Quality Improvement Committee Research Articles

Emergency Surgical Treatment and Triage: Targeting Optimal Outcomes for Emergency Surgical Patients From Index Encounter Through Definitive Care.

Patients with emergency surgical conditions (ESCs) experience higher complication rates than those without emergency conditions. Our purpose was to improve time-based key performance indicators (KPIs) of care for ESC patients, including diagnostic workup, empiric stabilization, and referral to definitive care. A rapid response program (ESTAT) was developed to screen for and coordinate optimal, timely care for a spectrum of high-risk ESCs, from the patient's index clinical encounter up to definitive care. The Mann-Whitney test assessed whether any differences in KPIs were statistically significant (P < .05) before compared to after the implementation of ESTAT. 98 patients were identified: 44 in ESTAT group (70% age ≥55, 57% male); 54 in control group (57% age ≥55, 44% male). There were significant decreases from time of index clinical encounter to resuscitation (5min. vs 34min., P < .001), to diagnostic imaging (52min. vs 1hr. 19min., P = .004), and to definitive care (2hr. 17min. vs 3hr. 51min., P = .007) in the ESTAT group compared to the control group, respectively. Improving time-based KPIs for delivery of clinical services is a common goal of medical emergency response systems (MERS) in numerous specialties. Implementation of an ESTAT program provides a screening tool for at-risk patients and reduces time to stabilize, diagnose and triage to definitive surgical intervention. These time benefits may ultimately translate to reduced complication rates for ESC patients. ESTAT may also represent a patient onboarding mechanism for surgical specialty verification programs promoted by quality improvement committees of various professional societies.

Quality metrics for same day emergency care—Consensus of a multi-professional panel of experts using a modified Delphi process

Same Day Emergency Care (SDEC) services are at the heart of recovery plans for Emergency Care in the National Health Service. There are no validated metrics for the quality of care in SDEC.The Society for Acute Medicine's Quality Improvement Committee invited to a three-stage modified Delphi process to gather metrics used by clinicians. Proposed metrics were ranked and further explored by 33 participating experts from a broad range of backgrounds including clinicians, data scientists and operational managers.Experts ranked five system-based metrics highest. These focus on optimisation of the proportion of patients receiving same day care in and out of SDEC units. Patient and staff experience metrics were ranked low, possibly due to present lack of viable examples.The paper adds a glossary with the rationale for ranking of metrics and their use for the improvement of quality and safety of clinical care.

Optimizing resource utilization: palliative care consultations in critically ill pediatric trauma patients

ObjectivesThe American College of Surgeons Trauma Quality Improvement Program (TQIP) and Committee on Trauma released a best practice guideline for palliative care in trauma patients in 2017. Utilization of pediatric...

Improving Radiation Oncology Staff Engagement with Quality Improvement and Safety through a QI Committee Visiting Staff Initiative.

An interdisciplinary, team-based approach to safety and quality is a critical value of radiation oncology. Quality Improvement (QI) programs can be meaningful contributors. A visiting staff initiative to the monthly QI meeting was developed, with goals of broadening staff engagement with QI activities, providing transparency, encouraging a culture of reporting, and offering additional perspectives to the standing QI Committee (QIC). From 5/2021 - 1/2023, 24 staff, including physicians (n = 11), radiation therapists (n = 6), dosimetrists (n = 4), and administrative staff (n = 3) from 4 community-based radiation oncology clinics rotated through the monthly QI meeting as visitors. The meeting was held virtually. Prior to the meeting, visitors were provided with a background on QI operations and encouraged to be active participants. The QIC has 30 standing members including physicians (n = 2), physicists (n = 8), dosimetrists (n = 2), nursing (n = 3), radiation therapists (n = 4), IT (n = 2), administrative staff (n = 4), and QIC support staff (n = 2), out of a total of 115 staff members. Visitors filled out pre- and post-attendance surveys. A survey of the QIC (n = 14) was conducted to assess the value of the program to the committee. Survey responses were on a Likert scale (1 = Strongly Disagree; 5 = Strongly Agree). A 2-tail t-test was used for statistical analysis. Nearly all visitors stated that they learned something new through participation in the QI meeting (92%), and most said they were interested in future QI participation (63%). Most visitors were familiar with the process of submitting a safety report (75%), and nearly half submitted one in the past year (46%). After the first 10 visitors participated in QIC, the standing QIC was surveyed and agreed that visitors offered new perspective (4.3), and that the visitor program enhanced quality and safety in the department (4.2). The QIC visiting staff initiative was significantly effective in educating interdisciplinary staff members, establishing a safety culture, increasing transparency around QI functions, and providing new perspectives. At baseline, there was appreciation for the role of QI and safety. Implementing a QI visiting staff initiative is feasible and beneficial and may be of even higher impact in less established QI programs.

