Led Quality Improvement Research Articles

Factors influencing family physician engagement in practice-based quality improvement: Qualitative study.

To explore the experiences of family physicians leading quality improvement (QI) efforts and to better understand facilitators and barriers related to advancing QI in family practice. Qualitative descriptive study. The Department of Family and Community Medicine at the University of Toronto in Ontario. The department launched a quality and innovation program in 2011 with the dual goals of teaching QI skills to learners and supporting faculty in leading QI efforts in practice. Family physician faculty who held QI leadership roles at any of the department's 14 teaching units between 2011 and 2018. Fifteen semistructured telephone interviews were conducted over 3 months in 2018. Analysis was informed by a qualitative descriptive approach. Consistency of responses across the interviews was suggestive of thematic saturation. Substantial variation was found in the level of engagement with QI in practice settings despite the common training, forms of support, and curriculum the department provided. Four factors influenced the uptake of QI. First, committed leadership across the organization was fundamental to developing an effective QI culture. Second, external drivers such as mandatory QI plans sometimes motivated engagement in QI but sometimes were barriers, particularly when internal priorities conflicted with external demands. Third, at many practices, QI was widely perceived as extra work rather than as a way to enable better patient care. Finally, physicians described lack of time and resources as a challenge, particularly in community practices, and advocated for practice facilitation as a mechanism to support QI efforts. Advancing QI in primary care practice will require committed leaders, a clear understanding among physicians of the potential benefits of QI, alignment of external demands with internal drivers for improvement, and dedicated time for QI work along with support such as practice facilitation.

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

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

Professional development of school principals – how do experienced school leaders make sense of their professional learning?

A growing body of research has emphasised the importance of school leadership for quality improvement in schools, which reinforces the importance of school leaders’ continuous professional development in working life. However, less is known about the professional development of experienced principals. Against this background, the purpose of this study is to examine experienced school leaders’ sense-making of their professional learning in relation to their professional development. Drawing on sense-making theory, a qualitative case study design was adopted, and data consisted of semi-structured interviews, and course evaluations. Qualitative content analysis was performed using the Atlas 6.2 software tool. The findings showed that important sense-making for the principals related to the value of continuous professional learning and interactions with professional peers, and professional learning implications. This qualitative Swedish study can be seen as a contribution to experienced principals’ professional learning, as the professional development of experienced principals is under-researched.

74 Development and content validation of a tool to assess quality of primary care practice

OBJECTIVES/GOALS: Primary care practices struggle to identify which combination of care structures and processes need to be implemented to improve practice performance and subsequently, patient outcomes. The goal of this study is to develop and validate a tool to assess care structures and processes that are associated with better quality and patient outcomes. METHODS/STUDY POPULATION: Data from a scoping review, Delphi study, and qualitative interviews with high-performing primary care practices contributed to the development and content validation of the Tool for Advancing Practice Performance (TAPP). From these sources we identified 314 items representing care structures (e.g., care team makeup, use of electronic health records) and processes (e.g., care coordination, panel management). We developed criteria for deleting and rescuing items and received input from our expert panel to refine the pool of items. We eliminated items that were redundant and lacked clarity/specificity. The tool was further modified based on feedback from cognitive interviewing and pilot testing with practice managers, quality improvement leaders, and physicians from primary care practices. RESULTS/ANTICIPATED RESULTS: The pool of 314 items was winnowed to 188 after applying criteria for deleting and rescuing items. During the expert review, 70 items were eliminated and 8 new items were added, resulting in a working tool of 126 items. We conducted eight cognitive interviews with the 126-item tool and received feedback on the content, item structure, and language, which led to the elimination of 13 items that were poorly or incorrectly understood by respondents. We also modified the language of 23 items for clarity. After cognitive interviewing, the resulting tool comprised 113 items. Fifteen practices piloted the tool and no additional items were eliminated. We modified the instructions for completing the tool and resolved technical issues related to online administration. DISCUSSION/SIGNIFICANCE: TAPP is a novel tool for assessing care structures and processes that are associated with better quality and patient outcomes in primary care settings. The tool can be used by researchers and primary care clinicians to identify areas for improvement in practice performance and patient outcomes related to chronic disease prevention and management.

Country learning on maintaining quality essential health services during COVID-19 in Timor-Leste: a qualitative analysis

ObjectiveThis case study examines the enabling factors, strengths, challenges and lessons learnt from Timor-Leste (TLS) as it sought to maintain quality essential health services (EHS) during the COVID-19 pandemic.DesignA qualitative...

