Quality Improvement Model Research Articles

Abstract TP483: Improving Patient Stroke Education by Acute Care Nurses

Background and Issues: Patient education is a vital component of preventing a future stroke for survivors of ischemic stroke. Each year, twenty-five percent of strokes diagnosed in the United States are secondary strokes. Hospital-based interventions in the acute phase of care post-stroke can help reduce the likelihood of secondary stroke. Teaching patients tactics for decreasing their stroke risk is one such intervention. Methods: This project utilized the Plan-Do-Check-Act (PDCA) quality improvement model. Educational in-services were conducted by the project leader on two nursing units and the float pool. An education initiative was developed using evidence based guidelines to improve nursing knowledge of patient education best-practices and the guidelines from the Centers for Medicare & Medicaid Services (CMS) & The Joint Commission regarding patient stroke education and documentation. Nursing knowledge before and after the education initiative was evaluated using a pre-test/post-test survey and nursing satisfaction with the education program was evaluated using a Likert survey. Results: Thirty-seven RNs attended the educational in-services and 27 of those completed a pre & post-test. The average improvement seen after the education was 14.7% (pre-test score 73.1%, post-test 87.8%). The RNs rated their satisfaction an average of 4.5 on a 5 point scale. There was no correlation between years of nursing experience and scores on the pre/post-test. This demonstrates the educational initiative was valuable for staff nurses regardless of unit experience. Conclusions: Increasing nursing knowledge and professional competence in delivering and documenting stroke education that is compliant with national guidelines may lead to inpatient nurses providing higher quality stroke education. Understanding risk factors for a second stroke may improve long-term health outcomes for stroke patients and potentially decrease the incidence of secondary stroke. Next steps for this initiative are integration of the education developed in this project into the new RN orientation for the units involved as well as inclusion of the information in ongoing continuing nursing education classes conducted by the clinical site.

Abstract WP388: Improvement of Adherence to Performance Measures in Patients With Acute Ischemic Stroke by Using Automatic Extraction of Electronic Medical Records: Baseline Characteristics of the Network of Shanghai Stroke Service System (4S)

Introduction: Several stroke quality control and outcome projects have demonstrated the success in improving stroke care quality through structured process. However, Chinese healthcare systems are challenged with its overwhelming numbers of patients, limited resources and large regional disparities. This study aims to Improve quality of stroke care to address regional disparities. Methods: The Shanghai Stroke Service System (4S) was established as a regional network for stroke care quality improvement in Shanghai. The 4S registry uses a web-based database that automatically extracts data from structured electronic medical records. Thirty-six hospitals including 10 regional stroke centers and 25 district stroke centers. Registry began enrolling all patients with diagnosed acute ischemic stroke (AIS) in 2017. Primary outcome is to evaluate the differences in quality metrics performance before and after the implementation structured quality improvement process. Results: Among 14461 patients with AIS registered, patient’s average age was 73 years old with 4958 women (34.2%) in 2017. Compared to the data from the previous registry, web-based database enrolled more patients (3175 in 2014, 4815 in 2015, 12387 in 2016, p<0.001). With the best use of resource(Table1), AIS patients in 4S were more likely to receive performance measures than those of previous registry (composite measure 83%, Figure 1A). A trend of gradually decreased hospital mortality and rate of unplanned re-admission within 30 days was observed in 4S hospitals (Figure 1B). Conclusions: The study has helped to identify areas stroke care deficiencies and improvement. Despite of challenges of healthcare in China, 4S proved the feasibility and potentially effective as a regional stroke network model for quality improvement. This model could be duplicated at other large cities or regions in China. Clinicaltrials.gov Identifier NCT02735226

Implementation of an Evidence-Based, Nurse-Driven Sepsis Protocol to Reduce Acute Care Transfer Readmissions in the Inpatient Rehabilitation Facility Setting.

