Quality Improvement Guidelines Research Articles

Transforming Hospital Housekeeping: The Kayakalp Journey

Introduction The Kayakalp guidelines for public healthcare facilities under the Swachh Bharat Abhiyan (Clean India Mission) focus on improving sanitation, cleanliness, and infection control at public hospitals in India. This study was conducted in a 960-bed tertiary-level teaching hospital in eastern India. Housekeeping has been a challenge in public institutions, with factors like overcrowding and resource constraints. Tobacco and betel nut chewing, spitting, poor sanitation practices, and open urination are major challenges in ensuring sanitation at the hospital. The research objective was to study the implementation of the Kayakalp guidelines for quality improvement in housekeeping services at the institution. Methods A pre- and post-interventional study was conducted using the Plan-Do-Check-Act (PDCA) quality tool. Plan phases included the gap assessment using the Kayakalp checklist with numerical scoring. Necessary interventions were done under three headings: structure, processes, and outcomes in the “Do” phase. The “Check” phase included monitoring of the activities followed by the “Act” phase, which included a review of the action plan. External experts nominated by the government conducted the final assessments and recommended it as one of the cleanest hospitals. Results A 360-degree improvement was observed in hospital services, with assessment score improvement from 73.68% to 95.0%. The institution received the first prize in 2020 and 2021 and runners-up Kayakalp National Award under category “B” (Institute of National Importance) Hospitals in 2019. Conclusion The implementation of Kayakalp guidelines of the Government of India proved to be efficient in the improvement of housekeeping and infection control practices in the institution.

Building a NICU quality & safety infrastructure

The American Academy of Pediatrics (AAP) Standards for Levels of Neonatal Care, published in 2023, highlights key components of a Neonatal Patient Safety and Quality Improvement Program (NPSQIP). A comprehensive Neonatal Intensive Care Unit (NICU) quality and safety infrastructure (QSI) is based on four foundational domains: quality improvement, quality assurance, safety culture, and clinical guidelines. This paper serves as an operational guide for NICU clinical leaders and quality champions to navigate these domains and develop their local QSI to include the AAP NPSQIP standards.

Virtual Molecular and Precision Medicine Clinic to Improve Access to Clinical Trials for Patients With Metastatic Breast Cancer: An Academic/Community Collaboration.

There is a demand for improved care delivery surrounding genomic testing and clinical trial enrollment among patients with metastatic breast cancer (MBC). We sought to improve the current process via real-time informal consultation and prescreening assessment for patients with MBC treated by community and academic medical oncologists by implementing a virtual molecular and precision medicine (vMAP) clinic. The vMAP program used a virtual referral system directed to a multidisciplinary team with precision medicine expertise. Providers contacted vMAP regarding patients with MBC, and on receipt of referral, the vMAP team engaged in discussion to identify if further diagnostics were needed (including genomic testing) and to identify potential clinical trials or standard treatment options. Recommendations were then sent to the referring provider within 72 hours. Pre-/postsurveys were issued to network physicians to assess for barriers, clinical trial access, and vMAP referral experience. Program implementation was evaluated with the Squire 2.0 reporting guidelines for quality improvement in health care as a framework. Eighty-one cases from 22 providers were referred to vMAP over a 26-month period. The average response time to the referring provider with a finalized recommendation was 1.90 ± 1.82 days. A total of 86.4% of cases had clinical trial options on vMAP prescreen, with 40.7% initiating formal screening assessments and 27 patients (33.3%) ultimately enrolling on trials. On resurvey, 92% of survey responses across community oncology referring providers said that they were very likely to use vMAP again. In the initial 2-year period, vMAP demonstrated an efficient means to offer real-time interpretation of genomic testing and identification of clinical trials for patients with MBC, with effective clinical trial enrollment and high rates of referring provider satisfaction.

