Pilot Quality Improvement Initiative Research Articles

Implementation of video assisted point-of-care germline genetic education and testing for patients with peri-diagnostic pancreatic cancer.

e22530 Background: Germline genetic testing is universally recommended for patients with exocrine pancreatic cancer (PC). Pretest consultation with a genetics professional is recommended to ensure patients are informed about risks, benefits, and limitations of testing. This is a resource intensive process and is associated with a suboptimal testing rate (~30%). Prior work demonstrates that video-assisted pre-test education does not increase patient anxiety compared to traditional pre-test genetic counseling in peridiagnostic ovarian cancer patients. In this report, we assess the feasibility of using a similar video assisted, streamlined genetic education and testing approach in peridiagnostic PC patients. Methods: As part of a pilot quality improvement initiative, patients with a diagnosis of exocrine PC seen in a single academic practice were offered streamlined, video-assisted genetic education followed by germline testing. Patient eligibility for this pilot included: new diagnosis or radiographic suspicion of PC; English language proficiency; and no prior germline testing. After this approach was presented by the medical oncology team, eligible patients viewed a 9-minute educational video describing the goals, pros, and cons of germline genetic testing. After watching the video, patients were given the option to proceed with testing that day. Patients with pathogenic mutations were referred for formal post-test genetic counseling, and patients with variants of uncertain significance (VUSs) were referred on a case-by-case basis. Following IRB approval, we conducted a retrospective review of the experience of all patients presenting to this pilot site from April-Dec 2023. Results: During the study period, 56 new patients with exocrine PC presented to the pilot site. 50 patients were eligible for participating in the pilot program. All patients, except one who declined on the basis of transferring care, consented to testing (49/50; 98%). Median patient age was 71, 49% were female. Race distribution was: White (30), Asian (6), Black (4), Other (2), Declined (7). Median time from patient diagnosis to testing was 11 days. One patient had a germline ATM mutation, and this patient was seen for formal posttest counseling 18 days after testing was initiated. Seven patients had VUSs. Six new patients presenting during the study period were not eligible for this pilot, all due to limited English proficiency. All 6 of these patients underwent genetic testing after translation service assisted counseling by either the primary oncology or cancer genetics team. Conclusions: Video assisted point-of-care genetics education and testing led to nearly universal uptake of genetic testing in peridiagnostic PC patients. This workflow was feasible, timely, and optimized use of genetic counseling resources.

Screening to understand pregnancy preferences and offer referrals and treatment (SUPPORT): Results of a pilot quality improvement initiative.

To assess the feasibility of integrating a pregnancy intention assessment screening algorithm into the electronic medical record (EMR) at a multispecialty clinic focused on the health of women and people assigned female at birth (AFAB). This pilot quality improvement project implemented a series of clinician reminders, new data fields in the patient record, and templated clinical notes to prompt care providers across specialties to ask AFAB reproductive age individuals about their desire for future pregnancies. Investigators created a novel screening question based on prior literature and expert input. Prospective observational study of one year of during-intervention EMR data on screening uptake and documentation, contraceptive use, and referrals to obstetrics and gynecology (OBGYN) for preconception care, contraceptive care, and related services. SUPPORT launched in February 2020 and was paused for 6 months due to the COVID-19 pandemic. During the intervention period through July 2021, 18% of patients for whom the automated screening reminder was activated had a documented pregnancy intention. Patients were screened in OBGYN, internal medicine, and eight subspecialty medical clinics. Among those screened, individuals who reported they did not desire pregnancy in the next year were more likely to use contraception (aOR 1.8, 95% CI 1.1, 3.1). Individuals that did desire pregnancy in the next year were more likely to be subsequently referred to OBGYN (aOR 2.7, 95% CI 1.2, 6.0). Despite the competing demands of the COVID-19 pandemic, the SUPPORT intervention was utilized at higher rates than prior similar interventions and across multiple disease specialties. Results from the SUPPORT pilot suggest that pregnancy intention screening of reproductive age AFAB individuals with an EMR-based screening prompt is feasible at scale.

