Participation In Quality Improvement Activities Research Articles

Access of Low-Resource Areas to ASCO Quality Initiatives: Initial Experience and Lessons Learned.

With the aim of improving the quality of cancer care globally, ASCO began to offer its quality improvement programs to interested international oncology practices. In this manuscript, we describe the experiences with ASCO quality initiatives in low- and middle-income countries (LMICs). The experience acquired from different practices in Latin America and Africa was reviewed and various action steps were summarized. Encountered challenges and implemented solutions to mitigate these challenges were identified to list as lessons learned for oncology practices in LMICs or low-resource settings to use in their future quality improvement initiatives and providing a proactive approach for those practices considering starting quality improvement programs. Having programs tailored to LMICs may facilitate the participation of more practices and help them take advantage of these programs to enhance patient care. The preliminary data and learning are promising and demonstrate that participation in quality improvement activities can have a positive effect. Although this early experience is encouraging, each country and resource-limited practice will have its own unique challenges as highlighted in this article. Having more practices participate will further enhance the knowledge base, build experience in addressing challenges, and enable oncology patients to reap the benefits worldwide.

An Innovative Experiential Approach to Learning About Quality Improvement Processes.

Baccalaureate nursing students receive education to develop quality and safety competencies. Approaches vary due to time constraints and availability of clinical sites. In this innovative, semester-long activity, student groups applied quality improvement resources from the Institute for Healthcare Improvement, addressing problems such as stethoscope hygiene practices and weekly screen time. Students' evaluation of the experience indicated a growth in knowledge, skills, and positive attitudes toward quality improvement. Experiential nonclinical practices are an innovative and effective way to prepare baccalaureate students for participation in quality improvement activities.

Variables Associated With Nurse-Reported Quality Improvement Participation

Lack of staff engagement in quality improvement (QI) is a persistent challenge in improving quality in health care. In this study, we examined variables associated with nurse-reported participation in QI using data from over 500 registered nurses employed in US hospitals. Of the 16 studied variables, based on the adjusted multivariate regression analysis, the following were positively associated (p

Service quality from the perspective of myocardial infarction patients.

Service quality (SQ) generally refers to the nonclinical aspects of health services and primarily focuses on the relationship between the care provider and the customers, and the environment in which care services are delivered. The aim of this study was to assess the SQ provided for myocardial infarction (MI) from the patients' perspective. A cross-sectional study was conducted with 164 patients with MI at the Tabriz Shahid Madani cardiology clinic. Study participants were selected using convenience sampling. SQ was measured using a validated Comprehensive Quality Measurement in Healthcare SQ questionnaire. The reliability was confirmed based on Cronbach's alpha coefficient (α=0.81). SQ was calculated using the formula SQ=10- (importance × performance), based on the importance and performance of non-health-related aspects from the customers' perspective. Importance scores ranged from 1 to 10 and performance was scored between 0 and 1. Of 164 participants, about 75% were men and almost 44% were between 51 and 65 years of age. From the customers' perspective, the total SQ score was 6.80 (0-10 scale), and the individual scores for all SQ aspects were below an acceptable level. Confidentiality, dignity and continuity were given the highest scores, while availability of support groups had the lowest score. The study findings revealed an opportunity to improve SQ. Patient and provider participation in quality improvement activities could be an effective strategy to improve the aspects of health care quality that were most important to the customers and those with low scores, such as availability of support groups.

Integrating Quality Improvement Education into the Nephrology Curricular Milestones Framework and the Clinical Learning Environment Review.

