, in a year, 51 participants were screened. Participants stated that distress screening allowed for discussion of intimate questions that may not have otherwise occurred in an intake interview.ConclusionIt was demonstrated that CSS identified psychosocial and practical needs, facilitating the referral process and identification of community resources. Application of the PDSA model was an effective quality improvement model that can be used for the implementation and sustainability of distress screening across settings.

Implementing Medical Education Continuous Quality Improvement Using Design‐Based Research

The goal of this study is to present efficient measures to improve the quality of medical education through using a developed and applied continuous quality improvement (CQI) model suitable for medical education. To achieve this purpose, we developed a theoretical CQI model through a review of the literature according to the design-based research method. Through repetitive productive cyclical processes and professional reviews, we finally deduced an appropriate CQI model for medical education. The most important results of this study are as follows: First, the CQI model for medical education is defined as a quality management system with a cyclical course of planning, implementation, evaluation, and improvement of medical education. Second, the CQI model for medical education is composed of quality management activities of educational design, work, and evaluation. In addition, each activity has the implementation strategies of planning, doing, checking, and improving based on the PDCA model (Plan-Do-Check-Act model). Third, the CQI model for medical school education is composed of committees related to medical education doing improvement activities, as well as planning, implementing and evaluating it with CQI. As a result, we can improve teaching by using the CQI model for medical education. It is more meaningful because this gives us organized and practical measures of quality management and improvement in medical education as well as in the educational process.

Reliability analysis and power quality improvement model using enthalpy based grey wolf optimizer

With the modern era of a restructured power system environment, there are various power quality issues faced when it is being transferred within different utilities. To overcome these issues and deliver maximum effective power maintaining its quality in terms of Voltage Stability, Losses, distortion in the signal received etc. is the major challenge. This paper presents the enthalpy based Grey Wolf Optimisation (GWO) model and aims to solve the issues of the node voltage deviation power system, feeder power losses, power factor, and total harmonic distortion in a power system. The results of the model presented is compared with different conventional algorithms and found to be most suitable due to its simplicity, faster convergence and high search precision. The analysis of the presented method is performed on IEEE 30 and 57 test bus systems in MATLAB/SIMULINK environment. When compared with the conventional models, our proposed method shows 0.49, 0.69 and 1.41% better fitness accuracy for IEEE 30 and 3.23, 2.37 and 1.45% better for IEEE 57 than PSO, ABC and GA respectively. The proposed method has proved to be effective in terms of all the objectives stated above and attaining the maximum quality of power.

Reducing admission hypothermia in newborns at a tertiary care NICU of northern India: A quality improvement study.

Hypothermia at admission to neonatal intensive care units (NICU) is associated with increased morbidity and mortality in newborns. A baseline study at a tertiary care hospital with all out-born babies showed admission hypothermia of 82%. To reduce admission hypothermia (moderate) in newborns at least by 50% in next 6 months. A quality improvement (QI) study was planned using WHO Point of Care Quality Improvement Model (POCQI), [17] using PDSA (Plan-Do-Study-Act) cycle approach from April 2018 to March 2019, and including 427 term and preterm babies. We educated the staff, reinforced the use of caps, cling wraps, warm linen, introduced Ziploc bags and ensured adequate use of transport incubator. After 6 months, overall admission hypothermia decreased from 82% to 45%, moderate hypothermia reduced from 46% to <10% (P < 0.001) and severe hypothermia (3%) was completely eliminated. There was also significant reduction in incidence of Intraventricular hemorrhage (13% Vs 4.7%), Late onset neonatal sepsis (38% Vs 19%) and metabolic acidosis (43% Vs 28%). We were able to sustain this improvement for the next 6 months and is ongoing. The strongest predictor of hypothermia was newborns being in the phase before QI initiative was started (OR 2.36, 95% CI 1.47, 3.23). This study is a cost effective approach in reducing admission hypothermia in NICU in a resource limited setting with all outborn babies, and further decreasing the morbidity associated with it. Hence, emphasizing the importance of maintaining euthermia, not only in delivery rooms, but also during transportation.