Process control: simply a matter of efficiency or of survival and costs? A single-centre quality improvement project in living donor renal transplant

BackgroundRising incidence and prevalence of end-stage renal disease is a worldwide concern for sustainability of healthcare systems and societies. Living donor renal transplant [LDRT] provides highest health achievements and cost containment than any alternative form of renal replacement therapy. Nonetheless, about 25% of potential LDRTs are missed for causes directly related with inadequate timing in donor assessment. Our quality improvement (QI) project implement process control tools and strategy aiming at reducing total evaluation time for donor candidates and minimizing dialysis exposure for intended recipients, which are the two main determinants of clinical outcomes and costs.MethodsThe study includes patients who underwent donor nephrectomy between January 1, 2017 and December 31, 2021. Six Sigma DMAIC approach was adopted to assess Base Case performance (Jan2017-Jun2019) and to design and implement our QI project. Study of current state analysis focused on distribution of time intervals within the assessment process, analysis of roles and impacts of involved healthcare providers and identification of targets of improvement. Improved Scenario (Jul2019-Dec2021) was assessed in terms of total lead time reduction, total pre-transplantation dialysis exposure and costs reduction, and increase in pre-emptive transplantations. The study was reported following SQUIRE 2.0 Guidelines for QI projects.ResultsStudy population includes 63 patients, 37 in Base Case and 26 in Improved Scenario. Total lead time reduced from a median of 293 to 166 days and this in turn reduced pre-transplantation dialysis exposure and costs by 45%. Rate of potential pre-emptive donors’ loss changes from 44% to 27%.ConclusionsLean methodology is an effective tool to improve quality and efficiency of healthcare processes, in the interest of patients, healthcare professionals and payers.

Survey on human milk feeding and enteral feeding practices for very-low-birth-weight infants in NICUs in China Neonatal Network

BackgroundThe breastfeeding rate in China is lower than that in many other countries and the extent of adoption of the “Feeding Recommendations for Preterm Infants and Low Birth Weight Infants” guideline in NICUs remains unclear.MethodA web-based survey about the current status of human milk feeding and enteral feeding practices at NICUs was sent to all China Neonatal Network’s cooperation units on September 7, 2021, and the respondents were given a month to send their responses.ResultsAll sixty NICUs responded to the survey, the reply rate was 100%. All units encouraged breastfeeding and provided regular breastfeeding education. Thirty-six units (60.0%) had a dedicated breastfeeding/pumping room, 55 (91.7%) provided kangaroo care, 20 (33.3%) had family rooms, and 33 (55.0%) routinely provided family integrated care. Twenty hospitals (33.3%) had their own human milk banks, and only 13 (21.7%) used donor human milk. Eight units (13.3%) did not have written standard nutrition management guidelines for infants with body weight < 1500 g. Most units initiated minimal enteral nutrition with mother’s milk for infants with birth weight ˂1500 g within 24 h after birth. Fifty NICUs (83.3%) increased the volume of enteral feeding at 10–20 ml/kg daily. Thirty-one NICUs (51.7%) assessed gastric residual content before every feeding session. Forty-one NICUs (68.3%) did not change the course of enteral nutrition management during drug treatment for patent ductus arteriosus, and 29 NICUs (48.3%) instated NPO for 1 or 2 feeds during blood transfusion.ConclusionThere were significant differences in human milk feeding and enteral feeding strategies between the NICUs in CHNN, but also similarities. The data obtained would be useful in the establishment of national enteral feeding guidelines for preterm infants and quality improvement of cooperation at the national level.

Leadership Driven Persistent Reduction in Cesarean Trends: An Interventional Study for Quality Improvement.

This is a quality improvement study in North India undertaken to observe the efficacy and safety of a proposed set of interventions along Quality Improvement guidelines to reduce cesarean rates. It was a retrospective cross-sectional study conducted in New Delhi. Measures were iteratively introduced from 2017 and improved using multiple PDSA (Plan, Do, Study, Act) cycles to note the overall reduction in cesarean rates. Chi square tests were done with subanalysis based on the Robsons classification. There was a significant reduction of annual cesarean rates from 36.35 to 22.87% over four years (p < 0.01) and in neonatal nursery admissions (p < 0.01). Covid outbreak saw a comparatively increased cesarean rate in 2020, for which it was excluded from the detailed study. The relative risk of cesarean delivery in the postintervention period was 0.62. Maximum reductions were seen in Robsons II, VI &VII. Devising multipronged interventions and their implementation through PDSA cycles are essential. Such measures in moderate resources are replicable elsewhere as well.

