Opportunities For Practice Improvement Research Articles

A critical reflection on process of a collaborative inquiry in a mental health service

Collaborative inquiry involves a group of people in iterative examination of a shared experience, action to address identified concerns, and reflection. We describe our attempt to conduct a collaborative inquiry into the roles and experiences of health professionals designated as recovery champions within a mental health service. Our linked goals were to work with champions to support the desired shift in approach to care and implementation of recovery practices, and to gather data to develop our own understanding of the service culture. The inquiry opened up a communicative space in which robust discussion elucidated the complexities of implementing ‘recovery’ within a highly governed and scrutinised environment. Numerous problems and some opportunities for practice improvement were identified but with too little time and emotional space to engender group identity and work through ambiguity inherent in collaborative inquiry, no actions were implemented. However, champions came to appreciate substantial progress made and understand the service as one ‘in recovery’. They developed a sense of themselves as agents of change and agreed to continue the process independently. Review of the process sheds light on successes and limitations, drawing attention to the importance of context and realistic planning when considering such an inquiry.

Potential pitfalls of binary reporting metrics using a QOPI end-of-life (EOL) sample.

261 Background: Practice accountability through measurement is emergent in the United States. The National Quality Forum has adopted several EOL metrics as national standards. Care at EOL is highly variable due to patient and family preference, symptom management, and psychosocial care. We hypothesize binary measures with fixed cut-points limit the understanding of EOL practice thus reducing opportunities for care improvement. Methods: We previously demonstrated limitations of the QOPI sampling methodology among all patients at Dana-Farber Cancer Institute Satellites following the QOPI sampling strategy between July 1, 2012 and December 31, 2012. Using the same population, we examined the distribution of chemotherapy administration in the last two weeks of life. We compared our QOPI EOL data (A) with simulated scenarios modeled via log-normal distributions (B, C, D, E). The binary metric was held constant at the observed proportion to illustrate potential variability in other statistical metrics. Results: A total of 193 patients received chemotherapy before death. Chemotherapy administration in the last two weeks of life was measured at 11%, with a mean of 84 days (inter-quartile range, IQR: 92 days). Different distributions were generated by varying the mean and SD as demonstrated in the table below. Conclusions: As our simulated scenarios show, practices disseminating the same binary metric may stem from very different distributions. We have identified two limitations of binary reporting metrics with fixed cut-points. First, binary metrics risk misrepresenting actual delivered care as substantially different practice patterns can result in the same binary result. Second, binary metrics greatly limit the ability to learn from actual practice patterns. Quality improvement projects may be wrongly prioritized based on the national standards and project focus may be misaligned with practice need. EOL care is multifaceted and nuanced; binary metrics are convenient, but may be misleading to practice accountability and limit opportunities for practice improvement. [Table: see text]

Sa1034 Mixed Cryoglobulinemia Arising After Liver Transplantation

between vitamin D and PTH at 4-months post-LT (r: -0.26, P=0.019), while there was a trend toward an association between PTH at evaluation and MELD score at listing for LT (P=0.051). Conclusion: Vitamin D deficiency, in particular moderate-severe deficiency, was very prevalent in a cohort of patients undergoing evaluation for LT. Deficiency was improved with increased vitamin D (>400,00 IU) replacement therapy, indicating an opportunity for practice improvement. Vitamin D deficiency at LT was not associated with worse bone or functional outcomes post-LT. Patients receiving induction immunosuppressant therapy with basiliximab had a significantly greater degree of worsening in BMD post-LT. Table 1: Prevalence of Vitamin D Deficiency

Same-day cancellation of cardiac surgery: A retrospective review at a large academic tertiary referral center

