Provide Quality Improvement Research Articles

Integrating services: translating data into practice

The 2021 MS Trust conference offered many valuable insights, including into the way in which nurses and allied health professionals are currently undertaking bladder management. Using one of the symposiums as a foundation, Sue Thomas outlines how health professionals can use data to provide quality improvements in relation to bladder management in multiple sclerosis.

Quality Control of Frame Production Using DMAIC Method in Plastic PP Corrugated Box Manufacturer

Corrugated carton boxes as a storage for products is common use in industry nowadays, corrugated carton box has many advantages, hardiness, air resistance, more neat and strong. To produce this corrugated box, it needed a frame to support the edge of the carton to make it stronger. This study was conducted at one of the pp corrugated manufacturers in Indonesia. The company oftenly receive complaints caused of quality problems of the frame. Research aimed to provide quality improvement using DMAIC (defining-measuring-analyzing-improving-control) as analysis method. The results of study concluded that the causes of defect consist of several factors, human factors, poorly trained of machine operators. The second cause is the engine factor, the barrel screw used has an incorrect temperature and rotation speed of the screw is inappropriate. The third cause is the material factor, dirty materials that was entered the machine affected the size of materials produced. Improvements carried out using design of experiment and standard operation procedures.

Providing quality improvement training in an advanced pharmacy practice experience elective

Background and purposeQuality Improvement (QI) science is a burgeoning component of healthcare systems and the practice of pharmacy. There is limited published literature on the implementation of QI training in undergraduate pharmacy education. We describe the development and implementation of QI training in an experiential course. Educational activity and settingA QI curriculum was developed for an existing eight-week pharmacy practice elective experience for year four pharmacy students. The curriculum was divided into two, four-week blocks, combining didactic instruction and applied learning activities. A partnership between university departments and a local health organization provided a QI preceptor along with an interdisciplinary clinical team in an acute care setting to improve clinical services. FindingsSix students have completed the elective along with completing three QI projects. The Kirkpatrick 4 level model guided course evaluation. A curriculum strength was no additional cost or educational burden on the faculty of pharmacy and pharmaceutical sciences. Students recognized benefit from (1) course flexibility and independence to learn, (2) clear expectations and weekly guidance from the preceptor, (3) alignment of weekly readings and real-time application of QI concepts, and (4) the Institute for Healthcare Improvement education modules. Reducing the number of assigned tasks per week and improving availability of the clinical QI team to support student learning were identified as areas for improvement. SummaryThis elective course demonstrated a starting point from which QI education can be formally included in pharmacy undergraduate education.

State-wide quality improvement addressing overutilization of neurokinin-1 receptor antagonists.

8 Background: The overuse of neurokinin-1 receptor antagonists (NK1-RAs) is a focus of quality measurement within the American Society of Clinical Oncology Quality Oncology Practice Initiative (ASCO-QOPI) and the American Board of Internal Medicine (ABIM) as a Choosing Wisely measure. The Michigan Oncology Quality Collaborative (MOQC) is a statewide collaborative with participation of nearly 100% of oncologists. The purpose of this project was to provide quality improvement practice support for deimplementation of NK1-RAs in the upfront prevention of chemotherapy- induced nausea and vomiting (CINV) for low and moderate emetic chemotherapy regimens (QOPI measure SMT28a) to less than 30% in practices across the State, with lower scores indicating better performance. Methods: In 2018, MOQC added the QOPI SMT28a measure as part of its standard quality measure module for collection by all MOQC practices. A quality improvement intervention was initiated that consisted of 1) baseline assessments of measure performance, prescriber knowledge and beliefs, and pre-populated antiemetic order sets, 2) reporting practice and state-level performance to MOQC practices, 3) state-wide CINV education, and 4) a value-based reimbursement (VBR) related to measure performance. Post-intervention performance was assessed with the Fall 2019 and Spring 2020 QOPI-measurement. Results: Responses from a survey assessing pre-populated antiemetic order sets (32/43, 74% response rate), 23% of practices had a pre-populated order set for NK1-RA and/or olanzapine in moderate emetic regimens. The post-education order set survey found that 48% of respondents (25/43, 54% response rate) either modified or were in the process of modifying their order sets. Conclusions: Deimplementation of unnecessary and low value antiemetics in patients receiving low- or moderate emetic chemotherapy was possible via a state-wide quality improvement program that involved performance reporting to practices, collaborative-wide education, modification of standing order sets, and VBR based on performance. [Table: see text]

