Practice Quality Improvement Research Articles

Application of lean principles in a medicare insurance counseling service learning course

BackgroundLean principles are increasingly applied in healthcare to improve quality and cost. A service-learning course providing Medicare insurance counseling requiring rapid transformation due to the COVID-19 pandemic provided an opportunity for pharmacy students to apply lean skills. Educational activityStudents, already introduced to lean skills earlier in their curriculum, enrolled in the insurance education certificate during their third year in Fall 2020. Students were oriented to the mandated service delivery restrictions. After a review of lean principles, students analyzed existing process for in-person counseling using a value-stream map. Students worked in teams to complete a cause analysis and develop solutions. Collaboratively, students clarified the value of the Medicare insurance counseling services to the community, adapted these components to accommodate environmental risk, and developed standard work for client acquisition, communication procedures, and service delivery to optimize client satisfaction and safety. Outcomes compared before and after application of lean skills included number of pharmacy students completing insurance counselor training, number of clients counseled, and the mean out-of-pocket savings identified for Medicare beneficiaries. FindingsStudents applied lean skills to transform an insurance counseling service by developing and implementing a future state value-stream map and new standard work. Overall Medicare insurance counseling service metrics decreased compared to previous years, but the service was sustained despite pandemic restrictions. Application of lean skills and service redesign provided a method for students to provide services via telepharmacy. Application of lean principles increased student engagement with the course and provided an opportunity to practice quality improvement skills. Lean provides a flexible set of skills that can be introduced and applied in different pharmacy instructional settings.

Quality Improvement in the Management of Subarachnoid Hemorrhage: Current State and Future Directions.

Aneurysmal subarachnoid hemorrhage carries high mortality and morbidity. Quality improvement (QI) efforts in the management of this disease process are growing as the field of neurocritical care matures. This review provides updates in QI in subarachnoid hemorrhage (SAH) and discusses gaps and future directions. Literature published on the topic over the past 3years were evaluated. An assessment of current QI practices pertaining to the acute care of SAH was conducted. These include processes surrounding acute pain management, inter-hospital coordination of care, complications during the initial hospital stay, role of palliative care, and quality metrics collection, reporting, and monitoring. SAH QI initiatives have shown promise by decreasing ICU and hospital lengths of stay, health care costs, and hospital complications. The review reveals substantial heterogeneity, variability, and limitations in SAH QI protocols, measures, and reporting. Uniformity in QI research, implementation, and monitoring will be crucial as disease-specific QI develops in neurological care.

Impact of time to full enteral feeding on long-term neurodevelopment without mediating by postnatal growth failure in very-low-birth-weight-infants

This study aimed to determine if time to achieve full enteral feeding (TFF) directly impacted long-term neurodevelopmental delay (NDD) and whether long-term postnatal growth failure (PGF) was a mediator of this association in very-low-birth-weight (VLBW) infants. Using prospectively collected cohort data from the Korean Neonatal Network, we included eligible VLBW infants who achieved TFF at least once and classified enrolled infants into four groups using exposure severity (P1 to P4 as TFF < 16, 16–30, 31–45, and > 45 postnatal days, respectively). After adjusting for confounding variables, survival without NDD was significantly decreased in P4 infants compared with that in P2 infants. P1 infants had a lower risk of weight and height PGF than P2 infants; however, P4 infants had higher risks of height and head circumference PGF than P2 infants. Weight and height PGF were significantly associated with an increased risk of NDD. In mediation analysis, early and delayed TFF revealed direct positive and negative impacts, respectively, on the risk of NDD without mediation by PGF. TFF impacted survival without NDD, and PGF did not mediate this association in VLBW infants. Additionally, these results can be translated into evidence-based quality improvement practice.

Performance of standardised colposcopy to detect cervical precancer and cancer for triage of women testing positive for human papillomavirus: results from the ESTAMPA multicentric screening study