The Role of Professional Advocate in Endoscopy: The A-Equip Model

In endoscopy, quality improvement (QI) is paramount and integral to Joint Advisory Group (JAG) accreditation. The challenge is to keep staff engaged and enthused in the face of factors that influence their emotions and behaviour. This was demonstrated in the author's endoscopy recovery units being used to cope with an inpatient surge for 14 months, which increased stress, sickness and turnover and lowered compliance with clinical audits. The professional advocate (PA) was tasked with addressing this and established that the QI systems in place were inadequate without investment in the team's human and social capital. The PA acted according to the Advocating and Educating for Quality Improvement (A-EQUIP) model to create a positive environment and support continuous improvement using various wellbeing tools and techniques. Restorative clinical supervision, human factors training and concepts from neurological and social sciences were employed to increase self-awareness, improve attitudes and build resilience in the workforce. These techniques have received positive feedback and become integral to the service. Endoscopy services should prioritise investment in workforce education and wellbeing and adopt the role of PA, which should be considered as part of JAG workforce standards.

Developing a Sustainable Antimicrobial Stewardship (AMS) Programme in Ghana: Replicating the Scottish Triad Model of Information, Education and Quality Improvement.

(1) Background: Our aim was to develop robust and reliable systems for antimicrobial stewardship (AMS) in Keta Municipal Hospital and Ghana Police Hospital. Objectives were to build capacity through training staff in each hospital, establish AMS teams, collect data on antibiotic use and support local quality improvement initiatives. (2) Methods: The Scottish team visited Ghana hospitals on three occasions and the Ghanaian partners paid one visit to Scotland. Regular virtual meetings and email communication were used between visits to review progress and agree on actions. (3) Results: Multi-professional AMS teams established and met monthly with formal minutes and action plans; point prevalence surveys (PPS) carried out and data collected informed a training session; 60 staff participated in training delivered by the Scottish team and Ghanaian team cascaded training to over 100 staff; evaluation of training impact demonstrated significant positive change in knowledge of antimicrobial resistance (AMR) and appropriate antibiotic use as well as improved participant attitudes and behaviours towards AMR, their role in AMS, and confidence in using the Ghana Standard Treatment Guidelines and antimicrobial app. (4) Conclusions: Key objectives were achieved and a sustainable model for AMS established in both hospitals.

Integrating "Exercise Is Medicine" into primary care workflow: a study protocol.

As a major contributor to the burden of most chronic diseases, insufficient physical activity (PA) creates a significant financial burden on the health care system. Numerous interventions effectively increase PA, but few are integrated into primary care clinic workflows. Exercise Is Medicine (EIM) is a global health initiative committed to the belief that PA is integral to the prevention and treatment of diseases and should be routinely assessed as a vital sign and treated in the health care setting. This paper describes an in-progress embedded quality improvement (QI) project that integrates EIM into routine clinical practice. A combination of implementation science (IS) and QI models are used to adapt, implement, and evaluate the integration of EIM into six primary care clinics. The Practical, Robust Implementation and Sustainability Model (PRISM) guided preimplementation evaluation and adaptation of EIM protocol, materials, and delivery strategies. The learning evaluation QI model is used to design, test, refine, and implement EIM using rapid, 3 month Plan-Do-Study-Act microcycles. Learning meetings are used to obtain feedback and optimize workflow. The Stirman Framework is used to document adaptations to the program throughout implementation. Reach, adoption, implementation, effectiveness, and maintenance outcomes embedded within PRISM will guide the program evaluation to determine sustainability and scalability. Using an innovative approach of combining IS and QI methods to improve the identification of primary care patients with insufficient PA to increase their activity levels has great population health potential. Our work will inform the best approaches for EIM integration in primary care.

A principle-empirical model based on Bayesian network for quality improvement in mechanical products development

Mechanical product quality depends on many quality characteristics (QCs). There are many coupling relations between these QCs that are required to analyze these relations. A principle − empirical (P–E) model for quality improvement is proposed in this study. The architecture of the model is first introduced. The method of the P–E model structure learning is provided, and the QC relations are determined by empirical data. These discovered QC relations are validated by principal knowledge. The P–E model structure is built based on the validated QC relations. The maximum likelihood estimation (MLE) is used for parameter learning. Finally, a case study is given to demonstrate the P–E model. The results show that the learned structure based on the P–E model is superior to the K2 algorithm when the data size is small. The difference between the P–E model and the K2 algorithm is not significant when the data size is large.

Improving uptake of cervical cancer screening services for women living with HIV and attending chronic care services in rural Malawi

Malawi has the second highest age-standardised incidence rate and the highest mortality rate of cervical cancer in the world. Though the prevalence of HIV is currently 11.7% for Malawian women...