Evaluation of a charge nurse leadership development program.

Evaluation of a charge nurse leadership development program.

Establishment of a Cohort at Chosun University College of Medicine for Social Accountability

Cohorts are established and operated at medical schools as part of efforts to improve the quality of education. Chosun University College of Medicine clarified the purpose of establishing three cohorts in light of its core values and developed criteria and indicators for each purpose. An organization focusing on cohort construction and operation was established as the Cohort Committee under the Quality Improvement Committee, and guidelines were proposed. In addition, a database and system were developed to handle primary data efficiently, and tools for measuring psychological variables were created. The data collected by establishing a cohort, regions, and admission types of graduates were first analyzed for the following projects: (1) an analysis of the educational process and quality improvement to educate medical professionals who contribute to the community after graduation, and (2) an analysis of the educational process and quality improvement to secure excellence in the medical field (e.g., knowledge and clinical reasoning), using information on the academic achievements of students and graduates as primary data. Chosun University College of Medicine is conducting cohorts and longitudinal studies gradually, starting with a simple, practically feasible system to solve the difficulties faced in cohort establishment and operation. Medical educators hope that future data collection and analysis will improve the quality of medical school education and have practical implications.

Student Engagement in Student Support System Reform: A Case Study

Educational evaluation involves data collection and the analysis of various education-related factors to make decisions that improve educational quality. Systematic educational evaluation is essential for enhancing the quality of education. This study reports a case of student-conducted process evaluation of a medical school’s student support system and the procedure for devising improvement plans. Sixteen Inje University College of Medicine students participated in the Education Evaluation Committee (IUCM-EEC) to understand the educational improvement process as learners and actively achieve improvement. The Quality Improvement Committee of the Inje University College of Medicine (IUCM-QIC) decided to reform its student support system based on a previous educational evaluation in 2019. The evaluation of the student support system was conducted for 10 months in 2021 by the student subcommittee, under the guidance of the IUCM-EEC. The CIPP (context-input-process-product) evaluation model was used for a systematic evaluation. Accordingly, the subcommittee developed evaluation criteria and indicators, and analyzed relevant data collected from surveys and the previous literature. For further recommendations and revision ideas, the student subcommittee members interviewed faculty members from six other medical schools and also conducted a focus group interview with the dean and vice deans of IUCM. Finally, the student subcommittee submitted a report to the IUCM-QIC. Communication with various stakeholders is essential for a successful evaluation process. In this case, students, as key stakeholders in education, evaluated the student support system. Their active participation helped improve their understanding of the evaluation process.

Measurement Strategies for The Joint Commission Health Care Disparities Standard: Defining Hospital-Based Requirements—Part 1

Measurement Strategies for The Joint Commission Health Care Disparities Standard: Defining Hospital-Based Requirements—Part 1

Participation in a multidisciplinary institutional committee, “RQUEST,” to enhance quality improvement education, project design, and implementation for hematology/oncology fellows.

