Quality Improvement Expertise Research Articles

Improving the Outpatient Pain Management Plan for Patients with Sickle Cell Disease with Electronic Medical Record-Based Pain Action Plans

Background: Patients with sickle cell disease (SCD) experience recurrent vaso-occlusive crises (VOC) as a primary manifestation of their illness. The American Society of Hematology (ASH) best practice guidelines recommend that individuals with SCD have individualized care plans to effectively begin pain management at home prior to presenting to the emergency room. A needs assessment of the comprehensive sickle cell program at Rady Children's Hospital San Diego (RCHSD) identified the need for a standardized approach for the provision of Pain Action Plans (PAP). In 2022, an outpatient PAP Quality Improvement (QI) project was initiated at RCHSD with the global aim to improve outpatient pain management and quality of life for patients with SCD. SMART Aim: Within 6 months (January-June 2023), to increase the proportion of patients with SCD receiving a PAP during a comprehensive clinic visit from 0 to 50%. Methods: The QI project was conducted by an interprofessional team with clinical, QI, and information technology expertise. An initial approach utilizing the Med Action Plan function in EPIC had technical challenges and was not implemented. We identified an existing Epic Asthma Action Plan which could be adapted to a SCD PAP. Meetings with clinical informaticists, pulmonology (consultants), and hematology teams informed the QI tools (process mapping, key driver and Ishikawa diagrams) that we used to design our PDSA cycles. The PAPs were modeled after the existing Asthma Action Plan, with green, yellow, and red zones to indicate different levels of pain management. Patients were given laminated Youth Acute Pain Functional Ability Questionnaire (YAPFAQ) and a comfort measures sheet to complete prior to their visit with the provider to inform the PAP which included pain medication details and supportive care measures for each zone. PAPs were created within the clinic note at comprehensive clinic visits and then provided to the family as a printed letter in person and via MyChart (if activated). Our outcome measure was the percentage of patients who were provided a PAP at their SCD comprehensive clinic visit. Process measures included the percentage of patients who had documentation in the PAP of the YAPFAQ and comfort measures, percentage of patients who had a PAP routed to patient via MyChart, percentage of patients who confirmed receipt of their PAP, percentage of patients who had used their PAP by parental report after one week, and percentage of patients who had used their PAP after 3 months per Epic documentation. Balancing measures were the perceived burden of patient care/documentation for the PAP to be evaluated with pre and post surveys among providers. Results: Interventions were evaluated using PDSA cycles. PDSA Cycle 1 (January-March 2023) included development of the SCD PAP by adapting the existing Asthma Action Plan to a SCD PAP. This included the creation of medication templates, integrating comfort measures and pain triggers, creating EPIC smart phrases to document the YAPFAQ. We educated providers on the SCD PAP and documentation process and worked with the interdisciplinary team including case managers, nurses, child life specialists, and psychologist to incorporate YAPFAQ and comfort measures into the comprehensive clinic visit. PDSA Cycle 2 (April-June 2023) included additional education, training, and targeted e-mail reminders to hematology attendings. From May 2023 to July 2023, 94% percent (13/14) of patients seen at a comprehensive clinic visit received a PAP. One patient had the PAP created but did not receive the printed letter due to time constraints for family. Feedback from families indicated that they felt the PAP was a valuable tool to have at home during VOC, however none had yet utilized it in the week since they were seen in clinic. Early provider feedback has indicated that this functionality is easy to use and efficient during the comprehensive clinic visit. Conclusion: The adaptation of the Asthma Action Plan to the SCD PAP allowed for successful implementation of PAPs for our patients with SCD. Subsequent PDSA cycles will focus on optimizing implementation in the clinic and utilization for pain events. We will evaluate the clinical impact of the PAPs on pain management outcomes.

Transforming health care: A large health organizations' journey to become an age-friendly health system (AFHS) and beyond.