Myocardial infarction classification and its implications on measures of cardiovascular outcomes, quality, and racial/ethnic disparities.

Heart disease continues to be the leading cause of death in the United States, with approximately 805 000 cumulative deaths from myocardial infarctions (MI) from 2005 to 2014. Gender and racial/ethnic disparities in MI diagnoses are becoming more evident in quality review audits. Although recent changes in diagnostic codes provided an improved framework, clinically distinguishing types of MI remains a challenge. MI misdiagnoses and health disparities contribute to adverse outcomes in cardiac medicine. We conducted a literature review of relevant biomedical sources related to the classification of MI and disparities in cardiovascular care and outcomes. From the studies analyzed, African Americans and women have higher rates of mortality from MI, are more probably to be younger and present with other comorbidities and are less probably to receive novel therapies with respect to type of MI. As high‐sensitivity troponin assays are adopted in the United States, implementation should account for how race and sex differences have been demonstrated in the reference range and diagnostic threshold of the newer assays. More research is needed to assess how the complexity of health disparities contributes to adverse cardiovascular outcomes. Creating dedicated medical quality teams (physicians, nurses, clinical documentation improvement specialists, and medical coders) and incorporating a plan‐do‐check‐adjust quality improvement model are strategies that could potentially help better define and diagnose MI, reduce financial burdens due to MI misdiagnoses, reduce cardiovascular‐related health disparities, and ultimately improve and save lives.

Education for sustainable healthcare: Leadership to get from here to there

The current global crises, including climate, COVID-19, and environmental change, requires global collective action at all scales. These broad socio-ecological challenges require the engagement of diverse perspectives and ways of knowing and the meaningful engagement of all generations and stages of personal and professional development. The combination of systems thinking, change management, quality improvement approaches and models, appreciative/strength-based approaches, narratives, storytelling and the strengths of Indigenous knowledges, offer synergies and potential that can set the stage for transformative, strengths-based education for sustainable healthcare (ESH). The need for strong leadership to enact a vision for ESH is outlined here with the intent to enable and nurture the conditions for change, ultimately improving health and well-being across generations.

A quality improvement model for the development of complex products based on data mining and mechanism analysis

ABSTRACT To improve the quality of complex products, a quality improvement model is developed in this study. An object-oriented representation is employed to express the quality problems, quality characteristics, product nodes, and causal factors of quality problems. The quality data are collected with an information system. The associations between quality problems can be identified by data mining. The mentioned associations should be explored to verify their correctness since some quality problems may occur accidentally. To deal with such a situation, quality problem mechanism analysis is proposed to determine the causality between the quality problems and the causal factors. The quality problem mechanism analysis primarily consists of the quality problem explicit mechanism analysis and the quality problem implicit mechanism analysis. The quality problem explicit mechanism analysis is adopted to determine the causes of QPs from the aspect of QCs associations. The quality problem implicit mechanism analysis is employed to determine the causes of the QPs from the aspect of manufacturing resources (e.g. man, machine, material and measurement). A case study is conducted to demonstrate the application of such quality improvement model. The associations of the QPs can be found by using the proposed model.

Development of a hub and spoke model for quality improvement in rural and urban healthcare settings in India: a pilot study

ObjectiveHub and spoke model has been used across industries to augment peripheral services by centralising key resources. This exercise evaluated the feasibility of whether such a model can be developed...

The Diamond Project: A Quality Improvement Model for Adopting Shared Service Delivery in the Washington Vaccines for Children Program.

Context: Increasing federal requirements with no change in the Centers for Disease Control and Prevention budget creates an unsustainable delivery model between states and their local counterparts for programs like Vaccines for Children (VFC).Project: The Washington State Department of Health collaborated with the Washington Association of Local Public Health Officials to identify how best to improve the quality of the VFC program.Approach: Utilizing Quality improvement and Lean Six Sigma methods, the project team was able to adopt a new shared-service delivery model to improve the quality of the VFC program in Washington State.Discussion: Through utilization of quality improvement methods and Lean methodology Washington State Department of Health identified recommendations to adopt a shared-service delivery and implemented those changes.

Oral Care with Mother's Own Milk in Sick and Preterm Neonates: A Quality Improvement Initiative.