Development and validation of an algorithm of diagnostic and procedural codes for the identification of children hospitalized with a tracheostomy in Ontario, Canada

The requirement for a tracheostomy in children is associated with significant morbidity, mortality, and healthcare utilization. Easy identification of children with tracheostomies would facilitate important research on this population and provide quality improvement initiatives. The purpose of this study is to determine whether an algorithm of diagnostic and procedural codes can accurately identify children hospitalized with a tracheostomy using routinely collected health data. Chart reviews were performed at the Children's Hospital of Eastern Ontario (CHEO) and the London Health Sciences Center (LHSC) to establish a true positive cohort of pediatric patients with tracheostomies admitted between 2008 and 2016. A multidisciplinary team developed algorithms of diagnostic and procedural codes contained within the Canadian Institute for Health Information Discharge Abstract Database. Algorithms were tested and refined against the true-positive and true-negative cohort. The accuracy of the diagnostic codes related to tracheostomy complications was also evaluated. A chart review identified 158 unique children with tracheostomies (77 at CHEO, 81 at LHSC) with 901 individual admissions (401 at CHEO, 507 at LHSC). The best algorithms for identifying children with a tracheostomy had a sensitivity and specificity of more than 99%, a positive predictive value (PPV) of 94.0% and negative predictive value (NPV) of 100%. The algorithm for the identification of tracheostomy-related complications had a sensitivity of 76.7%, aspecificity of 65%, PPV of 52.3%, and an NPV of 84.7%. This study provides an algorithm for the accurate identification of children hospitalized in Canada with a tracheostomy, facilitating population-level epidemiological research and quality improvement initiatives.

Modelos teóricos utilizados por enfermeiros para avaliação da família: reflexão teórica

Objetivo: identificar a produção científica no período de 10 anos completos, a partir da implementação da Atenção Básica no Brasil, sobre os modelos teóricos utilizados e que influenciaram os enfermeiros na avaliação de famílias no brasil e no mundo. Métodos: Trata-se de um estudo teórico-reflexivo, construído com base na leitura crítica da avaliação dos modelos familiares pelos profissionais de enfermagem, em estudos científicos, que referenciam as avaliações familiares como fatores preditores na melhora significativa no cuidado direto ao paciente. Essa construção teórica aproxima-se da abordagem qualitativa, tendo em vista a interpretação e análise dos elementos teóricos obtidos por meio de uma revisão integrativa. Resultados: Foram utilizados 20 artigos e encontrados 19 modelos. Os Modelos Calgary, o APGAR de família e o Genograma e Ecomapa são mais comumente utilizados na prática clínica do enfermeiro. Considerações Finais: A utilização de modelos teóricos de avaliação propicia melhoria na qualidade do cuidado dispensado bem como a sistematização da assistência, a integração da família e suas relações no cuidar promovendo um fortalecimento familiar.

Earmarking Tax for Indonesia's Economic Growth through the Education and Health Sector in the Long and Short Term Period

The earmarking tax policy is expected to provide quality improvements as a result of the certainty of fund allocation. There are two examples of the government undertaking an earmarking tax approach in Indonesia, where 20% of funds are allocated for education, and 5% of funds are allocated for health. This measure of quality improvement can be seen from the improvement of the Human Development Index (HDI), Expected Years of Schooling (EYS), and Life Expectancy at Birth (LEB) that in turn impacts increasing economic growth (EG) during the period of earmarking tax policy in Indonesia. This research uses Path Analysis and Error Correction Model. Earmarking tax cause a negative indirect effect on EG through the education and health sector. However, in the long term, it has a positive effect on both sectors, while EYS and LEB has a negative effect. In the short term, only the health sector can increase EG.