In 2017, the John A. Hartford Foundation partnered with the Institute for Health Care Improvement, American Hospital Association, and Catholic Health Care Organization to define the 4Ms framework to improve quality of care and health outcomes for older adults. The senior leadership of one of the largest integrated healthcare organizations (HCO) in the country recognized the relevance of these recommendations to the aging demographic of the United States. The health system provides care to over 2,000,000 unique patients annually, about 20% of whom are aged ≥65. We describe how commitment to becoming an Age-Friendly Health System (AFHS) has taken this HCO beyond the targets set by the initiative. Steps guiding evolution of the AFHS model of care are as follows: Initiation, assessment, planning, implementation, sustainability. An AFHS leadership team including geriatrics and quality improvement expertise oversees the initiative. Plan-Do-Study-Act cycles are utilized at multiple stages to develop structures for data collection and reporting outcomes. Initiation and assessment stages identified key champions and existing efforts and programs that were leveraged to implement 4Ms best practices. Working committees with relevant expertise for each M selected evidence-based quality measures and designed/adapted training materials. The EHR is used to integrate quality measures and gather outcome data to inform changes in care. Dashboards capturing quality measures for each M have been implemented and pilot-tested at a community-based hospital and these processes are being adapted and disseminated to other settings. Leadership and stakeholders convene regularly to review lessons learned and next steps. On the health system level, partnering with quality management leaders has led to development of processes that feed into organizational level data used to track longitudinal improvements in patient outcomes. Outcome data in each of the 4M domains are presented. Learning points are shared to help others take a systems-approach to age-friendly change.

Building Resident Quality Improvement Knowledge and Engagement Through a Longitudinal, Mentored, and Experiential Learning-Based Quality Improvement Curriculum.

Quality improvement (QI) training is an essential component of resident medical education and a part of the ACGME core competencies. We present our residency's evidence-based QI curriculum, which outlines key components identified in the literature for successful QI education. Our curriculum included a mandatory five-part longitudinal educational series during ambulatory education sessions for second-year residents. Modeled after the Institute for Healthcare Improvement model for improvement and taught by a chief resident, our curriculum introduced residents to key QI concepts through case-based, just-in-time didactics and applied experiential learning via concurrent resident-led longitudinal QI projects. Residents received structured, multilayer mentorship from a faculty mentor in their field of interest and the chief resident of quality and patient safety. Their work-in-progress projects were presented to faculty QI experts and institutional leadership for additional feedback and mentorship. Since 2016, a total of 234 internal medicine residents have completed our QI curriculum and developed 67 QI projects, which have been presented at various local, regional, and national conferences. In the 2 most recent academic years, Quality Improvement Knowledge Application Tool Revised (QIKAT-R) scores significantly increased from 4.6 precurriculum to 6.3 postcurriculum (p < .001). A longitudinal, experiential, and mentored QI curriculum teaches residents QI skill sets through incorporating mechanisms associated with successful educational initiatives and adult learning theory. Our QIKAT-R results and project output show that our curriculum is associated with improved trainee QI knowledge and systems-level improvements.

Quality improvement knowledge in pediatric hematology/oncology physicians: A need for improved education.

Pediatric hematology/oncology fellows face unique quality improvement challenges given the danger of chemotherapy and caring for immunocompromised patients. Curricula to teach pediatric hematology/oncology fellows about quality improvement are lacking. We conducted a needs assessment of pediatric hematology/oncology physicians as a first step for creating a quality improvement curriculum for pediatric hematology/oncology fellows. Curricular topics were identified: root cause analysis, run charts, process mapping, chemotherapy/medication safety, implementation/adherence to guidelines. Identified barriers to curriculum implementation included a possible lack of quality improvement expertise, lack of awareness of quality improvement resources, and limited time.

