Performance Improvement Efforts Research Articles

Abstract T P339: Plan-Do-Study-Act Model Has Positive Impact on Dysphagia Screening in the Emergency Room

Background: Dysphagia is a serious complication of stroke, which can cause aspiration pneumonia leading to increased length of stay or death. Baptist Medical Center (BMC) is one of five Primary Stroke Center Certified hospitals in the Baptist Health System (BHS). In October 2013 it was noted that BMC dysphagia screen measure results had trended downward to be the lowest in the system. Purpose: The purpose of this abstract is to outline actions taken to address the documentation of the dysphagia screen in the emergency room (ER) at BMC. Methods: An analysis of BMC’s dysphagia screen fall outs revealed four contributing factors for this quality measure including: no screen completed (34%), oral intake prior to the screen (38%), a delay in stroke diagnosis 22%) or incomplete documentation (6%). Initially the dysphagia screen was completed on paper while the rest of the ER documentation was completed in the electronic medical record (EMR). In October a performance improvement effort was implemented using a Plan-Do-Study-Act Model (PDSA). Initial changes included placing dysphagia screening forms in each room for easier access, 1:1 teaching with staff for fall outs, and designating a nurse Stroke Champion. Inconsistent improvement was seen so dysphasia documentation was add to the EMR, a patient complaint list was developed and attached to each computer, and any patient with a Head CT order was automatically screened. In April, the directors started assigning a dysphagia screen education module to any staff member with 2 or more fallouts. The PDSA graph and action plan was posted in the ER and discussed during monthly staff meetings. Results: Dysphagia screen documentation in stroke patients in the ER at BMC improved from a low of 73.7% in October 2013 to 100% in May 2014. The drop in April 2014 to 88.5% was attributed to leadership changes and staff turnover. Conclusion: A focus on dysphagia improved the screening of stroke patients in the ER. The commitment to 1:1 teaching and further education emphasized the importance of screening. Dysphagia screening results will continue to be monitored, posted, and discussed monthly.

Recent trends in survival from out-of-hospital cardiac arrest in the United States.

Despite intensive efforts over many years, the United States has made limited progress in improving rates of survival from out-of-hospital cardiac arrest. Recently, national organizations, such as the American Heart Association, have focused on promoting bystander cardiopulmonary resuscitation, use of automated external defibrillators, and other performance improvement efforts. Using the Cardiac Arrest Registry to Enhance Survival (CARES), a prospective clinical registry, we identified 70 027 U.S. patients who experienced an out-of-hospital cardiac arrest between October 2005 and December 2012. Using multilevel Poisson regression, we examined temporal trends in risk-adjusted survival. After adjusting for patient and cardiac arrest characteristics, risk-adjusted rates of out-of-hospital cardiac arrest survival increased from 5.7% in the reference period of 2005 to 2006 to 7.2% in 2008 (adjusted risk ratio, 1.27; 95% confidence interval, 1.12-1.43; P<0.001). Survival improved more modestly to 8.3% in 2012 (adjusted risk ratio, 1.47; 95% confidence interval, 1.26-1.70; P<0.001). This improvement in survival occurred in both shockable and nonshockable arrest rhythms (P for interaction=0.22) and was also accompanied by better neurological outcomes among survivors (P for trend=0.01). Improved survival was attributable to both higher rates of prehospital survival, where risk-adjusted rates increased from 14.3% in 2005 to 2006 to 20.8% in 2012 (P for trend<0.001), and in-hospital survival (P for trend=0.015). Rates of bystander cardiopulmonary resuscitation and automated external defibrillator use modestly increased during the study period and partly accounted for prehospital survival trends. Data drawn from a large subset of U.S communities suggest that rates of survival from out-of-hospital cardiac arrest have improved among sites participating in a performance improvement registry.

Utility of a sports medicine model in military combat concussion and musculoskeletal restoration care.

