Quality Improvement In Clinical Practice Research Articles

Collaborating to DrEaM bigger and better: the challenges in using digital data to drive quality improvement in clinical practice

Background: Supporting patients to Drink, Eat and Mobilise (DrEaMing) within 24 h of major surgery is associated with reduced length of hospital stay and late complications.1 This quality metric was assigned a financial incentive in the 2022 NHS England CQUIN scheme with a compliance target of 60–70% for specific surgical patient cohorts. Beyond the CQUIN, we wanted to deliver DrEaMing to all surgical patients and embed a culture change by reinvigorating core concepts of enhanced recovery pathways. Optimal use of our electronic healthcare record, EPIC, was key to our strategy, aiming to provide surgical teams with sustainable real-time data to drive quality improvement (QI) through electronic extraction of CQUIN metrics. Methods: CQUIN specialty data were extracted from EPIC quarterly. Anaesthetic registrars worked as DrEaMing champions alongside clinical nurse specialists (CNS) to facilitate collaborative working within the perioperative team. Key stakeholders were educated on how to record DrEaMing instructions and provision allowing electronic audit of CQUIN compliance with accurate time stamps. A total of 26 ward staff involved in DrEaMing provision on postoperative surgical wards were surveyed on barriers to DrEaMing. Results: EPIC data from 2022–23 showed varying CQUIN compliance rates across surgical specialties. Gynae-oncology documentation of postoperative DrEaMing instructions increased from 0% in April to 100% by January, however, postoperative DrEaMing provision plateaued around 60–70%. Overall CQUIN attainment across the year was <50%. Colorectal CQUIN compliance was limited by poor documentation of postoperative eating instructions and subsequent poor ward eating provision (Fig. 6), reflecting the heterogenous nature of colorectal procedures undertaken and varied recovery approach by teams. Surveys of ward staff across women’s health and colorectal surgery revealed burden of documentation, lack of access to means to document and unclear surgical postoperative instructions were important barriers to ward documentation of DrEaMing provision. Conclusion: DrEaMing compliance using EPIC data extraction at UCLH remains poor, despite motivated staff and a culture of QI, but was significantly higher with manual review of the notes trawl highlighting disparity between clinical practice and use of new EPIC builds. Our aim to make DrEaMing data easily accessible for QI requires further buy-in from surgical teams and engagement with ward staff. Permanent CNS act as pivotal change champions, through education and raising awareness. 1.Oliver CM, Warnakulasuriya S, McGuckin D, et al. Br J Anaesth 2022; 129: 114–26

Discussion Guide for the van Nieuw Amerongen Article.

Discussion Guide for the van Nieuw Amerongen Article.

Practice Variation Research in Degenerative Lumbar Disc Surgery: A Literature Review on Design Characteristics and Outcomes.

Study DesignLiterature review.ObjectiveTo describe whether practice variation studies on surgery in patients with lumbar degenerative disc disease used adequate study methodology to identify unwarranted variation, and to inform quality improvement in clinical practice. Secondary aim was to describe whether variation changed over time.MethodsLiterature databases were searched up to May 4th, 2021. To define whether study design was appropriate to identify unwarranted variation, we extracted data on level of aggregation, study population, and case-mix correction. To define whether studies were appropriate to achieve quality improvement, data were extracted on outcomes, explanatory variables, description of scientific basis, and given recommendations. Spearman’s rho was used to determine the association between the Extreme Quotient (EQ) and year of publication.ResultsWe identified 34 articles published between 1990 and 2020. Twenty-six articles (76%) defined the diagnosis. Prior surgery cases were excluded or adjusted for in 5 articles (15%). Twenty-three articles (68%) adjusted for case-mix. Variation in outcomes was analyzed in 7 articles (21%). Fourteen articles (41%) identified explanatory variables. Twenty-six articles (76%) described the evidence on effectiveness. Recommendations for clinical practice were given in 9 articles (26%). Extreme Quotients ranged between 1-fold and 15-fold variation and did not show a significant change over time (rho= −.33, P= .09).ConclusionsPractice variation research on surgery in patients with degenerative disc disease showed important limitations to identify unwarranted variation and to achieve quality improvement by public reporting. Despite the availability of new evidence, we could not observe a significant decrease in variation over time.