Oral care with mother's own milk (OC-MOM) in sick and preterm neonates provides immune protection, improves feed tolerance and helps in earlier achievement of full enteral nutrition. This quality improvement (QI) initiative was undertaken when authors documented scanty awareness regarding neonatal oral care practices among care-givers in their neonatal unit. The project aimed to improve the proportion of OC-MOM in sick and preterm neonates from the baseline of 5.9% to 80%. The QI project was designed as per Point of Care Quality Improvement (POCQI) model and conducted over 6 mo (January 14,2019 to July 12, 2019). Preterm and sick term neonates on enteral fasting or gavage feeding were included. Neonates with major congenital malformation and whose MOM was not available were excluded. An OC-MOM team was formed and baseline data were collected. Flow charts and fish-bone diagrams were used to analyse the problem and identify the key issues. Mouth assessment tool (MAT) was customized and adapted as one of the outcome measures. An OC-MOM protocol was designed and implemented as a part of routine neonatal care. Four Plan-Do-Study-Act (PDSA) cycles were conducted to achieve the target. After successful implementation of OC-MOM protocol, proportion of neonates receiving OC-MOM increased to 83.3% from a baseline of 5.9% and proportion of neonates having MAT score "0" improved to 94.4% from a baseline of 24.4%. This QI initiative using POCQI model resulted in a significant and sustained improvement in the proportion of neonatal oral care with MOM using locally available resources.

Creating a Pediatric and Neonatal Pressure Injury Prevention Program When Evidence Was Sparse or Absent: A View From Here.

Pressure injuries are a common occurrence in the pediatric population, but only within the past decade has prevention intervention been developed specifically for the pediatric patient. At the time of the safety collaborative described, pressure injuries in children were considered nonexistent. A safety collaborative was formed to see if the pressure injury prevention guidelines for adults could be adapted to the pediatric patient. The PDSA (plan-do-study-act) quality improvement model was utilized. The collaborative brought forth not only prevention interventions specifically for the pediatric population, but the work also described medical device-related pressure injuries that were not being considered prior to the collaborative. Several national initiatives transpired that elevated pressure injury prevention of the pediatric population as a hospital safety concern.

Pengaruh Penegerian Madrasah Terhadap Manajemen Peningkatan Mutu Pendidikan di MAN 2 Manggarai, Nusa Tenggara Timur

The government implements private madrasa in order to improve Islamic education services. The strengthening of the existence of madrasa is inseparable from the participation of stakeholders. Especially in the fields of managerial, human resources, and infrastructure. The combination of a traditional Islamic education system with a modern Islamic education system is an appropriate alternative policy. This study aims to describe the concept of education management in the madrasa, the role of stakeholders, and the influence of madrasa enforcement on the implementation of education quality improvement in Madrasah Aliyah Negeri (MAN) 2 Manggarai, East Nusa Tenggara. This research is a case study with an interpretive or post positivistic approach. The findings of this study are the establishment of madrasa has a positive effect on the madrasah management which is more transparent, accountable, collaborative, coordinative, and while maintaining the characteristics of madrasas. Cooperative Participation Management based on religiosity become model of education quality improvement in MAN 2 Manggarai.

Review of New Model of Quality Improvement in Educational Systems

Since the turn of the new century, there have been drastic impacts from economic globalization, advances in information technology, international market competitions, and rapidly increasing local social-political demands on nearly every country in the world. Facing up these impacts and challenges, numerous education reforms have been initiated in the Asia-Pacific Region and other places. According to Cheng, the world-wide education reforms are experiencing three waves since the 1970s. The three waves of reforms are mainly based on different changes and theories of education effectiveness, and they result in the employment of different strategies and approaches to changing schools and education. This paper aims to review the characteristics and changes of quality assurance in the first and second waves and then explain why the coming initiatives for quality assurance should be moving towards the third wave which emphasizes strongly Future Quality Assurance in terms of ensuring the relevance to new education functions in the new century as well as the relevance to the new changes of education.