e18733 Background: Participation in quality improvement (QI) projects allows medical trainees to develop an essential skillset to systematically analyze practice and implement changes with the goal of practice improvement. The ACGME designates QI education and participation as a core competency for all fellows. Training programs and institutions can vary significantly in QI educational format, participation, and direct support for project design and implementation. Here we present a description of the Resident Quality, Experience, and Safety Team (RQUEST) committee, which is being utilized by Hematology and Oncology fellows for QI project design and implementation at our institution. Methods: The first RQUEST committee was convened in August of 2021. RQUEST holds formal monthly meetings from August to June of each academic year. At the initial meetings, committee members are introduced to quality, safety, and patient experience structures and receive introductory training in QI tools and techniques. RQUEST members are then split into smaller project groups and work to select a QI project, perform current state analysis and baseline data collection, design and implement improvement interventions, and re-measure to determine the impact of the chosen interventions. The year concludes with each team presenting their project at a joint session to a larger audience of program directors, quality officers, service line directors, department chairs, graduate medical education staff, and hospital leadership RQUEST participation provides fellows with direct access to a multidisciplinary team and resources throughout project design and implementation. The timeline of monthly meetings provides both accountability and productive feedback. This facilitates the identification of system-specific opportunities for improvement and the most practical points of contact within the hospital, clinic, or EMR to design and apply quality interventions promptly and effectively. Results: We sent a voluntary survey to RQUEST participants, and 40% of participants responded to the survey. 100% of those who responded said participating in RQUEST has been beneficial in developing and implementing a QI project, and 100% said they would recommend participating in RQUEST to other medical trainees. The most common benefits listed were: · Structured approach/guidance · Institutional support and resources · A collaborative environment with a team of members from various departments, including IT. Conclusions: Fellow participation in a multidisciplinary QI committee at our institution has improved fellow QI education, participation, and project implementation. This engagement model has proven valuable to fellows and faculty in enhancing QI competency and clinical practice.

Learning and development needs for successful staff and consumer partnerships on healthcare quality improvement committees: a co-produced cross-sectional online survey.

Objectives This study aimed to conduct a learning and development needs analysis of quality improvement partnership capabilities of staff and consumers on partnership committees at an Australian metropolitan hospital and health service. Objectives were to compare consumer and staff self-rated capability importance, performance, and learning needs; to investigate if years of partnership experience influenced ratings; and to ascertain staff and consumer preferred learning strategies. Methods An online cross-sectional survey was adapted from the Hennessy-Hicks Training Needs Analysis questionnaire. Participants self-rated the importance of, and their performance on, 10 capabilities, across four domains, of an internationally validated co-produced capability development framework. They also rated preferences regarding learning approaches and media. Results A total of 199 members from 41 committees (174 staff; 25 consumers; response rate 35.38%) participated. There was a statistically significant learning and development need across all capabilities (P < 0.01). The highest learning need was for influencing organisational systems and policy (mean = -0.96; s.d. = 1.23), followed by equalising power and leadership (mean = -0.91; s.d. = 1.22), and then implementing partnership best practices (mean = -0.89; s.d. = 1.22). There were no statistically significant differences between consumers and staff on ratings, or correlations between years of partnership experience and ratings (P < 0.01). A combination of learning approaches was preferred, followed by learning through experience. Self-reflection was least preferred, which is concerning given it may promote equalising power and leadership. Face-to-face then videoconferencing were the preferred learning media. Conclusions Continuous co-learning for staff and consumers about QI partnerships is essential. Committee members needed more feedback regarding their influence and to be engaged in innovative co-design practices.

What guidelines?: Attitudes and behaviors for prescribing prophylactic hepatic encephalopathy medications.

What guidelines?: Attitudes and behaviors for prescribing prophylactic hepatic encephalopathy medications.

Statewide Perinatal Quality Improvement, Teamwork, and Communication Activities in Oklahoma and Texas.