Quality of Care: Performance Measurement and Quality Improvement in Clinical Practice

Attention to the quality of care within the United States health care system has grown tremendously over the past decade. We have witnessed a significant change in how quality improvement and clinical performance measurement are approached. The current focus on quality and safety stems in part from the increasingly clear realization that more services and technological advancement are not automatically equivalent to high-quality care. Much of the discussion about cost and quality in health care is shifting towards the concept of value. Value is defined as health outcomes achieved per dollar spent (in other words, an assessment of the quality of care per cost). This chapter reviews the current state of quality improvement in health care and, because improvement cannot be determined without measurement, reviews several aspects of effective clinical performance measurement. Since many measures are already in place, the chapter describes some of the organizations involved in quality measurement and improvement, as well the approaches they utilize. It looks at the multiple strategies in place to improve quality, from process management to collaboration, from financial incentives to transparency, and reviews newer models of care delivery that may materialize in the near future. Tables list types of quality measures, characteristics to consider when developing a quality measure, and organizations involved in quality improvement and performance measurement. A figure shows strategies used by the federal government to spur performance measurement and quality improvement. This chapter contains 56 references.

Quality of Care: Performance Measurement and Quality Improvement in Clinical Practice

Attention to the quality of care within the United States health care system has grown tremendously over the past decade. We have witnessed a significant change in how quality improvement and clinical performance measurement are approached. The current focus on quality and safety stems in part from the increasingly clear realization that more services and technological advancement are not automatically equivalent to high-quality care. Much of the discussion about cost and quality in health care is shifting towards the concept of value. Value is defined as health outcomes achieved per dollar spent (in other words, an assessment of the quality of care per cost). This chapter reviews the current state of quality improvement in health care and, because improvement cannot be determined without measurement, reviews several aspects of effective clinical performance measurement. Since many measures are already in place, the chapter describes some of the organizations involved in quality measurement and improvement, as well the approaches they utilize. It looks at the multiple strategies in place to improve quality, from process management to collaboration, from financial incentives to transparency, and reviews newer models of care delivery that may materialize in the near future. Tables list types of quality measures, characteristics to consider when developing a quality measure, and organizations involved in quality improvement and performance measurement. A figure shows strategies used by the federal government to spur performance measurement and quality improvement. This review contains 1 figure, 3 tables, and 56 references Keywords: Quality of care, performance measure, quality improvement, clinical practice, sigma six, transparency

Quality of Care: Performance Measurement and Quality Improvement in Clinical Practice

Attention to the quality of care within the United States health care system has grown tremendously over the past decade. We have witnessed a significant change in how quality improvement and clinical performance measurement are approached. The current focus on quality and safety stems in part from the increasingly clear realization that more services and technological advancement are not automatically equivalent to high-quality care. Much of the discussion about cost and quality in health care is shifting towards the concept of value. Value is defined as health outcomes achieved per dollar spent (in other words, an assessment of the quality of care per cost). This chapter reviews the current state of quality improvement in health care and, because improvement cannot be determined without measurement, reviews several aspects of effective clinical performance measurement. Since many measures are already in place, the chapter describes some of the organizations involved in quality measurement and improvement, as well the approaches they utilize. It looks at the multiple strategies in place to improve quality, from process management to collaboration, from financial incentives to transparency, and reviews newer models of care delivery that may materialize in the near future. Tables list types of quality measures, characteristics to consider when developing a quality measure, and organizations involved in quality improvement and performance measurement. A figure shows strategies used by the federal government to spur performance measurement and quality improvement. This review contains 1 highly rendered figure, 3 tables, and 56 references.