Colposcopy, currently included in WHO recommendations as an option to triage human papillomavirus (HPV)-positive women, remains as the reference standard to guide both biopsy for confirmation of cervical precancer and cancer and treatment approaches. We aim to evaluate the performance of colposcopy to detect cervical precancer and cancer for triage in HPV-positive women. This cross-sectional, multicentric screening study was conducted at 12 centres (including primary and secondary care centres, hospitals, laboratories, and universities) in Latin America (Argentina, Bolivia, Colombia, Costa Rica, Honduras, Mexico, Paraguay, Peru, and Uruguay). Eligible women were aged 30-64 years, sexually active, did not have a history of cervical cancer or treatment for cervical precancer or a hysterectomy, and were not planning to move outside of the study area. Women were screened with HPV DNA testing and cytology. HPV-positive women were referred to colposcopy using a standardised protocol, including biopsy collection of observed lesions, endocervical sampling for transformation zone (TZ) type 3, and treatment as needed. Women with initial normal colposcopy or no high-grade cervical lesions on histology (less than cervical intraepithelial neoplasia [CIN] grade 2) were recalled after 18 months for another HPV test to complete disease ascertainment; HPV-positive women were referred for a second colposcopy with biopsy and treatment as needed. Diagnostic accuracy of colposcopy was assessed by considering a positive test result when the colposcopic impression at the initial colposcopy was positive minor, positive major, or suspected cancer, and was considered negative otherwise. The main study outcome was histologically confirmed CIN3+ (defined as grade 3 or worse) detected at the initial visit or 18-month visit. Between Dec 12, 2012, and Dec 3, 2021, 42 502 women were recruited, and 5985 (14·1%) tested positive for HPV. 4499 participants with complete disease ascertainment and follow-up were included in the analysis, with a median age of 40·6 years (IQR 34·7-49·9). CIN3+ was detected in 669 (14·9%) of 4499 women at the initial visit or 18-month visit (3530 [78·5%] negative or CIN1, 300 [6·7%] CIN2, 616 [13·7%] CIN3, and 53 [1·2%] cancers). Sensitivity was 91·2% (95% CI 88·9-93·2) for CIN3+, whereas specificity was 50·1% (48·5-51·8) for less than CIN2 and 47·1% (45·5-48·7) for less than CIN3. Sensitivity for CIN3+ significantly decreased in older women (93·5% [95% CI 91·3-95·3] in those aged 30-49 years vs 77·6% [68·6-85·0] in those aged 50-65 years; p<0·0001), whereas specificity for less than CIN2 significantly increased (45·7% [43·8-47·6] vs 61·8% [58·7-64·8]; p<0·0001). Sensitivity for CIN3+ was also significantly lower in women with negative cytology than in those with abnormal cytology (p<0·0001). Colposcopy is accurate for CIN3+ detection in HPV-positive women. These results reflect ESTAMPA efforts in an 18-month follow-up strategy to maximise disease detection with an internationally validated clinical management protocol and regular training, including quality improvement practices. We showed that colposcopy can be optimised with proper standardisation to be used as triage in HPV-positive women. WHO; Pan American Health Organization; Union for International Cancer Control; National Cancer Institute (NCI); NCI Center for Global Health; National Agency for the Promotion of Research, Technological Development, and Innovation; NCI of Argentina and Colombia; Caja Costarricense de Seguro Social; National Council for Science and Technology of Paraguay; International Agency for Research on Cancer; and all local collaborative institutions.

Adherence to practice, management regulations, and quality improvement activities in community pharmacies in Bayelsa state and Rivers state, Nigeria

Community pharmacist had suffered more intrusions from allied health care professionals and non-health professionals in the fields of practice/or endeavor, in history and even lately. Efforts in improving on its tenets of practice in Nigeria are still at the seeding states. This study determines the extent of practice carried out in pharmacy administrative areas such as premises and structure, practice management and quality improvement domains in community pharmacies in Bayelsa State and Rivers States as at the year 2017. Of three hundred and thirty-seven (337) questionnaires distributed, three hundred and twelve (312) were successfully retrieved (92.58% response rate), and results were analyzed using SPSS VERSION 27. The study reveals involvement of more male pharmacists (161; 51.6%) most of whom are below age 30 (177; 56.7%) having B.Pharm (177; 56.7%) having 6 to 10 years’ experience (140; 44.9%) in self-owned premises (190; 60.8%) located mostly in Rivers States (172; 55.1%). There was a significant adherence to premises and structure regulations (p

Study What You Do: Developing a Psychotherapy Tracking Database in a Large-Scale Integrated Behavioral Health Service.