The Accreditation Council for Graduate Medical Education requires that trainees show progressive milestone attainment in the practice-based learning and systems-based practice competencies. As part of the Clinical Learning Environment Review, sponsoring hospitals must educate trainees in health care quality improvement, provide them with specialty-specific quality data, and ensure trainee participation in quality improvement activities and committees. Subspecialty-specific quality improvement curricula in nephrology training programs have not been reported, although considerable curricular and assessment material exists for specialty residencies, including tools for assessing trainee and faculty competence. Nephrology-specific didactic material exists to assist nephrology fellows and faculty mentors in designing and implementing quality improvement projects. Nephrology is notable among internal medicine subspecialties for the emphasis placed on adherence to quality thresholds-specifically for chronic RRT shown by the Centers for Medicare and Medicaid Services Quality Incentive Program. We have developed a nephrology-specific curriculum that meets Accreditation Council for Graduate Medical Education and Clinical Learning Environment Review requirements, acknowledges regulatory quality improvement requirements, integrates with ongoing divisional quality improvement activities, and has improved clinical care and the training program. In addition to didactic training in quality improvement, we track trainee compliance with Kidney Disease Improving Global Outcomes CKD and ESRD quality indicators (emphasizing Quality Improvement Program indicators), and fellows collaborate on a yearly multidisciplinary quality improvement project. Over the past 6 years, each fellowship class has, on the basis of a successful quality improvement project, shown milestone achievement in Systems-Based Practice and Practice-Based Learning. Fellow quality improvement projects have improved nephrology clinical care within the institution and introduced new educational and assessment tools to the training program. All have been opportunities for quality improvement scholarship. The curriculum prepares fellows to apply quality improvement principals in independent clinical practice-while showing milestone advancement and divisional compliance with Clinical Learning Environment Review requirements.

Measuring reflection on participation in quality improvement activities for maintenance of certification.

To validate a measure of reflection on participation in quality improvement (QI) activities and to identify associations with characteristics of QI projects, participants, and teams. This was a prospective validation study of all Mayo Clinic team participants who submitted QI projects for maintenance of certification (MOC) credit from 2010 to 2012. The authors developed a measure of reflection on participation in QI activities and explored associations between participants' overall reflection scores and characteristics of projects, participants, and teams. A total of 922 participants (567 physicians) on 118 teams completed QI projects and reflections. Factor analysis revealed a two-dimensional model with good internal consistency reliabilities (Cronbach alpha) for high (0.85) and low (0.81) reflection. Reflection scores (mean [standard deviation]) were associated with projects that changed practice (yes: 4.30 [0.51]; no: 3.71 [0.57]; P < .0001), changed the health care system (yes: 4.25 [0.54]; no: 4.03 [0.62]; P < .0001), and impacted patient safety (P < .0001). Physicians' reflection scores (4.27 [0.57]) were higher than support staff scores (4.07 [0.55]; P = .0005). A positive association existed between reflection scores and the number of QI roles per participant (P < .0001). There were no associations with participant gender, team size, or team diversity. The authors identified associations between participant reflection and the impact of QI projects, participants' professional roles, and participants' involvement with projects. With further study, the authors anticipate that the new measure of reflection will be useful for determining meaningful engagement in MOC.

Forging an advanced practice role for pharmacists in palliative care

The role of the hospice is well established in providing quality care for the dying. With the drive for greater emphasis on community-based palliative care, there is a need to enable elements (especially medicines management practices) from the inpatient hospice model to be more readily available in the community environment. This paper describes the incorporation of an advanced practice pharmacist into a large metropolitan palliative care service. The focus of this appointment has been to develop strategic engagement with primary care providers to better support medicines management for people registered within a metropolitan palliative care service. Through the development of education programs, participation in quality improvement activities and by supporting the ambulatory palliative care team, the advanced practice pharmacist has engaged the community pharmacist as part of the broader palliative care team. There are challenges and opportunities for pharmacists to assist in providing improved palliative care services delivery within the Australian healthcare system.

Education in quality improvement for practice in primary care during residency training and subsequent activities in practice.

Quality improvement (QI) is an integral aspect of graduate medical education and an important competence for physicians. We examined the QI activities of recent family medicine residency graduates and whether a standardized curriculum in QI during residency resulted in greater self-reported participation in QI activities in practice after graduation. The family medicine residency programs affiliated with the South Carolina Area Health Education Consortium (N = 7) were invited to participate in this study. Following completion of introductory educational activities, each site implemented regularly occurring (at least monthly) educational and patient care activities using QI principles and tools. Semiannually, representatives from each participating site met to review project aims and to provide updates regarding the QI activities in their program. To examine the impact of this project on QI activities, we surveyed graduates from participating programs from the year prior to and 2years after the implementation of the curriculum. Graduates in the preimplementation and postimplementation cohorts reported participating in periodic patient care data review, patient care registries, QI projects, and disease-specific activities (57%-71% and 54%-63%, respectively). There were no significant differences in QI activities between the 2 groups except in activities associated with status of their practice as a patient-centered medical home. Most but not all family medicine graduates reported they were actively involved in QI activities within their practices, independent of their exposure to a QI curriculum during training.