Quality of Care: Performance Measurement and Quality Improvement in Clinical Practice

Quality of Care: Performance Measurement and Quality Improvement in Clinical Practice

Quality of Care: Performance Measurement and Quality Improvement in Clinical Practice

Attention to the quality of care within the United States health care system has grown tremendously over the past decade. We have witnessed a significant change in how quality improvement and clinical performance measurement are approached. The current focus on quality and safety stems in part from the increasingly clear realization that more services and technological advancement are not automatically equivalent to high-quality care. Much of the discussion about cost and quality in health care is shifting towards the concept of value. Value is defined as health outcomes achieved per dollar spent (in other words, an assessment of the quality of care per cost). This chapter reviews the current state of quality improvement in health care and, because improvement cannot be determined without measurement, reviews several aspects of effective clinical performance measurement. Since many measures are already in place, the chapter describes some of the organizations involved in quality measurement and improvement, as well the approaches they utilize. It looks at the multiple strategies in place to improve quality, from process management to collaboration, from financial incentives to transparency, and reviews newer models of care delivery that may materialize in the near future. Tables list types of quality measures, characteristics to consider when developing a quality measure, and organizations involved in quality improvement and performance measurement. A figure shows strategies used by the federal government to spur performance measurement and quality improvement. This review contains 1 figure, 3 tables, and 56 references Keywords: Quality of care, performance measure, quality improvement, clinical practice, sigma six, transparency

Quality of Care: Performance Measurement and Quality Improvement in Clinical Practice

Attention to the quality of care within the United States health care system has grown tremendously over the past decade. We have witnessed a significant change in how quality improvement and clinical performance measurement are approached. The current focus on quality and safety stems in part from the increasingly clear realization that more services and technological advancement are not automatically equivalent to high-quality care. Much of the discussion about cost and quality in health care is shifting towards the concept of value. Value is defined as health outcomes achieved per dollar spent (in other words, an assessment of the quality of care per cost). This chapter reviews the current state of quality improvement in health care and, because improvement cannot be determined without measurement, reviews several aspects of effective clinical performance measurement. Since many measures are already in place, the chapter describes some of the organizations involved in quality measurement and improvement, as well the approaches they utilize. It looks at the multiple strategies in place to improve quality, from process management to collaboration, from financial incentives to transparency, and reviews newer models of care delivery that may materialize in the near future. Tables list types of quality measures, characteristics to consider when developing a quality measure, and organizations involved in quality improvement and performance measurement. A figure shows strategies used by the federal government to spur performance measurement and quality improvement. This review contains 1 figure, 3 tables, and 56 references Keywords: Quality of care, performance measure, quality improvement, clinical practice, sigma six, transparency

Quality of Care: Performance Measurement and Quality Improvement in Clinical Practice

Attention to the quality of care within the United States health care system has grown tremendously over the past decade. We have witnessed a significant change in how quality improvement and clinical performance measurement are approached. The current focus on quality and safety stems in part from the increasingly clear realization that more services and technological advancement are not automatically equivalent to high-quality care. Much of the discussion about cost and quality in health care is shifting towards the concept of value. Value is defined as health outcomes achieved per dollar spent (in other words, an assessment of the quality of care per cost). This chapter reviews the current state of quality improvement in health care and, because improvement cannot be determined without measurement, reviews several aspects of effective clinical performance measurement. Since many measures are already in place, the chapter describes some of the organizations involved in quality measurement and improvement, as well the approaches they utilize. It looks at the multiple strategies in place to improve quality, from process management to collaboration, from financial incentives to transparency, and reviews newer models of care delivery that may materialize in the near future. Tables list types of quality measures, characteristics to consider when developing a quality measure, and organizations involved in quality improvement and performance measurement. A figure shows strategies used by the federal government to spur performance measurement and quality improvement. This review contains 1 highly rendered figure, 3 tables, and 56 references.

Quality of Care: Performance Measurement and Quality Improvement in Clinical Practice

Attention to the quality of care within the United States health care system has grown tremendously over the past decade. We have witnessed a significant change in how quality improvement and clinical performance measurement are approached. The current focus on quality and safety stems in part from the increasingly clear realization that more services and technological advancement are not automatically equivalent to high-quality care. Much of the discussion about cost and quality in health care is shifting towards the concept of value. Value is defined as health outcomes achieved per dollar spent (in other words, an assessment of the quality of care per cost). This chapter reviews the current state of quality improvement in health care and, because improvement cannot be determined without measurement, reviews several aspects of effective clinical performance measurement. Since many measures are already in place, the chapter describes some of the organizations involved in quality measurement and improvement, as well the approaches they utilize. It looks at the multiple strategies in place to improve quality, from process management to collaboration, from financial incentives to transparency, and reviews newer models of care delivery that may materialize in the near future. Tables list types of quality measures, characteristics to consider when developing a quality measure, and organizations involved in quality improvement and performance measurement. A figure shows strategies used by the federal government to spur performance measurement and quality improvement. This review contains 1 highly rendered figure, 3 tables, and 56 references.