What makes an effective Quality Improvement Manager? A qualitative study in the New Zealand Health System

PurposeQuality improvement is an international priority, and health organisations invest heavily in this endeavour. Little, however, is known of the role and perspectives of Quality Improvement Managers who are responsible for quality improvement implementation. We explored the quality improvement managers’ accounts of what competencies and qualities they require to achieve day-to-day and long-term quality improvement objectives.DesignQualitative exploratory design using an interpretivist approach with semi-structured interviews analysed thematically.Setting and participants.Interviews were conducted with 56 quality improvement managers from 15 (out of 20) New Zealand District Health Boards. Participants were divided into two groups: traditional and clinical quality improvement managers. The former group consisted of those with formal quality improvement education—typically operations managers or process engineers. The latter group was represented by clinical staff—physicians and nurses—who received on-the-job training.ResultsThree themes were identified: quality improvement expertise, leadership competencies and interpersonal competencies. Effective quality improvement managers require quality improvement experience and expertise in healthcare environments. They require leadership competencies including sense-giving, taking a long-term view and systems thinking. They also require interpersonal competencies including approachability, trustworthiness and supportiveness. Traditional and clinical quality improvement managers attributed different value to these characteristics with traditional quality improvement managers emphasising leadership competencies and interpersonal skills more than clinical quality improvement managers.ConclusionsWe differentiate between traditional and clinical quality improvement managers, and suggest how both groups can be better prepared to be effective in their roles. Both groups require a comprehensive socialisation and training process designed to meet specific learning needs.

Identifying and Analyzing Systems Failures: An Interactive, Experiential Learning Approach to Quality Improvement for Clerkship-Level Medical Students.

IntroductionMedical students are positioned to observe, document, and explore opportunities to improve patient safety and quality in their institutions. Medical schools are introducing quality improvement (QI) knowledge and skills in the preclinical classrooms, yet few provide opportunities to apply these tools in the clinical setting.MethodsClerkship students participated in two 1-hour sessions, organized in groups of 12–15 students, led by faculty with QI expertise. The sessions in the module introduced core concepts in QI and patient safety, while drawing on students' own clinical experiences. Students identified a system failure they encountered in their own clinical setting/practice and analyzed contributing factors using the 5 Whys Tool. We evaluated the efficacy of the two-session module with a pre- and postsurvey of students' self-reported change in knowledge, skills, and attitudes. Surveys also assessed students' satisfaction with module content and format. Faculty perspectives were solicited by email.ResultsIn April-May 2019, 59 students at a large US medical school participated. Of students, 73% and 53% completed pre- and postsurveys, respectively. All students submitted a report of an identified systems failure and their analysis of contributing factors. Students' self-rated knowledge and skills increased significantly. Students preferred active engagement compared to passive learning. Students and faculty identified areas for future module improvement.DiscussionThe educational program was well received and increased students' knowledge and confidence in core concepts of QI and safety. The module addressed the requirement for graduating students to identify safety incidents and contribute to a culture of QI.

Collaborative improvement in Scottish GP clusters after the Quality and Outcomes Framework: a qualitative study.

BackgroundScotland abolished the Quality and Outcomes Framework (QOF) in April 2016, before implementing a new Scottish GP contract in April 2018. Since 2016, groups of practices (GP clusters) have been incentivised to meet regularly to plan and organise quality improvement (QI) as part of this new direction in primary care policy.AimTo understand the organisation and perceived impact of GP clusters, including how they use quantitative data for improvement.Design and settingThematic analysis of semi-structured interviews with key stakeholders (n = 17) and observations of GP cluster meetings (n = 6) in two clusters.MethodThis analytical strategy was combined with a purposive (variation) sampling approach to the sources of data, to try to identify commonalities across diverse stakeholder experiences of working in or on the idea of GP clusters. Variation was sought particularly in terms of stakeholders’ level of involvement in improvement initiatives, and in their disciplinary affiliations.ResultsThere was uncertainty as to whether GP clusters should focus on activities generated internally or externally by the wider healthcare system (for example, from Scottish Health Boards), although the two observed clusters generally generated their own ideas and issues. Clusters operated with variable administrative/managerial and data support, and variable baseline leadership experience and QI skills. Qualitative approaches formed the focus of collaborative learning in cluster meetings, through sharing and discussion of member practices’ own understandings and experiences. Less evidence was observed of data analytics being championed in these meetings, partly because of barriers to accessing the analytics data and existing data quality.ConclusionCluster development would benefit from more consistent training and support for cluster leads in small-group facilitation, leadership, and QI expertise, and data analytics access and capacity. While GP clusters are up and running, their impact is likely to be limited without further investment in developing capacity in these areas.