Services quality for people with rheumatoid arthritis: Iranian patients′ perspective

Background: Service quality (SQ) refers primarily to how the care received is perceived and is influenced by the physical, social, and cultural context and nonhealth aspects of care, such as access, respect, and confidentiality. This study aimed to assess SQ for people with rheumatoid arthritis (RA) from the patients' perspective. Subjects and Methods: A cross-sectional study was conducted with 172 people with RA who received care from specialist clinics of Isfahan University of medical sciences in 2013. SQ was measured using comprehensive quality measurement in healthcare_service quality (CQMH_SQ) questionnaire. Questionnaire content validity was reviewed and confirmed by 10 experts and its reliability was confirmed based on Cronbach's alpha index (α =0. 803). A measure of SQ was derived by combining the relative importance and actual performance. Data analyzed using the SPSS-17 statistical package. Results: Study findings indicate average SQ score were 7.91 (0.87) and demonstrated which aspects of SQ took a weak score in total SQ for people with RA. Confidentiality and choice of care provider achieved the highest and availability of support group had the lowest scores SQ scores. Participants with good control of their disease had higher scores (P = 0.042) and SQ score customer quality score have positive relationship with increasing each year in elapsed time of diagnosis (P = 0. 028). Conclusions: According to average score of customer quality, study findings indicate that patient and provider participation in quality improvement activities can be used as an effective solution and also needs for focus on such aspect of health care quality that were more important for consumer, also dimension have worst quality such as availability of support group.

Characteristics of Primary Care Safety-Net Providers and Their Quality Improvement Attitudes and Activities

No current national data exist to characterize safety-net physicians and their attitudes toward and participation in quality improvement activities compared with non-safety-net physicians. The authors conducted a national random sample survey of internal medicine, family practice, and pediatrics primary care physicians (PCPs) and used weighted multivariable regression models to assess attitudes and participation in quality improvement activities. After multivariable adjustment, there were no significant differences in provider attitudes about or participation in quality improvement activities between safety-net and non-safety-net physicians. However, safety-net providers were almost twice as likely to look for racial/ethnic disparities in care within their practices and are as likely to be involved in quality improvement activities as non-safety-net providers; their attitudes are consistent with providing equitable and universal care. Increasing access by expanding Medicaid eligibility will require continued investment in the number and training of safety-net PCPs.

Quality improvement in medical education: current state and future directions

During the last decade, there has been a drive to improve the quality of patient care and prevent the occurrence of avoidable errors. This review describes current efforts to teach or engage trainees in patient safety and quality improvement (QI), summarises progress to date, as well as successes and challenges, and lists our recommendations for the next steps that will shape the future of patient safety and QI in medical education. Trainees encounter patient safety and QI through three main groups of activity. First are formal curricula that teach concepts or methods intended to facilitate trainees' participation in QI activities. These curricula increase learner knowledge and may improve clinical processes, but demonstrate limited capacity to modify learner behaviours. Second are educational activities that impart specific skills related to safety or quality which are considered to represent core doctor competencies (e.g. effective patient handover). These are frequently taught effectively, but without emphasis on the general safety or quality principles that inform the relevant skills. Third are real-life QI initiatives that involve trainees as active or passive participants. These innovative approaches expose trainees to safety and quality by integrating QI activities into trainees' day-to-day work. However, this integration can be challenging and can sometimes result in tension with broader educational goals. To prepare the next generation of doctors to make meaningful contributions to the quality mission, we propose the following call to action. Firstly, a major effort to build faculty capacity, especially among teachers of QI, should be instigated. Secondly, accreditation standards and assessment methods, both during training and at end-of-training certification examinations, should explicitly target these competencies. Finally, and perhaps most importantly, we must refocus our attention at all levels of training and instil fundamental, collaborative, open-minded behaviours so that future clinicians are primed to promote a culture of safer, higher-quality care.