Nasal povidone-iodine implementation for preventing surgical site infections: Perspectives of surgical nurses.

Preoperative nasal decolonization of surgical patients with nasal povidone-iodine (PI) has potential to eliminate pathogenic organisms responsible for surgical site infections. However, data on implementation of PI for quality improvement in clinical practice is limited. The purpose of this study was to evaluate the implementation feasibility, fidelity and acceptability of intranasal PI solution application by surgical nurses using the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) conceptual framework. Using the i-PARIHS framework to frame questions and guide interview content areas, we conducted 15 semi-structured interviews of pre- and post-operative care nurses in two facilities. We analyzed the data using deductive content analysis to evaluate nurses' experience and perceptions on preoperative intranasal PI solution decolonization implementation. Open coding was used to analyze the data to ensure all relevant information was captured. Each facility adopted a different quality improvement implementation strategy. The mode of facilitation, training, and educational materials provided to the nurses varied by facility. Barriers identified included lack of effective communication, insufficient information and lack of systematic implementation protocol. Action taken to mitigate some of the barriers included a collaboration between the study team and nurses to develop a systematic written protocol. The training assisted nurses to systematically follow the implementation protocol smoothly to ensure PI administration compliance, and to meet the goal of the facilities. Nurses' observations and feedback showed that PI did not cause any adverse effects on patients. We found that PI implementation was feasible and acceptable by nurses and could be extended to other facilities. However further studies are required to ensure standardization of PI application.

Planning and implementing quality improvement projects in clinical practice: Third-year nursing students' learning experiences.

To evaluate the impact of an educational design to develop nursing students' competence to work systematically with quality improvement in clinical practice. Competence in how to improve the quality and safety of healthcare services based on new knowledge is crucial for healthcare quality. Nursing education should give students opportunities to engage in quality improvement projects to gain this competence. This project qualitatively evaluated the impact of the course on students' ability to plan and implement a quality improvement project in their clinical placement. Data from retrospective focus group interviews and written project reports were analysed by means of qualitative content analysis. Fifty-five students participated in the study. COREQ reporting guidelines were used. Three themes were derived from the analysis: (a) the importance of anchoring the quality improvement project in the clinic; (b) experiencing the steps of a quality improvement project; and (c) challenging student role. Course design that facilitates student-run small-scale quality improvement projects under supervision can enhance nurse students' competence in quality improvement work, as well as raise the students' awareness of the responsibility they will undertake as future nurses. Nursing students work on quality improvement project in clinical placement may enhance their awareness and competence in developing quality and safety of healthcare services as future nurses.

Improving Wait Time for Patients Receiving Chemotherapy at Johns Hopkins Aramco Healthcare Oncology Center: A Clinical Practice Quality Improvement Initiative

Improving Wait Time for Patients Receiving Chemotherapy at Johns Hopkins Aramco Healthcare Oncology Center: A Clinical Practice Quality Improvement Initiative

Health care quality from the patients' perspective: a comparative study between an old and a new, high-tech hospital.

