Plan-Do-Study-Act Research Articles

Improved oral anticancer medication (OAM) adherence/toxicity assessment documentation.

409 Background: Based on national OAM guidelines and to improve patient safety, most OAM programs monitor toxicity/adherence within 10-14 days following OAM initiation. At our institution, only 50% of toxicity/adherence documentation tasks were completed by day 10 of cycle 1 after initiating OAM. We aimed to increase toxicity/adherence documentation tasks to at least 75% by day 10 of cycle 1 following a newly prescribed OAM in collaboration with Hematology/Oncology Pharmacy Association/American Society of Clinical Oncology 2022 quality training program (QTP). Methods: We engaged a multidisciplinary team to gather/interpret data, create process map, and identify barriers. Outcome measure was documentation of toxicity/adherence by day 10 of cycle 1. Included all cancer patients initiating OAM treatment plan. Excluded those on intravenous/oral regimens and gynecology/oncology patients. Process measure was percentage of 9 crucial tasks identified as necessary to appropriately document toxicity/adherence. Balance measures included provider visits, emergency department visits, telephone/electronic medical record OAM-related messages, and nursing satisfaction. A cause-and-effect diagram, pareto chart and prioritization matrix were used to narrow focus of improvement changes. Two plan-do-study-act (PDSA) cycles were conducted from January 2023-June 2023. All data were analyzed using Statistical Process Control Charts with 3-sigma control limits. Results: Original high-impact, easy-to-implement intervention (re-training staff) delayed due to institutional-directed intervention (education documentation retraining due to The Joint Commission survey). Education documentation retraining did not significantly improve toxicity/adherence task completion rate (50% to 53%) by improved provider and emergency department visits (16.7% and 12.5% to 0%) (see Table 1). Nursing turnover, lack of formal OAM process training and institutional buy-in for OAM program/training likely contributed to results. Re-training supported with institutional buy-in completed. PDSA cycle 2 data collection is ongoing; preliminary results show no change in task completion rate. Conclusions: Education documentation and retraining alone is insufficient to improve OAM toxicity/adherence documentation rates. Other interventions are needed to attain our goal.[Table: see text]

Improving ambulatory infusion drug delivery through alarm management using a quality improvement model and team learning.

472 Background: A quality outpatient cancer program depends on the accurate delivery of chemotherapy using a computerized ambulatory infusion pump to deliver a therapeutic dose of chemotherapy for patients. Between April and July 2021, our cancer center hotline reported an excessive rate of 60% of ambulatory pump were generating alarms. This resulted in interruptions in dose delivery, disruptions in clinical workflows, and negatively impacted patient satisfaction. Methods: A multidisciplinary team of frontline nurses, pharmacists, nurse leaders, and quality specialists was assembled to analyze six months of alarm data using a plan-do-study-act (PDSA) model. Quality tools were utilized to determine the root cause of the alarms and arrive at solutions to improve drug delivery by reducing alarms and calls to the infusion hotline. The team discovered 49% (n=22/45) of alarm could not be resolved, resulting in a dose interruption of the planned chemotherapy infusions. Patients returned to the infusion suite without receiving the total dose of chemotherapy as ordered. A full 70% of the hotline calls (n=16/22) were due to a “No Disposable” alarm code. Analysis of these returned units by both our group and the vendor led us to recommend a more advanced replacement model which was implemented in June/July of 2022. Results: Between July and December 2022, MCI outpatient ambulatory pump medication variances related to “No Disposable” improved by 100%. A total of 34 calls were received by the Hotline Nurse with 91% (31/34) of calls were successfully resolved. None of the ambulatory patients experienced an interruption in chemotherapy drug delivery. Conclusions: Forming a multidisciplinary working group resulted in a timely and significant improvement in chemotherapy safety using the PDSA model of quality improvement. Most importantly, confidence in chemotherapy drug delivery using ambulatory infusion pump was expressed by infusion nurses, pharmacists, and medical providers.