A reduction in hospital length of stay reduces costs for colorectal surgery: an economic evaluation of the National Surgical Quality Improvement Program in Singapore.

In 2017, the National Surgical Quality Improvement Program (NSQIP) was introduced in the Department of Colorectal Surgery at Singapore General Hospital as a pilot quality improvement initiative. This study aimed to examine the cost-effectiveness of NSQIP by evaluating its effects on surgical outcomes, length of stay (LOS), and costs. We retrospectively reviewed patients undergoing colorectal surgery (2017-2020). Patients were divided into two cohorts: pre-NSQIP (2017-2018) and post-NSQIP (2019-2020). Outcomes evaluated were 30-day postoperative complications, LOS, and costs. Total cost-savings from NSQIP intervention's impact on LOS were estimated using a decision model with a one-way sensitivity analysis. Multivariate logistic regression was performed to identify factors for prolonged LOS. 1905 patients underwent colorectal surgery, with 996 in the pre-NSQIP cohort and 909 in the post-NSQIP cohort. A significant reduction in overall postoperative complications of 4.7% was observed in the post-NSQIP cohort (36.5% vs. 31.8%, p = 0.029). Patients in the post-NSQIP cohort had a shorter median LOS (8.0 vs. 6.0days, p < 0.001). The implementation of NSQIP resulted in an 8.5% decrease in prolonged LOS > 6days (p < 0.001), saving S$0.31 million on LOS. Total costs per case were reduced by 20.8% following NSQIP (S$39,539.05 vs. S$31,311.93, p < 0.001). Implementing NSQIP has significantly reduced overall postoperative complications, LOS, and costs and achieved cost savings following colorectal surgery.

Leading for High Reliability During the COVID-19 Pandemic: A Pilot Quality Improvement Initiative to Identify Challenges Faced and Lessons Learned

Leading for High Reliability During the COVID-19 Pandemic: A Pilot Quality Improvement Initiative to Identify Challenges Faced and Lessons Learned

Determinants of Blood Donor Retention in a Nigerian Tertiary Health Care Blood Transfusion Facility: A Pilot Quality Improvement Initiative

Determinants of Blood Donor Retention in a Nigerian Tertiary Health Care Blood Transfusion Facility: A Pilot Quality Improvement Initiative

Determinants of Blood Donor Retention in a Nigerian Tertiary Health Care Blood Transfusion Facility: A Pilot Quality Improvement Initiative

Determinants of Blood Donor Retention in a Nigerian Tertiary Health Care Blood Transfusion Facility: A Pilot Quality Improvement Initiative

Implementation of a Clinical Decision Support (CDS) Tool for the Management of Functional Constipation in Pediatric Primary Care.

Constipation is common in general pediatrics and often results in potentially unnecessary referrals to pediatric gastroenterology. We hypothesized that a clinical decision-making tool would support primary care providers to manage pediatric constipation, improve workflow, and prevent unnecessary subspecialty care. In this pilot quality improvement initiative, a multidisciplinary team completed a root cause analysis related to challenges with the care of pediatric constipation. The results informed the development of interventions including a Clinical Decision Support tool and patient educational materials embedded within an existing order-set in the electronic health record, which we implemented in our primary care network. The use of the updated order-set continues to increase monthly, and there is reported improved workflow and increased confidence by providers. These interventions demonstrated that it is feasible to implement tools to support primary care clinicians in their management of pediatric patients with constipation.

Pregnancy Intention Screening in Patients With Systemic Rheumatic Diseases: Pilot Testing a Standardized Assessment Tool.