Same-day cancellations of cardiac surgery are unfortunate and costly occurrences that potentially place patients at risk of adverse events. We retrospectively reviewed all same-day cancellations of cardiac operations requiring cardiopulmonary bypass from 2010 to 2012 at a large academic tertiary referral center. Of 7081 cardiac operations, 134 patients experienced 142 same-day cancellations of cardiac surgery. The foreseeable cancellation causes comprised 17% of cancellations, nonforeseeable 59%, and indeterminate 24%. The reasons for cancellation were medical (51%), administrative or scheduling (17%), unknown (12%), procedure no longer required (11%), patient cancellation (6%), and preincisional complication (3%). The mean interval from the patient seeing a nonsurgeon provider to cancellation was 8.6 ± 16.2 days. No statistically significant differences existed between the foreseeable and nonforeseeable cancellations and the timing of the visit to a nonsurgeon provider (15, 30, 45, and 60 days) before cancellation. Seven patients (5%) had died within 30 days of cancellation. Of those subsequently operated on, the mean interval from cancellation to performance of the operation was 12.2 ± 22.7 days. Of the 142 cancelled surgical procedures, 28 (20%) were never subsequently performed. Same-day cancellation of cardiac surgery occurred infrequently (2% of cardiac operations performed) at our institution. The cancellations were for foreseeable causes in a few cases. Seeing a nonsurgeon provider more recently before cancellation was not significantly associated with nonforeseeable versus foreseeable cancellations. Although uncommon at our institution, same-day cancellations should be viewed as an opportunity for practice improvement, given the foreseeable nature of some cancelations, associated 30-day mortality, and portion of patients not subsequently undergoing cardiac surgery.

Evaluation of Nurse Engagement in Evidence-Based Practice

The purpose of this project was to explore nurses' willingness to question and change practice. Nurses were invited to report practice improvement opportunities, and participants were supported through the process of a practice change. The project leader engaged to the extent desired by the participant. Meetings proceeded until the participant no longer wished to continue, progress was blocked, or practice was changed. Evaluation of the evidence-based practice change process occurred. Fifteen nurses reported 23 practice improvement opportunities. The majority (12 of 15) preferred to have the project leader review the evidence. Fourteen projects changed practice; 4 were presented at conferences. Multiple barriers were identified throughout the process and included loss of momentum, the proposed change involved other disciplines, and low level or controversial evidence. Practice issues were linked to quality metrics, cost of care, patient satisfaction, regulatory compliance, and patient safety. Active engagement by nurse leaders was needed for a practice change to occur. Participants identified important problems previously unknown to hospital administrators. The majority of nurses preferred involvement in practice change based on clinical problem solving when supported by others to provide literature review and manage the process through committees. Recommendations include supporting a culture that encourages employees to report practice improvement opportunities and provide resources to assist in navigating the identified practice change.

Evaluation of Nurse Engagement in Evidence-Based Practice

The purpose of this project was to explore nurses’ willingness to question and change practice. Nurses were invited to report practice improvement opportunities, and participants were supported through the process of a practice change. The project leader engaged to the extent desired by the participant. Meetings proceeded until the participant no longer wished to continue, progress was blocked, or practice was changed. Evaluation of the evidence-based practice change process occurred. Fifteen nurses reported 23 practice improvement opportunities. The majority (12 of 15) preferred to have the project leader review the evidence. Fourteen projects changed practice; 4 were presented at conferences. Multiple barriers were identified throughout the process and included loss of momentum, the proposed change involved other disciplines, and low level or controversial evidence. Practice issues were linked to quality metrics, cost of care, patient satisfaction, regulatory compliance, and patient safety. Active engagement by nurse leaders was needed for a practice change to occur. Participants identified important problems previously unknown to hospital administrators. The majority of nurses preferred involvement in practice change based on clinical problem solving when supported by others to provide literature review and manage the process through committees. Recommendations include supporting a culture that encourages employees to report practice improvement opportunities and provide resources to assist in navigating the identified practice change.

Low-Grade Squamous Intraepithelial Lesion, Cannot Exclude High-Grade Squamous Intraepithelial Lesion

"Low-grade squamous intraepithelial lesion (LSIL), cannot exclude high-grade squamous intraepithelial lesion" (LSIL-H) is an increasingly used, equivocal interpretive category in gynecologic cytology. In an effort to evaluate its potential usefulness as a measure of quality assurance, we studied patterns of use of the LSIL-H diagnosis compared with "LSIL" and "high-grade squamous intraepithelial lesion" (HSIL) with corresponding histologic outcomes for 10 cytopathologists in our practice. In our laboratory, while the overall rate of associated cervical intraepithelial neoplasia 2 or greater on histologic follow-up for LSIL-H was intermediate between that of LSIL and HSIL, the outcomes for individual cytopathologists varied widely. Monitoring this particular utilization-outcome data with periodic confidential feedback to individual cytopathologists offers an opportunity for practice improvement within a laboratory and serves as an additional measure of quality assurance. These data may be useful for establishing and/or realigning the diagnostic criteria for this equivocal cytologic interpretation endorsed by a pathology practice.