Improving bivalent COVID-19 vaccination rates among adult patients with cancer: An ASCO/CDC initiative.

427 Background: Vaccines protect immunosuppressed cancer patients from developing severe illness, hospitalization, and death. However, vaccination rates in cancer patients remain low, jeopardizing their long-term outcomes. Kaiser Permanente Northern California (KPNC) is one of eight health systems in the U.S. selected to participate in the Specialty Societies Advancing Adult Immunization Project awarded to ASCO and funded by the CDC and the Council of Medical Specialty Societies (CMSS). In conjunction with the ASCO Quality Training Program, we assessed the barriers to bivalent COVID-19 vaccination and applied quality improvement initiatives to increase the vaccination rate for adult cancer patients at KP Roseville. Our aim was to achieve a 50% bivalent COVID-19 vaccination rate by June 2023. Methods: Our population of interest included adult cancer patients receiving intravenous or oral chemotherapy. To assess the barriers to bivalent COVID-19 vaccinations, we distributed 100 surveys to oncology patients. We then performed two PDSA (Plan-Do-Study-Act) cycles for quality improvement and monitored the trends in bivalent COVID-19 vaccination rates from 3/20/2023 to 5/25/2023 with data extracted from electronic health records. Results: Surveys were returned from 63 of 100 oncology patients (35 unvaccinated, 28 vaccinated). Barriers to bivalent COVID-19 vaccination included lack of awareness (37%), fear of interaction with treatment (17%), inconvenience (14%), did not want it (14%), did not elaborate (14%), and prior reaction to the vaccine (3%). We conducted PDSA cycle 1 from 3/20/2023 to 4/14/2023. To improve awareness, we added bivalent COVID-19 vaccine content to the mandatory class for new cancer patients and distributed educational flyers at the oncology clinic. Only 1 out of 61 attendees during this period received vaccination following the class. PDSA cycle 2 was conducted from 5/1/2023 to 5/25/2023. We updated the educational flyer with the latest FDA/CDC recommendations. We also implemented a bi-weekly onsite vaccine station at the oncology clinic waiting area to improve convenience. By 5/25/2023, 78 of 320 eligible oncology patients received bivalent COVID-19 vaccines. As a result, bivalent COVID-19 vaccination rates at KP Roseville increased from 45% to 49% by June 2023. Conclusions: Despite the survey showing a lack of awareness as a major barrier to vaccination, increased awareness by itself had minimal impact on bivalent COVID-19 vaccination rates. However, the addition of a convenient onsite vaccine station in the oncology clinic along with providing education resulted in an increase in vaccinations. Our interventions led to promising results (49%) in the setting of generalized vaccine fatigue in the U.S. Our future goal is to expand these efforts to other KPNC oncology centers, establish stable onsite vaccine stations and include additional vaccine types.

Enhancing policy communication: Establishing a formal channel for disseminating policy updates to improve staff access and engagement.

43 Background: Institutional policies serve as a fundamental framework that enables staff to fulfill their roles and responsibilities. A comprehensive analysis of 5 months of policy access log data extracted from Ellucid, our policy management system, showed that the average views per updated pharmacy policy ranged from 0 to 3 within the 7-day period following the updates. These findings reveal a notable lack of visibility and limited user engagement with policy updates within the pharmacy department, which consists of approximately 300 staff members. To bridge this gap and enhance policy communication, we aim to keep pharmacy staff well-informed and provide easy access to the most up-to-date policies at Dana-Farber Cancer Institute. Methods: The study employed the Plan-Do-Study-Act (PDSA) cycle methodology to guide the quality improvement process. An assessment of preintervention data from the policy access log was conducted to identify the problem. Subsequently, a survey was designed and administered to evaluate staff’s ability to navigate the policy management system, their awareness of policy updates, and their preferred communication channels for receiving updates. Descriptive statistics were utilized to summarize the survey responses, providing valuable diagnostic data. Additionally, a Statistical Process Control (SPC) chart was employed to monitor the process change over time, ensuring ongoing improvement. Results: The survey was distributed to select pharmacy staff in various areas, with a response rate of 30% (13/42). The majority of participants (80%) indicated that email is their preferred communication method for receiving policy updates on a quarterly basis. In the first cycle of the PDSA, an email communication channel was established using the Staffbase program to disseminate policy updates and was piloted within the pharmacy department. The email communication included a summary of all pharmacy policy updates from the past three months, with key changes highlighted. Each policy was attached with a hyperlink directing staff to the full policy on Ellucid, facilitating convenient access. Staff were also provided with education on navigating the communication email. These interventions resulted in a two-fold increase in the policy access rate compared to the baseline. Conclusions: The implementation of a formal communication channel for policy updates, along with improved accessibility to relevant content, successfully enhanced pharmacy staff access to policies. Ongoing monitoring of the policy access log will be maintained to ensure the sustainability of these improvements in the future.