The aim of this study was to determine if implementing an evidence-based, nurse-driven sepsis protocol would reduce acute care transfer (ACT) readmissions from an inpatient rehabilitation facility compared to nonprotocolized or usual standard of care for adult sepsis patients undergoing physical rehabilitation. This study used a preintervention and postintervention model for quality improvement, which involved comparing the nonprotocolized care of adult sepsis patients in the inpatient rehabilitation population to the application of an evidence-based, nurse-driven sepsis protocol to determine its effect on reducing ACT readmissions. Patients who screened positive for suspected sepsis and received protocolized interventions were analyzed to determine the occurrence of ACT readmission. Compliance with protocol elements was also evaluated. The sepsis-related ACT readmission rate decreased from 36.28% to 25% in 8 weeks, and compliance with protocolized sepsis interventions increased. Nurse-driven, protocolized assessment and treatment can improve the management and care of sepsis patients undergoing physical rehabilitation and can reduce ACT readmissions. This review provides rehabilitation nurses an evidence-based, nurse-driven approach to the clinical management of sepsis patients in the inpatient rehabilitation setting and discusses how this approach can reduce ACT readmissions and improve clinical outcomes.

System dynamics model for service quality improvement: a case study of Surakarta tourism, Indonesia

System dynamics model for service quality improvement: a case study of Surakarta tourism, Indonesia

System dynamics model for service quality improvement: a case study of Surakarta tourism, Indonesia

Value co-creation concept implies that customers can actively participate in every stage of the service development process. Service providers are encouraged to build a unique and memorable experience to remain competitive. The concept is applicable in tourism settings. This study adopts system dynamics approach to study the conditions of tourism in Surakarta City, Indonesia. This study incorporates SERVQUAL dimensions of tangibility, reliability, responsiveness assurance and empathy to construct a co-created tourism policy in the city. There are five interventions proposed in the study: infrastructure, platform, human resource, events and promotions. The study reveals that to increase the number of tourists, Surakarta city is urged to invest bigger in the transportation sector and perform interactive online platform to accommodate a co-creation among stakeholders in the tourism sector. This study proposes alternatives to help the decision maker to understand the complexity of tourism sector in Surakarta both in theory and practice.

Managers' perceptions of the effects of a national mandatory accreditation program in Danish hospitals. A cross-sectional survey.

This study aimed to examine and compare middle and senior hospital managers' perceptions of the effects of a mandatory accreditation program in Denmark, the Danish Healthcare Quality Program (Den Danske Kvalitetsmodel [DDKM]) after it was terminated in 2015. A cross-sectional online questionnaire survey. All 26 somatic and psychiatric public hospitals in Denmark. All senior and middle managers. A questionnaire with open and closed response (five-point Likert scale) questions. Quantitative data were analyzed descriptively and through ordered logistic regression by management level. Qualitative data were subjected to a software-assisted content analysis. The response rate was 49% (533/1059). In both the qualitative and quantitative data sets, participants perceived the DDKM as having: led to an increased focus on registration, documentation and additional and unnecessary procedures. While the DDKM was perceived as increasing a focus on quality, the time required for accreditation was at the expense of patient care. There were significant differences by management level, with middle managers having more negative perceptions of the DDKM related to time spent on documentation and registration. While the DDKM had some perceived benefits for quality improvement, it was ultimately considered time-consuming and outdated or having served its purpose. Including managers, particularly middle managers, in refinements to the new quality improvement model could capitalize on the benefits while redressing the problems with the terminated accreditation program.

EPIDEM: A Model for Quality Improvement.

Existing quality improvement (QI) models have been used with varied success in health care. We developed the EPIDEM Model of Quality Improvement to apply QI principles to health care and promote a widespread culture of quality and patient safety. The EPIDEM acronym can be used to teach and remember the steps of process improvement: explore relevant issues and contextual factors, promote to the right people, implement timely solutions, document steps, evaluate with meaningful measures, and make modifications to improve interventions further. The EPIDEM model requires no previous QI training and can be used in conjunction with other QI tools. Our model uniquely emphasizes understanding local context, culture, and resources throughout the QI process. We hope that this new QI model will help facilitate an "EPIDEMic" of healthcare QI for our institution and others by providing a foundational framework to successfully implement QI initiatives.

A quality improvement project to improve pediatric medical provider sleep and communication during night shifts.