The purpose of this study was to describe statewide perinatal quality improvement (QI) activities, specifically implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units in Oklahoma and Texas. In January-February 2020, we conducted a survey of AIM-enrolled hospitals in Oklahoma (n = 35) and Texas (n = 120) to gather data on obstetric unit organization and QI processes. Data were linked to hospital characteristics information from the 2019 American Hospital Association survey and hospitals' maternity levels of care from state agencies. We generated descriptive statistics for each state and created an index to summarize adoption of QI processes. We fitted linear regression models to examine how this index varied by hospital characteristics and self-reported ratings for patient safety and AIM bundle implementation. Most obstetric units had standardized clinical processes for obstetric hemorrhage (94% Oklahoma; 97% Texas), massive transfusion (94% Oklahoma; 97% Texas), and severe hypertension in pregnancy (97% Oklahoma; 80% Texas); regularly conducted simulation drills for obstetric emergencies (89% Oklahoma; 92% Texas); had multidisciplinary QI committees (61% Oklahoma; 83% Texas); and conducted debriefs after major obstetric complications (45% Oklahoma; 86% Texas). Few obstetric units offered recent staff training on teamwork and communication to their staff (6% Oklahoma; 22% Texas); those who did were more likely to employ specific strategies to facilitate communication, escalate concerns, and manage staff conflicts. Overall, adoption of QI processes was significantly higher in hospitals in urban than rural areas, teaching than nonteaching, offering higher levels of maternity care, with more staff per shift, and greater delivery volume (all P < .05). The QI adoption index scores were strongly associated with respondents' ratings for patient safety and implementation of maternal safety bundles (both P < .001). Adoption of QI processes varies across obstetric units in Oklahoma and Texas, with implications for implementing future perinatal QI initiatives. Notably, findings highlight the need to reinforce support for rural obstetric units, which often face greater barriers to implementing patient safety and QI processes than urban units.

Lessons learned about policymaking: Moving an emergency department-initiated screening protocol to systemwide input in the development and implementation process.

Lessons learned about policymaking: Moving an emergency department-initiated screening protocol to systemwide input in the development and implementation process.

Variability in Reporting eGFR at Dialysis Initiation in Canada: A Research Letter.

Estimated glomerular filtration rate (eGFR) at dialysis initiation is increasingly recognized as a key quality indicator (QI) for patients with end-stage kidney disease (ESKD). Specifically, guidelines recommend assessing deferral of dialysis initiation until symptoms arise or if the eGFR is ≤6 mL/min/1.73 m2. Despite the recognition of the importance of this QI, how eGFR at the time of dialysis initiation is defined, collected, and tracked at dialysis centers across Canada remains unknown. To identify how provincial renal programs define eGFR at dialysis initiation, to compare practice across Canadian provinces, and to determine if there is a consistent benchmark for deferred dialysis start. Cross-sectional survey distributed to the medical leads of each provincial renal program, administered from July 2021 to November 2021. Quebec was not included given it did not yet participate in Canadian Organ Replacement Register (CORR) data submission. The survey was designed and distributed by the Canadian Society of Nephrology Quality Improvement & Implementation Science Committee (CSN-QUIS) Indicator Working Group. The survey asked respondents on how eGFR is defined, collected, reported, and perceived barriers to QI data collection. The National Senior Renal Leaders Forum helped identify the key provincial medical leads to disseminate the survey for completion. Surveys were distributed to the medical leads of the 9 provincial renal programs that participate in CORR. In total, there were 8 responses. Five provinces submit eGFR for all new dialysis starts and 3 provinces only submit this information for chronic patients. There is variation in determining when a patient with acute kidney injury requiring dialysis is classified as a chronic patient. Four provinces use a 30-day trigger, 3 provinces use a 90-day trigger, and the patient's nephrologist makes this determination in 1 province. The creatinine used for the eGFR at dialysis initiation was the value measured on the first dialysis session (ie, day 0) for 5 provinces; the last outpatient clinic creatinine value in 2 provinces, and 1 province did not have a standard definition. Three provinces did not have a benchmark target for eGFR at dialysis initiation, 1 province had a target of <9.5 mL/min/1.73 m2, 3 provinces had a target of <10 mL/min/1.73 m2, 1 province had a target of <15 mL/min/1.73 m2. All 8 responding provincial medical leads support the establishment of a national benchmark for this measure. This survey was restricted to provincial medical leads and therefore is unable to determine practice at individual dialysis sites. The survey was not anonymous, so it may be subject to conformity bias. There is wide variability in how eGFR at dialysis initiation is measured and reported across Canada. Additionally, there is no consensus on a benchmark target for an intent-to-defer dialysis strategy. Standardization of target eGFR at dialysis initiation may facilitate national reporting and quality improvement initiatives.

