Led Quality Improvement Research Articles

Evidence of Interventions and Strategies to Bridge the Quality Improvement Gap Led by HCW at the Frontline in SSA: A Scoping Review

Abstract Introduction Poor quality health care is a significant cause of preventable deaths, especially in low- and middle-income countries (LMICs). Quality improvement is multifaceted and includes strategies such as standard setting, quality assurance and clinic audits. In order to move quality improvement in health care into every day practice it is essential to fully engage the frontline where health care is delivered. The objective of this scoping review is to investigate front line health care worker line led quality improvement in Sub Saharan Africa (SSA). Methods We conducted a scoping review to identify, map and synthesize evidence on health care worker led quality improvement initiatives in Sub Sahara Africa using electronic databases PubMed, Cochrane, Embase, CINAHL, Scopus and Psychinfo to identify peer-reviewed literature published between January 2000 and January 2021. To identify grey literature, we used the same search terms in google search to a maximum of 10 pages or when there was no new information. All evidence was scored based on the 6 criteria described by Backhouse et al., which clearly distinguish quality improvement from clinical audit and research. Inclusion criteria were studies that involved frontline health care workers to test “change ideas” and used data systems to measure improvement in service delivery. Results A total of 75 records were identified and including 52 from the peer review search and 23 records from the grey literature search. Only 15 of 47 countries had publications (peer-review or grey literature) describing QI initiatives. Most quality improvement (QI) initiatives were multicomponent and included knowledge transfer, skills building, mentorship and learning visits. Most publications reported QI initiatives aimed at reproductive, maternal, neonatal and child health (n=23) and HIV (n=14) service delivery. Only 6 had experimental designs. No publications were identified prior to 2012 and a rapid escalation of published quality improvement initiatives from 2012 to 2020 was seen. Conclusion QI is in the very nascent stage in SSA. Most large-scale public health QI initiatives are sector specific, siloed, and donor driven. QI initiatives within sector specific programs have not moved horizontally and have had limited ability to change the broader system. Energy must be exerted to change the status quo. Making health care safer and more effective is not spontaneous.

‘We are data rich but information poor’: how do patient-reported measures stimulate patient involvement in quality improvement interventions in Swedish hospital departments?

ObjectiveThis study aimed to investigate if and how patient-reported measures from national and local monitoring stimulate patient involvement in hospital quality improvement (QI) interventions. We were also interested in the...

Implementation evaluation of a leadership development intervention for improved family experience in a private paediatric care hospital, Pakistan

BackgroundA study from a tertiary care center in Pakistan demonstrated that a leadership development intervention led to improved family experience of care outcomes. The objective of the current paper is to assess the implementation of this intervention and identify barriers and facilitators to inform sustainability and scalability.MethodsA working group designed the intervention using a theory-of-change model to strengthen leadership development to achieve greater employee engagement. The interventions included: i) purpose and vision through purpose-driven leadership skills trainings; ii) engaging managers via on-the-job mentorship programme for managers, iii) employee voice i.e., facilitation of upward communication to hear the employees using Facebook group and subsequently inviting them to lead quality improvement (QI) projects; and iv) demonstrating integrity by streamlining actions taken based on routine patient experience data. Implementation outcomes included acceptability, adoption, fidelity across degree & quality of execution and facilitators & barriers to the implementation. Data analyzed included project documentation records and posts on the Facebook group.Analysis indicated acceptability and adoption of the intervention by the employees as178 applications for different QI projects were received. Leadership sessions were delivered to 455 (75%) of the employees and social media communication was effective to engage employees. However, mentorship package was not rolled out nor the streamlined processes for action on patient experience data achieved the desired fidelity. Only 6 QI projects were sustained for at least a year out of the 18 approved by the working group. Facilitators included leadership involvement, real-time recognition and feedback and value-creation through participation by national and international celebrities. Challenges identified were the short length of the intervention and incentives not being institutionalized.The authors conclude that leadership development through short training sessions and on-going communications facilitated by social media were the key processes that helped achieve the outcomes. However, a long-term strategy is needed for individual managerial behaviours to sustain.

Supporting the Pursuit of Quality Improvement Publication: What Your Organization Can Do Now.

Many health care organizations encourage frontline staff to pursue quality improvement (QI), local spread of those improvements, and publication of their work. Although much has been written about building and sustaining a culture of continuous QI, less is known about how to support success in QI rigor, credibility, spread, and publication. In this perspective article, we offer QI leaders practical suggestions to identify challenges in publishing QI and strategies to overcome these challenges. Health care organizations can assist QI teams with publication by intentionally formalizing scholarship early in their QI project work, providing accountability, and connecting the QI team to necessary resources. A carefully designed program supporting QI publication can both improve the rigor of QI work and enhance the professional development of QI professionals.