Combat-related concussions are significant sources of injury and morbidity among deployed military service members. Musculoskeletal injury also is one of the most prevalent battle and nonbattle-related deployed injury types. Both injuries threaten the service member's physical condition as well as unit and mission readiness due to reduced duty status or evacuation from military theater of operations. In August 2010, the Concussion Restoration Care Center (CRCC) was established at Camp Leatherneck, Afghanistan, to address the need for consistent and specialized evaluation and care of concussion and musculoskeletal injury. This performance improvement effort examined evaluation and treatment of concussion and musculoskeletal injury at the CRCC. Among 4,947 military personnel evaluated at the CRCC between August 2010 and May 2013, 97.9% were returned to duty and retained in theater. Members averaged 10 to 12 days of limited duty status to achieve complete recovery. Concussion injury was secondary to blast injury in 90% of cases. Sport/recreation, occupational, and other accidental injuries each represented 30% of the musculoskeletal injuries with only 10% reported as result of combat. The utilization patterns and outcome measures demonstrate the success and utility of a multidisciplinary clinical model of care for these two types of injuries in the far-forward deployed setting.

Declining trends in local health department preparedness capacities.

We examined local health department (LHD) preparedness capacities in the context of participation in accreditation and other performance improvement efforts. MetHODS: We analyzed preparedness in 8 domains among LHDs responding to a preparedness capacity instrument from 2010 through 2012. Study groups included LHDs that (1) were exposed to a North Carolina state-based accreditation program, (2) participated in 1 or more performance improvement programs, and (3) had not participated in any performance improvement programs. We analyzed mean domain preparedness scores and applied a series of nonparametric Mann-Whitney Wilcoxon tests to determine whether preparedness domain scores differed significantly between study groups from 2010 to 2012. Preparedness capacity scores fluctuated and decreased significantly for all study groups for 2 domains: surveillance and investigation and legal preparedness. Significant decreases also occurred among participants for plans and protocols, communication, and incident command. Declines in capacity scores were not as great and less likely to be significant among North Carolina LHDs. Decreases in preparedness capacities over the 3 survey years may reflect multiple years of funding cuts and job losses, specifically for preparedness. An accreditation program may have a protective effect against such contextual factors.

Multifaceted approach to reducing unnecessary red blood cell utilization

•Strong organizational leadership, experienced project leaders, and the engagement of front-line stakeholders are critical elements for performance improvement efforts.•A holistic approach, including incentives, feedback, a collaborative interdisciplinary process, decision support, and education may be necessary to change clinician behavior.•A multifaceted performance improvement effort can lead to dramatic improvement in value for patients and society.

New-Generation Drillpipes Enhance Extended-Reach Drilling in South China Sea

This article, written by JPT Technology Editor Chris Carpenter, contains highlights of paper IPTC 16798, ’New Generation of Aluminum Drillpipes Enhanced ERD Performances in the Huizhou Field, South China Sea,’ by W. Scaruffi, E. Cristofanelli, S. Yu, and A. Trocchia, Eni China, and C. Molaschi and A. Merlo, Eni, prepared for the 2013 International Petroleum Technology Conference, Beijing, 26-28 March. The paper has not been peer reviewed. Copyright 2013 International Petroleum Technology Conference. Reproduced by permission. This paper presents the results of a performance-improvement effort in extended-reach drilling (ERD) in three campaigns in the Huizhou HZ 25-4 oil field in the South China Sea. The new methodological approach and the deployment of new-generation aluminum drillpipes (ADPs) have resulted in a reduction of drilling risk and increased cost savings. Introduction ERD allows the reduction of the number of drilling sites, including offshore platforms, artificial islands, or other structures, and allows better control of total field-development costs. In addition, ERD technology makes it possible to reach reservoirs located at a considerable distance offshore, reducing the environmental impact of a wellsite. ERD operations are gaining momentum in the industry because they allow reserves exploitation previously considered too expensive when using conventional drilling methods. In addition, ERD techniques increase singlewell production by enlarging the drainage area. Because of their lighter weight when compared with steel drillpipes (SDPs), the use of ADP is a key solution for drilling extended- reach wells for the following reasons: A reduction in operating costs of approximately 10–20% (including savings in rig-capacity upgrade costs, transportation and energy costs, time-hosting costs, and tool-joint/casing-wear costs). An increase in the horizontal deviation of wells of approximately 10–30% (reduced torque-and-drag effect, less pressure drop, higher buckling resistance). Heightened reserves and production growth. A reduction in operative risk. Comparison of ADPs and SDPs Eni E&amp;P first considered ADPs in July 2003, during the proposal and approval of a research-and-development project.