A Quality Improvement Initiative to Improve Implementation of Guideline-Concordant Hereditary Myeloid Malignancy Syndrome Evaluation

Background: Myeloid malignancies such as acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) are traditionally thought of as sporadic disorders. Recently, there has been increasing awareness of hereditary myeloid malignancy syndromes (HMMS) and their impact on MDS/AML treatment decisions, other organ and cancer surveillance, and at-risk family member management. Detection of patients with an HMMS is challenging due to variable expressivity, lack of physical signs, incomplete family history information, and limited provider awareness. In 2021, the National Comprehensive Cancer Network (NCCN) guidelines added recommendations for genetic evaluation of patients with MDS/AML meeting certain clinical or molecular criteria to facilitate identification of patients with an HMMS. The impact of utilizing these criteria on the proportions of patients with MDS/AML needing germline genetic evaluation and their efficacy in detecting the subset with an HMMS have not been studied. We established a quality improvement (QI) committee to implement and test the utility and efficacy of NCCN MDS/AML referral criteria. Methods: A QI committee, including a cancer geneticist, a molecular pathologist, hematology faculty and fellows, clinical pharmacists, research coordinators, and a genetic counselor, was formed to implement NCCN recommendations and evaluate patients with MDS/AML for referral to the UW Hereditary Hematology Clinic. At each monthly meeting, clinical and family history and molecular data are reviewed for patients with MDS/AML who had a next-generation sequencing panel performed in the prior month. Patients meeting criteria for referral are identified, and an HMMS evaluation referral recommendation note is written in the electronic medical record and routed to the patient's primary hematologist. To assess the impact of implementing these guidelines on need for HMMS evaluations in routine MDS/AML care, we compared the proportion of patients meeting criteria and referral rates before (1/2019-8/2021) and after (9/2021-4/2022) our intervention. Results: From 9/1/21 through 4/31/22, 42 patients (20 AML, 22 MDS) were reviewed by the committee. 34 patients had a new diagnosis, whereas eight had an established diagnosis but had molecular data obtained for the first time after 9/1/2021. Overall, 23 patients (55%) met criteria for referral. Six patients met clinical criteria, seven patients met molecular criteria, and 10 patients met both clinical and molecular criteria. Eight patients were ultimately referred for HMMS evaluation, corresponding to a referral rate of 35%. Two patients were found to have a pathogenic variant in DDX41, two patients had at least one variant of unknown significance (VUS), one patient had negative testing, and three patients have pending results. For the 15 patients who were not referred, three were deceased at the time of committee meeting, two were pursuing hospice, one patient declined, and one patient was lost to follow-up; the remaining eight patients were not referred for unknown reasons. In the pre-intervention cohort, 71 of 114 patients met criteria for referral (63%), and 8 were ultimately referred for HMMS evaluation, corresponding to a referral rate of 11%. One patient had a pathogenic variant in ANKRD26, two patients had at least one VUS, four patients had negative testing, and one patient declined genetic evaluation. Conclusion: Implementation of current NCCN germline genetic testing criteria for MDS/AML resulted in ~60% of unselected MDS/AML patients meeting referral criteria for HMMS evaluation. Formalized referral recommendations in the form of a QI committee referral note in the medical record increased provider referrals from 11% to 35% in those meeting criteria. Clinical acuity and patient mortality were the largest barriers to referral for HMMS evaluation in this patient population. Among the small proportion actually referred, 5% of patients in the intervention cohort and 1% of patients in the pre-intervention cohort were found to have an HMMS. This experience demonstrates that implementing current NCCN guidelines via a QI committee will significantly increase the proportion of patients recommended to have HMMS evaluation and increases detection of patients with HMMS. Whether these criteria can be refined to maximize detection while minimizing burden on patient care and the healthcare system warrants further investigation. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Developing priorities for quality improvement in acute medicine using a modified Delphi method A consensus process hosted by the Society for Acute Medicine Quality Improvement Committee (SAM-QI).