Many individuals with behavioral health challenges receive services in primary care, and integrated behavioral health (IBH) programs can help increase access to evidence-based interventions. IBH programs can benefit substantially from integrating standardized tracking databases that allow for the implementation of measurement-based care to evaluate patient-, clinician-, and practice-level outcomes. We describe the development and integration of Mayo Clinic's pediatric and adult primary care psychotherapy tracking database. IBH practice leaders directed the development of a large psychotherapy tracking database that continuously populates from Mayo Clinic's electronic health record system. The database captures numerous patient variables including demographics, behavioral health and substance use issues, psychotherapy principles used, and self-reported symptoms. We retrieved current data for patients empaneled in Mayo Clinic's pediatric and adult primary care psychotherapy programs from June 2014 to June 2022. The tracking database contained data for 16,923 adult patients and 6,298 pediatric patients. The mean age of adult patients was 43.2 years (SD 18.3), 88.1% were non-Latine White, and 66.7% identified as female. The mean age of pediatric patients was 11.6 years (SD 4.2), 82.5% were non-Latine White, and 56.9% identified as female. We provide examples of practical applications of the database across clinical, educational, research, and administrative domains. The development and integration of a psychotherapy tracking database supports clinician communication, examination of patient outcomes, practice quality improvement efforts, and clinically relevant research. Our description of Mayo Clinic's IBH database may serve as a model for other IBH practices.

The effect of process quality improvement and lean practices on competitive performance in the UAE healthcare industry

The purpose of this paper is to empirically examine a theoretical model which identifies the effect of process quality improvement and lean practices on competitive performance in the healthcare industry in the United Arab Emirates (UAE). The study uses a quantitative research technique with convenient cluster sampling through applying a descriptive, causal and analytical research design. A valid sample size of 270 respondents is used for analysis by linear regression and hypothesis testing using SPSS. The results indicate a direct significant relationship between process quality improvement and a direct significant relationship between lean practices and competitive performance. Given the substantial resources spent and efforts to improve healthcare quality, the absence of studies demonstrating the impact of quality-related operations and activities would require future research. Hospitals in one city in UAE have access that limits the research results. It is recommended that future research assess more variables dependency on the healthcare sector that can affect increase competitiveness. The research provides some managerial implications that could help hospital managerial members improve their healthcare delivery system's leanness and quality improvement to get competitiveness. Quality improvement and lean practices help increase competitive performance and can assist the healthcare sector in providing better service using these practices that have never been considered in research.

Walking the line between assessment, improvement and learning: a qualitative study on opportunities and risks of incorporating peer discussion of audit and feedback within quality improvement in general practice

ObjectivesThere is a broad call for change towards ‘new era’ quality systems in healthcare, in which the focus lies on learning and improving. A promising way to establish this in...

Discussion Guide for the van Nieuw Amerongen Article.

Discussion Guide for the van Nieuw Amerongen Article.

Implementation Science Toolkit for Clinicians: Improving Adoption of Evidence in Practice.

Clinicians are often familiar with quality improvement (QI) and evidence-based practice (EBP) processes, which provides guidance into what evidence should be implemented; however, these processes do not address how to successfully implement evidence. Clinicians would benefit from a deeper understanding of implementation science, along with practical tools for how to use these principles in QI and EBP projects. We provide a brief background of the principles of implementation science, an overview of current implementation science models and a toolkit to facilitate choosing and using common implementation science strategies. In addition, the toolkit provides guidance for measuring the success of an implementation science project and a case study showing how implementation science strategies can be used successfully in clinical practice. Using an implementation science toolkit for designing, conducting, and evaluating a QI or EBP project improves the quality and generalizability of results.

Total quality management as a key step to healthcare transformation; the Saudi experience

Total quality management (TQM) is a comprehensive approach to healthcare management that emphasizes continuous improvement in service quality through stakeholder engagement. In Saudi Arabia, a new model of care (MoC) was introduced aimed at elevating healthcare quality across different care levels. This MoC comprises six care systems and service layers, integrating clinical governance to ensure ongoing improvements in service quality. The integrated clinical care pathway (ICCP) functions as a customizable disease management pathway tailored to the unique needs of each health cluster. Within the ICCP, a robust quality management program has been implemented, covering quality planning, control, and improvement practices. This program fosters a culture of knowledge exchange and continuous learning, ensuring that changes within the healthcare system are grounded in scientific principles and subject to ongoing assessment. To ensure the success of ICCPs and fulfill their objectives, the Health Holding Company (Health Co.) partnered with the Institute of Healthcare Improvement (IHI). This collaboration aims to enhance the capacity and capabilities of quality improvement teams within ICCPs, driving MoC transformation, inspiring an innovation and improvement culture, and facilitating knowledge and expertise exchange. The primary goal of the quality improvement program is to enhance population health by addressing prevalent risk factors for chronic diseases improving the quality of life through enhancing all healthcare pathways. It seeks to bridge the gap between current healthcare practices and best practices, utilizing improvement coaches (ICs) and advisors to promote effective teamwork. Initially implemented in Saudi Arabia&amp;apos;s Al-Hasa region, the TQM program within ICCPs underwent a feedback-gathering workshop. This collaborative effort involved input from ICs and cluster leadership, focusing on various program aspects. The collected feedback aims to further refine and enhance the program for widespread implementation throughout the Kingdom. This review focuses on TQM as a critical step in healthcare transformation, highlighting the Saudi Arabian experience.