Safer Care for Older Persons in (residential) Environments (SCOPE): a pragmatic controlled trial of a care aide-led quality improvement intervention

BackgroundThe increased complexity of residents and increased needs for care in long-term care (LTC) have not been met with increased staffing. There remains a need to improve the quality of care for residents. Care aides, providers of the bulk of direct care, are well placed to contribute to quality improvement efforts but are often excluded from so doing. This study examined the effect of a facilitation intervention enabling care aides to lead quality improvement efforts and improve the use of evidence-informed best practices. The eventual goal was to improve both the quality of care for older residents in LTC homes and the engagement and empowerment of care aides in leading quality improvement efforts.MethodsIntervention teams participated in a year-long facilitative intervention which supported care aide-led teams to test changes in care provision to residents using a combination of networking and QI education meetings, and quality advisor and senior leader support.This was a controlled trial with random selection of intervention clinical care units matched 1:1 post hoc with control units. The primary outcome, between group change in conceptual research use (CRU), was supplemented by secondary staff- and resident-level outcome measures. A power calculation based upon pilot data effect sizes resulted in a sample size of 25 intervention sites.ResultsThe final sample included 32 intervention care units matched to 32 units in the control group. In an adjusted model, there was no statistically significant difference between intervention and control units for CRU or in secondary staff outcomes. Compared to baseline, resident-adjusted pain scores were statistically significantly reduced (less pain) in the intervention group (p=0.02). The level of resident dependency significantly decreased statistically for residents whose teams addressed mobility (p<0.0001) compared to baseline.ConclusionsThe Safer Care for Older Persons in (residential) Environments (SCOPE) intervention resulted in a smaller change in its primary outcome than initially expected resulting in a study underpowered to detect a difference. These findings should inform sample size calculations of future studies of this nature if using similar outcome measures. This study highlights the problem with measures drawn from current LTC databases to capture change in this population. Importantly, findings from the trial’s concurrent process evaluation provide important insights into interpretation of main trial data, highlight the need for such evaluations of complex trials, and suggest the need to consider more broadly what constitutes “success” in complex interventions.Trial registrationClinicalTrials.gov, NCT03426072, registered August 02, 2018, first participant site April, 05, 2018.

An Evidence-Based Approach to Protecting Our Biggest Organ: Implementation of a Skin, Surface, Keep Moving, Incontinence/Moisture, and Nutrition/Hydration (SSKIN) Care Bundle

Background: The skin, surface, keep moving, incontinence/moisture, and nutrition/hydration (SSKIN) bundle is a resource to aid in care planning when at risk of pressure injuries. The bundle uses best practices to minimize variations in care. Objectives: The objectives of this quality improvement (QI) pilot project were as follows: (a) increase nurses' knowledge of pressure injury prevention, (b) increase nurses' knowledge of the use of the SSKIN bundle, and (c) to pilot the use of an SSKIN bundle in the clinical setting designed to standardize nursing interventions and documentation. Methods: Nurses completed a module on pressure injury prevention that included a pre- and posttest to determine knowledge. Education on the use of the SSKIN bundle was provided, followed by a posttest to establish understanding and knowledge gained. The bundle was utilized in the acute inpatient rehabilitation unit for 4 weeks, and compliance was assessed using the "all-or-none" approach (100% compliance). At the conclusion of the pilot project, staff nurses completed a post-survey created by the QI leader (Likert scale format). The survey included topics on the ease of learning to use the bundle, improved knowledge, perceived reduction in variation of care, perceived facilitation of discussion on skin, opinions on whether the bundle should be instituted hospital-wide, and incorporation of the bundle into the electronic health record (EHR). Results: There was an increase in pressure injury prevention knowledge from an average score of 88.89% on the pretest to 98.15% on the posttest. The mean score on the SSKIN bundle posttest was 93.75%. The bundle ran for 4 weeks and was initiated for ten patients during 74 shifts. Compliance with all components of the bundle was 77%. Conclusion: A pressure injury prevention initiative, such as the SSKIN bundle, can be a useful tool to help standardize nursing interventions and documentation. Implications for Nursing: Results revealed Nutrition as the component with the highest degree of noncompliance. Practice recommendations include documenting every patients nutrition information, regardless of Braden score.