Culturally Aligned Health Care: Implications for Patient Care and the Nursing Profession.

Professional nurses utilize person-centered/patient-centered models of care to provide meaningful and effective healing or promotion of wellness. Using their skills, knowledge, and expertise, nurses are poised to lead quality improvement efforts that enhance patient outcomes, reduce inequities among populations, and contain costs. Culturally aligned organizational models are built on key concepts of cultural competency, patient- and family-centered care, and diversity, equity, inclusion, and belonging concepts. Nurses are poised to lead cultural alignment innovations across health-care professional teams, using their foundational skills to enhance quality and safety across the health-care spectrum.

Reducing thoracic and lumbar radiographs in an urban emergency department through a clinical champion led quality improvement intervention

BackgroundLow back pain is a common emergency department (ED) complaint that does not always necessitate imaging. Unnecessary imaging drives medical overuse with potential to harm patients. Quality improvement (QI) interventions have shown to be an effective solution. The purpose of this QI intervention was to increase the percentage of appropriately ordered radiographs for low back pain while reducing the absolute number.MethodsA multi-component intervention led by a clinician champion including staff education, patient education, electronic medical record modification, audit and peer-feedback, and clinical decision support tools was implemented at an urban public hospital Emergency Department. In addition to the total number ordered, Choosing Wisely and American College of Radiology recommendations were used to assess appropriateness of all ED thoracic and lumbar conventional radiographs by chart review over eight months.ResultsThe percent of appropriately ordered radiographs increased from 5.8 to 53.9% and the monthly number of radiographs ordered decreased from 86 to 47 over the eight-month initiative. There were no compensatory increases in thoracic or lumbar computed tomography (CT) scans during this time frame.ConclusionA multi-component QI intervention led by a clinician champion is an effective way to reduce the overutilization of thoracic and lumbar radiographs in an urban public hospital emergency department.

The German Quality Network Sepsis: Evaluation of a Quality Collaborative on Decreasing Sepsis-Related Mortality in a Controlled Interrupted Time Series Analysis.

BackgroundSepsis is one of the leading causes of preventable deaths in hospitals. This study presents the evaluation of a quality collaborative, which aimed to decrease sepsis-related hospital mortality.MethodsThe German Quality Network Sepsis (GQNS) offers quality reporting based on claims data, peer reviews, and support for establishing continuous quality management and staff education. This study evaluates the effects of participating in the GQNS during the intervention period (April 2016–June 2018) in comparison to a retrospective baseline (January 2014–March 2016). The primary outcome was all-cause risk-adjusted hospital mortality among cases with sepsis. Sepsis was identified by International Classification of Diseases (ICD) codes in claims data. A controlled time series analysis was conducted to analyze changes from the baseline to the intervention period comparing GQNS hospitals with the population of all German hospitals assessed via the national diagnosis-related groups (DRGs)-statistics. Tests were conducted using piecewise hierarchical models. Implementation processes and barriers were assessed by surveys of local leaders of quality improvement teams.ResultsSeventy-four hospitals participated, of which 17 were university hospitals and 18 were tertiary care facilities. Observed mortality was 43.5% during baseline period and 42.7% during intervention period. Interrupted time-series analyses did not show effects on course or level of risk-adjusted mortality of cases with sepsis compared to the national DRG-statistics after the beginning of the intervention period (p = 0.632 and p = 0.512, respectively). There was no significant mortality decrease in the subgroups of patients with septic shock or ventilation >24 h or predefined subgroups of hospitals. A standardized survey among 49 local quality improvement leaders in autumn of 2018 revealed that most hospitals did not succeed in implementing a continuous quality management program or relevant measures to improve early recognition and treatment of sepsis. Barriers perceived most commonly were lack of time (77.6%), staff shortage (59.2%), and lack of participation of relevant departments (38.8%).ConclusionAs long as hospital-wide sepsis quality improvement efforts will not become a high priority for the hospital leadership by assuring adequate resources and involvement of all pertinent stakeholders, voluntary initiatives to improve the quality of sepsis care will remain prone to failure.

Win-win: Summer QI programme for medical students.