Precepting and symbolic interactionism – a theoretical look at preceptorship during clinical practice

To present a discussion of precepting through the use of symbolic interactionism as exemplified by findings from an ethnographic study. It is a well-known fact that clinical practice, where students are supervised by precepting nurses, is an important part of nursing education. Several previous studies have stressed the vital role preceptors have for the development of student nurses' clinical competence. Despite this, few of these findings are discussed from a theoretical standpoint to further explain and illustrate the complexity of preceptorship. This article builds on findings from an ethnographic study undertaken between November 2006-May 2007 and again between March-September 2009. Full details of the empirical findings have been reported elsewhere. Precepting can be understood as a trusting relationship between preceptor and student interacting and sharing nursing activities. The participants' actions will influence and shape the meaning and understanding of these activities. Precepting is a complex and advanced role for nurses that they need to be properly prepared for. Thus, preceptor preparation needs to be organized in collaboration between healthcare organizations and universities. It is suggested that preceptor preparation programmes should focus on reflection, critical thinking and communication skills. Symbolic interactionism can serve as a potential theory that will expand the understanding of and give new perspectives of nursing practice. It would therefore be encouraging to see further testing of suitable theories to interpret empirical findings and create opportunities for practice improvement.

Review of a Fluid Resuscitation Protocol

Recent reviews of burn resuscitation have included the suggestion that "fluid creep" may be influenced by practitioner error. Our center uses a nursing-driven resuscitation protocol that permits titration of fluid based on hourly urine output, including the addition of colloid when patients fail to respond appropriately. The purpose of this study was to examine protocol compliance. We reviewed 140 patients (26 children) with burns of ≥20% TBSA who received protocol-directed resuscitation from 2005 to 2010. We compared each patient's actual hourly fluid infusion with that predicted by the protocol. Sixty-seven patients (48%) completed resuscitation using crystalloid alone, whereas 73 patients required colloid supplementation. Groups did not differ in age, gender, weight, or time from injury to admission. Patients requiring colloid had larger median total burns (33.0 vs 23.5% TBSA) and full-thickness burns (15.5 vs 4.5% TBSA) and more inhalation injuries (60.3 vs 28.4%; P < .001) than those who resuscitated with crystalloid alone. Because we included basic maintenance fluids in their regimen, patients had median predicted requirements of 5.4 ml/kg/%TBSA. Crystalloid-only patients required fluid volumes close to Parkland predictions (4.7 ml/kg/%TBSA), whereas patients who received colloid required more fluid than the predicted volume (7.5 ml/kg/%TBSA). However, the hourly difference between the predicted and received fluids was a median of only 1.0% (interquartile range: -6.1 to 11.1%) and did not differ between groups. Pediatric patients had greater calculated differences than adults. Crystalloid patients exhibited higher urine outputs than colloid patients until colloid was started, suggesting that early over-resuscitation did not contribute to fluid creep. Adherence to our protocol for burn shock resuscitation was excellent overall. Fluid creep exhibited by more seriously injured patients was not due to nurses' failure to follow the protocol. This review has illuminated some opportunities for practice improvement, possibly using a computerized decision support system.

A Preliminary Study of Staff Meetings as Viewed by Dental Hygienists

Staff meetings in general dental practices represent what is believed to be a key management strategy to build teams and to enhance efficiency and effectiveness. However, very little research has been done regarding staff meetings in dental offices. This study examined staff meetings from the viewpoint of dental hygienists who grow in unique careers in that they work largely independently of the dentist and yet typically within a dental practice while providing patient care and education. One-hundred-six dental hygienists completed a survey about staff meetings in dental offices. Key findings include: only approximately 43% of dental offices conduct morning huddles to get the day off to a smooth and organized start, 72% of dental practices conduct longer staff meetings with largely positive outcomes, including increasing practice efficiency and productivity, few practices (12%) hold specific meetings only for the hygiene-department (and probably thereby miss some opportunities for practice improvement), the most important variable by far to hygienists' job satisfaction is respect from the owner-dentist, and there exists an important and synergistic relationship among job satisfaction, relationships with other staff and relationship with the owner-dentist.