Outpatient versus inpatient delivery of intensive chemotherapy for patients with hematological neoplasms: A 5-year experience from a tertiary center.

7 Background: There has been a shift towards the utilization of outpatient delivery of intensive chemotherapy due to potential improvements in quality of life measures and resource utilization. Herein, we aim to report the findings of a five-year quality improvement project comparing the outcomes and healthcare costs of outpatient and inpatient delivery of post-induction intensive chemotherapy amongst patients with hematological neoplasms. Methods: Using Plan-Do-Study-Act (PDSA) methodology, a multidisciplinary team was established to determine appropriate strategies for delivering outpatient intensive chemotherapy and improving healthcare resource utilization. Records of patients receiving inpatient chemotherapy from 2016-2017 were retrospectively reviewed. Process mapping was utilized to design interventions to facilitate the outpatient delivery of chemotherapy. The interventions included the initiation of an outpatient chemotherapy clinic, creating clinical pathways for chemotherapy protocols, developing educational materials for patients and healthcare staff, and facilitating access to emergency care services. During 2018-2022, patients were prospectively identified and enrolled to receive outpatient chemotherapy. Results: 288 patients were enrolled with 70 (24.3%) receiving inpatient chemotherapy and 218 (75.7%) receiving outpatient chemotherapy. The median age for the inpatient and outpatient chemotherapy groups was 34 and 38, respectively [P = 0.027]. Patients enrolled in this project had diagnoses of acute leukemia (53.2%), Hodgkin’s lymphoma 16.3%, and non-Hodgkin’s lymphoma (30.6%). Febrile neutropenia was observed in 64.3% of patients receiving inpatient chemotherapy and in 27.5% of patients receiving outpatient chemotherapy [P < 0.001]. Death during the course of the chemotherapy regimens was seen in 4% of patients receiving inpatient chemotherapy compared to 0.5% of outpatient chemotherapy patients [P = 0.003]. Outpatient chemotherapy resulted in a 53.4% reduction in total bed days occupied. The estimated total cost saving due to this intervention during the years of 2018-2022 was $2.88 million USD. Conclusions: Outpatient delivery of intensive chemotherapy for hematological malignancies is an effective approach which results in comparable safety outcomes and significant improvements in cost-effectiveness and resource utilization.

Reducing Environmental Impacts at a Midwestern Academic Medical Center: Making Carbon Emissions Reduction a Reality