Night-shift medical providers frequently experience limited sleep resulting in fatigue, often because of paging activity. Streamlined medical-specific communication interventions are known to improve sleep and communication among these providers. We found that non-urgent paging communication occurred frequently during night-shifts, leading to provider sleep disturbances within our institution. We tested a quality improvement (QI) intervention to improve paging practices and determined its effect on provider sleep. We used a Plan-Do-Study-Act QI model aimed at improving clinician sleep and paging communications. We initially conducted focus groups of nurses and physician trainees to inform the creation of a standardized paging intervention. We collected actigraphy and sleep log data from physicians, nurse practitioners, and physician trainees and performed electronic collection of paging frequency data. Data were collected between December 2015 and March 2017 from pediatric residents, pediatric hematology/oncology (PHO) fellows, hospitalist medicine nocturnists and nurses working during night-shift hours in PHO inpatient units. We collected baseline data before implementation of the QI intervention and at 1 month post-implementation. Although objective measures and provider reports demonstrated improved medical-specific communication paging practices, provider sleep was not affected. Provider-based standardization of paging communication was associated with improved medical-specific communication between nurses and providers; however, provider sleep was not affected. The strategies used in this intervention may be transferable to other clinics and institutions to streamline medical-specific communication.

A System-Level Approach to Improve HIV Screening in an Urban Pediatric Primary Care Setting

Less than 50% of youth living with HIV know their status. The Centers for Disease Control and Prevention and the United States Preventive Services Task Force recommend universal HIV screening in adolescence. Pediatric primary care settings are still lacking in testing youth who are at risk for HIV. Our objective was to determine whether implementing rapid HIV screening improved HIV screening rates and result receipt in 13- to 25-year-old pediatric primary patients. From March 2014 to June 2015, a 4-cycle plan-do-study-act quality improvement model was used. A total of 4433 patients aged 13 to 25 years were eligible for HIV screening on the basis of Centers for Disease Control and Prevention criteria. Logistic regression with random effects was used to estimate the odds of HIV screening and screening with a rapid test compared with each previous cycle. Statistical process control charts using standard interpretation rules assessed the effect of patients receiving rapid HIV screening. Baseline HIV screening rate was 29.6%; it increased to 82.7% in cycle 4. The odds of HIV screening increased 31% between cycle 1 and baseline (odds ratio 1.31 [95% confidence interval: 1.01-1.69]) to a 1272% increase between cycle 4 and baseline (odds ratio 12.72 [95% confidence interval: 10.45-15.48]), with most (90.4%) via rapid screening. Rapid screening yielded higher same-day result receipt . Five patients were identified with HIV and immediately linked to on-site care. Rapid HIV screening and system-level modifications significantly increased screening rates and result receipt, revealing this to be an effective method to deliver HIV services to youth.

Development and Implementation of Core Competencies for Integrated Care Community Health Teams: a UK experience

Introduction: UK Integrated community care teams ICCT have been encouraged by policy initiatives and legislation 1, 2 to establish and provide better methods of integrating care IC across health and social care; reducing duplication of provision, improving efficiency and service experiences 3. A UK IC partnership identified the need for a set of core competencies for ICCT. This team supports people in their community to develop independence and self-management skills, and offers diverse health and social care input to improved mental and physical health. An initial literature review indicated few UK publications about ICCT competencies. Practice Change Implemented: Implementation of core professional competencies for ICCT. Aim and Theory of Change: The project is based upon the quality improvement model of Plan Do Study Act 4. Targeted Population and Stakeholders: The population served by the ICCT have complex multiple mental and physical health and social care needs. Stakeholder within the project included service users, ICCT including care navigators, nurses, OT's, psychologists, physiotherapists, and social worker and and the health and social care partnership organisations. Highlights: Core competencies for ICCT were developed through review of the international literature, telephone interviews with the stakeholders, analysis of international competency guidance and job descriptions/ competencies for all professional groups within the ICCT. The competencies were revised through focus groups and piloted with the ICCT. Feedback on the competencies was obtained. Principles from the international competency documents on integrated care were combined to produce a UK ICCT core competency document. ICCT found potential utilisation across the professionals and at all levels. ICCT found them useful in considering their collective understanding of IC and in facilitating their understanding of other professionals' roles within the ICCT. ICCT could see the value of them in assessing and developing their IC competence. Comments on Sustainability: The development led to a document containing eight core competency themes. The PDSA model requires continued adoption and adaptation the ICCT core competencies. Comments on Transferability: The competencies should be transferable and adaptable across the UK utilisng the PDSA model. Due to the incorporation of the published international competencies for integrated care the ICCT core competencies may have use internationally. Conclusion: Identification of ICCT Core Competencies that were acceptable to a wide range of professionals was possible. A variety of practical usages were identified. The ICCT Core Competencies have national and international potential. Lessons Learned: Wider evaluation of this primary care service improvement initiative is required. Gaining a shared understanding of ICCT is key to efficient working.