ObjectiveSystemic rheumatic conditions affect reproductive‐aged patients and often require potentially teratogenic medications. We assessed the feasibility and impact of a standardized pregnancy intention screening question (One Key Question [OKQ]) in a large academic rheumatology practice.MethodsThis 6‐month pilot quality improvement initiative prompted rheumatologists to ask female patients aged 18 to 49 years about their pregnancy intentions using OKQ. We administered surveys to assess rheumatologists’ barriers to and comfort with reproductive health issues. We performed chart reviews to assess uptake and impact on documentation, comparing charts with OKQ documented with 100 randomly selected charts eligible for pregnancy intention screening but without OKQ documented.ResultsWhen we compared 32 of 43 preimplementation responses with 29 of 41 postimplementation responses, the proportion of rheumatologists who reported they were very comfortable with assessing their patients’ reproductive goals increased (31%‐38%) and the proportion reporting obstetrics and gynecology (OB/GYN) referral challenges as barriers to discussing reproductive goals decreased (41%‐21%). During the implementation period, 83 of 957 (9%) eligible patients had OKQ documented in their chart. Female providers were more likely to screen than male providers (odds ratio 2.42, 95% confidence interval 1.21‐4.85). Screened patients were more likely to have their contraceptive method documented (P < 0.001) and more likely to have been referred to OB/GYN for follow‐up (P = 0.003) compared with patients who were not screened with OKQ.ConclusionAlthough uptake was low, this tool improved provider comfort with assessing reproductive goals, the quality of documentation, and the likelihood of OB/GYN referral. Future studies should examine whether automated medical record alerts to prompt screening increase uptake.

Pregnancy Risk Screening and Counseling for Women Veterans: Piloting the One Key Question in the Veterans Healthcare Administration.

Women veterans have a high prevalence of comorbidities that increase the risk of adverse pregnancy outcomes. Screening for pregnancy desires in primary care provider (PCP) visits offers an opportunity to optimize preconception health. This pilot quality improvement initiative sought to assess Veterans Healthcare Administration provider preferences on One Key Question (OKQ) implementation, identification of veterans' reproductive needs, and the effect of training on documentation in a women's primary care clinic in Salt Lake City, Utah. We hosted OKQ training sessions for providers and staff, audio recorded group discussions on implementation barriers, and explored themes. Women veterans presenting for a PCP visit in July 2018 self-completed a paper OKQ screening tool. We calculated summary statistics on responses. We conducted a pre-post analysis, with respect to training sessions, to measure for changes in family planning documentation during PCP visits. Nineteen providers and staff completed the training. They acknowledged the importance, but believed that the screening tool should be completed by veterans and not be provider prompted. Forty-two women veterans completed the screening tool: 21% desired pregnancy in the next year and 26% desired contraceptive information. Chart reviews found a nonsignificant increase in current contraceptive method documentation between periods (20% vs 37%; P = 0.08), a decline in documentation of reproductive goals (22% vs 3%; P = 0.02), and no significant change in counseling. Veterans identify reproductive needs via the OKQ screening tool, but provider documentation did not reflect changes in care following training. Further study is necessary to develop an optimal, patient-centered tool and implementation plan to support women veterans in their reproductive goals.

Identifying the risk of suicide among adolescents admitted to a children's hospital using the Ask Suicide-Screening Questions.

Suicides are now the second leading cause of death among teenagers and young adults, 10-24. Many people who die by suicide visit a healthcare provider in the months before their death. Unfortunately, many healthcare clinicians do not routinely screen for mental health concerns such as suicide risk even though the American Academy of Pediatrics recommends screening adolescents for suicide risk. The Ask Suicide-Screening Questions (aSQ), a four-question screening instrument, was administered by nurses to all patients, 12 years and older, admitted to the general pediatric wards of a tertiary Children's Hospital. Nursing feedback and comfort levels were assessed before and after the 6-week pilot program. During the 6 weeks, 152 eligible children were admitted to the general pediatric wards and 67 were screened using the ASQ; 3/67 had a nonacute "positive" screen and received a further psychiatric assessment. This pilot quality improvement initiative showed that suicide screening is feasible and acceptable to patients and families in a general pediatric inpatient setting. However, nurses would benefit from further teaching and training around asking suicide screening questions.