AN MDS 3.0 BEHAVIORAL INDICATOR: RELIABILITY AND VALIDITY WHEN MEASURING BEHAVIOR SYMPTOMS OF DEMENTIA IN CLCS

Persons with dementia frequently demonstrate behavior symptoms of dementia (BSD), associated with poorer outcomes. A measure of BSD was created for routine use in VA Community Living Centers (CLCs). Reliability and validity of Minimum Data Set (MDS 3.0) behavior items was established using exploratory factor analysis and a multitrait, multimethod correlation matrix. 385 CLC residents with BSD were assessed using validated measures of BSD, depression, and anxiety, and team ratings of the frequency and severity of target behaviors identified for intervention. Factor analysis on MDS items closest to baseline resulted in two stable factors. MDS behavior factors related to validated clinical measures in predicted ways at baseline and post-intervention. MDS distress behavior factor sensitivity to change was evaluated by using change score correlations with validated clinical measures. The MDS distress behavior factor can be used routinely, evaluate the impact of intervention effectiveness, and provide quality improvement feedback.

National Asthma and COPD Audit Programme and the NHS Long Term Plan

National Asthma and COPD Audit Programme and the NHS Long Term Plan

Models of care that avoid or improve transitions to hospital services for residential aged care facility residents: An integrative review

Care transitions for older people moving from residential aged care facilities (RACFs) to hospital services are associated with greater challenges and poorer outcomes. An integrative review was conducted to investigate models of care designed to avoid or improve transitions for older people residing in RACFs to hospital settings. Twenty-one studies were included in the final analysis. Models of care aimed to either improve or avoid transitions of residents through enhanced primary care in RACFs, promoting quality improvement in RACFs, instilling comprehensive hospital care, conducting outreach services, transferring information, or involved a combination of outreach services and comprehensive hospital care. As standalone interventions, standardised communication tools may improve information transfer between RACFs and hospital services. For more complex models, providing quality improvement and outreach to RACFs may prevent some types of hospital admissions.

Survey of preterm neuro-centric care practices in California neonatal intensive care units.

Objective:Examine the adoption and presence of preterm, neuro-centric care practices across Neonatal Intensive Care Units (NICUs).Study Design:Statewide, cross-sectional survey of California NICUs. Data were collected surrounding the timing of adoption and presence of delivery room practices, nursing protocols, provider management practices and quality improvement initiatives.Result:Among the 95 NICUs completing the survey (65%), adoption of all surveyed practices increased between 2005 and 2016, though rates of uptake changed over time and varied by practice. Adoption of indomethacin prophylaxis increased 1.8-fold whereas delayed cord clamping increased 78-fold. Adoption of premedication for intubation and a patent ductus arteriosus management algorithm differed by unit level. Additionally, two underlying practice domains were identified; adoption of delivery room practices and adoption of any preterm practice.Conclusion:Adoption of preterm, neuro-centric care practices across California NICUs has increased, though uptake patterns vary by practice and level.

Quality Improvement of Herbal Sachet in filling Powder Machine Using Six Sigma Method

This paper discusses the search for problem-solving product defects herbal sachets powder that occurs in the herb filling machine, using Six Sigma method with the concept of DMAIC (define, measure, Analyze, improve and control). In this study, 15% defects are found, the magnitude of this defect becomes one of the causes of the loss of production costs due to defects caused to the herbal sachets cannot be repaired or reused. Therefore, this paper will try to reduce the defects of these products using the stages of DMAIC repair. The quality tools used to solve this problem is by using Pareto, FTA (Fault Tree Analysis) and 5W + 1H. Ultimately, this study was able to provide quality improvement results by calculating the sigma level of defects of the herbal sachet product powder. The results of the improvement are: reduced sachets defect less than 2% with an increase in the sigma level value from 3.25 to 4.375. The use of this six sigma method is the right method and able to find problems, find solutions and be able to improve the quality.