Deep Learning-Based Natural Language Processing in Radiology: The Impact of Report Complexity, Disease Prevalence, Dataset Size, and Algorithm Type on Model Performance

In radiology, natural language processing (NLP) allows the extraction of valuable information from radiology reports. It can be used for various downstream tasks such as quality improvement, epidemiological research, and monitoring guideline adherence. Class imbalance, variation in dataset size, variation in report complexity, and algorithm type all influence NLP performance but have not yet been systematically and interrelatedly evaluated. In this study, we investigate these factors on the performance of four types [a fully connected neural network (Dense), a long short-term memory recurrent neural network (LSTM), a convolutional neural network (CNN), and a Bidirectional Encoder Representations from Transformers (BERT)] of deep learning-based NLP. Two datasets consisting of radiologist-annotated reports of both trauma radiographs (n = 2469) and chest radiographs and computer tomography (CT) studies (n = 2255) were split into training sets (80%) and testing sets (20%). The training data was used as a source to train all four model types in 84 experiments (Fracture-data) and 45 experiments (Chest-data) with variation in size and prevalence. The performance was evaluated on sensitivity, specificity, positive predictive value, negative predictive value, area under the curve, and F score. After the NLP of radiology reports, all four model-architectures demonstrated high performance with metrics up to > 0.90. CNN, LSTM, and Dense were outperformed by the BERT algorithm because of its stable results despite variation in training size and prevalence. Awareness of variation in prevalence is warranted because it impacts sensitivity and specificity in opposite directions.

Retrospective Analysis of the Safety and Outcomes of Percutaneous Radiologic Gastrostomy in Obese vs Nonobese Patients.

The purpose of this study is to compare the safety and outcomes of percutaneous radiologic gastrostomy (PRG) in obese vs nonobese patients. This is an institutional review board-approved retrospective study of 109 patients (male:female, 68:41; mean age, 64.7 years; range, 21-94 years) who underwent PRG with or without gastropexy at a single academic medical center between 2015 and 2018. Body mass index (BMI) of ≥30 kg/m2 was defined as obese. Patient demographics, indications, technical success, intraoperative variables, and major/minor complications were analyzed. Major and minor complications occurring within 30 days of the procedure were recorded and categorized based on the Society of Interventional Radiology Quality Improvement guidelines. Of 109 patients included in the study, 22.9% (n = 25) of patients were obese (average BMI, 34.6 kg/m2 ; range, 30-50). Overall technical success in the obese and nonobese groups was 100% each. In the obese vs nonobese group, major and minor complications were not significantly different. There were also no significant differences in procedure time, fluoroscopy time, or contrast volume. However, mean peak skin dose was significantly increased in the obese group vs nonobese group (190.3 ± 224.2 vs 59.1 ± 71.1 mGy; P < .0001). PRG is a safe procedure in obese patients with similar technical success, major and minor complication rates, procedure time, fluoroscopy time, and contrast volume. However, PRG is associated with increased radiation dose with obese patients; therefore, optimal methods of radiation protection should be utilized.

Notable Variability in Opioid-prescribing Practices After Common Orthopaedic Procedures.

The purpose of this study was to evaluate nationwide trends and regional variability in opioid prescriptions after common orthopaedic procedures. A retrospective analysis of privately insured subjects from the MarketScan database between 2015 and 2016 was conducted. Median oral morphine equivalents and interquartile ranges were analyzed by region for the initial post-op prescriptions and 90-day total prescriptions for opioid-naive patients undergoing the following: carpal tunnel release; anterior cruciate ligament reconstruction; arthroscopic meniscectomy; bimalleolar ankle fracture open reduction and internal fixation; distal radius fracture open reduction and internal fixation; arthroscopic rotator cuff repair; single-level anterior cervical discectomy and fusion; and total shoulder, hip, and knee arthroplasties. We hypothesized that notable regional variability exists with postoperative narcotic prescribing habits. Seventy three thousand nine hundred twenty-one opioid-naive patients were identified. A notable regional variability was observed across the United States in the prescriptions given for all procedures, except total joint arthroplasty. Furthermore, although patients undergoing soft-tissue-only procedures required the fewest refills, patients undergoing total joint arthroplasty required the most. Notable regional variability exisits in opioid prescribing patterns for many common orthopaedic procedures. Furthermore, prescriptions were smallest in the region most affected by the opioid epidemic. This information can be used to re-evaluate recommendations, serve as a benchmark for surgeons, and develop institutional and quality improvement guidelines to reduce excess postoperative opioid prescriptions. Level III observational cohort study.