Most undergraduate medical students (UMS) do not receive any formal exposure to quality improvement (QI) efforts in healthcare during the entirety of their undergraduate programme. This is despite the rising interest amongst UMS and the unique potential that UMS hold as an innovator unencumbered by previous biases. To explore this, we implemented an undergraduate training programme that provides experiential QI education. The 15-week Summer Healthcare Improvement Programme (SHIP) was established in 2017, supported by a regional physician QI leadership coalition, a QI consultant preceptor who is linked to both the local university and health organisation and an UMS leadership group. Students were assigned QI projects that were aligned with the health organisation's purpose and scope. Students co-led the project to completion with mentorship from both physician QI leaders, and residents. Student competencies were formatively assessed by completing QI activities and a programme survey. From 2017 to 2019, 19 students completed 22 QI projects, academic posters and publications, and all received QI certification. The majority (72%) of students felt involvement in SHIP increased their QI knowledge and skills, 90% believed SHIP would benefit their peers, and 71% of students felt it directly applied to their future careers. Benefits of the programme were threefold: provided students with early experiential QI exposure, provided student QI leaders who possess dedicated time and effort to complete projects over the summer months and provided a physician QI learning continuum implemented with minimal to no additional cost to either the university or health organisation.

Physician-led quality improvement: a blueprint for building capacity

Physicians have a vital role to play in health system transformation, and their committed involvement provides an opportunity for comprehensive improvement and change. Health care has been shifting to a team-based, integrated, and collaborative approach, with a greater expectation for physicians to engage and lead quality improvement (QI). However, there are many barriers to physician QI capability, participation, and leadership. A physician leader at a university and a provincial health care organization’s executive director recognized this challenge and developed an innovative coalition, the Strategic Clinical Improvement Committee, to build organizational capacity for physician-led QI. Six key principles and approaches underpin the coalition: QI as inseparable from care, accountability, a team approach, organic growth through training, academic credibility, and return on investment, including 14 enabler strategies. To date, achievements include the completion of over 60 physician-led QI projects, development of a summer health care improvement elective course, receipt of grants totaling $250 000, 16 QI papers published in peer-reviewed journals, and numerous projects shared nationally and internationally at conferences. The coalition has propelled a shift toward a physician-led improvement culture at the direct care level. The criticality of sustaining this culture of physician QI engagement and leadership will require balancing competing priorities, limited resources, and various other health system influences.

A Clinical Nurse Specialist–Led Quality Improvement Initiative to Identify Barriers to Adherence to a Bundle for Central Line Maintenance

PurposeThis clinical nurse specialist–led quality improvement project identified barriers to adherence to a bundle for central line maintenance and examined the relationship between increased bundle adherence and central line–associated bloodstream infections.Project DescriptionOncology and critical care nurses were surveyed to identify barriers to adherence to a bundle for central line maintenance. Targeted initiatives based on survey responses were implemented focusing on antimicrobial bathing, increasing confidence in an evidence-based bundle, and its ability to reduce infections. Adherence and central line–associated bloodstream infection rates were monitored at baseline and at 3, 9, and 15 months post intervention.OutcomesAdherence to bundle elements improved post intervention in 4 areas in critical care units: correctly labeling catheter dressings, maintaining an occlusive dressing, clamping unused catheter lumens, and daily antimicrobial bathing. In oncology units, adherence improved in clamping unused lumens and daily antimicrobial bathing. At 9 months post intervention, infection rates decreased from 6.08 to 1.48 in critical care units and 3.13 to 0.30 in oncology units.ConclusionsIdentifying unit-specific barriers to adherence to bundles for central line maintenance and implementing targeted initiatives to reduce barriers increase adherence and prevent central line infections.

SCOPE: safer care for older persons (in residential) environments\u2014a pilot study to enhance care aide-led quality improvement in nursing homes

BackgroundNursing home residents require daily support. While care aides provide most of this support they are rarely empowered to lead quality improvement (QI) initiatives. Researchers have shown that care aide-led teams can successfully participate in a QI intervention called Safer Care for Older Persons in Residential Care Environments (SCOPE). In preparation for a large-scale study, we conducted a 1-year pilot to evaluate how well coaching strategies helped teams to enact this intervention. Secondarily, we measured if improvements in team cohesion and communication, and resident quality of care, occurred.MethodsThis study was conducted using a prospective single-arm study design, on 7 nursing homes in Winnipeg Manitoba belonging to the Translating Research in Elder Care research program. One QI team was selected per site, led by care aides who partnered with other front-line staff. Each team received facilitated coaching to enact SCOPE during three learning sessions, and additional support from quality advisors between these sessions. Researchers developed a rubric to evaluate how well teams enacted their interventions (i.e., created actionable aim statements, implemented interventions using plan-do-study-act cycles, and used measurement to guide decision-making). Team cohesion and communication were measured using surveys, and changes in unit-level quality indicators were measured using Resident Assessment Instrument-Minimum Data Set data.ResultsMost teams successfully enacted their interventions. Five of 7 teams created adequate-to-excellent aim statements. While 6 of 7 teams successfully implemented plan-do-study-act cycles, only 2 reported spreading their change ideas to other residents and staff on their unit. Three of 7 teams explicitly stated how measurement was used to guide intervention decisions. Teams scored high in cohesion and communication at baseline, and hence improved minimally. Indicators of resident quality care improved in 4 nursing home units; teams at 3 of these sites were scored as ‘excellent’ in two or more enactment areas, versus 1 of the 3 remaining teams.ConclusionsOur coaching strategies helped most care aide-led teams to enact SCOPE. Coaching modifications are needed to help teams more effectively use measurement. Refinements to our evaluation rubric are also recommended.