Multicomponent Fuzzy Model for Evaluating the Energy Efficiency of Chemical and Power Engineering Processes of Drying of the Multilayer Mass of Phosphorite Pellets

A multicomponent fuzzy model was proposed for evaluating the energy efficiency of the chemical and power engineering processes of the drying of a dynamic multilayer mass of phosphorite pellets in a complex multistage chemical and power engineering system (roasting conveyor machine). The developed model includes a set of fuzzy component models for analyzing the chemical and power engineering processes of pellet drying corresponding to the results of the decomposition of these processes, a set of neuro-fuzzy production models for evaluating the energy efficiency of the individual stages of the chemical and power engineering processes of pellet drying, and a neuro-fuzzy production model of generalized evaluation of the energy efficiency of the chemical and power engineering process of pellet drying. The use of the proposed model makes it possible to evaluate the energy efficiency of both the individual stages and, in general, the chemical and power engineering process of phosphorite pellet drying under conditions of uncertainty of their thermophysical characteristics and the processes themselves; to perform online structural adjustment and parametric adaptation of the model when the mode and chemical and power engineering process of pellet drying are changed; to perform online evaluation of the energy efficiency of the chemical and power engineering process of pellet drying; and to provide quality improvement and speed of decision making on optimization of the chemical and power engineering process of pellet drying to increase the energy efficiency of these processes.

Possibilities of Small Water Reservoir Impact Improvement on Surface Water Quality in Agricultural Landscape

In the Czech Republic, a significant amount of agricultural landscape nutrients is swept away by surface washes and leakages to subsoil. Subsequently there is a negative influence on surface water quality, where of course also point sources of pollution participate in. Flowing surface water often becomes stagnant while the certain self‑purifying processes proceed both in the flowing and stagnant waters. It can be simultaneously stated that the self‑purifying process is practically uncontrollable, primarily due to the impact of many entering factors. One of the environmental and technical elements providing quality improvement of water running off a water reservoir is deployment of constructed floating wetlands (CFW). The theoretical background, as well as the laboratory measurements carried out on the test land of the Brno University of Technology in experimental tanks, evidence the significant treatment efficiency of the CFW. Within the research activities, we focused on the general pollution parameters set for surface waters. The first results show that the total phosphorus concentration removal efficiency is 38.8 % after 22 days with employment of the CFW which is a considerably higher value compared to the lysimeter with no CFW where the removal efficiency was only 4.37 %. The results can be large‑scale applied to most of the small water reservoirs situated in the agricultural landscape.

Taking Innovation To Scale In Primary Care Practices: The Functions Of Health Care Extension.

Health care extension is an approach to providing external support to primary care practices with the aim of diffusing innovation. EvidenceNOW was launched to rapidly disseminate and implement evidence-based guidelines for cardiovascular preventive care in the primary care setting. Seven regional grantee cooperatives provided the foundational elements of health care extension-technological and quality improvement support, practice capacity building, and linking with community resources-to more than two hundred primary care practices in each region. This article describes how the cooperatives varied in their approaches to extension and provides early empirical evidence that health care extension is a feasible and potentially useful approach for providing quality improvement support to primary care practices. With investment, health care extension may be an effective platform for federal and state quality improvement efforts to create economies of scale and provide practices with more robust and coordinated support services.

Adherence Rates to Recommended Guidelines for Paracentesis in Cirrhotic Patients at a Tertiary Care Center and Associated Complications

Introduction: Ascites is the leading cause of hospitalization in cirrhotic patients. The American Association for the Study of Liver Diseases (AASLD) provides guidelines regarding paracentesis. While many providers give platelets and fresh frozen plasma (FFP) prior to paracentesis, AASLD discourages this as its evidence in reducing bleeds or morbidity is lacking. Regarding albumin infusion, AASLD reports survival benefit if given after large volume paracentesis (LVP), fluid removal greater than 4-5L. Nonadherence to these recommendations may result in poor outcomes, such as volume overload and acute kidney injury (AKI). We describe the results of adherence to guidelines for LVP in cirrhotic patients at a tertiary care center in the hopes of providing quality improvement and improving overall survival. Methods: We retrospectively constructed an inpatient cohort of consecutive patients eligible for paracentesis admitted to MGUH from Jan 2011-Sept 2015 (Table 1). Eligible patients had 1 of 3 primary diagnoses- ascites, spontaneous bacterial peritonitis, or hepatic encephalopathy (HE)- and a secondary diagnosis of cirrhosis. Cases of HE required ascites as a secondary diagnosis. The independent variable was chart reviewed, verifying receipt of any LVP during hospitalization. The primary outcome variable was receipt of IV albumin. Secondary outcomes included receipt of FFP or platelets; AKI; and inpatient mortality. The chi square test was employed for all analyses.Table: Table. Patient DemographicsResults: Of the 280 cases that met eligibility criteria, 177 had any paracentesis--119 were diagnostic and 58 were LVPs. When compared with diagnostic paracentesis, receipt of LVP was associated with receipt of IV albumin (p<0.001). However, only 64% of patients undergoing LVPs received albumin. LVP was not associated with receipt of blood products. Of patients undergoing LVP, 22.2% and 17.3% received FFP and platelets respectively (Table 2).Table: No Caption availableConclusion: Our preliminary data shows room for improvement with regard to paracentesis and adherence to AASLD guidelines. IV albumin is not universally administered for LVPs; and potentially unnecessary blood products are being administered in a minority of patients undergoing paracentesis. Improved adherence to guidelines could result in fewer cases of volume overload and post-LVP AKI. Future safety interventions aimed at optimizing inpatient paracentesis practice can utilize these data as baseline to which post-intervention data can be compared.