Application of Parafilm As a Physical Barrier on CVC Connections Is Feasible and May Reduce Clabsi Among Pediatric HCT Patients

Central line associated bloodstream infections (CLABSI) result in significant morbidity and mortality in hematopoietic cell transplantation (HCT) patients. Pediatric data is sparse, and previous/current interventions may impact bacterial flora and antibiotic resistance. Risks in pediatric HCT patients include prolonged immunosuppression, long-term central venous catheter (CVC) need, and external environmental contamination. Parafilm is made of paraffin and primarily utilized to seal/protect containers in laboratories; applied as a barrier, it significantly reduced CLABSI in TPN-dependent pediatric short gut patients. We hypothesized that parafilm application on CVC connections would be feasible and reduce CLABSI occurrence in pediatric HCT patients. The aims of this non-randomized pilot quality improvement initiative were to examine the feasibility of parafilm as a physical barrier on CVC tubing connections and obtain preliminary data to support its use preventing CLABSI among pediatric HCT patients. This IRB-approved cohort study included pediatric patients ages 0-21, with a tunneled external CVC, who were undergoing allogeneic or autologous HCT for any indication. Patients receiving other interventions to prevent CLABSI were ineligible. Parafilm was supplied in pre-cut 2 × 2 inch, single-use sections. It was applied over the CVC hub (if not connected) or around the CVC connection sites (if connected) and was reapplied at least once daily, as well as when connections were accessed or at the caregiver's discretion. Data were collected on patient, disease, and HCT characteristics as well as standard HCT outcomes and compared to a historical control group. The occurrence of NHSN/CDC-defined CLABSI was compared between groups using pairwise comparison, with significance defined as p Forty-eight patients undergoing first HCT from 6/2015-1/2017 received parafilm and were compared to historical control patients (n=71; HCT in preceding 16 months). No difference in age, sex, indication for HCT, stem cell source, or type of HCT was observed between groups. Patients receiving parafilm had a CLABSI rate of 3.69 per 1000 line days, compared to 4.37 for historical controls (p=0.6919). Univariate analysis of all patients demonstrated no impact of HCT type or sex on CLABSI rate, although the rate was lower in patients transplanted for a non-malignant disease compared to solid tumor (p=0.0326). Application of parafilm as a protective CVC barrier in pediatric HCT patients is feasible, and it may lead to a decrease in CLABSI. Sub-analyses are ongoing to see if parafilm may be more beneficial in subset(s) of patients, such as younger aged patients who remain in diapers or patients with graft-versus-host disease. Future trials will examine the use of a novel device, created specifically to protect CVC hubs/connection sites from environmental contamination, to reduce CLABSI.

Assurance of Myeloid Growth Factor Administration in an Infusion Center: Pilot Quality Improvement Initiative.

Four incident reports involving missed doses of myeloid growth factors (MGFs) triggered the need for an outcome-driven initiative. From March 1, 2015, to February 29, 2016, at University of California Irvine Health Chao Infusion Center, 116 of 3,300 MGF doses were missed (3.52%), including pegfilgrastim, filgrastim, and sargramostim. We hypothesized that with the application of Lean Six Sigma methodology, we would achieve our primary objective of reducing the number of missed MGF doses to < 0.5%. This quality improvement initiative was conducted at Chao Infusion Center as part of a Lean Six Sigma Green Belt Certification Program. Therefore, Lean Six Sigma principles and tools were used throughout each phase of the project. Retrospective and prospective medical record reviews and data analyses were performed to evaluate the extent of the identified problem and impact of the process changes. Improvements included systems applications, practice changes, process modifications, and safety-net procedures. Preintervention, 24 missed doses (20.7%) required patient supportive care measures, resulting in increased hospital costs and decreased quality of care. Postintervention, from June 8, 2016, to August 7, 2016, zero of 489 MGF doses were missed after 2 months of intervention ( P < .001). Chao Infusion Center reduced missed doses from 3.52% to 0%, reaching the goal of < 0.5%. The establishment of simplified and standardized processes with safety checks for error prevention increased quality of care. Lean Six Sigma methodology can be applied by other institutions to produce positive outcomes and implement similar practice changes.