(1) Background: Human-generated greenhouse gas (GHG) emissions are the largest contributor to climate change worldwide. Climate change negatively impacts human and planetary health, threatening the existence of life on earth. The healthcare industry is responsible for approximately 8.5% of carbon emissions in the United States. Measuring baseline GHG emissions is the first step in emissions reduction. However, very few models of measurement exist for health care organizations. This project aimed to develop and implement a program to measure and track GHG emissions at a midwestern academic medical center (MAMC) and to educate staff on how to manage the process. (2) Methods: A Plan, Do, Study, Act (PDSA) cycle and Quality Improvement methodology were used to develop, implement, and assess a standardized GHG emission inventory process to measure Scope 1 and Scope 2 baseline emissions and provide virtual training and education to the accountable staff. A pre- and post-survey design was used to measure the knowledge and readiness of the staff after the implementation of the GHG inventory training. (3) Results: The GHG inventory process was validated through an external verification process, and the measurement of Scope 1 and Scope 2 baseline GHG emissions was completed and verified for accuracy through a data comparison review. The pre-post-training survey showed an increase in the knowledge and readiness of staff to maintain a GHG inventory. (4) Conclusions: This work shows the feasibility of obtaining baseline GHG emissions data at large medical centers. It represents the initial phase of the overarching goal to develop site-wide and system-wide carbon reduction strategies and a climate action plan within this health system.

Assessment of quality improvement of simulation-based learning using an evidence-based framework in dental education.

Simulation-based education is of paramount importance in a dental pre-clinical setting. Hence, continuous quality improvement is crucial to optimize students' knowledge and clinical skills. This study aimed to evaluate the impact of evidence-based simulation learning (EBSL) compared with traditional-based simulation learning (TBSL) using Plan-Do-Study-Act (PDSA) model. This quality improvement project was undertaken at a private university. Guided by the PDSA model, rubber dam application tasks were conducted in the simulation lab in 2 phases. Phase 1 included TBSL and phase 2 included EBSL comprising of 2 PDSA cycles. 'Plan' stage involved obtaining feedback from students and the concerned staff. 'Do' stage included implementation of EBSL in eight steps adopted from Higgins's framework. 'Study' stage evaluated the outcomes and in 'Act' stage amendments were made to the first EBSL cycle. In the second PDSA cycle re-implementation and evaluation of the rubber dam application exercises were carried out. Descriptive data were presented as percentages and mean scores were compared using paired t-test. Thirty-seven year 2 students participated in this study. A significant improvement in the mean scores was observed between TBSL and EBSL (3.02 + 0.16 and 3.91 + 0.27, respectively, p < .001) using PDSA model with the highest mean score for rubber dam application in the second PDSA cycle for EBSL (4.00 + 0.01). Ninety-five per cent of the students provided positive feedback pertaining to EBSL. EBSL was effective in achieving high student satisfaction, desired knowledge, and skills required during simulation-based exercises. The PDSA cycle can be considered to optimize pre-clinical skills learning.

A Trainee-Led Quality Improvement Project Using Change Management Theory to Improve Bedside Rounding.

The coronavirus disease 2019 pandemic disrupted the practice of family-centered rounds. After the height of the pandemic, a trainee-led team identified a low percentage of bedside rounds on general pediatrics resident teams and combined a quality improvement framework and change management theory to increase bedside rounds. Initial efforts focused on a single general pediatrics team with the aim to increase bedside rounds from 18% to 50% within 6 months and sustain improvement for 12 months. A second aim was to increase bedside rounds from 7% to 50% for all general pediatrics resident teams within 6 months of spread. The Model for Improvement informed the identification of 3 primary drivers of bedside rounds: knowledge, culture, and logistics. Twelve plan-do-study-act (PDSA) cycles were implemented. Measures included the percentage of bedside rounds (primary outcome), caregiver attendance (secondary outcome), and nurse attendance and rounding time (balancing measures). For the initial team, 13 522 patient days were analyzed for the primary outcome with the average percentage of weekly bedside rounds increasing from 18% to 89% with 12 months of sustained improvement. The spread of the intervention to all teams revealed an increase in bedside rounding from 7% to 54%. The most significant improvements occurred after PDSA cycle 2, a communication bundle, and PDSA cycle 5, when the project was spread to all teams. This trainee-led initiative reveals the strength of the incorporation of change management theory within a quality improvement framework, resulting in rapid and sustainable increase in bedside rounds.