How Does Prior Experience Pay Off in Large-Scale Quality Improvement Initiatives?

To examine the association of prior investment on the effectiveness of organizations delivering large-scale external support to improve primary care. Mixed-methods study of 7 EvidenceNOW grantees (henceforth, Cooperatives) and their recruited practices (n = 1720). Independent Variable: Cooperatives's experience level prior to EvidenceNOW, defined as a sustained track record in delivering large-scale quality improvement (QI) to primary care practices (high, medium, or low). Dependent Variables: Implementation of external support, measured as facilitation dose; effectiveness at improving (1) clinical quality, measured as practices' performance on Aspirin, Blood Pressure, Cholesterol, and Smoking (ABCS); and (2) practice capacity, measured using the Adaptive Reserve (AR) score and Change Process Capacity Questionnaire (CPCQ). Data were analyzed using multivariable linear regressions and a qualitative inductive approach. Cooperatives with High (vs low) levels of prior experience with and investment in large-scale QI before EvidenceNOW recruited more geographically dispersed and diverse practices, with lower baseline ABCS performance (differences ranging from 2.8% for blood pressure to 41.5% for smoking), delivered more facilitation (mean=+20.3 hours, P = .04), and made greater improvements in practices' QI capacity (CPCQ: +2.04, P < .001) and smoking performance (+6.43%, P = .003). These Cooperatives had established networks of facilitators at the start of EvidenceNOW and leadership experienced in supporting this workforce, which explained their better recruitment, delivery of facilitation, and improvement in outcomes. Long-term investment that establishes regionwide organizations with infrastructure and experience to support primary care practices in QI is associated with more consistent delivery of facilitation support, and greater improvement in practice capacity and some clinical outcomes.

Implementation of a Clinical Protocol to Reduce Urinary Tract Infections Among Women With Urinary Retention After Pelvic Reconstructive Surgery: A Prospective Quality Improvement Study

ObjectiveWe implemented and assessed a clinical practice quality improvement protocol aimed at decreasing postoperative urinary tract infections (UTIs) among patients with transurethral catheters. MethodsThis was a quality improvement study with pre- and post-intervention comparisons. Patients requiring postoperative transurethral catheters underwent 3 interventions: (1) shortening the time from surgery to repeat voiding trials to 3–5 days for pelvic reconstructive surgeries and to 1–3 days for mid-urethral slings, (2) avoiding routine urine cultures at the time of voiding trials, and (3) recommending 2 L of water intake daily until 3 days after the voiding trial. The primary outcome was the percentage of patients receiving antibiotics for UTIs within 6 weeks. Secondary outcomes included rates of failing office voiding trials, UTI symptoms/cultures, adherence to hydration, and health care resource utilization. ResultsWe included 31 patients before and 40 patients after the intervention. The 2 cohorts had similar demographic and clinical characteristics. Among patients requiring catheterization, rates of antibiotic treatment for UTIs decreased from 65% to 40% after the intervention (P = 0.04). UTI symptoms and urine cultures sent for analysis decreased significantly (P = 0.04 and P = 0.005, respectively). There was high adherence (84%) to increased hydration. Rates of failing office voiding trials remained similar. The number of phone calls decreased by 43% (P = 0.003), and there was no increase in office or emergency department visits. Multivariate regression showed that UTIs were 2.04 times more likely before than after the intervention. ConclusionOur quality improvement intervention was practical to implement and effective in reducing postoperative UTIs among patients with urinary catheters.

Evaluating Healthcare Performance in Low- and Middle-Income Countries: A Pilot Study on Selected Settings in Ethiopia, Tanzania, and Uganda.