Using the Plan-Do-Study-Act Quality Improvement Model to Provide Dental Hygiene Care for Youth with Type 2 Diabetes

Using the Plan-Do-Study-Act Quality Improvement Model to Provide Dental Hygiene Care for Youth with Type 2 Diabetes

Using the EPIDEM Model of Quality Improvement to Increase Value of BCR-ABL1 Tests.

As pathologists and laboratorians, we can enhance patient care by promoting the appropriate ordering of diagnostic tests. Our goal was to improve the ordering of BCR-ABL1 tests by using the EPIDEM model of quality improvement. We applied the EPIDEM model, which emphasizes understanding local context, culture, and resources, to explore inappropriate BCR-ABL1 ordering, promote and implement a new reflexive testing strategy in-house, document and evaluate effectiveness, and make stepwise modifications. Multiple quality improvement interventions correlated with cost savings and decreased total errors and incorrect orders for both BCR-ABL1 major and minor positive patients. Furthermore, our laboratory built stronger collaborative relationships with colleagues within and outside of pathology. Our molecular pathology laboratory successfully used the EPIDEM model of quality improvement to improve the ordering of BCR-ABL1 tests and promote better patient care by focusing on educational efforts and modification of laboratory workflow.

The Acute Care for Elders Unit Model of Care.

Older patients are at risk for loss of self-care abilities during the course of an acute medical illness that results in hospitalization. The Acute Care for Elders (ACE) Unit is a continuous quality improvement model of care designed to prevent the patient’s loss of independence from admission to discharge in the performance of activities of daily living (hospital-associated disability). The ACE unit intervention includes principles of a prepared environment that encourages safe patient self-care, a set of clinical guidelines for bedside care by nurses and other health professionals to prevent patient disability and restore self-care lost by the acute illness, and planning for transitions of care and medical care. By applying a structured process, an interdisciplinary team completes a geriatric assessment, follows clinical guidelines, and initiates plans for care transitions in concert with the patient and family. Three randomized clinical trials and systematic reviews of ACE or related interventions demonstrate reduced functional disability among patients, reduced risk of nursing home admission, and lower costs of hospitalization. ACE principles could improve elderly care in any acute setting. The aim of this commentary is to describe the ACE model and the basis of its effectiveness.

Overview of quality management models for inpatient healthcare settings. A scoping review.

This scoping review aimed to generate an overview of existing quality management (QM) models for inpatient healthcare published in peer-reviewed literature. Peer-reviewed publications published until June 2016 were retrieved from the databases Medline, PubMed, CINAHL and Cochrane Library using search terms related to QM and models. Publications mentioning a QM model for general application in healthcare or inpatient care in their title or abstract were included. Languages considered were: English, French, German, Italian and Spanish. Data extraction was 3-fold. First, publication characteristics were summarized. Second, the frequency of each identified model was documented and the publications were divided into conceptual and implementation publications. Third, relevant QM models were identified and information regarding the model, including content and relationship with other models, was extracted. Of 925 retrieved publications, 213 were included. The included publications reported on 64 different QM models that were suitable for or used in inpatient care. Seventeen models were identified as being relevant. The 17 models were then categorized into three different levels: conceptual quality improvement models, concrete application models and country specific adaptations. This scoping review provides an overview of 17 existing QM models for inpatient care and their relationships with each other. Various types of models with differing aspects and components exist. In searching for QM models, many different concepts like QM system, accreditation or methodologies appeared. For future investigation, concepts of interest should be clarified.