Immediate Skin to Skin Contact and Zero Separation of Mother Infant Dyads Among Healthy Term Infants Delivered Vaginally: A Quality Improvement Initiative in a Tertiary Care Institute in South India

Background The neonatal resuscitation program (NRP) recommends immediate skin-to-skin contact (SSC) of the neonate with the mother’s abdomen. Early establishment of SSC has increased the duration of breastfeeding and decreased neonatal morbidity significantly. Objective To achieve immediate SSC and zero separation of infant–mother dyads for a minimum of 30 min in vaginally born healthy term babies from 0% to 50% over 3 months by implementing a quality improvement (QI) initiative. Methods A QI initiative was undertaken at the maternity-newborn care unit of a tertiary-care hospital between March 2022 and December 2022. A team including neonatologists, obstetricians, pediatric postgraduates, and nurses (both neonatal and obstetric) in the concerned areas was identified. Using 5-why technique and fishbone analysis, the root cause analysis was done. Two plan-do-study-act (PDSA) cycles were undertaken. First, sensitization of healthcare personnel was done, and a written policy was made. Efforts were made to sustain the QI. Continuous surveillance, internal audits, and regular interprofessional team meetings were carried out. Results Prior to this QI, baseline data showed that no babies received SSC for 30 min. During the first PDSA cycle, 16.6% (4/24) of babies received SSC and zero separation for 30 min. During the II PDSA cycle, among 46 eligible neonates, 50% (23/46) received SSC &gt;30 min. During the sustenance phase, among 262 eligible neonates, 75.2 % (197/262) received &gt;30 min of SSC immediately after delivery. Conclusion Immediate SSC and zero separation for 30 min could be achieved by implementing simple measures through this QI initiative. The major hurdles, including the knowledge gap, fear, and safety of neonates, were tackled through simple strategies like education sessions, ergonomic modification, and sensitization of the healthcare team.

Improving Utilization of a Nursing-Initiated Supportive Medication Order Panel in the Inpatient Setting.

Many medications are low-risk but must undergo the same ordering process as high-risk medications in the inpatient setting. Nurses identify the need for supportive medications and notify providers. An order panel and policy were developed to allow nurses to order low-risk, supportive medications. The aim of this study was to increase order panel utilization from a 6% to a goal of 15%. This was a quality improvement study at a 1000-bed academic medical center. Five plan-do-study-act (PDSA) cycles were implemented. The primary end point was order panel utilization, and secondary end points were individual nursing unit utilization and the number of orders for each medication on the panel. After each PDSA cycle, order panel utilization improved to 7.8%, 13.2%, 7.5%, 10.2%, and 10.6%, respectively. The units using the order panel most often were general medicine (n = 95, 28%), medical intensive care (n = 71, 21%), and inpatient oncology (n = 40, 12%). The medication most frequently ordered was lanolin alcohols-mineral oil with petrolatum (Eucerin) cream (n = 220, 28%). Order panel utilization improved from a baseline of 6% to an average of 9.9%. Increasing awareness of the order panel and adding medications will contribute to improvement in order panel utilization in the long-term.

Feasibility of implementing patient-reported outcome measures into routine breast cancer care delivery using a novel collection and reporting platform.

imPROVE is a new Health Information Technology platform that enables systematic patient-reported outcome measure (PROM) collection through a mobile phone application. The purpose of this study is to describe our initial experience and approach to implementing imPROVE among breast cancer patients treated in breast and plastic surgery clinics. We describe our initial implementation in 4 phases between June 2021 and February 2022: preimplementation, followed by 3 consecutive implementation periods (P1, P2, P3). The Standards for Reporting Implementation Studies statement guided this study. Iterative Plan-Do-Study-Act (PDSA) cycles supported implementation, and success was evaluated using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Qualitative interviews conducted during the preimplementation phase elicited 4 perceived implementation barriers. Further feedback collected during each phase of implementation resulted in the development of brochures, posters in clinic spaces, and scripts for clinic staff to streamline discussions with patients, and the resolution of technical issues concerning patient login capabilities, such as compatibility with cell phone software and barriers to downloading imPROVE. Feedback also generated ideas for facilitating provider interpretation of PROM results. By the end of P3, 2961 patients were eligible, 1375 (46.4%) downloaded imPROVE, and 1070 (36.1% of those eligible, 78% of those who downloaded) completed at least 1 PROM. Implementation efforts across 2 surgical departments at 2 academic teaching hospitals enabled collaboration across clinical specialties and longitudinal PROM reporting for patients receiving breast cancer care; the implementation effort also highlighted patient difficulties with mobile app-based PROM collection, particularly around initial engagement.