Addressing Core Competencies Through Hospital Quality Improvement Activities: Attitudes and Engagement

Hospital quality improvement initiatives are becoming increasingly common. Little is known about the influence of these initiatives on resident learning and attitudes. Our objective was to assess whether training in a hospital committed to involving residents in hospital-initiated, continuous quality improvement (CQI), and to participation in such activities, would influence residents' attitudes toward CQI and engagement in the hospital community. We surveyed Seattle Children's Hospital pediatric residents, from residency graduation years 2002-2009. We included questions about participation in quality improvement activities during residency and measures of attitude toward CQI and of workplace engagement. We used descriptive statistics to assess trends in resident participation in hospital CQI activities, attitudes toward CQI and workplace engagement. The overall response rate was 84% (162 of 194). Among graduated residents, there was a significant trend toward increased participation in CQI activities (P = .03). We found no difference in attitude toward CQI between those who had and those who had not participated in such activities nor between residents who began training before and those who began after the hospital formally committed to CQI. Sixty-three percent of residents (25 of 40) who participated in CQI activities were engaged in the hospital community compared with 53% (57 of 107) who did not participate in CQI activities (P = .21). Training in a hospital committed to involving residents in CQI was associated with a high rate of participation in CQI activities. Although such training and participation in CQI were not associated with resident attitudes toward CQI or hospital engagement, it may allow residents to learn skills for practice-based learning and improvement and systems-based practice.

The Next Phase of Pediatric Residency Education: The Partnership of the Milestones Project

concerns of patient safety, policymakers and the public are demanding a response. The American Board of Pediatrics, the Accreditation Council of Graduate Medical Education (ACGME), the Association of Pediatric Program Directors (APPD), and other organizations are working together to position pediatrics to meet these demands and keep the public trust for excellence in the care of children. Program directors and educators recognize that there are many barriers to medical education reform, including but not limited to lack of resources; traditional training of physicians, which lacks a focus on curricular design and learner and program assessment; and a foundation in conducting educational research. 2 However, the public and government stakeholders expect safe and effective care documented by patient outcome data, 3 ongoing participation in quality improvement activities, and assurances of adequate supervision for trainees. Recent health care reform bills contain specific language that speaks to ‘‘demonstration of outcomes in medical education.’’ 3 Upon graduation, patients and families want assurance that both new generalist and specialist pediatricians have become skilled in all aspects of the 6 ACGME competencies 4 (Table 1), which translates into a physician who provides patient-centered care, applies best evidence, functions effectively in multidisciplinary teams to coordinate care, and advocates for their patient needs by helping them navigate the complexities of the health care system. Moreover, as the hours and structure of training change, we are obligated to demonstrate that future graduates are prepared to enter practice without direct supervision. We must have a sense of urgency to address these expectations or we will face additional external oversight beyond our own programs, institutions, and current accreditation organizations. The Milestones Project provides a way for us, as a self-regulating profession, to uphold the public trust. The ACGME, in partnership with the American Board of Pediatrics, has initiated the Milestones Project as the next step in moving toward an outcomes-based measurement of training, evolving beyond more basic structure and process measures. 5–7 The plan is to partner with each member board within the American Board of Medical Specialties to spearhead the development of a grassroots effort to further define the ACGME competencies within the context of their specialty. Pediatrics is 1 of the first 3 disciplines, along with internal medicine and surgery, to construct Milestones as outcome measures of the competencies.