Relationship between critical reflection and quality improvement proposal scores in resident doctors

transformative learning theory supports the idea that reflection on quality improvement (QI) opportunities and the ability to develop successful QI projects may be fundamentally linked. We used validated methods to explore associations between resident doctors' reflections on QI opportunities and the quality of their QI project proposals. eighty-six residents completed written reflections on practice improvement opportunities and developed QI proposals. Two faculty members assessed residents' reflections using the 18-item Mayo Evaluation of Reflection on Improvement Tool (MERIT), and assessed residents' QI proposals using the seven-item Quality Improvement Project Assessment Tool (QIPAT-7). Both instruments have been validated in previous work. Associations between MERIT and QIPAT-7 scores were determined. Internal consistency reliabilities of QIPAT-7 and MERIT scores were calculated. there were no significant associations between MERIT overall and domain scores, and QIPAT-7 overall and item scores. The internal consistency of MERIT and QIPAT-7 item groups were acceptable (Cronbach's α 0.76-0.94). the lack of association between MERIT and QIPAT-7 scores indicates a distinction between resident doctors' skills at reflection on QI opportunities and their abilities to develop QI projects. These findings suggest that practice-based reflection and QI project development are separate constructs, and that skilful reflection may not predict the ability to design meaningful QI initiatives. Future QI curricula should consider teaching and assessing QI reflection and project development as distinct components.

Managing the adverse event occurring during elective, ambulatory pediatric surgery

Adverse medical events occurring in the context of care of children undergoing elective surgical procedures are usually truly unexpected occurrences with the potential for long-term consequences. Such events, when they occur, are obviously devastating to the patient and family, but frequently also to the pediatric surgeon and his/her team. When such events occur, it is important to ensure uninterrupted care of the patient, a full disclosure of events leading to harm, and an ongoing accessibility to the family for disclosure of new information as it becomes available. Finally, it is important that the adverse event be systematically reviewed as a "critical incident," so that opportunities for practice improvement leading to enhanced patient safety can be realized and compliance with new care standards monitored through ongoing quality assurance.

The Radiology Report of the Future: A Summary of the 2007 Intersociety Conference

A radiology report is the official record documenting the contribution of a radiologist to a patient's care. The use of structured reports and a common lexicon will help referring physicians better understand the contents of reports. These same features in electronic health records will enable radiologists to mine reports for utilization management information as well as form the basis for clinical investigations.

Spirometry Utilization for COPD: How Do We Measure Up?

<h3>Background</h3> COPD is a significant cause of morbidity and mortality. Guidelines recommend the confirmation of a COPD diagnosis with spirometry. Limited evidence exists, however, documenting the frequency of spirometry use in clinical practice. <h3>Methods</h3> The National Committee for Quality Assurance recruited five health plans to determine the proportion of patients ≥ 40 years old with a new diagnosis of COPD who had received spirometry during the interval starting 720 days prior to diagnosis and ending 180 days after diagnosis. Patients were identified via International Classification of Diseases, Ninth Revision diagnostic codes for encounters during the period July 1, 2002, through June 30, 2003. For each patient, the participating plans provided patient demographic and claims data from administrative data systems. <h3>Results</h3> Participating health plans covered 1,597,749 members with a total of 5,039 eligible COPD patients identified. Patients in the 40 to 64 age range had the highest percentage of new COPD diagnoses. Women were also slightly more likely to undergo spirometry (33.5% vs 29.4%, p=0.001). Approximately 32% of patients with a new diagnosis of COPD had undergone spirometry in the specified interval. Spirometry frequency was lowest in older patients, with the lowest frequency in those ≥ 75 years old. <h3>Conclusions</h3> Our study suggests that approximately 32% of a broad range of patients with a new COPD diagnosis had undergone spirometry within the previous 2 years to 6 months following diagnosis. In addition, spirometric testing appeared to decrease with increasing age. As opposed to a prior report, women were not less likely to have undergone spirometry. This study shows that spirometry is infrequently used in clinical practice for diagnosis of COPD and suggests opportunities for practice improvement.

Evaluation of a Weight‐Based Heparin Dosing Protocol

ABSTRACTAimTo describe the anticoagulant effect, as assessed by initial activated partial thromboplastin time (APTT) results and time taken to reach the target APTT range, using a weight‐based heparin protocol. A secondary aim was to assess the level of concordance with the protocol.MethodRecords of 50 patients admitted to the coronary care unit via the emergency department during a relevant 2‐month period with a preliminary diagnosis of unstable angina, myocardial infarction, chest pain or ischaemic heart disease and commenced on intravenous heparin, were retrospectively reviewed.ResultsThe initial APTT was documented for 98% (49/50) of patients. The proportion of initial APTTs &gt; 100 seconds was 12% (6/49). Initial APTTs were within the therapeutic range (60–85 seconds) for 27% (13/49) of patients. The initial APTT was subtherapeutic (&lt; 60 seconds) in 47% (23/49) of patients. The median time to a therapeutic APTT was 12.2 hours and the median time to the first measurement of APTT was 7.3 hours. The heparin order documented on the medication chart was concordant with the protocol 36% (18/50) of the time. There was no patient weight recorded on the medication chart 28% (14/50) of the time, and an incorrect starting heparin rate prescribed 18% (9/50) of the time. The desired APTT range was specified in 74% (37/50) of records reviewed. Overall, the rate was adjusted according to the protocol 70% (35/50) of the time.ConclusionThe evaluation of application of the weight‐based heparin protocol has identified opportunities for practice improvement. Subsequent interventions include linking heparin prescribing protocol details with the existing electronic information systems at the point‐of ‐care.