Improving Physician Documentation of Hospice Eligibility: Findings of an Ongoing Multi-State Effort (FR402)

1.Describe prognostic criteria for determining hospice eligibility, as defined by the various Medicare Administrative Contractors' Local Coverage Determinations.2.Describe incorporating these criteria into key elements needed for optimally documenting hospice eligibility, as derived from feedback from an ongoing, multi-state performance improvement effort.3.Discuss effective techniques for modifying clinician behavior to improve documentation as well as potential pitfalls and hazards of not continuously monitoring documentation performance. Determining prognosis is an integral function for clinicians involved in hospice and palliative medicine. Because the Medicare Hospice Benefit defines hospice eligibility in terms of prognosis, proper and optimal documentation of this by clinicians is vital both for clinical accuracy and for financial viability of the hospice program. We will describe our 3-year, ongoing experience involving more than 450 hospice medical directors (HMDs) in 31 states across all four of the Medicare Administrative Contractors and their respective, different Local Coverage Determinations. In an ongoing fashion, we determine our internal performance, which is compared to published standards and to other non-published feedback from the multiple regulatory auditing entities. Because of our size, we are virtually always undergoing external reviews somewhere across our organization. This information has led to key elements being identified and recommended for optimal documentation. By using standard performance improvement techniques, education and feedback is provided to HMDs and other hospice clinicians regarding both clinical standards as well as documentation methods. This presentation will describe the techniques found to be most effective in modifying clinician behavior to improve documentation. We will also describe processes for minimizing and clarifying potentially contradictory documentation elements across time or among different clinicians. Results of our effort have substantially improved internal compliance scores as well as resulting in significantly better external regulatory audit findings. The key elements, processes, and forms used for our project will all be shared.

Managing innovation in hospitals and health systems: Lessons from the Malcolm Baldrige National Quality Award Winners

Hospitals and other health systems increasingly must rely on innovation as they seek creative approaches for improving patient outcomes while simultaneously dealing with regulatory and cost constraints. The management of innovation is an integral component of hospitals/healthcare systems that are recognized for their excellence by the Malcolm Baldridge National Quality Award in Health Care. Using a framework based on in the 2011–2012 Healthcare Criteria for Performance Excellence and organizational literature, this paper identifies the best practices in innovation as demonstrated by the 15 Baldridge winners. The results indicate that Baldridge winners engage in Innovation Leadership by incorporating innovation into their vision, mission, and values statements and explicitly stating support from senior leadership; strategic planning for innovation by including innovation initiatives in strategic goals and action plans and soliciting stakeholder involvement in innovation; and management of innovation processes by integrating innovation with performance improvement efforts and harnessing human resources. Best practices are summarized to guide leaders in other hospitals/healthcare systems in bringing innovation to the forefront of their initiatives.

Balancing the risk of mortality and major bleeding in the treatment of NSTEMI patients – A report from the National Cardiovascular Data Registry

We sought to describe real-world patterns of care in NSTEMI patients across different risk profiles for bleeding and mortality. The NCDR ACTION Registry-GWTG in-hospital mortality and major bleeding risk scores were developed to assess patient risk and optimize treatment decisions. However, little is known about the alignment of contemporary clinical management patterns with these risk estimates. We studied 61,366 NSTEMI patients in the NCDR ACTION-Registry-GWTG from January 2007 to March 2009, stratifying them into four groups based on estimated risk of mortality and major bleeding. There were 24,709 (40.3%) patients in each of the concordant risk groups (low:low; high:high) and 5974 (9.7%) in each of the discordant risk groups (low:high; high:low). Subjects at high estimated risk for both mortality and major bleeding were least likely to receive guideline-based adjunctive pharmacotherapy or to undergo angiography within 48 hours but most likely to receive an excess dose of an antithrombotic agent. Patients at low estimated risk for mortality and bleeding received the most intensive adjunctive therapy and were most likely to undergo invasive angiography. There are significant differences in contemporary patterns of care across varying risk profiles of mortality and major bleeding. Despite practice patterns which seem to emphasize avoiding harm with reduced use of antithrombotic therapy, patients at high risk for major bleeding continue to receive excess doses of antithrombotic therapy. Additional performance improvement efforts are needed to optimize outcomes in NSTEMI patients with high risk for both bleeding and mortality.