Identifying value in healthcare transformation initiatives: an evaluation of an approach to benefits realisation

Benefits realisation management (BRM) aims to facilitate the process of identifying, measuring and tracking desired benefits derived from a project. Improvement methodology frameworks often describe BRM as integral to identifying...

Sustaining extended Kangaroo mother care in stable low birthweight babies in NICU: a quality improvement collaborative of six centres of Karnataka

BackgroundKangaroo mother care (KMC) is a proven intervention for intact survival in preterms. Despite evidence, its adoption has been low. We used a point of care quality improvement (QI) approach...

Improving Early Initiation of Breastfeeding in Newborns Delivered at a Tertiary Care Hospital: A Quality Improvement Study

Introduction Neonatal mortality is the major contributor for under five mortality. WHO and UNICEF have mentioned that it is vital to initiate breastfeeding within the first hour of birth for reducing mortality. In India, it has been reported that only 42.7% babies receive breastfeeding within 1 hour of birth, and at our institute, we noticed only 61% of stable babies delivered vaginally received breastfeeding within 1 hour of birth. So, we planned a quality improvement study at our hospital using POCQI (point of care quality improvement). Aims and Objectives To increase the early initiation of breastfeeding (EIBF) practice in neonates born through vaginal delivery at or above 36 weeks of gestation from the observed baseline of 61% to &gt;85% over 3 months period. Methods The study was conducted in Labor Room of a tertiary care hospital over a period of three months (Dec 2022–Feb 2023) and a sustenance phase from April 2023 to June 2023. A root-cause analysis was done using the fishbone framework focusing on various barriers related to mothers, hospital staff, policy, place, and practices. Based on this, a comprehensive early breastfeeding initiation intervention was planned utilizing Plan-Do-Study-Act (PDSA) cycles. Results At the end of the 3 months, we were able to achieve 100% compliance in EIBF from baseline of 61% and same compliance was maintained during sustenance phase. Run charts used for interpretation showed increase in compliance and reduction in time of initiation of breastfeeding. Conclusion This study brought out various hurdles to EIBF and demonstrated that it can be improved by using simple quality improvement model.

A Quality Improvement Initiative to Increase Documentation of Preferences for Life-Sustaining Treatment in Hospitalized Adults

Portable Orders for Life-Sustaining Treatment (POLST) forms allow patients to codify their preferences for life-sustaining treatments across inpatient and outpatient settings. In 2019 only 29.5% of our hospitalized internal medicine patients with an inpatient do-not-resuscitate (DNR) order and no DNR POLST at admission discharged with a DNR POLST. This presented an opportunity to improve POLST completion and avoid undesired or inappropriate care after discharge. Using electronic health record (EHR) data, the authors identified hospitalized adults (age ≥ 50 years) admitted to an internal medicine service with a DNR order and discharged alive. Patient records were cross-referenced with the state's POLST registry for an active POLST form. Among patients with a missing or full-code POLST form at admission, the authors calculated the proportion with a DNR POLST form completed by discharge. These data were tracked over time with control charts to detect performance shifts following three Plan-Do-Study-Act (PDSA) cycles over 34 months, which included a single educational training on electronic POLST navigation, an EHR discharge navigator notification, and quarterly e-mailed individualized performance reports. The study population (N = 387) was 55.0% male and predominately non-Hispanic white (80.9%). Patients discharging to a skilled nursing facility or hospice were three times more likely to discharge with a DNR POLST compared to patients discharging home. Overall, the proportion of DNR POLST forms completed by discharge increased from 0.36 to 0.60 after three PDSA cycles (p < 0.001). This quality improvement initiative demonstrated improved POLST form completion rates in a target population of adults at elevated risk for readmission and death.