STARD Adherence in an Interventional Radiology Guideline for Diagnostic Arteriography.

Objective: To assess the quality of reporting in diagnostic accuracy studies (DAS) referenced by the Quality Improvement Guidelines for Diagnostic Arteriography and their adherence to the Standards for Reporting of Diagnostic Accuracy (STARD) statement.Materials and Methods: Citations specific to the Society of Interventional Radiology's Quality Improvement Guidelines for Diagnostic Arteriography were collected. Using the 34-item STARD checklist, two authors in a duplicate and blinded fashion documented the number of items reported per diagnostic accuracy study. Authors met, and any discrepancies were resolved in a resolution meeting.Results: Of the 26 diagnostic accuracy studies included, the mean number of STARD items reported was 17.8 (SD ± 3.1). The median adherence was 18 (IQR, 17-19) items. Ten articles were published prior to 2003, the original date of STARD publication, and 16 articles were published after 2003. The mean number of reported items for the articles published prior to STARD 2003, and after STARD 2003 was 17.4 (SD ± 2.4) and 18.1 (SD ± 3.5), respectively. There were 14 STARD items that demonstrated an adherence of < 25%, and 13 an adherence > 75%.Conclusion: The dichotomous distribution of adherence to the STARD statement by DAS investigated demonstrates that areas of deficient reporting may be present and require attention to ensure complete and transparent reporting in the future.

Medical Error, Adverse Events, and Complications in Interventional Radiology: Liability or Opportunity?

This review suggests that there is a critical need to renew understanding of adverse events and complications within interventional radiology and to redefine a robust commitment to patient safety a...

Agreement between a single, self-defined burnout item and the ProQOL burnout subscale for behavioural health staff.

Burnout in the field of behavioural health care is widespread. Occupational burnout can negatively impact providers' well-being and patient care, as well as lead to substantial fiscal cost to healthcare institutions. The objective of this quality improvement project was to develop a single-item survey to rapidly assess individual burnout and workforce well-being among behavioural health staff in our urban, safety-net hospital. We examined the degree of agreement between a single, self-defined burnout item from the Mini-Z and the ProQOL burnout subscale among one hundred and thirty-five nurses, behavioural technicians and administrative staff. Our findings indicate that ProQOL and Mini-Z have a low-to-moderate correlation at a baseline (k=0.52, 95% CI 0.26, 0.69). However, using a modified ProQOL cut-off score with a binary classification of both surveys yields a moderate-to-high agreement (K=0.67, 95% CI 0.54, 0.80). To our knowledge, this is the first published comparison of the Mini-Z with the ProQOL instrument. The project adheres to the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 reporting guidelines for quality improvement (Ogrinc et al., 2016). A single, validated question measuring burnout allows for more rapid assessment and the maximization of response rates, both of which are important steps in evaluating the level of burnout of the collective whole.

Improving inmate attendance at a male psychiatric housing unit in a national prison

ABSTRACT In Singapore, there are Psychiatric Housing Units located within correctional facilities that play an important role in the treatment and rehabilitation of inmates with mental disorders. These units are staffed by forensic psychiatrists, nurses and allied health practitioners. However, the daily attendance rate for classes in the male unit is only about 70%, out of which 15% of inmates are absent from classes without a valid reason. Our quality improvement project sought to increase the daily attendance rate. We followed WHO guidelines for quality improvement, determined the root cause of poor attendance, and devised five Plan–Do–Study–Act cycles over 12 weeks from February to May 2019. A brief survey of inmates in the unit was done to gather their opinions about the rehabilitation programme. We focused on inmates who were absent from classes without valid reasons and sought to persuade them to attend using motivational interviewing within the structure of individualised care plans. Following the implementation of our strategies, the attendance rate rose to 85%. However, without continued efforts to incorporate the strategies into standard operations, attendance rates were unsustainable. This is one of the few quality improvement projects to be done outside of the traditional hospital setting.