Going Forward: A Lean Way to Design

That's not what I meant. Generally speaking, this phrase does not mean the end of the world, and the affected parties can quickly come to terms and remedy the misunderstanding. In the world of design, how- ever, such a phrase can imply disaster for the designer and client, if not resolved early enough in the process of a building project. And in the history of design, this phrase is probably heard more often than many designers are willing to admit.As with many areas where inspiration evolves organically with the passing of time, the world of design and build is undergoing a renaissance. New tools and approaches, including patient-centered design, computer simulation and itera- tive data-driven design are being applied in the healthcare setting, and this issue of HERD is dedicated to examining them. In each of these thought-provoking articles, we challenge conventional approaches to design-and conventional wis- dom-and offer new techniques that promise to create more effective environ- ments in which to practice and receive care.The idea that conventional wisdom must be challenged in the world of design grew from the very successful application of Lean and Six Sigma principles in hospital operations, dating back over a decade. In 1999, nobody in healthcare had heard of these methods, and it might not be unusual to hear in the halls of the hospital is Sigma and why is she sick? Today, two separate studies, one by the American College of Healthcare Executives and the other by the Ameri- can Society for Quality, indicate that over 40% of hospitals have applied Lean and Six Sigma to improve quality and reduce costs.My own experience with these methods has been consistent with industry. In 2000, I earned a Blackbelt in Six Sigma and went about helping hospitals to realize their full potential in operational, workflow and quality changes. Unfor- tunately, even the smallest amount of data can be intoxicating to managers, who are often quick to conclude that they understand the root cause of performance problems. Executives were absolutely convinced they knew how to improve pro- cesses and many initiated performance improvement efforts with a solution in mind. The industry became replete with examples of performance improvement efforts that actually had a deleterious effect because they were based on flawed data. It would take another several years before the industry realized that for data-driven design to work, it must demand accurate data, patience, and the ability to surrender to the process of discovery before rushing to solutions.Fortunately, such patience has paid off. In a study conducted by Creative Health- care including over 150 projects conducted by 10 healthcare systems over the past 10 years, Six Sigma projects were shown to yield an average return on invest- ment (ROI) of 7:1. With this compelling evidence to embolden us, it's time to take these methods as far as they can go.How does one begin the process of undertaking a Lean or Six Sigma journey in an environment where such concepts are potentially new and unproven? A research paper offered by Maartje van Reedt Dortland et al. in this issue of HERD discusses the findings from an exploratory survey with options for con- struction that facilitate understanding of the contemporary view of available options, while another research paper by Vanessa Okken et al. …

Leadership Sustainability

AbstractToday's leaders require leadership sustainability, the ability to make personal improvements stick over the long term. Ulrich and Smallwood contend that leaders fail at the stage of implementation, even after enthusiastically embracing coaching, learning, and other performance improvement efforts. The challenge, they write, “is how to turn these events into an ongoing pattern.” Their research found seven principles driving sustainability: simplicity, time, accountability, resources, tracking, melioration (“a new term for a whole complex of actions and attitudes designed to make things better”), and emotion. They also list more than 20 crucial books on such subjects as change, influence, and self‐discipline.

Travel Reengineering: A Military Case Study

This article highlights the U.S. Department of Navy's performance improvement efforts to reduce the cost of travel management and increase customer satisfaction. The study details human performance technology principles and standards applied to solving a complex enterprise problem. The project engaged leaders and customers alike, resulting in Department of Defense and national recognition.

FUEL SAVING STRATEGY IN SPARK IGNITION ENGINE USING FUZZY LOGIC ENGINE TORQUE CONTROL

In the case of injection gasoline engine, or better known as spark ignition engines, an effort to improve engine performance as well as to reduce fuel consumption is a fairly complex problem. Generally, engine performance improvement efforts will lead to increase in fuel consumption. However, this problem can be solved by implementing engine torque control based on intelligent regulation such as the fuzzy logic inference system. In this study, fuzzy logic engine torque regulation is used to control the throttle position entered by the driver to achieve optimal engine torque. An engine torque vs. throttle position and engine speed mapping for vehicles with economical function is used to build this control process regulation. From the simulation result, it can be concluded that this control strategy is very effective to reduce fuel consumption and simultaneously to optimize the engine performance.