Preparing early educators as frontline leaders and change agents with a leadership development initiative

The present study examined the impact of a leadership development program, Leading for Change (LfC) that focused on building the capacity of early educators to lead change as frontline leaders and change agents. Bringing together a relational-entrepreneurial leadership theory lens, the LfC was designed to foster early educators’ leadership mindset, knowledge, and skills that could potentially bring a long-lasting impact on many aspects of the early care and education (ECE) field. With a sample of 31 racially and linguistically diverse early educators, the present study compared participants’ entrepreneurial mindset, leadership competencies, and capacity to act as change agents and leaders before and after the LfC program. Results showed that participants’ perceptions of themselves as leaders were increased after completing the LfC. They also demonstrated more confidence in their own ability to drive positive change where they work and more broadly in the ECE field. Findings from this study suggest that the relational-entrepreneurial leadership approach taps into early educators’ insights, passions, and knowledge and equips them to participate in leadership for quality improvement and positive change.

Character Based Leadership in Higher Quality Improvement

Character Based Leadership in Higher Quality Improvement

Early Career Outcomes following a Quality Improvement Leadership Track in Graduate Medical Education.

Early Career Outcomes following a Quality Improvement Leadership Track in Graduate Medical Education.

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.

Facilitators and Barriers to Implementing Two Quality Improvement Interventions Across 10 Pediatric Intensive Care Units: Video Laryngoscopy-Assisted Coaching and Apneic Oxygenation.

To better understand facilitators and barriers to implementation of quality improvement (QI) efforts, this study examined 2 evidence-based interventions, video laryngoscopy (VL)-assisted coaching, and apneic oxygenation (AO). One focus group with frontline clinicians was held at each of the 10 participating pediatric intensive care units. Qualitative analysis identified common and unique themes. Intervention fidelity was monitored with a priori defined success as >50% VL-assisted coaching or >80% AO use for 3 consecutive months. Eighty percent of intensive care units with VL-assisted coaching and 20% with AO met this criteria during the study period. Common facilitator themes were adequate device accessibility, having a QI culture, and strong leadership. Common barrier themes included poor device accessibility and perception of delay in care. A consistently identified theme in the successful sites was strong QI leadership, while unsuccessful sites consistently identified insufficient education. These facilitators and barriers should be proactively addressed during dissemination of these interventions.

A Pilot of a Sustainability-Extending Intervention in Canadian Nursing Homes

Understanding of intervention sustainability processes is limited. Failure to sustain evidence-based innovations means that intended improvements are short-lived, scale-up and spread are unlikely, and real losses are incurred on research investments. We explored the sustainability of a health care aide (HCA)-led quality improvement (QI) initiative, Safer Care for Older Persons (in residential) Environments (SCOPE), that was implemented in long-term care homes (LTCHs) in Manitoba, Canada. Based on our understanding of factors influencing post-implementation sustainability processes, we developed and piloted a “low-dose” and “high-dose” “Booster” intervention to extend the two-year post-implementation period over which SCOPE was naturally sustained. Both versions of the “Booster” involved the following components: a HCA-led team with management support, a workshop to review SCOPE QI approaches and tools, a binder of QI resources, and supports from an experienced Quality Advisor (QA). We collected data from various sources to depict the most accurate account of QI sustainability and conducted thematic analysis to understand each team’s experience with sustainability processes. We used a qualitative assessment rubric to evaluate the impact of the “Booster” conditions on the teams’ performance against core SCOPE components. Our results suggest that the “Booster” served to establish more relaxed expectations and generally renew interest in LTCH QI initiatives. The calibre of management support was associated with teams’ performance and management support varied with the level of QA support. These pilot results will inform the next study phase, which examines longer-term sustainability of QI initiatives in LTCHs beyond the initial 2-year post-implementation period.