Group Visits for Overdose Education and Naloxone Distribution in Primary Care: A Pilot Quality Improvement Initiative.

Opioid prescribing for chronic pain significantly contributes to opioid overdose deaths in the United States. Naloxone as a take-home antidote to opioid overdose is underutilized and has not been evaluated in the high-risk chronic pain population. The objective was to increase overdose education and naloxone distribution (OEND) to high-risk patients on long-term opioid therapy for pain by utilizing group visits in primary care. Quality improvement intervention among two primary care clinics. A large, academic facility within the Veterans Health Administration. Patients prescribed ≥100 mg morphine-equivalent daily dose or coprescribed opioids and benzodiazepines. One clinic provided usual care with respect to OEND; another clinic encouraged attendance at an OEND group visit to all of its high-risk patients. We used attendance at group visits, prescriptions of naloxone issued, and patient satisfaction scores to evaluate this format of OEND. Group OEND visits resulted in significantly more naloxone prescriptions than usual care. At these group visits, patients were engaged, valued the experience, and all requested a prescription for the naloxone kit. This quality improvement pilot study suggests that OEND group visits are a promising model of care.

What Patients Value About Reading Visit Notes: A Qualitative Inquiry of Patient Experiences With Their Health Information.

BackgroundPatients are increasingly asking for their health data. Yet, little is known about what motivates patients to engage with the electronic health record (EHR). Furthermore, quality-focused mechanisms for patients to comment about their records are lacking.ObjectiveWe aimed to learn more about patient experiences with reading and providing feedback on their visit notes.MethodsWe developed a patient feedback tool linked to OpenNotes as part of a pilot quality improvement initiative focused on patient engagement. Patients who had appointments with members of 2 primary care teams piloting the program between August 2014-2015 were eligible to participate. We asked patients what they liked about reading notes and about using a feedback tool and analyzed all patient reports submitted during the pilot period. Two researchers coded the qualitative responses (κ=.74).ResultsPatients and care partners submitted 260 reports. Among these, 98.5% (256/260) of reports indicated that the reporting tool was valuable, and 68.8% (179/260) highlighted what patients liked about reading notes and the OpenNotes patient reporting tool process. We identified 4 themes describing what patients value about note content: confirm and remember next steps, quicker access and results, positive emotions, and sharing information with care partners; and 4 themes about both patients’ use of notes and the feedback tool: accuracy and correcting mistakes, partnership and engagement, bidirectional communication and enhanced education, and importance of feedback.ConclusionsPatients and care partners who read notes and submitted feedback reported greater engagement and the desire to help clinicians improve note accuracy. Aspects of what patients like about using both notes as well as a feedback tool highlight personal, relational, and safety benefits. Future efforts to engage patients through the EHR may be guided by what patients value, offering opportunities to strengthen care partnerships between patients and clinicians.

Feasibility of a clinic-based central line care teach-back program for pediatric oncology families.

183 Background: Pediatric oncology (PO) patients with central lines (CLs) are at high risk for CL associated bloodstream infections (CLABSI), which increase morbidity, mortality, and costs. A large portion of ambulatory CL care in the home is provided by families who often have limited opportunities to develop the needed skills and adhere to best practice line care. Methods: A pilot quality improvement initiative was undertaken from 5/2015-6/2016 to develop a coaching program for families to demonstrate external CL care with a nurse during a routine clinic visit (teach-back), either on a simulation model or the patient. Tests of change were implemented to add teach-backs during routine clinic visits and ensure teach-back documentation in the medical record. Initial steps included assessing family interest in teach-backs by conducting surveys about CL care at home and unstructured incorporation into routine care by existing clinic nursing staff. After assessment of the pilot phase, targeted interventions started April 2016 including dedicated staff for scheduling, tracking, and performing teach-backs during routine clinic visits; culture change including an expectation that all families would participate and on-going staff education about the program; language change to increase participation by avoiding family perception of being tested; and incentives (gift-card raffle) for nurses to provide coaching. Results: Before April 2016, less than 25% of families participated due to a combination of family refusal; lack of nursing availability, space, or time; and inability to approach prior to line removal. In April 2016, 52% of families participated, reaching 90% by June 2016. Informal feedback from both staff and patient/family participants suggested increased job satisfaction by nurses and wide acceptance by all. In addition, many families participated in multiple teach-back sessions to improve line care skills. Conclusions: A CL teach-back program in a busy ambulatory PO clinic is feasible, but requires dedicated resources and culture change. Ongoing improvements are in place to ensure sustainability of the program and measure the impact on ambulatory CLABSI rate and family distress and line care skills.