Abstract 227: Aldosterone Antagonists in Post-Acute Myocardial Infarction Use, Predictors, and Temporal Trends of a Class I Recommendation

Objectives: To measure the use of guideline-recommended aldosterone antagonist therapy in eligible patients with post-MI and reduced ejection fraction (EF), temporal trends, and characteristics associated with use. Background: Current guidelines recommend the initiation of aldosterone antagonist therapy post-AMI for those with an EF ≤ 40% with heart failure or diabetes prior to hospital discharge, in the absence of contraindications. We explored the relationship between this Class IA recommendation issued in 2004 (STEMI)/2007 (NSTEMI) and its implementation into practice. Methods: Data from the AHA’s Get with the Guidelines-CAD national database were analyzed for 81,570 post-AMI patients from 219 hospitals between January 1, 2006 and December 29, 2009 of whom 11,255 (13.8%) were eligible for aldosterone antagonist therapy. Results: Among eligible patients, 1023 (9.1%) were prescribed an aldosterone antagonist at discharge. There was wide variation in use among hospitals (0% to 40.0) with no hospital treating even half their eligible patients. Patient and hospital characteristics independently associated with prescription of aldosterone antagonists were history of diabetes, heart failure, or coronary revascularization. Conversely, patients less likely to have an aldosterone antagonist prescribed had a history of renal insufficiency, were smokers, and had higher EF. Larger hospital size was associated with higher aldosterone antagonist use. Prescription of an aldosterone antagonist increased in the study population from 6.0% to 13.4% from January 2006 to December 2009 (p&lt;0.001). Conclusions: Fewer than one in ten post-MI patients eligible for an aldosterone antagonist, were discharged with this Class IA recommended therapy. Although rates of utilization are rising modestly over time, compliance continues to be extremely low. This discrepancy between evidence based therapy and actual prescribing patterns suggests the need for specific targeted performance improvement efforts.

Performance in Practice: Clinical Module for the Care of Patients With Major Depressive Disorder

The APA's Performance in Practice modules are guided practice improvement programs created for psychiatrists, designed to meet Part 4 MOC requirements for clinical modules. Modules follow a three-stage Performance Improvement CME structure that takes place within a 24 month period. By 2017, when ABPN MOC requirements are fully in place, MOC participants will be required to complete three PIP units, each consisting of both a clinical module (chart review) and a feedback module (patient/peer survey). In STAGE A - Chart Review, the physician compares his or her current practice (through a review of chart documentation) to guidelines and measures provided for the topic area (5 credits). In STAGE B – Improvement, based upon the results of chart review, the physician then selects an area where improvement is needed and documents his or her strategy for improvement. This improvement plan is for the personal use of the physician (5 credits). In Stage C – Second Chart Review, the physician reassesses his or her performance with review of 5 patient charts, and determines the results of his or her performance improvement effort (10 credits). Clinical Module for the Care of Patients with Major Depressive Disorder is approved by ABPN for MOC Part 4.

The Use of a Hospital Discharge Database to Track Performance Improvement and Mortality From Severe Sepsis

PURPOSE: Sepsis is a common cause of mortality nationwide. To improve the identification and care of septic patients at our institution, we have provided bundled care, adopting a sepsis bundle based on the Surviving Sepsis Campaign (SSC) guidelines. We hypothesized that we could successfully track the appropriate identification of patients with severe sepsis, as well as their overall mortality, using our hospital discharge database. METHODS: Our hospital discharge database was prospectively queried over 6 fiscal years, beginning July 1 and ending June 30, annually, during 2005-2010. This period coincided with adoption of the SSC database and care bundles. An annual estimate of the number of severe sepsis cases in our institution throughout this period was made using a method derived from Angus, et al. Physician-diagnosed severe sepsis was identified by ICD-9 codes 995.92, 785.52. Additionally, the database was queried for all-cause mortality of these patients. RESULTS: In FY 2005, only 171 of 426 patients identified to have severe sepsis by the modified Angus method were given an ICD-9 diagnosis of severe sepsis or septic shock (40%). This grew to 958 out of 1,205 (80%) by FY 2010. Simultaneously, the all-cause in-hospital mortality rate of patients diagnosed with severe sepsis fell from 49% in FY 2005 to 25% in FY 2010. The mortality index (observed mortality/expected mortality) fell from 1.56 in FY 2005 to 0.88 in FY 2010. Average LOS declined from 24.4 days in FY 2005 to 15.9 days in FY 2010. Severe sepsis as a recognized contribution to overall hospital mortality rose from 18.5% in FY 2005 to 48.4% in FY 2010. CONCLUSIONS: The comparison of the modified Angus method with coded discharges for severe sepsis and septic shock demonstrated improved recognition of severe sepsis. Enhanced recognition, combined with systematic improvements in patient care, effectively reduced the mortality of severe sepsis by approximately 50% over a five-year period. CLINICAL IMPLICATIONS: The hospital discharge database is an effective tool for measuring the outcomes of performance improvement efforts in severe sepsis. DISCLOSURE: The following authors have nothing to disclose: Lucas Pitts, Michael Moncure, Chad Cannon, Steven Simpson No Product/Research Disclosure Information