AN EMPIRICAL INVESTIGATION ON QUALITY ASSURANCE PRACTICES IN SOFTWARE INDUSTRIES: BANGLADESH PERSPECTIVE

Software companies often follow a planned and systematic process to ensure that the end product is error free and performs as per the requirements, often termed as Software Quality Assurance (SQA) process. However, it has been reported that these companies (especially, mid-size and start-up companies) in developing countries often cut corners to the SQA process due to time and budget limit, and to rush into the market, compromising the quality. This research empirically investigated the SQA process followed in the software companies in Bangladesh. A survey with nine established companies is carried out with qualitative and quantitative data analysis. According to the assessment more than half of the companies fall short in adhering SQA practices within their SDLC. The rest, either fully or partially comply to it. This study further proposed an SQA model based on inspection process and provide guidelines for continuous quality improvement. The model and guidelines are derived to best support these software companies to improve SQA practices.

How the morphology of urban street canyons affects suspended particulate matter concentration at the pedestrian level: An in-situ investigation

Exposure to near-ground air pollution in urban street canyons poses a serious threat to pedestrian health. To develop design guidelines for air quality improvement, correlations among PM1, PM2.5, PM4, PM10, TSP, street canyons morphology and climatic conditions were investigated by field experimental studies. The results showed that street canyons morphology and air humidity were two of the most important factors affecting suspended particulate matter concentration in urban street canyons. The concentrations of PM1 (9.18 ± 0.17 μg/m3), PM2.5 (18.12 ± 0.43 μg/m3), PM4 (31.66 ± 0.82 μg/m3), PM10 (77.57 ± 2.04 μg/m3) and TSP (104.06 ± 2.85 μg/m3) in deep canyons were significantly lower than those in medium and wide canyons. The pollutants distributed in E-W or N-S street directions were at a lower concentration compared with those in NE-SW or NW-SE street directions. Moreover, the pollutants showed significantly lower concentration in high-rise building areas than in multilayer building areas. This study provides a reference for future urban planning to reduce suspended particulate matter concentration in street environments.

Analysis of medication patterns for pediatric asthma patients in emergency department: Does the sequence placement of glucocorticoids administration matter?

Objectives: Timely glucocorticoid administration is associated with decreased admission rate and is thus a common quality metric for ED asthma care; less is known about the impact of the timing of glucocorticoids in the context of the sequence of asthma medications administered. Therefore, we investigated the distribution of asthma medication sequences in one ED and analyzed the effect of the sequence placement of glucocorticoids administration on treatment outcomes.Methods: A retrospective study using five-year electronic health record data obtained from an academic urban children’s hospital ED was conducted. We clustered the sequences of medication administration using an exact string-matching algorithm to identify the most frequently used asthma medication sequences. Then, we used the identified patterns to perform statistical tests to examine the effect of the sequence placement of glucocorticoids administration on the outcomes length-of-stay and ED disposition.Results: A total of 4,844 encounters were included in our study. The ten most common treatment sequences accounted for 43% of all encounters. Stratified analyses confirmed that treatment sequences pattern was correlated with patient severity, but ED crowding does not impact treatment sequences. In multivariable models, glucocorticoids administration earlier in the treatment sequence was associated with shorter length of stay and lower hospital admission rates.Conclusions: By analyzing medication sequence patterns for the ED encounter of pediatric asthma, we found that the earlier sequence placement of glucocorticoids administration is associated with improved outcomes. Our findings can help inform quality improvement and clinical guideline development related to ED asthma care for children.

Stakeholder perceptions on patient-centered care at primary health care level in rural eastern Uganda: A qualitative inquiry.