Practice and Quality Improvement Leaders Survey of Expectations of DNP Graduates' Quality Improvement Expertise.

Input from practice leaders will improve how doctor of nursing practice (DNP) education is meeting the needs of the employer and improving patient outcomes. This article describes the expectations practice leaders have of new DNP graduates' ability to contribute to quality improvement (QI) efforts within health care organizations. A survey of practice leaders and QI experts investigated the importance and use of QI knowledge and skills. Practice leaders were also asked about the expectations of DNP graduates at the time of hire. The results of this study support the need for nurses pursuing a DNP in advanced nursing practice to have education and training beyond their area of specialization, specifically in QI methods and tools. Faculty need to provide DNP students education that includes concepts in QI and leadership to meet the expectations of future employers and the needs of a complex and changing health care system.

Recommendations for enhancing collaboration between the Canadian emergency department quality improvement and research communities.

ObjectivesWhile quality improvement (QI) and clinical research embody two distinct scientific approaches, they have the same ultimate goal—to improve health and patient care outcomes. By leveraging their respective strengths there is a higher likelihood of achieving and sustaining health improvements. Our objective was to create recommendations to enhance the collaboration of the Canadian emergency medicine QI and clinical research communities.MethodsAn expert panel of eight ED clinicians with diverse QI and clinical research expertise drafted a list of recommendations based on their professional expertise and a scoping review of the literature. These recommendations were refined through consultation with national stakeholders and reviewed at the 2020 CAEP Virtual Academic Symposium, where feedback was received through several virtual platforms.ResultsThe final six recommendations include that all emergency medicine providers should: (1) understand the role and application of both clinical research and QI science; that academic emergency medicine physicians should: (2) contribute to both local adoption and broad dissemination of project findings, (3) leverage QI methodologies in research projects to improve knowledge translation, and (4) ensure that project outcomes prioritize patient care; and that academic leaders should: (5) enhance the infrastructure for oversight of research and QI projects, and (6) encourage collaboration between researchers and QI experts by ensuring that academic and operational infrastructures align and support both.ConclusionSix recommendations are presented to help the Canadian emergency medicine community achieve greater collaboration between researchers and QI experts with the ultimate goal of improving patient care outcomes.

Improving Quality of Care Through a Mandatory Provincial Audit Program: Ontario’s Emergency Department Return Visit Quality Program

The Emergency Department Return Visit Quality Program was launched in Ontario, Canada, to promote a culture of quality. It mandates the province's largest-volume emergency departments (EDs) to audit charts of patients who had a return visit leading to hospital admission, including some of their 72-hour all-cause return visits with admission and all of their 7-day ones with sentinel diagnoses (ie, acute myocardial infarction, subarachnoid hemorrhage, and pediatric sepsis), and submit their findings to a governmental agency. This provides an opportunity to identify possible adverse events and quality issues, which hospitals can then address through quality improvement initiatives. A group of emergency physicians with quality improvement expertise analyzed the submitted audits and accompanying narrative templates, using a general inductive approach to develop a novel classification of recurrent quality themes. Since the Return Visit Quality Program launched in 2016, 125,698 return visits with admission have been identified, representing 0.93% of the 86 participating EDs' 13,559,664 visits. Overall, participating hospitals have conducted 12,852 detailed chart audits, uncovering 3,010 (23.4%) adverse events/quality issues and undertaking hundreds of quality improvement provincewide projects as a result. The inductive analysis revealed 11 recurrent themes, classified into 3 groupings: patient characteristics (ie, patient risk profile and elder care), ED team actions or processes (ie, physician cognitive lapses, documentation, handover/communication between providers, radiology, vital signs, and high-risk medications or medication interactions), and health care system issues (ie, discharge planning/community follow-up, left against medical advice/left without being seen, and imaging/testing availability). The Return Visit Quality Program is the largest mandatory audit program for EDs and provides a novel approach to identify local adverse events/quality issues to target for improved patient safety and quality of care. It provides a blueprint for health system leaders to enable clinicians to develop an approach to organizational quality, as well as for teams to construct an audit system that yields defined issues amenable to improvement.