Quality of Midwife-provided Intrapartum Care in Amhara Regional State, Ethiopia

BackgroundDespite much progress recently, Ethiopia remains one of the largest contributors to the global burden of maternal and newborn deaths and stillbirths. Ethiopia’s plan to meet the sustainable development goals for maternal and child health includes unprecedented emphasis on improving quality of care. The purpose of this study was to assess the quality of midwifery care during labor, delivery and immediate postpartum period.MethodsA cross-sectional study using multiple data collection methods and a 2-stage cluster sampling technique was conducted from January 25 to February 14, 2015 in government health facilities of the Amhara National Regional State of Ethiopia. Direct observation of performance was used to determine competence of midwives in providing care during labor, delivery, and the first 6 h after childbirth. Inventory of drugs, medical equipment, supplies, and infrastructure was conducted to identify availability of resources in health facilities. Structured interview was done to assess availability of resources and performance improvement opportunities. Data analysis involved calculating percentages, means and chi-square tests.ResultsA total of 150 midwives and 56 health facilities were included in the study. The performance assessment showed 16.5% of midwives were incompetent, 72.4% were competent, and 11.1% were outstanding in providing routine intrapartum care. Forty five midwives were observed while managing 54 obstetric and newborn complications and 41 (91%) of them were rated competent. Inventory of resources found that the proportion of facilities with more than 75% of the items in each category was 32.6% for drugs, 73.1% for equipment, 65.4% for supplies, 47.9% for infection prevention materials, and 43.6% for records and forms. Opportunities for performance improvement were inadequate, with 31.3% reporting emergency obstetric and newborn care training, and 44.7% quarterly or more frequent supportive supervision. Health centers fared worse in provider competence, physical resources, and quality improvement practices except for supportive supervision visits and in-service training.ConclusionsAlthough our findings indicate most midwives are competent in giving routine and emergency intrapartum care, the major gaps in the enabling environment and the significant proportion of midwives with unsatisfactory performance suggest that the conditions for providing quality intrapartum care are not optimal.