BackgroundPatient-centered care (PCC) offers opportunities for African health systems to improve quality of care. Nonetheless, PCC continually faces implementation challenges. In 2015, Uganda introduced PCC as a concept in their national quality improvement guidelines. In order to investigate whether and how this is implemented in practice, this study aims to identify relevant stakeholders’ views on the current quality of primary health care services and their understanding of PCC. This is an important step in understanding how the concept of PCC can be implemented in a resource constrained, sub-Saharan context like Uganda.MethodsThis qualitative study was conducted in Uganda at national, district and facility level, with a focus on three public and three private health centres. Data collection consisted of in-depth interviews (n = 49); focus group discussions (n = 7); and feedback meetings (n = 14) across the four main categories of stakeholders identified: patients/communities, health workers, policy makers and academia. Interviews and discussions explored stakeholder perceptions on the interpersonal aspects of quality primary health care and meanings attached to the concept of PCC. A content analysis of Ugandan policy documents mentioning PCC was also conducted. Thematic content analysis was conducted using NVivo 11 to organize and analyze the data.Findings and conclusionWhile Ugandan stakeholder groups have varying perceptions of PCC, they agree on the following: the need to involve patients in making decisions about their health, the key role of healthcare workers in that endeavor, and the importance of context in designing and implementing solutions. For that purpose, three avenues are recommended: Firstly, fora that include a wide range of stakeholders may offer a powerful opportunity to gain an inclusive vision on PCC in Uganda. Secondly, efforts need to be made to ensure that improved communication and information sharing–important components of PCC–translate to actual shared decision making. Lastly, the Ugandan health system needs to strengthen its engagement of the transformation from a community health worker system to a more comprehensive community health system. Cross-cutting the entire analysis, is the need to address, in a culturally-sensitive way, the many structural barriers in designing and implementing PCC policies. This is essential in ensuring the sustainable and effective implementation of PCC approaches in low- and middle-income contexts.

공동주택 기계설비 공사 하자 유형분석과 실무적 관점에서의 예방 및 개선 가이드라인 제안

While MEP/FP construction scope and cost for apartments are getting increased, defect disputes between owners and constructors are also getting increased. More than often, owners’ dissatisfaction over construction defects and constructor’s reaction tends to increase filing lawsuits. This study aims to provide an analysis of residential building construction defects, in particular for mechanical and plumbing works, which are classified into nine groups and typed according to defect severity to investigate the causality. Based on the analysis, this study suggests a preventive and continuous construction quality improvement guideline for practitioners. The defect data has been collected for about 20,050 apartments units built by A construction firm from 2010 to 2017. 84.6 percent of the collected defects are found in sanitary plumbing, drain and sewage piping, hot water piping, and unit ventilator and fan installation works; the detailed defects for each work are classified and the causes are carefully investigated. Eventually the database containing case studies, causes and effects, preventive measures, and warranty measures has been developed. This database can be used as an education material for agents in charge of the quality warranty on after project delivery as well as the quality assurance right before project delivery. It is authors’ strong recommendation that the construction defect database should be built and managed at the enterprise level, the experience and knowledge of which needs to be shared by all stakeholders.

A New Quality Improvement Guideline for ERCP and Endoscopic Ultrasound

Sponsoring Organizations: European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology (UEG)Target Audience: Endoscopists

Systematic review of uterine artery embolisation practice guidelines: are all the guidelines on the same page?

To evaluate the degree of concordance amongst the currently available guidelines informing the use of uterine artery embolisation (UAE), and identify any inconsistencies present. Standards of practice and quality improvement guidelines were retrieved through a search of PubMed and EMBASE. Additional sets of guidelines were retrieved directly from the websites of known obstetrics and gynaecology and radiological associations. Eleven guidelines were retrieved from organisations located in Europe, North America, and Australia. Two main points of divergence were identified in the presented guidance: firstly, on whether submucosal, subserosal, and/or pedunculate fibroids should be considered a relative contraindication to UAE; secondly, on whether UAE should be recommended as an option in patients desiring future fertility. The guidelines reviewed generally suggest UAE to be a safe and effective option for fibroid treatment that can be offered as an alternative to surgical management; however, the number of differing interpretations arising from an apparently similar pool of evidence raises questions about the objectivity of practice guidelines. Although practice guidelines are understood to be a synthesis of clinical evidence and expert opinion, a systematic approach to presenting evidence is necessary to clearly distinguish empirically versus experientially informed guidance.