Nationwide Qualitative Study of Practice Leader Perspectives on What It Takes to Transform into a Patient-Centered Medical Home.

Despite widespread adoption of patient-centered medical home (PCMH), little is known about why practices pursue PCMH and what is needed to undergo transformation. Examine reasons practices obtained and maintained PCMH recognition and what resources were needed. Qualitative study of practice leader perspectives on PCMH transformation, based on a random sample of primary care practices engaged in PCMH transformation, stratified by US region, practice size, PCMH recognition history, and practice use of Consumer Assessment of Healthcare Providers and Systems (CAHPS®) PCMH survey. 105 practice leaders from 294 sampled practices (36% response rate). Content analysis of interviews with practice leaders to identify themes. Most practice leaders had local control of PCMH transformation decisions, even if practices adopted quality initiatives under the direction of an organization or network. Financial incentives, being in a statewide effort, and the intrinsic desire to improve care or experiences were the most common reasons practice leaders decided to obtain PCMH recognition and pursue associated care delivery changes. Leadership support and direction were highlighted as essential throughout PCMH transformation. Practice leaders reported needing specialized staff knowledge and significant resources to meet PCMH requirements, including staff knowledgeable about how to implement PCMH changes, track and monitor improvements, and navigate implementation of simultaneous changes, and staff with specific quality improvement (QI) expertise related to evaluating changes and scaling-up programs. PCMH efforts necessitated support and assistance to frontline, on-site practice leaders leading care delivery changes. Such change efforts should include financial incentives (e.g., direct payment or additional reimbursement), leadership direction and support, and internal or external staff with experience with the PCMH application process, implementation changes, and QI expertise in monitoring process and outcome data. Policies that recognize and meet the needs of on-site practice leaders will better promote primary care practice transformation and move practices further toward their PCMH transformation goals.

Developing a Normative Standard for Selecting Hospitalized Adults with Whom to Have an ACP Conversation: Results from a Delphi Panel (GP766)

• Identify an empirical standard for ACP conversations with hospitalized elders.• Understand the methodologic issues in eliciting clinician recommendations about best practice behavior. Advance care planning (ACP) improves the quality of care that patients receive as they approach the end of life. Hospitalizations offer one opportunity to initiate ACP conversations. Guidelines suggest that hospitalists prioritize patients for ACP and goals of care conversations based on the presence of ‘serious illness.’ To establish a normative standard for clinicians to prioritize hospitalized patients with whom they should have an ACP conversation We performed a web-based Delphi survey of multi-disciplinary clinicians with research and quality improvement expertise in ACP (n=108 invited; March 2019 to June 2019). We solicited opinions about the risk of mortality (short-term and 1-year), as well as other variables, that influenced their prioritization of hospitalized adults age 65 and older for ACP conversations using both case vignettes to observe their decision making as well as direct elicitation of their judgment. We sought to achieve consensus by selecting cases in each round to probe areas of controversy, providing aggregated feedback to panelists after each round, and increasing the transparency of the study design over time. 57 (52%) clinicians participated in the Delphi process, and 47 (44%) completed three rounds of surveys. Panelists agreed that all hospitalized adults over the age of 65 would benefit from an ACP conversation during their hospitalization. For patients with ≤10% (low) short-term and <19% (low) 1-year mortality, panelists recommended that conversations occur before discharge and focus on post-acute care preferences. For patients with >10% (high) short-term and ≥34% (high) 1-year mortality, panelists recommended that conversations occur immediately and focus on goals of care. They did not achieve consensus on the type or timing of ACP conversations with patients with ≤10% (low) short-term and ≤19%-<33% (intermediate) 1-year mortality. Experts recommend ACP conversations for all patients over the age of 65.