PurposePrevious studies show that the hospital environment and the behavior of health care personnel may predict patients’ perceptions of care quality. The aim of the study was to explore changes in perceived care quality from the patients’ perspective (QPP) when hospital services are relocated from an old to a new high-tech hospital and to describe what is important for patients in the high-tech hospital.Patients and methodsA comparative cross-sectional design was used. The questionnaire QPP, which is based on a theoretical model of the quality of care comprising four quality dimensions, was used. Data were collected in 2015 (old hospital) and 2016 (new hospital), with 253 and 324 respondents, respectively, by consecutive sampling. Comparative statistics was used to test differences between patients’ care quality perceptions (perceived reality [PR] and subjective importance [SI]) (P≤0.05).ResultsThe patients rated PR of all four quality dimensions (the care organization’s physical-technical conditions and sociocultural approach and the caregivers’ medical-technical competence and identity-oriented approach) higher in the new hospital. However, only the two quality dimensions concerning the care organization were rated significantly more highly. On an item level, five of the 27 items scored significantly higher on patients’ SI than on patients’ PR of the care in the new hospital, indicating a quality deficiency from the patients’ perspective. This comprised receiving effective pain relief, receiving examination and treatment within an acceptable waiting time, receiving useful information on self-care, receiving useful information on which doctors were responsible for their medical care, and having a comfortable bed.ConclusionThe increase in care QPP was associated with improved environmental conditions, and no significant improvement in care quality was associated with the health care personnel. The results indicate that being in a high-tech environment does not improve patients’ perceptions of care quality provided by health care personnel. The results gave valuable information for quality improvement in clinical practice, based on the patients’ perspective.

Readmission and complications within 30days after intrathecal baclofen pump placement.

To describe 30-day outcomes after intrathecal baclofen (ITB) pump placement in children and identify risk factors for readmission, reoperation, and perioperative complication using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database. Patients aged 0 to 18years who underwent ITB pump placement (2012-2014) comprised the study cohort defined in the database. Multivariate regression analysis was performed using preoperative and perioperative data from the American College of Surgeons' NSQIP-P database. Outcomes of interest within 30 days of surgery were (1) unplanned reoperation; (2) unplanned readmission; and (3) composite postoperative event, including complication, reoperation, and/or readmission. We identified 423 surgeries; 246 (58.2%) patients were male, 177 (41.8%) patients were female. Median age was 12years and 11months. Median operative time was 70minutes (interquartile range 56-97min). Mean length of stay was 3.8days. The patient population had a high number of medical comorbidities. The overall readmission rate was 7.3%; mean postoperative admission date was 14.1days after surgery. Of readmitted patients, 64.5% underwent reoperation. The most common indication for reoperation was surgical site infection. Female sex was associated with decreased risk of readmission (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.09-0.65; p=0.01); American Society of Anesthesiologists Classification of greater than or equal to 3 was associated with decreased risk of unplanned return to surgery (OR 0.26, 95% CI 0.11-0.66; p=0.04); length of stay greater than or equal to 3days at index surgery was associated with increased risk of composite 30-day perioperative event (OR 2.33, 95% CI 1.29-4.20; p=0.01). Our data provide national perspectives on 30-day perioperative outcomes for ITB pump placement in children. Results illustrate NSQIP-P database collection methodology and highlight opportunities for quality improvement in clinical practice. Seven percent of patients who underwent intrathecal baclofen pump placementrequired readmission within 30days. The most common indication for reoperation was surgical site infection.

Goals of care documentation in advanced cancer.

58 Background: Documenting goals of care (GOC) is integral to patient centered care, decision making and quality performance. Studies show patients value conversations about GOC after receiving a terminal diagnosis. Positive effects have been demonstrated for survival, quality of life, disease management and healthcare savings. The ASCO QOPI recommends documentation within 3 visits from diagnosis of metastatic cancer. For hospital inpatients, GOC are more often integrated into care planning, as admissions frequently reflect changes in illness trajectory, yet documentation remains poor. This Quality Improvement (QI) initiative aims to increase GOC documentation for ambulatory patients and referral rates to Palliative Medicine. Methods: A retrospective cohort receiving palliative chemotherapy for metastatic lung, pancreas, colorectal and breast cancers during 2010-2015 were identified from pharmacy records at a Canadian Regional Cancer Centre. Inclusion criteria required a minimum of 4 clinic visits post treatment. Clinical notes of Oncologists and Palliative Medicine Physicians were reviewed for GOC documentation and referrals to Palliative Medicine. Baseline data determined improvement target rates. A clinical practice QI initiative applied passive and active phases, beginning May 2016. Passive phase included the development of a guideline, documentation template and referral process. The active phase is the implementation process (ongoing). Results: A cohort included 456 patients with metastatic cancer, 63% lung cancer. Oncologists documented GOC in 6% (26/456) and referred 47% to Palliative Medicine. GOC rate was 48% post-referral. Improvement target rates were set at 40% and for referrals 70% by March 2017. Analysis during the passive phase showed Oncologists’ GOC documentations increased to 15%. Analysis of the active phase is ongoing and preliminary results will be presented. Conclusions: Low rates of GOC documentation and referrals to Palliative Medicine persist. The passive phase of engaging physicians in the QI development positively influenced GOC documentation. This QI initiative will inform the sustainability of GOC documentation, Palliative Medicine referrals and standardization of institutional guidelines.