Medication supply at hospital discharge via community pharmacy: a quality improvement study.

Patient delays at the point of their discharge account for more than half a million additional bed days every year in Scotland, United Kingdom. Bottlenecks in discharge medication dispensing contribute to such delays. To test whether the discharge process could be made more time-efficient by utilising community pharmacy supply of medicines on the day of discharge, rather than hospital pharmacy supply. Glasgow Royal Infirmary, Scotland. Local community pharmacy staff received training and communication about each patient discharge. Pharmacies could access an immediate discharge letter (IDL) on a shared electronic record. The existing pandemic law allowed medication dispensing from this IDL, without a prescription. The programme was implemented from June to November 2020, across three Plan-Do-Study-Act (PDSA) cycles. Comparisons were made between the new community pharmacy model and standard hospital model. Across three PDSA cycles, in total 335 patients had community pharmacy supply compared to 376 patients eligible for hospital pharmacy supply. The median time taken from creation of the IDL to final completion was significantly lower in the new community pharmacy model compared to the hospital pharmacy model; 154min (interquartile range (IQR) 82-272min) vs 296min (IQR 197-1281min) p value < 0.000 CONCLUSION: A community pharmacy supply model compared to a standard hospital pharmacy model resulted in a median time saving of 142min per patient. Such a time saving has the potential to deliver a transformational change in patient flow and free up hospital pharmacy staff to deliver other clinical interventions.

Using a quality improvement tool, Plan-Do-Study-Act cycle, to boost TB notification in India post-Covid-19 pandemic

Quality improvement tools such as the Plan-Do-Study-Act (PDSA) cycle hold tremendous potential to improve the quality of healthcare in India. The electronic-PDSA tool was previously developed by CETI (Collaboration to Eliminate TB among Indians) and successfully piloted in small groups. In this study the e-PDSA was scaled up across the nation over a brief 10 week period to boost TB notification by training District Tuberculosis Officers (DTOs) virtually post-Covid-19 pandemic. Quality improvement counselors, who were interns from Masters in Public Health Institutions, were liaisons to “hand-hold” and assist the DTOs through the PDSA cycle. The course was voluntary and offered to all DTOs through Central TB Division and State TB Officers from May 2022 to July 2022. Of the 779 Districts in India and nearly equal number of DTOs, 546 (70%) DTOs enrolled in the course and of these 437 (80%) conducted a PDSA while 342 (43%) districts/DTOs did not enroll or did not complete a PDSA. With a baseline notification in February-March-April 2022 and intervention in May-June-July 2022; 55% of the districts in the PDSA group showed improvement in TB Notification compared to 45% in the non-PDSA group. When data was analyzed by population (not district) there was a trend in increase in notification post-pandemic in both PDSA and non-PDSA groups, and the PDSA group had a slightly higher 5.6 per 100,000 population improvement compared to 5.0 per 100,000 in the non-PDSA group. The cost of intervention was $40,000 or $92 per DTO for three months. The course was highly acceptable with DTOs rating 4.3 out of 5 in recommending the course to other DTOs. Our data shows that a large scale-up of the PDSA cycle is feasible, economical and effective with little additional resources. The focus was on increasing the efficiency of the existing processes well within the authority of the DTO. Repeat cycle of PDSA with notification and other measures such as presumptive sputum examination could significantly impact the program and help to achieve TB Free India.

A Quality Improvement Initiative to Increase the Milk Donation to the Human Milk Bank Post-Coronavirus Disease-19 Pandemic.