The Relationship Between Perceived Practice Quality and Quality Improvement Activities and Physician Practice Dissatisfaction, Professional Isolation, and Work-Life Stress

The importance of physician well-being has been well-documented. However, little is known about how physicians' self-reported quality improvement (QI) activities and quality of care are related to their practice dissatisfaction, professional isolation, and work-life stress. We surveyed a random sample of 1884 physicians in Massachusetts by mail and assessed their practices' participation in QI activities and quality of care, as well as their feelings of professional isolation, work-life stress, and practice dissatisfaction. A total of 1345 physicians responded (71.4% response rate). Most respondents reported QI activities in their practices (85%) and subsequent evaluation of these activities (62%). Approximately one-third (33%) reported quality problems in their practice. In linear regression analyses, the presence of quality problems was independently associated with increased professional isolation, work-life stress, and practice dissatisfaction. In contrast, physicians from practices that were involved in the evaluation of QI activities had significantly less isolation, stress, and dissatisfaction. Participation in QI activities was also independently associated with less dissatisfaction. A substantial fraction of physicians reported moderate to severe problems with isolation (17%), work-life stress (31%), and dissatisfaction (27%). Substantial practice dissatisfaction, professional isolation, and work-life stress are experienced by physicians and they seem to be inversely correlated with QI activities. Physicians who perceive quality problems in their practices are more likely to experience dissatisfaction, isolation, and stress. Efforts to engage physicians in QI and systems change should assess how these programs affect physicians themselves and the care that they deliver.

Job and organizational determinants of nursing home employee commitment, job satisfaction and intent to turnover

The purpose of this study was to examine whether job characteristics, the work environment, participation in quality improvement activities and facility quality improvement environment predicted employee commitment and job satisfaction in nursing homes, and whether those same predictors and commitment and satisfaction predicted turnover intention. A total of 6584 nursing home employees from 76 nursing homes in a midwestern state participated. A self-administered questionnaire was used to collect the data. The results supported the hypotheses that job and organizational factors predicted commitment and satisfaction while commitment and satisfaction predicted turnover intentions. The implications for retaining nursing home employees are discussed.

Randomized Trial of Quality Improvement Intervention to Improve Diabetes Care in Primary Care Settings

To assess the impact of a quality improvement (QI) intervention on the quality of diabetes care at primary care clinics. Twelve primary care medical practices were matched by size and location and randomized to intervention or control conditions. Intervention clinic staff were trained in a seven-step QI change process to improve diabetes care. Surveys and medical record reviews of 754 patients, surveys of 329 clinic staff, interviews with clinic leaders, and analysis of training session videotapes evaluated compliance with and impact of the intervention. Mixed-model nested analyses compared differences in the quality of diabetes care before and after intervention. All intervention clinics completed at least six steps of the seven-step QI change process in an 18-month period and, compared with control clinics, had broader staff participation in QI activities (P = 0.04), used patient registries more often (P = 0.03), and had better test rates for HbA(1c) (A1C), LDL, and blood pressure (P = 0.02). Other processes of diabetes care were unchanged. The intervention did not improve A1C (P = 0.54), LDL (P = 0.46), or blood pressure (P = 0.69) levels or a composite of these outcomes (P = 0.35). This QI change process was successfully implemented but failed to improve A1C, LDL, or blood pressure levels. Data suggest that to be successful, such a QI change process should direct more attention to specific clinical actions, such as drug intensification and patient activation.

The Government’s Role in Hospital Accountability for Quality of Care

The role of the U.S. government in the accountability of hospitals for quality of care involves shaping the community of those interested in quality, developing methods and infrastructure, standardizing information, providing information and technical assistance, and enforcing standards. The federal government's role in shaping an atmosphere of trust or distrust is critical but underestimated. The research and development of methods and infrastructure is widely acknowledged and many health systems' reform proposals emphasize it. Several state governments have begun standardizing and providing quality information, and this role is also assigned to the federal government in several reform proposals. Enforcing standards, including licensure and certification, is the most widely understood governmental role; states license whereas the federal government certifies compliance with Medicare conditions of participation either directly or through accreditation by the Joint Commission. These standards are evolving rapidly. Only recently has government taken on the role of providing technical assistance for quality improvement. Health system reform legislation may shape hospital accountability by (a) mandating uniform quality performance measurement and disclosure, (b) replacing emphasis on minimum standards with emphasis on improvement, (c) changing the structure of certification requirements, (d) requiring participation in quality improvement activities, and (e) funding new quality improvement structures. Some support a federal role in developing and implementing measures, but there is disagreement on the feasible pace, the uses of the resulting information, and the federal role in quality improvement. There is also disagreement about the future form of Medicare-based federal quality improvement efforts.