South Island Well Child Tamariki Ora Quality Improvement Project

The Well Child Tamariki Ora (WCTO) Quality Improvement project is a national two year project that has been funded by the Ministry of Health. The aim of this project is to improve the quality of the WCTO programme and health outcomes for children aged 0-5 years. The Model for Improvement and the WCTO quality improvement framework have been used as tools to support each level of the sector to achieve family-centred, high quality, equitable and effective child health services that deliver the best possible health outcomes for all New Zealand children and their families/whanau. Childhood health care services in New Zealand, primary maternity services, the WCTO programme and primary health services are all interrelated and require an integrative approach to service provision, Strengthening the connections/links between Lead Maternity Carer’s, WCTO provider, B4School Check nurses, Oral Health services, hearing screening, breastfeeding services, primary health organisations and immunisation services has been achieved through quality improvement training and education, establishing multi-agency advisory/strategic groups to oversee facilitate the improved integration, coverage and coordination of WCTO services. The desired outcomes of the WCTO project is based upon the WCTO quality improvement triple aim framework which includes • All children living in New Zealand aged 0-5 years of age have equitable access to the WCTO programme • Best value for the health system resource is achieved • All WCTO service providers have access to high quality and effective quality improvement tools and training Initiatives that aligned with either an access, outcome or quality child health indicator focus were selected. These included quality Improvement workshops offered to the wider Child health and Maternity sector. Establishing District Health Board WCTO forums across the region to provide a more collaborative and integrated approach to achieving child health outcomes.Developing referral pathways to improve enrolment into all universal child health services. Distribution of newsletters and webpage to share learning and provide quality improvement resources. Enabling equity and access: Quality improvement indicator dashboards have been developed as a tool to plan and design services and to underpin the culture of continuous service improvement. The WCTO quality indicator dashboards enable the impact of the project to be measured against the desired outcomes. The South Island region has demonstrated an overall improvement in children receiving core contacts in the first 12 months and greater number of children being referred from their Lead Maternity Carer into the WCTO programme. Engaging children, families and communities: The journey of navigating and staying connected with health services from consumers’ perspectives has been explored. Families were invited to share their experience of the Well Child service as well as suggest ideas for improvement through a group or individual discussion session. Stories were filmed to inform practice and training/ education sessions. All improvement requires change but not all change will result in improvement. Thus, the Model for Improvement methodology has ensured all change ideas are sustainable, measureable and result in beneficial change in the provision of health care for all children living in New Zealand.

Supplier quality improvement: The value of information under uncertainty

We consider supplier development decisions for prime manufacturers with extensive supply bases producing complex, highly engineered products. We propose a novel modelling approach to support supply chain managers decide the optimal level of investment to improve quality performance under uncertainty. We develop a Poisson–Gamma model within a Bayesian framework, representing both the epistemic and aleatory uncertainties in non-conformance rates. Estimates are obtained to value a supplier quality improvement activity and assess if it is worth gaining more information to reduce epistemic uncertainty. The theoretical properties of our model provide new insights about the relationship between the degree of epistemic uncertainty, the effectiveness of development programmes, and the levels of investment. We find that the optimal level of investment does not have a monotonic relationship with the rate of effectiveness. If investment is deferred until epistemic uncertainty is removed then the expected optimal investment monotonically decreases as prior variance increases but only if the prior mean is above a critical threshold. We develop methods to facilitate practical application of the model to industrial decisions by a) enabling use of the model with typical data available to major companies and b) developing computationally efficient approximations that can be implemented easily. Application to a real industry context illustrates the use of the model to support practical planning decisions to learn more about supplier quality and to invest in improving supplier capability.

Our New Reality of Public Reporting: Shame Rather Than Blame?

he number of organizations issuing reports on hosTpital and physician quality performance has increased markedly over the past decade. Differences in the measures, data sources, and scoring methodologies produce contradictory results that lead to confusion for the public, providers, and governing boards, and impair the public’s ability to make well-informed choices about health care providers [1]. This variability continues today and points to concerns about validity and the ultimate reliability of the measures used by these groups. The hospital community and surgeons as a whole support the principle of accountability through public reporting of health care performance data. However, performance data that are inappropriately collected, analyzed, and displayed may add more confusion than clarity to the health care quality question [1]. For data to be understood and for results to be comparable, publicly reported data should adhere to a set of guiding principles. With that goal in mind, the Association of American Medical Colleges (AAMC) convened a panel of experts in 2012 and 2013 to develop a set of guiding principles that can be used to evaluate quality reports. The principles were organized into three broad categories: purpose, transparency, and validity. Under the domain of purpose, the AAMC recognized that public reporting and performance measurement should occur for a variety of reasons, including consumer education, provider quality improvement, and purchaser decision making. Relative to transparency, the AAMC believed that methodologic details should be clearly discerned as they can impact both providers’ performance data and the appropriate interpretation of the data. Transparency also requires that all information necessary to understand the data be available to and interpretable by the reader. Limitations in data collection and methodology as well as relevant financial interests should always be disclosed in language that is discernable. Lastly, validity of the data must ensure that the methodology, data collection, scoring, and benchmarks produce an accurate reflection of the characteristic being measured and reflect the care being provided by the hospital or physician. These guiding principles were expanded and proposed by the AAMC to facilitate adherence and to ensure appropriate interpretation of