Using the Plan-Do-Study-Act (PDSA) Model for Continuous Quality Improvement of an Established Simulated Patient Program.

To describe the use of a continuous quality improvement process for strengthening our simulated patient (SP) program and the initial steps that have been implemented. A workgroup that included five clinical faculty with significant experience working with SPs and a strong interest in improving the SP program was developed. The Plan-Do-Study-Act model was used as it allowed for incremental quality improvement changes, in order to ensure a high-quality SP program designed to optimize student learning. Data were gathered from students, SPs, and faculty. Opportunities for improvement were prioritized based on anticipated benefits and available resources. Changes related to planning, implementation, and evaluation and feedback have been executed. Changes related to planning that were implemented included developing handbooks for SPs, faculty, and graduate student instructors, as well as material for students in order to better describe the program. SPs are now referred to as "simulated" as opposed to "standardized" as part of a broader effort to clarify the purpose of SP interactions to students. Streamlined rubrics have been piloted, including electronic rubrics for first year students. SPs are being trained on fewer cases, in order to improve the training program. When possible, activities now take place in one large classroom instead of many small classrooms to improve oversight. Finally, additional feedback has been obtained from SPs via a retreat. These changes have been well received by students, SPs, and faculty. The collection of this data and initial quality improvement changes provided a basis for hiring a full-time employee who will: dedicate 50% of their time to programmatic assessment of the SP program, support faculty with logistics and training, and be the face of our program to the students and SPs. Further, formal quantitative and qualitative assessment of the SP program has begun.

Lessons Learned and Future Directions: CLER National Report of Findings 2018.

Lessons Learned and Future Directions: CLER National Report of Findings 2018.

Qualitative Evaluation of a Complex Intervention to Improve Rheumatic Heart Disease Secondary Prophylaxis.

BackgroundRheumatic heart disease is a high‐burden condition in Australian Aboriginal communities. We evaluated a stepped‐wedge, community, randomized trial at 10 Aboriginal communities from 2013 to 2015. A multifaceted intervention was implemented using quality improvement and chronic care model approaches to improve delivery of penicillin prophylaxis for rheumatic heart disease. The trial did not improve penicillin adherence. This mixed‐methods evaluation, designed a priori, aimed to determine the association between methodological approaches and outcomes.Methods and ResultsAn evaluation framework was developed to measure the success of project implementation and of the underlying program theory. The program theory posited that penicillin delivery would be improved through activities implemented at clinics that addressed elements of the chronic care model. Qualitative data were derived from interviews with health‐center staff, informants, and clients; participant observation; and project officer reports. Quantitative data comprised numbers and types of “action items,” which were developed by participating clinic staff with project officers to improve delivery of penicillin injections. Interview data from 121 health‐center staff, 22 informants, and 72 clients revealed barriers to achieving the trial's aims, including project‐level factors (short trial duration), implementation factors (types of activities implemented), and contextual factors (high staff turnover and the complex sociocultural environment). Insufficient actions were implemented addressing “self‐management support” and “community linkage” streams of the chronic care model. Increased momentum was evident in later stages of the study.ConclusionsThe program theory underpinning the study was sound. The limited impact made by the study on adherence was attributable to complex implementation challenges.

A Collaborative Model for Facilitating the Delivery of Smoking Cessation Treatments to Cancer Patients: Results From Three Oncology Practices in South Carolina