Outpatient advance care planning for patients with metastatic cancer: a pilot quality improvement initiative.

Despite American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) guidelines recommending that oncologists discuss advance care planning (ACP) with patients with stage IV cancer early in treatment, in standard practice ACP remains a late step of a terminal illness. ACP preserves comfort and dignity at the end of life, ensuring patients receive the care that they desire. A feasibility study in patients with stage IV cancer was developed to test whether incorporating ACP immediately after a stage IV cancer diagnosis is feasible. Inclusion criteria were consecutive new gastrointestinal and thoracic oncology patients treated by one of two oncologists. The project included creation of new workflow; development of an ACP patient education guidebook; training seminars for oncology staff; and enhancements to the electronic health record (EHR) to improve ACP documentation. The oncologists recorded 33 of 48 (69%) advance directive notes (ADNs) and 22 of 48 (46%) code status orders (CSOs) in the EHR of patients newly diagnosed with stage IV cancer by following ACP protocol during the 6-month trial period. Twenty-one of 33 ADNs were entered within 7 days of first consultation. The median time to ADN placement was 1 day after consultation. Twenty-two of 33 patients with ADNs had CSOs placed, of which 16 were do-not-resuscitate (DNR) and 6 were full code. One year prior to the feasibility study, only 1 of 75 deceased patients of the two oncologists had outpatient ADNs and CSOs. Outpatient ACP is feasible early in the care of patients with stage IV cancer through systematic improvement in workflow and motivated providers. Education and infrastructure were pivotal to routine development of advance care plans.

Compliance to select quality measures in a non-QOPI subspecialty academic practice: A pilot quality improvement initiative.

261 Background: ASCO’s Quality Oncology Practice Initiative (QOPI) includes core, disease and domain-specific quality measures. QOPI Certification requires an overall score of 72.62% in 24 core and 80% in adjuvant quality measures. There are currently 137 oncology practices with only 10 in New York State having achieved QOPI certification. At Mount Sinai Medical Center (MSMC), the large hematology and oncology practice is subdivided into disease-specific groups functioning semi-autonomously. The practice is not QOPI certified. With no prior measures of quality adherence in the overall or subspecialty groups we aimed to determine the baseline compliance to QOPI disease specific measures. Methods: All colorectal patient charts seen in the GI oncology group at MSMC over a four-month period from February 2012 to May 2012 were retrospectively reviewed. The team included two GI oncology physicians, one physician assistant and one registered nurse. Each member was assigned roles to meet the defined quality measures prior to project initiation. A separate auditor reviewed medical records during the study period. 17 quality measures were evaluated including 10 core and one adjuvant colorectal disease-specific measure. Results: The average compliance with the QOPI measures tested was 96%, 98%, 92%, and 97% (February to May respectively). The measures with the lowest compliance were not required for certification but included for internal review after recent practice changes. Despite the high compliance rate, compliance for an individual patient in all 17 categories was achieved in only 48% of patients. Conclusions: This study highlights that adherence to quality benchmarks in a disease-specific subset of a larger oncology program can be achieved by identifying staff, assigning roles and defining practice structure. The GI Oncology group attained a level of compliance with quality measures that would result in QOPI certification if maintained practice-wide. This study serves as the basis for a larger internal audit of quality measures across other subspecialty disease-specific areas of hematology and oncology at MSMC.