Background and Objective: Donor human milk (DHM) from the human milk bank (HMB) is the next best alterative in circumstances when mother's own milk is not available. There was a steep decline in the volume of DHM collected during the coronavirus disease-19 (COVID-19) pandemic due to various factors, while DHM demand increased. Hence, a quality improvement (QI) study was conducted to increase the volume of milk donation to HMB from postpandemic baseline of 300-400 to 1,000 mL/day over 8 weeks. Materials and Methods: Fish bone analysis was used to identify the potential barriers, and four Plan-Do-Study-Act (PDSA) cycles were conducted from January 2021 to March 2021 to address the key barriers. In the first PDSA cycle, training of health care providers was done. Sessions for educating mothers in the second PDSA cycle and individualized one-to-one counseling of mothers by a mother support group were done in the third PDSA cycle. The availability of breast pump was increased in the fourth PDSA cycle. Sustainability of the interventions was studied for 6 months and data were analyzed. Results: The average DHM collected per day at the end of each PDSA cycle was 900, 1,500, 1,000, and 1,100 mL. Although the sustenance phase was affected by the second COVID-19 wave, prompt identification of the issues and timely interventions prevented the donated volume from dropping to preintervention levels. Conclusion: QI initiatives customized for local settings can result in significant improvement in voluntary milk donation in HMB, which can result in more availability of DHM to premature babies.

Simulated learning for staff at a children's hospice: a quality improvement project.

Simulated learning has well known positive effects but its use in palliative care education is limited. A quality improvement project was undertaken at a children's hospice to develop and evaluate simulation workshops. The aim was to increase the knowledge, skills and confidence of nurses and healthcare assistants in managing challenging situations commonly experienced when caring for children with life-limiting conditions and their families. The Plan, Do, Study, Act (PDSA) model for improvement was used to test simulation workshops on a small scale using a post-workshop questionnaire and reflective diaries. Despite some initial anxiety, participants felt that the workshop had enhanced their confidence, knowledge and skills, particularly in relation to conducting challenging conversations. The project has provided insight and evidence to develop simulated learning at the children's hospice and further afield.

Leveraging quality improvement to promote health equity: standardization of prenatal aspirin recommendations

ObjectiveAspirin (ASA) is recommended for patients at elevated risk of preeclampsia. Limited data exists on adherence to guidelines for ASA prescription. This project evaluates the implementation of a standardized approach to ASA prescription in an academic OB/Gyn practice.MethodsWe implemented a quality improvement project to evaluate compliance with the United States Preventative Services Task Force (USPSTF) recommendations for ASA to prevent preeclampsia. Pre-intervention, we analyzed prescription adherence at 201 New Obstetric (NOB) visits. A multi-step intervention was then implemented at 199 NOB visits. Nurses utilized a checklist created from USPSTF guidelines to identify high-risk patients, defined as having ≥1 high-risk factor or ≥2 moderate-risk factors. ASA orders were placed by physicians. A Plan-Do-Study-Act (PDSA) cycle was performed, and changes implemented. Primary outcome was percent of patients screened at RN intake visit (goal = 90%). Secondary outcomes were percent of patients who screened positive that received the ASA recommendation (goal = 80%) and percent screened and recommended by race.ResultsPre-intervention, 47% of patients met criteria for ASA and 28% received a documented recommendation. Post-intervention, 99% were screened. Half (48%) met criteria for an ASA recommendation and 79% received a recommendation (p = < 0.001). Rates of appropriate recommendation did not differ by Black (80%) vs. non-Black (79%) status (p = 0.25). Subsequent PDSA cycles for 12 months neared 100% RN screening rates. Physicians correctly recommended ASA 80–100% of the time.ConclusionIt is feasible, sustainable and equitable to standardize screening and implementation of ASA to patients at high risk for preeclampsia. Providers can easily reproduce our processes to improve delivery of equitable and reliable preventative obstetric care.