The SAM Quality Improvement Committee (SAM-QI), set up in 2016, has worked over the last year to determine the priority Acute Medicine QI topics. They have also discussed and put forward proposals to improve QI training for Acute Medicine professionals. A modified Delphi process was completed over four rounds to determine priority QI topics. Online meetings were also used to develop proposals for QI training. Same Day Emergency Care (SDEC) was chosen as the priority topic for QI work within Acute Medicine. The SAM-QI group settled on SDEC being the priority topic for Acute Medicine QI development. Throughout the Delphi process SAM-QI has also developed proposals for QI training that will help Acute Medicine professionals deliver coordinated meaningful improvements in care.

108 Development and Implementation of a Burn Nurse Educator

IntroductionPrior to the introduction of the Burn Nurse Educator (BNE), at a growing and newly established burn center, the education of the Burn Trauma ICU staff was completed by the Burn Director and Burn Supervisor. In this burn center, large amounts of education became difficult to create and distribute by the current Burn Director and Burn Supervisor due to the demand of their respective job roles. The role of the BNE was to create initial and ongoing education for the Burn Trauma ICU Staff, Ortho-Trauma staff, ED staff, local EMS agencies, and the community.MethodsThe Burn Nurse Educator reviewed previous education that was provided to the staff, compared it to the Burn Nurse Competencies established by the American Burn Association, and was able to formulate a new education plan. The Burn Nurse Educator created several burn-based courses. These classes included: Floating into Burn Care, Burn Boot Camp, and Burns in the Pediatric Population. There was also the introduction of mock codes focused on the pediatric burn population. In addition to the formulation of these educational opportunities, the Burn Nurse Educator worked directly with the Quality Improvement Committee to find gaps in care. These gaps were then turned into project improvement plans and additional education was provided to the bedside staff. The Burn Nurse Educator formed relationships with local EMS agencies and was able to provide burn lectures and continuing education.ResultsEach class offered had a pre and post test administered, all with improved scores. A sample size of 30 nurses who enrolled in Burns in the Pediatric Population had a score increase from 46% to 94%. A sample size of 14 nurses had a score increase of 55% to 80% after enrolling in Floating into Burn Care. A sample size of 30 nurses who enrolled in Burn Boot Camp had a score increase of 71% to 95%. More importantly, the staff expressed a higher level of confidence when caring for a burn patient after these classes. The outreach with local EMS agencies also increased our EMS admits to the hospital, improved knowledge for caring for burn victims, and created a relationship with our local cities EMS.ConclusionsIt is anticipated that as the program continues to expand, the role of the Burn Nurse Educator will continue to grow and encompass new responsibilities. To ensure each nurse remains competent in their skill set, additional knowledge testing will be completed one year after a nurse has completed a class.

The impact of a multilevel approach to reduce emergency hysterectomy for postpartum haemorrhage: Insights from a tertiary referral centre in Northern Italy

ObjectiveTo assess the effectiveness of the implementation of a multilevel institutional program to reduce the rate of emergency peripartum hysterectomy (EPH) secondary to postpartum haemorrhage (PPH) in a Western world referral centre for obstetrics. Study designWomen who delivered at a tertiary care regional obstetric hub in Milan between 2012 and 2020 were retrospectively reviewed to identify cases of EPH. During the study period, several measures aimed at preventing EPH were progressively implemented: reduction of primary and repeated caesarean, update of PPH treatment protocol, implementation of massive transfusion protocol, dedicated clinical pathway for high-risk patients, regular educational sessions, daily review of critical cases with senior consultant, and periodical review of near miss cases by quality improvement committee. To investigate the possible benefits, we divided the detected cases into two groups based on the historical period (Period I, 2012–2016 vs. Period II, 2017–2020) with the main aim of comparing the rate of EPH calculated as EPH ratio per 1000 deliveries. ResultsDuring Period I and II there were 30,241 and 21,270 births; a total of 60 and 25 EPH were performed, respectively. EPH incidence decreased from 2.0 to 1.2‰ across the study periods (p = 0.027). Between Period I and II, we observed a reduction of institutional caesarean section rate (44.4% vs. 40.4%, p < 0.0001); among cases undergoing EPH, we reported a significant reduction of massive blood transfusion (83.3% vs. 52.2%, p = 0.002), increased use (56.7% vs. 96.0%, p = 0.0004) and appropriate administration (25.0% vs. 88.0%, p < 0.0001) of tranexamic acid, increased use of non-invasive Bakri Balloon tamponade (3.3% vs. 32.0%, p = 0.0002) instead of surgical techniques (38.3% vs. 16.0%, p = 0.043). ConclusionA reduction of EPH incidence as a severe outcome of obstetric haemorrhage is achievable through a multilevel institutional effort. Our study may inspire a larger-scale program to improve the safety of patients experiencing PPH.