Introduction: Continued smoking by cancer patients causes adverse cancer treatment outcomes, but few patients receive evidence-based smoking cessation as a standard of care.Aim: To evaluate practical strategies to promote wide-scale dissemination and implementation of evidence-based tobacco cessation services within state cancer centers.Methods: A Collaborative Learning Model (CLM) for Quality Improvement was evaluated with three community oncology practices to identify barriers and facilitate practice change to deliver evidence-based smoking cessation treatments to cancer patients using standardized assessments and referrals to statewide smoking cessation resources. Patients were enrolled and tracked through an automated data system and received follow-up cessation support post-enrollment. Monthly quantitative reports and qualitative data gathered through interviews and collaborative learning sessions were used to evaluate meaningful quality improvement changes in each cancer center.Results: Baseline practice evaluation for the CLM identified the lack of tobacco use documentation, awareness of cessation guidelines, and awareness of services for patients as common barriers. Implementation of a structured assessment and referral process demonstrated that of 1,632 newly registered cancer patients,1,581 (97%) were screened for tobacco use. Among those screened, 283 (18%) were found to be tobacco users. Of identified tobacco users, 207 (73%) were advised to quit. Referral of new patients who reported using tobacco to an evidence-based cessation program increased from 0% at baseline across all three cancer centers to 64% (range = 30%–89%) during the project period.Conclusions: Implementation of quality improvement learning collaborative models can dramatically improve delivery of guideline-based tobacco cessation treatments to cancer patients.

Uses and Limitations of Claims-based Performance Feedback Reports: Lessons From the Comprehensive Primary Care Initiative.

Performance feedback is central to data-driven models of quality improvement, but the use of claims-based data for feedback has received little attention. To examine the challenges, uses, and limitations of quarterly Medicare claims-based performance feedback reports generated for practices participating in the Comprehensive Primary Care (CPC) initiative from 2012 to 2015. Mixed methods study of nearly 500 CPC practices in seven regions, combining pilot testing; systematic monitoring; surveys; in-depth interviews; user feedback; and input from data feedback team. Designing reports required addressing issues about timing, data completeness and reliability, variations in patient risk across practices, and use of benchmarks and metrics understandable to users. Practices' ability to use reports constructively depended on their experience, analytic resources, expectations, and perceptions about the role of primary care in improving reported outcomes. Generating claims-based feedback reports that support practices' quality improvement efforts requires a significant investment of analytic expertise, time, resources, continuous improvement, and technical assistance. Claims-based performance feedback can provide insight into patterns of patients' care across provider settings and opportunities for improvement, but practices need data from other sources to manage patients in real time or assess the short-term effects of specific changes in care delivery.

Improving Diabetes Outcomes in Rural Dominican Republic

The Dominican Republic (DR) is a Caribbean country of 10 million with estimated diabetes prevalence at ∼11%. While the public health system has a diabetes program, there are few reliable surveillance data to portray diabetes outcomes in the DR. The HbA1c is not a widely available test for metabolic control in the DR. In 2010, a non-profit group, Chronic Care International (CCI), began a diabetes and hypertension program with 2 clinics in poor, rural DR. CCI developed a model of quality improvement for care and self-management with its Dominican medical team, including doctors, nurses and community health workers. We present process and outcome data collected over 6 years utilizing electronic medical records. In addition to quality improvement analyses, we fit a random-effects linear model to the data to assess trends over time. By May 2017, subjects (N=1,031) were adults: mean age 60.1 years, 45% men, 74% with T2DM. Of those with diabetes (n=758), 76% had an HbA1c <9%, with 86% having had an HbA1c test done in the last 4 mos. Of 650 with hypertension, 64% had a BP < 140/90mmHg. In assessing trends over time, we found the modeled HbA1c trajectory for those with diabetes showed an average decline of 0.13 percentage points per year (95% CI 0.10-0.15) over 6 years. The modeled BMI trajectory for all subjects showed an average decline of 0.kg/m2 per year (95% CI 0.04-0.08) over 6 years. For those with a dx of hypertension, the modeled BP trajectories are biphasic, showing decreases over years 1 and 2, followed by increases. Systolic BP averaged a decline of 3.5mmHg (95% CI 3.0-4.0) per year, followed by an average increase of 1.7mmHg (95% CI 1.3-2.1) per year. Diastolic BP averaged a decline of 2.4mmHg (95% CI 2.1-2.7) per year, followed by an increase of 0.27mmHg (95% CI 0.03-0.5) per year. While decline trends in HbA1c and BMI are encouraging for this model of care in rural areas of this developing country, some challenges in managing BP remain, even with access to several antihypertensive medications. Program sustainability and access to healthy food and exercise are DR priorities. Disclosure E.A. Walker: None. H.J. Dethlefs: None. R.A. Dowd: None. C. Schechter: None. C. Filipi: None.