Moving Data to Nursing Quality Excellence

Data must make their way to front line staff if performance improvement efforts are to be successful and sustainable. The steps of focus, display, distribute, and reward may be used as a process to ensure that data are delivered to and used by the front line staff. The focus on specific key measures, with subsequent consistent display and distribution, had a positive impact on the selected measures. Rewarding units with annual awards further encouraged staff to improve on important nurse-sensitive measures.

Potential impact of optimal implementation of evidence-based heart failure therapies on mortality

Although multiple therapies have been shown to lower mortality in patients with heart failure (HF) and reduced left ventricular ejection fraction, their application in clinical practice has been less than ideal. To date, empiric estimation of the potential benefits that could be gained from eliminating these existing treatment gaps with optimal implementation has not been quantified. Eligibility criteria for each evidence-based HF therapy, the estimated frequency of use/nonuse of specific treatments, the case fatality rates, and the risk reductions due to treatment were obtained from published sources. The numbers of deaths prevented or postponed because of each guideline-recommended therapy and overall were determined. Among patients with HF with reduced left ventricular ejection fraction in the United States (n = 2,644,800), the number eligible but not currently treated ranged from 139,749 for hydralazine/isorbide dinitrate to 852,512 for implantable cardioverter defibrillators. The comparative number of deaths that could potentially be prevented per year with optimal implementation of angiotensin-converting enzyme inhibitor/angiotensin receptor antagonist is 6,516; β-blockers, 12,922; aldosterone antagonists, 21,407; hydralazine/isorbide dinitrate, 6,655; cardiac resynchronization therapy, 8,317; and implantable cardioverter defibrillators, 12,179. If these treatment benefits were additive, optimal implementation of all 6 therapies could potentially prevent 67,996 deaths a year. A substantial number of HF deaths in this country could potentially be prevented by optimal implementation of evidence-based therapies. These data may underscore the importance of performance improvement efforts to translate evidence-based therapy to routine clinical practice so as to reduce contemporary HF mortality.

Manufacturing performance measurement and target setting: A data envelopment analysis approach

Manufacturing decision makers have to deal with a large number of reports and metrics for evaluating the performance of manufacturing systems. Since the metrics provide different and at times conflicting assessments, it is hard for the manufacturing decision makers to track and improve overall manufacturing system performance. This research presents a data envelopment analysis (DEA) based approach for performance measurement and target setting of manufacturing systems. The approach is applied to two different manufacturing environments. The performance peer groups identified using DEA are utilized to set performance targets and to guide performance improvement efforts. The DEA scores are checked against past process modifications that led to identified performance changes. Limitations of the DEA based approach are presented when considering measures that are influenced by factors outside of the control of the manufacturing decision makers. The potential of a DEA based generic performance measurement approach for manufacturing systems is provided.

Partnerships for Educational Excellence and Research: HPT in the townships of South Africa

Effective performance-based instruction is making a sustained and noticeable impact on township schools in the Eastern Cape of South Africa. We document the performance improvement effort made over the past 7 years by Partnerships for Educational Excellence and Research International (P.E.E.R), a team of educators, instructional system designers, and psychologists from South Africa and the United States. P.E.E.R.'s focus is the application of low-cost and effective instructional strategies to improve teaching and learning in high-need South African schools.