Tu1103 A DEEP LEARNING BASED GASTROINTESTINAL ENDOSCOPY PERFORMANCE MEASUREMENT SYSTEM IMPROVED LEISIONS DETECTION

Gastrointestinal endoscopic quality is operator-dependent. Previous studies assessing the effect of audit and feedback (A&F) to decrease variation in endoscopic quality have shown positive effects. A deep learning based endoscopic A&F system named Endo.Adm was constructed and its effect on endoscopic quality improvement was subsequently evaluated in our clinical practice. Endo.Adm system was developed using the methods of deep convolutional neural networks and deep reinforcement learning (DCNN). Endoscopists were recruited from Renmin Hospital of Wuhan University. Enrolled endoscopists were randomly assigned to groups that with or without the quality A&F of Endo.Adm. The form of A&F was a quality report card which was automatically generated by Endo.Adm. The primary end point was to ascertain if there was a difference in adenoma detection rate (ADR) in colonoscopy and gastric precancerous conditions (GPCs) detection rate before and after Endo.Adm A&F. Endo.Adm statistics cecal intubation, withdrawal time, gastroscopic inspection time and stomach photodocumentation with an accuracy of 96.33%, 91.3%, 99.0% and 91.0%, respectively. A total of 17 endoscopists were enrolled and randomised. 1587 colonoscopies and 3573 gastroscopies were analyzed in clinical trial, respectively. ADR was increased after A&F (4.3% - 10.4%, P=0.002, 95% C.I. 0.193-0.696) and endoscopists without A&F remained unchanged at 5.3%. GPCs detection rate increased in A&F group (3.9 - 7.5%, P=0.003, 95% C.I. 0.333-0.796) while no change was observed in control group. Endo.Adm A&F was associated with multifaceted improved Gastrointestinal (GI) endoscopic quality indicators. This intervention is practical to generate and implement and may serve as a standard model for quality improvement in different patient and physician groups.Gastric precancerous conditions detected on gastroscopy (as confirmed by histology) stratified by CQI and EQI endoscopists. Polyp and adenoma characteristics detected on colonoscopy (as confirmed by histology) stratified by CQI and EQI endoscopists.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

MON-118 Reducing Unnecessary Repeat HbA1c Testing in a Tertiary Academic Hospital

BackgroundGlycated hemoglobin (HbA1c) is a surrogate marker of glycemia over the preceding three months, where the last 30 days contributes to 50% of the value (1). Therefore guidelines often recommend repeating HbA1c only after 3 months in most situations (2), but repeat testing of HbA1c is often conducted earlier when not warranted (3). We aimed to conduct a Quality Improvement (QI) initiative to reduce unnecessary repeat testing of HbA1c at a large tertiary care academic hospital in Toronto, Ontario by 50% by May 2020.Methods:The Model for Improvement Quality Improvement (QI) framework was used in the design of the QI project to reduce repeat HbA1c. Problem characterization was conducted to understand root causes and iterative Plan-Do-Study-Act cycles were used to develop a change intervention. Unnecessary HbA1c tests were the primary outcome and defined as repeat HbA1c testing within 60 days; the top three specialities that ordered unnecessary HbA1c tests were targeted for education prior to implementation of the change intervention.Results:Baseline data on all HbA1c tests in 2018 revealed repeat testing in approximately 10% of 15,290 HbA1c tests, with estimated potential savings of more than $11,000 based on the provincial reimbursement rate. The top 3 ordering specialities targeted for education included Nephrology (n=410 repeat HbA1c tests), Cardiology (n=246 repeat HbA1c tests), and Endocrinology (n=136 repeat HbA1C tests). Root cause analysis revealed that providers often ordered repeat HbA1c tests due to being unaware of prior results and a knowledge gap of testing recommendations. A laboratory forced function will be implemented on December 1, 2019 to cancel any repeat HbA1c tests within 60 days and calls to the lab to add HbA1c testing will be tracked.Conclusions:Repeat HbA1c testing is frequent in hospital settings and can be an important target for QI efforts. A forced function to cancel processing of repeat HbA1c may be an appropriate QI intervention to reduce repeat testing to promote high-value care. Ongoing data analysis will be conducted to assess the impact of this intervention.References(1) Goldstein DE, Little RR, Lorenz RA, Malone JI, Nathan D, Peterson CM, Sacks DB. Tests of Glycemia in Diabetes. Diabetes Care 2004;27(7): 1761-1773.(2) Berard LD, Siemens R, Woo V. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Monitoring Glycemic Control. Can J Diabetes 2018;42(Suppl 1):S47-S53.(3) Chami N, Simons JE, Sweetman A, Don-Wauchope AC. Rates of inappropriate laboratory test utilization in Ontario. Clinical Biochemistry 2017;50: 822-827.