Re-admissions to inpatient paediatric pulmonary rehabilitation.

To describe re-admission rates, identify reasons for re-admission and examine characteristics of children requiring re-admission to inpatient pulmonary rehabilitation. Retrospective record review of infants and toddlers (less than three years of age) requiring oxygen or ventilator support discharged from an inpatient paediatric pulmonary rehabilitation programme between 1992 and 1999. Forty-one initial admissions resulted in 45 readmissions with a mean re-admission rate of 1.1 (SD = 1.41) re-admissions per child. Children with re-admissions (n = 22, 54%) required significantly more ventilator support (p = 0.001) and nursing care (p = 0.001) and were transferred to acute care more frequently (p = 0.002) than children without re-admissions. One-half of the children re-admitted to inpatient pulmonary rehabilitation were re-admitted two or more times. Based on this cohort of children, dependence on supplemental oxygen and/or mechanical ventilation and medical complexity may be indicators that children will require re-admission to rehabilitation following a transfer back to acute care. Further examination of re-admission rates and reasons and children's clinical characteristics may have predictive value and provide practice improvement opportunities.

Monitoring Anatomic Pathology Practice Through Quality Assurance Measures

This article describes the art and science of continuous performance measurement and applications for quality improvement in anatomic pathology. Numerous novel benchmarks derived from multi-institutional data acquired from the College of American Pathologists Q-Probes quality improvement program are illustrated as they relate to specific disciplines in anatomic pathology and aspects of the total testing cycle. Comparative data quantifying performance deficiencies and opportunities for practice improvement are also identified.

Wound infections after hysterectomy: Opportunities for practice improvement

This study was designed to determine the frequency of surgical site infection development after discharge from the hospital after abdominal or vaginal hysterectomy and the frequency of use of antimicrobial prophylaxis in this patient group. A prospective cohort study was performed on patients undergoing abdominal or vaginal hysterectomy between February 1 and December 31, 1995. Surgeons were contacted 1 month after the operations to determine which patients had acquired surgical site infections. Surgical site infection rates were calculated according to procedure, surgeon, and National Nosocomial Infection Surveillance system risk categories. A retrospective pharmacy record review was conducted to determine antimicrobial prophylaxis use according to procedure and surgeon. A total of 763 cases were surveyed; 55 (7.2%) met criteria for postoperative surgical site infection (7.7% abdominal and 4.5% vaginal hysterectomy). National Nosocomial Infection Surveillance system moderate-risk patients had significantly higher infection rates than did low-risk patients for both abdominal (p = 0.045) and vaginal (p = 0.05) procedures. Most patients (71.1%) were not given antimicrobial prophylaxis. There was a wide range of antimicrobial prophylaxis use by surgeon (3.6% to 94.4% of patients, p < 0.01). Despite long-standing and widespread recommendations for antimicrobial prophylaxis before hysterectomy, most of our patients were operated on without such prophylaxis. Surveillance programs permit detailed review of patient care practices that may reveal opportunities for improvement.

Outcomes management: an interdisciplinary search for best practice.

Rising U.S. health-care costs have resulted in mandates to reform the health system. Payors are closely scrutinizing care delivery and have empowered themselves as gatekeepers for consumer health-care access. In the late 1980s, outcomes management emerged as an interdisciplinary process advocating the measurement of health outcomes among populations undergoing medical care. Outcomes management provides a mechanism to foster development of patient-driven health services aimed to impact clinical quality through intermediate and long-term outcome analysis. Outcomes measurement facilitates ongoing enhancement of interdisciplinary health-care delivery, enabling determination of "best" practice and identification of opportunities for practice improvement. The advanced practice nurse's unique educational preparation provides a framework for development of the prerequisite leadership qualities necessary to cultivate an outcomes management program.