The literature reports some experiences regarding the design of integrated healthcare Performance Evaluation Systems (PES) applied in Low- and Middle-income Countries (LMIC). This study describes the design of an integrated and bottom-up PES aimed at evaluating healthcare services delivery in rural settings. The analysis involved four hospitals and their relative health districts in Ethiopia, Tanzania, and Uganda. The evaluation process was undertaken for those indicators that could be evaluated using the same reference standard. The evaluation scores were determined through the international standards identified in the literature or through benchmarking assessment. Both administrative and health data were extracted from the hospitals' registers and District Health Information Systems (DHIS) from 2017 to 2020. We defined 128 indicators: 88 were calculated at the hospital level and 40 at the health district level. The evaluation process was undertaken for 48 indicators. The evaluated indicators are represented using effective graphical tools. In settings characterised by multiple healthcare providers, this framework may contribute to achieving good governance through performance evaluation, benchmarking, and accountability. It may promote evidence-based decision-making in the planning and allocation of resources, thus ultimately fostering quality improvement processes and practices, both at the hospital and health district level.

Establishing a Cystic Fibrosis Learning Network: Interventions to promote collaboration and data-driven improvement at scale.

A learning health network is a type of learning health system in which stakeholders use network organization to improve health and health care. Building on existing resources in the cystic fibrosis (CF) community, the Cystic Fibrosis Learning Network (CFLN) was designed to improve medical outcomes and quality of life through an intentional focus on achieving reliable evidence-based chronic care delivery and creating a system for data-driven collaborative learning. We describe the development and growth of the CFLN considering six domains of a Network Maturity Grid: system leadership; governance and policy management; quality improvement (QI); engagement and community building; data and analytics; and research. We illustrate the impact of the CFLN experience on chronic care processes and indicators of collaborative infrastructure. The CFLN represents 36 accredited care centers in the CF Foundation Care Center Network caring for over 6300 patients. Of 6779 patient clinical care visits/quarter, 77% are entered into the CF Foundation Patient Registry within 30 days, providing timely means to track outcomes. Collaborative visit planning is occurring in 93% of clinical care visits to share agenda setting with patients and families. Almost all CFLN teams (94%, n=34) have a patient/family partner (PFP), and 74% of PFPs indicate they are actively participating, taking ownership of, or leading QI initiatives with the interdisciplinary care team. In 2022, 97% of centers reported completing 1-13 improvement cycles per month, and 82% contributed to monthly QI progress reports to share learning. The CFLN is a maturing, collaborative infrastructure. CFLN centers practice at an advanced level of coproduction. The CFLN fosters interdisciplinary and PFP leadership and the performance of consistent data-driven improvement cycles. CFLN centers are positioned to respond to rapid changes in evidence-based care and advance the practice of QI and implementation science on a broader scale.

Improve-mentation for Faster Testing and Spread of Health Service Delivery Innovations.

Can we speed the testing, implementation and spread of management innovations in a systematic way to also contribute to scientific knowledge? Researchers and implementers have developed an approach to test and revise a local version of an innovation during its implementation. The chapter starts with a case example of an application of this combination of implementation and quality improvement sciences and practices (improve-mentation). It then summarizes four examples of this approach so as to help understand what improve-mentation is and how it is different from traditional quality improvement and traditional implementation of evidence-based practices. It considers gaps in knowledge that are hindering both more use of improve-mentation to generate scientific knowledge about spread and implementation, as well as more use of improve-mentation by health care service organizations and researchers. It closes by proposing fruitful research and development that can address these knowledge gaps to speed the implementation, sustainment and spread of care and management innovations.

Agronomic and economic implications of cover crop and phosphorus fertilizer management practices for water quality improvement.

Phosphorus (P) fertilization practices and winter cover crops are promoted to protect water quality yet can potentially influence crop yield and profitability. This study examined the impacts of three P fertilizer management practices (no P, fall broadcast P, and spring injected P) and winter annual cover crop use on yields, net returns, and water quality in a no-till corn-soybean rotation. Treatments were replicated in a 4-yr field study where sediment, total P, and dissolved reactive P (DRP) losses in edge-of-field surface runoff were continuously monitored. Production budgets were developed for each treatment and coupled with water quality data to identify optimal practices and opportunity costs for improving water quality. Applying P fertilizers increased crop yield regardless of application method or cover crop, but the response was more pronounced in corn than soybean. The cover crop reduced corn grain yield in 1 yr with high temperature and low precipitation but did not impact grain yield in the other corn year or either year of soybean. The most profitable treatment was fall broadcast P fertilizer with no cover crop, which also had the greatest total P and DRP losses and near greatest sediment loss. The lowest-cost methods of reducing total P, DRP, and sediment losses were, respectively, no P fertilizer without a cover crop ($47.56kg-1 total P), spring injected P fertilizer without a cover crop ($56.47kg-1 DRP), and spring injected P fertilizer with a cover crop ($0.16kg-1 sediment). Widespread adoption of these practices will likely require monetary incentives.