Validity evidence for Quality Improvement Knowledge Application Tool Revised (QIKAT-R) scores: consequences of rater number and type using neurology cases

ObjectivesTo develop neurology scenarios for use with the Quality Improvement Knowledge Application Tool Revised (QIKAT-R), gather and evaluate validity evidence, and project the impact of scenario number, rater number and...

Maintenance of Certification Part IV in Residency Methods and Impact on Practice.

The American Board of Family Medicine (ABFM) is the first medical specialty board to require all residents participate in the maintenance of certification (MOC) process prior to sitting for board certification. This study used surveys and focus groups of family medicine residents in four university-affiliated residency programs to explore participants' perceived benefits and barriers to common methods of completing the performance improvement in practice (Part IV) MOC requirement, and the perceived impact on practice. Residents independently selected into one of three ABFM-approved methods of meeting the Part IV requirement. Following completion of the activity, participants completed a survey and then participated in a focus group. Residents cited time constraints as a major barrier to all Part IV methods. They also reported lack of relevance to practice, deficiencies in performance improvement skills, and access to clinical data. Ease of use was a benefit of online modules, but residents did not perceive them as relevant to practice or leading practice change. Portfolio and self-directed activities were perceived as most relevant to practice and improved patient care, and involved more team-based experiences. Most participants would not participate in Part IV if not required. Group quality improvement projects through the portfolio-approved and self-directed activities seemed to be the most positively reported way to complete the ABFM requirement. Regardless of method, time constraints and quality improvement expertise are significant barriers to completion of the requirement. Residency programs will need to grapple with these barriers to maximize benefits to residents as they prepare to become board certified.

X + Y = Time for QI: Meaningful Engagement of Residents in Quality Improvement During the Ambulatory Block.

Meaningful resident engagement in quality improvement (QI) remains challenging. Barriers include a lack of time and of faculty with QI expertise. We leveraged our internal medicine (IM) residency program's adoption of an "X" (inpatient rotations) plus "Y" (ambulatory block) schedule to implement a QI curriculum for all residents during their ambulatory block. We sought to engage residents in interprofessional QI, improve residents' QI confidence and knowledge and application to practice, and create opportunities for QI scholarship. In July 2015, the program provided dedicated time for QI in the ambulatory block. All categorical IM residents and 11 voluntary faculty mentors were divided into 10 teams based on clinic site and "Y" block schedule. Teams participated in resident-led, interprofessional ambulatory QI projects. Resident QI knowledge and confidence were assessed before the curriculum and 11 months after using the Quality Improvement Knowledge Application Tool-Revised (QIKAT-R) and surveys. QI project implementation and scholarship were tracked. All categorical residents (N = 81) participated. Residents reported increased confidence in all QI skills, and they demonstrated increased knowledge, with mean QIKAT-R paired scores improving from 15.8 ± 4.6 to 19.1 ± 5.9 (n = 45 pairs, P < .001). A total of 9 of 10 teams implemented process changes, and 6 team project improvements have been sustained. This ongoing curriculum engaged IM and IM-psychiatry residents in QI during their ambulatory block using volunteer clinic faculty mentors. Residents demonstrated improved QI confidence and knowledge. The majority of resident projects were sustained and generated scholarship.