Clinical Nurse Specialist: A Critical Member of the ICU Team

To describe the role of the clinical nurse specialist, an advanced practice registered nurse in the intensive care setting. The value and impact of the clinical nurse specialist role as a member of the ICU is presented along with a review of clinical nurse specialist education, licensure, and certification requirements as well as a description of the clinical nurse specialist role, scope of practice, and competencies. In addition, a selected review of clinical nurse specialist-led quality improvement and research that resulted in improved patient outcomes is provided. Review of published medical and nursing literature and expert opinion guidance from a collaborative effort between the Society of Critical Care Medicine, American Association of Critical-Care Nurses, and National Association of Clinical Nurse Specialists. Not applicable. Not applicable. Not applicable. The utilization of a clinical nurse specialist, an advanced practice role, in the ICU is a unique and valuable approach for organizations who strive to move evidence into sustainable practice and drive quality through an interprofessional approach. The valuable contributions made by the clinical nurse specialist efficiently and effectively meet the needs of patients, clinicians, and organizations while improving patient outcomes and optimizing cost avoidance strategies, which further lower economic demands on the healthcare system.

219 IMPROVING DELIRIUM SCREENING AND MANAGEMENT IN POST-ACUTE REHABILITATION: A MULTI-STAGE QUALITY IMPROVEMENT INITIATIVE

Abstract Background There is risk of delirium among older patients on transition from acute care to post-acute rehabilitation (Marcantonio et al. 2003). The 4AT is the recommended delirium detection tool for clinical practice (Tieges et al. 2020). A multi-disciplinary led quality improvement project was undertaken to standardise and improve delirium screening and management in the older person’s rehabilitation service of a post-acute rehabilitation hospital. Methods A retrospective audit of medical charts was completed for all patients admitted to a post-acute older person’s rehabilitation service from October 2019 to December 2019. Following that audit, there was a staff education intervention focusing on delirium awareness, screening and management. Furthermore, a dedicated ‘Delirium Champions Group’ was formed with representatives from the multi-disciplinary team. A Delirium Screen pro-forma was developed and implemented by this group. It included an attached 4AT sticker for all new admission medical charts. A post intervention medical chart audit was completed for all admissions to the same ward from October to December 2020. Results The pre-intervention chart audit showed 0% compliance with any form of formal delirium screening tool. The majority of patients had at least 2 delirium risk factors at the time of admission. The post-intervention audit recorded 92% compliance with 4AT use at the time of admission as well as full completion of the Delirium Screen pro-forma which included the documentation of risk factors for delirium. The Delirium Champions Group provide ongoing staff education, resources and are now exploring hospital environmental design and its role in delirium prevention. Conclusion This initiative lead to a significant improvement in the completion of delirium screening in post-acute rehabilitation. This project had the secondary benefit of prompting the formation of a dedicated delirium improvement group focusing on delirium awareness, screening, documentation, management and ultimately prevention.

Responsibilities and Interests of Pediatricians Practicing Hospital Medicine in the United States.

In 2016, the American Board of Medical Specialties (ABMS) approved pediatric hospital medicine (PHM) as the newest pediatric subspecialty. To characterize development of the field, this article aims to: (1) describe the responsibilities and practice settings of US pediatricians self-identifying as hospitalists; and (2) determine how exclusive PHM practice, compared with PHM practice in combination with general or subspecialty care, was associated with professional development interests. Pediatricians enrolling in the 2017-2018 American Board of Pediatrics (ABP) Maintenance of Certification program were offered a voluntary survey about their responsibilities, interests, and practice settings. Logistic regression was employed to characterize associations between exclusive PHM practice and: (1) interest in quality improvement (QI) leadership; (2) intention to take the PHM certifying exam; (3) satisfaction with allocation of professional time; and (4) intention to maintain more than one ABP certification. The survey response rate was 70.0%; 1662 (13.1%) self-reported PHM practice. Four-hundred ninety-one (29.5%) practiced PHM exclusively, 518 (31.1%) practiced PHM and general pediatrics, and 653 (39.3%) practiced PHM and one or more subspecialties. Respondents reporting exclusive PHM practice were significantly more likely to report interest in QI leadership or consultation (adjusted odds ratio [OR], 1.39; 95% CI, 1.09-1.79), PHM exam certification (adjusted OR, 7.10; 95% CI, 5.45-9.25), and maintenance of more than one ABP certification (adjusted OR, 2.64; 95% CI, 1.89-3.68). Hospitalists reported diverse clinical and nonclinical responsibilities. Those practicing PHM exclusively expressed high levels of interest in board certification and QI leadership. Ongoing monitoring of PHM responsibilities and practice settings will be important to support the professional development of the PHM workforce.