Quality improvement interventions to prevent unplanned extubations in pediatric critical care: a systematic review

BackgroundAn unplanned extubation is the uncontrolled and accidental removal of a breathing tube and is an important quality indicator in pediatric critical care. The objective of this review was to comprehensively synthesize literature published on quality improvement (QI) practices implemented to reduce the rate of unplanned extubations in critically ill children.MethodsWe included original, primary research on quality improvement interventions to reduce the rate of unplanned extubations in pediatric critical care. A search was conducted in MEDLINE (Ovid), Embase, and CINAHL from inception through April 29, 2021. Two reviewers independently screened citations in duplicate using pre-determined eligibility criteria. Data from included studies were abstracted using a tool created by the authors, and QI interventions were categorized using the Behavior Change Wheel. Vote counting based on the direct of effect was used to describe the effectiveness of quality improvement interventions. Study quality was assessed using the Quality Improvement Minimum Quality Criteria Set (QI-MQCS). Results were presented as descriptive statistics and narrative syntheses.ResultsThirteen studies were included in the final review. Eleven described primary QI projects; two were sustainability studies that followed up on previously described QI interventions. Under half of the included studies were rated as high-quality. The median number of QI interventions described by each study was 5 [IQR 4–5], with a focus on guidelines, environmental restructuring, education, training, and communication. Ten studies reported decreased unplanned extubation rates after the QI intervention; of these, seven had statistically significant reductions. Both sustainability studies observed increased rates that were not statistically significant.ConclusionsThis review provides a comprehensive synthesis of QI interventions to reduce unplanned extubation. With only half the studies achieving a high-quality rating, there is room for improvement when conducting and reporting research in this area. Findings from this review can be used to support clinical recommendations to prevent unplanned extubations, and support patient safety in pediatric critical care.Systematic review registrationThis review was registered on PROSPERO (CRD42021252233) prior to data extraction.

Impact on Dental Utilization of the Integration of Oral Health in Pediatric Primary Care Through Quality Improvement.

To evaluate child-level dental utilization and expenditure outcomes based on if and where children received fluoride varnish (FV) at quality improvement (QI) medical practices, at non-QI medical practices, at dental practices, or those who never received FV from any practice. Retrospective claims-based analysis cohort study. Children with Medicaid insurance through an Ohio pediatric accountable care organization. Children aged 1 to 5 years with 1 or more well-child visits between 2015 and 2017. FV receipt versus no FV. Among children who received FV, categorized if FV delivered by a QI-participating medical provider, a non-QI-participating medical provider, and a dental provider. Dental claims from 2014 to 2019 were collected for preventive dental visits, caries-related treatment visits, dental general anesthesia (GA) visit, and emergency department visit for a dental problem to examine utilization patterns, expenditures, and dental outcomes. The QI group had a significantly higher incidence of preventive dental visits than the dental (incidence rate ratio [IRR] = 0.93; 95% confidence interval [CI], 0.91-0.96) or non-QI groups (IRR = 0.86; 95% CI, 0.84-0.88). Compared with the QI group, the non-QI (adjusted odds ratio [aOR] = 2.6; 95% CI, 2.4-2.9) and dental (aOR = 2.9; 95% CI, 2.6-3.3) groups were significantly more likely to have caries-related treatment visits. The dental group children were significantly more likely to have dental treatment under GA than the QI group (aOR = 5.3; 95% CI, 2.0-14.4). Children seen at QI practices appear to have an increased uptake of preventive dental services, which may explain the lower incidence of dental caries visits and GA treatment.

Strategies for successfully completing a DNP final project.

Completion of a final project is an essential component of Doctor of Nursing Practice programs. Strategies for successful project planning, implementation, and evaluation are outlined, from identifying an evidence-based practice or quality improvement project, advisor, and practice mentor through completion, presentation, and dissemination of your work.