LO07: Developing a culture of quality across Ontario’s emergency departments: the return visit quality program

Introduction: In 2016, the Emergency Department (ED) Return Visit Quality Program (RVQP) was developed to promote a culture of quality in Ontario EDs, by mandating large-volume EDs to audit charts of patients who had a return visit leading to hospital admission (RV). This program provides an opportunity to identify possible adverse events (AEs) and quality issues, which can then be addressed to improve patient care. Methods: The RVQP requires EDs to audit a set number of 72-hour RVs for potential AEs/quality issues, as well as all 7-day RVs for one of three key paired sentinel diagnoses (acute myocardial infarction, subarachnoid hemorrhage, and pediatric sepsis). Submitted audits and their AEs/quality issues were analyzed by a team of emergency physicians with quality improvement (QI) expertise, and qualitative metrics were derived. Using the general inductive method, we conducted a qualitative analysis with Health Quality Ontario (HQO), and HQO completed an independent analysis of the submitted narrative reports. Our objective is to report on the qualitative and quantitative metrics of the program, and to explore emerging themes from the AEs/quality issues identified. Results: There were 36,304 72-hour RVs flagged, which represent 0.99% of all 3,672,708 ED visits in the province of Ontario for the 86 EDs participating in the first year of the program. Overall, 2,584 audits were conducted. For the audits involving all-cause 72-hour RVs, 571 (24%) of cases had AEs/quality issues identified. Of the 219 audits involving sentinel diagnoses, 107 (49%) audits identified AEs/quality issues. The qualitative analysis revealed 11 themes, which were classified into three groups : issues related to patient characteristics or actions (elder care, patient risk profile, left without being seen); issues related to actions or processes of the ED team (physician cognitive lapses, handover/communication, high risk medications, documentation, radiology, vital signs); and healthcare system issues (imaging/test availability, discharge planning). Over one hundred local QI projects were completed or planned as a result of the audits performed. Conclusion: The RVQP promotes a culture of quality by highlighting potential AEs and quality themes that can then be targeted to increase patient safety and quality of care in Ontario EDs. Numerous QI projects were undertaken in the first year of the program, and future efforts will monitor the completion and success of these. The program can be easily adapted in other jurisdictions.

What Works in Readmissions Reduction: How Hospitals Improve Performance.

Hospitals across the United States are pursuing strategies to reduce avoidable readmissions but the evidence on how best to accomplish this goal is mixed, with no specific clinical practice shown to reduce readmissions consistently. Changes to hospital organizational practices, a key component of context, also may be critical to improving performance on readmissions, but this has not been studied. The aim of this study was to understand how high-performing hospitals improved risk-stratified readmission rates, and whether their changes to clinical practices and organizational practices differed from low-performing hospitals. This was a qualitative study of 10 hospitals in which readmission rates had decreased (n=7) or increased (n=3). A total of 82 hospital staff drawn from hospitals that had participated in the State Action on Avoidable Readmissions quality improvement initiative. High-performing hospitals were distinguished by several organizational practices that facilitated readmissions reduction, that is, collective habits of action or interpretation shared by organization members. First, high-performing hospitals reported focused efforts to improve collaboration across hospital departments. Second, they helped postacute providers improve care by sharing the hospital's clinical and quality improvement expertise and data. Third, high performers enthusiastically engaged in trial and error learning to reduce readmissions. Fourth, they emphasized that readmissions represented bad outcomes for patients, de-emphasizing the role of financial penalties. Both high-performing and low-performing hospitals had implemented most clinical practice changes commonly recommended to reduce readmissions. Our findings highlight several organizational practices that hospitals may be able to use to enhance the effectiveness of their readmissions reduction efforts.

Creating a national culture of quality: the Tanzania experience.