A blueprint for building an emergency department quality improvement and patient safety committee.

The field of quality improvement and patient safety (QIPS) has matured significantly in emergency medicine over the past decade. From standalone, strategically misaligned, and incoherently designed QIPS projects years ago, emergency department (ED) leaders have now recognized that developing a more robust QIPS infrastructure helps prioritize and organize projects for a greater likelihood of success and impact for patients and the system. This process includes the development of a well-defined, accountable, and supported departmental QIPS committee. This can be achieved effectively using a deliberate and structured approach, such as the one described by Harvard Business School Professor John Kotter in his seminal work, “Leading Change.” Herein, we present a blueprint using this framework and include practical examples from our experience developing a robust and successful ED QIPS committee and infrastructure. The steps include how to develop a “burning platform,” select a guiding coalition of leaders, develop a strategic vision and initiatives, recruit a volunteer army of members, enable actions for the committee, generate short-term successes, sustain the pace of change, and, finally, enable the infrastructure to support ongoing improvements. This road map can be replicated by ED teams of variable sizes and settings to structure, prioritize, and operationalize their QIPS activities and ultimately improve the outcomes of their patients.Supplementary InformationThe online version contains supplementary material available at 10.1007/s43678-021-00252-2.

Optimizing Post-Cesarean Opioid Prescription Practices at Mayo Clinic: A Quality Improvement Initiative.

Optimal prescriptions practices of opioids in the post-cesarean period remain controversial. The primary aim of this initiative was to minimize unused prescription narcotic medication, with a goal of ≤4 leftover pills of 5-mg oxycodone at postoperative day (POD) 14 without affecting pain or satisfaction measures. This was a prospective longitudinal quality improvement (QI) initiative starting in 2017 utilizing the DMAIC methodology. The measurement phase consisted of validated surveys over 3 months, along with chart review to determine current institutional prescription practices and predictors of outpatient opioid use. Resulting recommendations were adopted, and 1 year later, all patients undergoing cesarean were surveyed for 3 months to determine the effectiveness of the intervention. The study was approved by the Department's QI Committee. The response rate was 48%, with 50 of 101 patients completing surveys pre-intervention and 52 of 111 post-intervention. Pre-intervention, surplus medication was predicted (p <0.05) only by the quantity of the opioid prescription. In addition, patients who required ≤37.5 morphine milligram equivalents (MMEs) during the inpatient postoperative stay did not require outpatient narcotic prescriptions. Thereafter, a strategy of matching inpatient use to outpatient prescription 1:1 in a linear regression model (p <0.001, R 2 0.55) optimally matched patient needs up to 200 MME. In the post-intervention survey, mean (SD) prescription decreased from 17.6 (13.7) MME to 8.4 (8.3) MME (p <0.01); 39% compared with 16% of women were discharged without a prescription (p <0.01); and amongst all patients 82.7% compared with 59.6% (p <0.01) had ≤4 pills remaining without differences in patient satisfaction or pain perception. This initiative highlights a practical approach to QI utilizing industry techniques in health care. This approach resulted in significant reductions in over-prescription and unused medication, without impacting pain or satisfaction scores. · 20% of patients may manage pain at home without opioids.. · In-hospital opioid use is reflective of outpatient need.. · Customize prescriptions to reduce leftover narcotics..