Abstract: Evaluation of the Use and Value of Nursing Care Plans in Nursing Practice at a Referral Hospital, Kigali, Rwanda: Nurses’ Perspectives

Background: The use of nursing care plans within nursing process is geared to move toward a more systematic approach to human needs assessment. The nursing care plan will support practice modalities by meeting physical, psychological, social and spiritual needs of patients resulting in quality nursing care.Objectives: The objectives of this study was to explore and describe the use of nursing care plans at a large teaching hospital in Rwanda.Methods: A non-experimental quantitative cross-sectional survey design, descriptive in nature was adopted. A checklist was utilized to conduct a file review through a stratified random sample and fishbowl technique (25%, n=101). A self-report questionnaire was used to conduct an assessment of knowledge, attitudes, and perceptions of registered nurses (n=28) in four units.Results: This study showed that most nurses (96%) felt that the use of nursing care plans increased the nurses’ ability to provide high quality care; but only 16% of the audited files had evidence of a care plan. The main thrust of reported barriers to care plan utilization noted by registered nurses included a lack of training, inaccessibility to available evidence-based nursing practice, and heavy workload.Conclusion: This study supports the need for creating increased awareness of the importance of nursing care plans and evidence based practice among registered nurses. Knowledge and training will increase the utilization of care plans by nurses’ usage and they will add to the existing quality improvement in clinical practice in the hospital.Keywords: registered nurse, nursing care plans, quantitative survey

Assessment of Volumetric and Dosimetric Variations for Image Guided Stereotactic Body Radiation Therapy Treatment

Assessment of Volumetric and Dosimetric Variations for Image Guided Stereotactic Body Radiation Therapy Treatment

Abstract W P264: Perception of Educational Benefits of Online National Institute of Health Stroke Scale Training by Nursing Staffs

Background: Primary Stroke Center at University Medical Center (UMC) in Lubbock, Texas requires nursing staffs who are directly caring for stroke patients to obtain NIHSS training by certification via an online training program by NINDS and/or AHA. One of quality improvement programs by UMC is to evaluate the compliance and reliability of neurologic assessment of stroke patients by nursing staff. Purposes: The purpose of this study is to evaluate the current perception and effectiveness of online training for quality improvement. Methods: We performed survey on licensed staff members in the Emergency Department (ED), Medical Intensive Care Units (MICUS) and one Medical Surgical Unit (MSU) to determine perception on the effectiveness of the current online education (OE) and on the inter-rater reliability between staffs and units. Results: 164 nurses completed the survey: 81 from ED, 63 from MICU, and 20 from MSU. 55% of staff rated the OE as excellent, 33% as good, and 12% as poor. 42% believed inter-rater reliability was excellent, 32% as good and 19% rated the intra-rater reliability as poor. Regarding how comfortable they were with performing the NIHSS exam, 11% rated themselves as poor, 29% as good, and 65% as excellent. The staffs performed three NIHSS exam (range 0– 40) on average after their training. Extinction and inattention, limb ataxia, dysarthria, and language were felt most difficult to assess, which was similar to previous studies. The majority of group which rated inter-rater reliability as poor worked at the ED and MICU. Some of the suggestions include hands-on training with standardized patient, hands-on training of intubated patients with simulation, regular onsite and online education, and enjoyable education materials. Conclusions: In conclusion, NIHSS online training is an effective way to train nursing staffs but additional and regular educations are needed after the initial online training. Based on the evaluation data, Stroke Program at UMC is developing NIHSS training program utilizing standardized patients in simulation and will implement in education for quality improvement in clinical practice and inter-rater reliability.