Although quality improvement has been a priority for Tanzania's health sector since the 1970s, few effective quality improvement initiatives were implemented, due to limited expertise, political commitment and resources. More recently, as the HIV epidemic gained momentum within the country, an influx of funding and of international organizations with quality improvement expertise accelerated the implementation of quality improvement projects, as well as efforts to institutionalize quality improvement at the national level. The support of US President's Emergency Plan for AIDS Relief (PEPFAR) and other donors, and the increasing numbers of HIV-implementing partners focused on quality management, and quality improvement strategies catalysed the development of HIV-specific quality improvement initiatives first, and then of national quality improvement frameworks. The diversity of quality improvement approaches championed by various donors and partners also presented important challenges to harmonization and institutionalization of quality improvement programmes.

Educational system factors that engage resident physicians in an integrated quality improvement curriculum at a VA hospital: a realist evaluation.

Learning about quality improvement (QI) in resident physician training is often relegated to elective or noncore clinical activities. The authors integrated teaching, learning, and doing QI into the routine clinical work of inpatient internal medicine teams at a Veterans Affairs (VA) hospital. This study describes the design factors that facilitated and inhibited the integration of a QI curriculum-including real QI work-into the routine work of inpatient internal medicine teams. A realist evaluation framework used three data sources: field notes from QI faculty; semistructured interviews with resident physicians; and a group interview with QI faculty and staff. From April 2011 to July 2012, resident physician teams at the White River Junction VA Medical Center used the Model for Improvement for their QI work and analyzed data using statistical process control charts. Three domains affected the delivery of the QI curriculum and engagement of residents in QI work: setting, learner, and teacher. The constant presence of the QI material on a public space in the team workroom was a facilitating mechanism in the setting. Explicit sign-out of QI work to the next resident team formalized the handoff in the learner domain. QI teachers who were respected clinical leaders with QI expertise provided role modeling and local system knowledge. Integrating QI teaching into the routine clinical and educational systems of an inpatient service is challenging. Identifiable, concrete strategies in the setting, learner, and teacher domains helped integrate QI into the clinical and educational systems.

Quality Improvement Educational Practices in Pediatric Residency Programs: Survey of Pediatric Program Directors

BackgroundThe Accreditation Council for Graduate Medical Education requires residents to learn quality improvement (QI) methods to analyze, change, and improve their practice. Little is known about how pediatric residency programs design, implement, and evaluate QI curricula to achieve this goal. We sought to describe current QI educational practices, evaluation methods, and program director perceptions through a national survey. MethodsA survey of QI curricula was developed, pilot tested, approved by the Association of Pediatric Program Directors (APPD), and distributed to pediatric program directors. Descriptive statistics were used to analyze the data. ResultsThe response rate was 53% (104 of 197). Most respondents reported presence of a QI curriculum (85%, 88 of 104), including didactic sessions (83%) and resident QI projects (88%). Continuous process improvement was the most common methodology addressed (65%). The most frequent topics taught were “Making a Case for QI” (68%), “PDSA [plan–do–study–act] Cycles” (66%), and “Measurement in QI” (60%). Projects were most frequently designed to improve clinical care (90%), hospital operations (65%), and the residency (61%). Only 35% evaluated patient outcomes, and 17% had no formal evaluation. Programs had a mean of 6 faculty members (standard deviation 4.4, range 2–20) involved in teaching residents QI. Programs with more faculty involved were more likely to have had a resident submit an abstract to a professional meeting about their QI project (<5 faculty, 38%; 5–9, 64%; >9, 92%; P = .003). Barriers to teaching QI included time (66%), funding constraints (39%), and absent local QI expertise (33%). Most PPDs (65%) believed that resident input in hospital QI was important, but only 24% reported resident involvement. Critical factors for success included an experiential component (56%) and faculty with QI expertise (50%). ConclusionsQI curricular practices vary greatly across pediatric residency programs. Although pediatric residency programs commit a fair number of resources to QI education and believe that resident involvement in QI is important, fundamental QI topics are overlooked in many programs, and evaluation of existing curricula is limited. Success as perceived by pediatric program directors appears to be related to the inclusion of a QI project and the availability of faculty mentors.