N12 Development and introduction of a pre-clinic screening, triage system and virtual consultations for patients with Inflammatory Bowel Disease: a nurse led quality improvement project (QIP)

Abstract Background •In the IBD centre, Mercy University Hospital( MUH), all patients (Approximately 4000 patients with IBD) attend the outpatient clinic for face-to-face consultations as per prescheduled appointments regardless of disease status. • Mismatch between need and access to care. Patients in remission attend for elective appointments, while patients in need of urgent specialist review may have to wait or else attend clinics which are already at capacity as an urgent appointment. The increasing strain on the OPD system calls for new models of care to be explored. • Aim :develop and implement a pre-clinic screening , triage system and virtual consultations for low-risk patients &amp; evaluate the impact on patient reported and health service outcomes. • Prioritise patients with more unstable IBD symptoms for face-to-face consultations, while for patient with stable IBD to increase consultation choice (virtual or face to face) • Examine impact on patient experience • Examine impact on OPD waiting lists Methods • QIP conducted over a 6 month period. 1980 patients included in the study. 1560 patients were scheduled to attend OPD in the 6month timeframe and 420 patients were on the IBD OPD waitlist for return/ first time consult. • logic model planning and PDSA cycles to develop ,test, refine and implement; 1.A pre-clinic screening, assessment and triage pack to assess patients clinical status and education needs 2.Inclusion and exclusion criteria for virtual consultations 3.Clinic pathway algorithms 4.Weekly virtual IBD MDTs Results • 95% of patients completed the pre-clinic screening and triage pack, of these 37% were eligible for telephone consultation and 89% of those deemed eligible were happy to switch from face to face to telephone consultation. • 30% of patients who attended for pre-clinic screening and triage assessment required fast tracking of OPD appointments due to unstable disease and received earlier interventions e.g. colonoscopies, MRI’s and medication optimisation. • IBD waiting list of 420 patients was cleared with this initiative, all patients were offered a telephone or OPD consultation based on the result of the pre-clinic triage assessment and patient preference. 83% of patients would be happy to continue with the new model as it was perceived as more convenient , time efficient and less disruptive to everyday life. Conclusion • This study highlighted that virtual management of IBD is acceptable to patients, significantly decreased clinic visit utilisation and can reduce the growing burden of IBD on health care resources .This initiative had many positive organisational outcomes including the elimination of the IBD OPD waiting list, reduction in non-essential clinic attendances and potential cost savings.

Quality improvement in urological care: Core methodological principles

Objectives: The aim of this article is to summarise core quality improvement (QI) methodologies and concepts to assist urology teams in conducting well-designed improvement projects. Materials and Methods: We provide an introduction to the methodological foundations of QI, including the model for improvement, plan-do-study-act, lean and six sigma and present some useful QI tools such as process modelling and pareto charts with examples of how they might be applied to urological care. We also introduce the concept of measurement for QI and describe how this differs from the more traditional measurement approaches used in research. Results: The key to successful QI work undoubtedly lies in the careful planning and appropriate selection of the available QI tools and methods, alongside pragmatic approaches to measurement that yield enough data to spot meaningful variation in outcomes. Conclusions: To support these core methods, QI leadership and stakeholder engagement will be critical to embedding QI into urological care and ensuring that improvements can be sustained once QI projects come to an end. Level of evidence: Not applicable.

Applying a Rural Lens to Physician Leadership in Quality Improvement: A Scoping Review

Looking at physician engagement in quality improvement through a rural lens highlights both the increased need for and challenges to the involvement of physician leaders in rural settings. There is accentuated need for a “rural voice” in quality improvement leadership. This review considers best available evidence on the impact of physician leadership on QI and health system transformation and examines this evidence through a rural lens.

Characteristics promoting behaviour change: physician experience with a coalition-led quality improvement initiative to reduce excessive laboratory test ordering

BackgroundAttempts have been made to reduce excessive laboratory test ordering; however, the problem persists and barriers to physician involvement in quality improvement (QI) remain. We sought to understand physician participation...

Impact Evaluation of a Resident-Driven Research Training Workshop in Idaho: A Feasibility Study.

Engagement in research activities is a critical component of clinical residency training. It is vital to build research capacity of residents to help interpret evidence-based medicine and design quality improvement projects. A mixed methods study was conducted to assess the impact of a 1-day research training workshop conducted at Eastern Idaho Regional Medical Centre, Idaho in May 2022. The workshop was targeted to improve the research knowledge of current clinical residents of Internal Medicine and Family Medicine. Workshop comprised of expert presentations, with assessment of difference in knowledge with a pretest and post-test. The sessions were organized around the core competencies of Institute of Medicine. Suggestions were also gathered from the audience. A pretest and post-test based on 13 questions was administered to the participants to assess change in research-related knowledge. Comments and suggestions of the participants were also recorded. Wilcoxon rank test was applied to determine statistical difference across each question and cumulative knowledge score. Conventional content analysis was applied to explore the comments and feedback. The mean score of participants improved across all 12 questions. Statistically significant results were observed for the questions about types of studies qualifying as qualitative research. The cumulative score of participants increased in the post-test from 8.57 to 9.35. The participants gained new knowledge (94.3%), and felt more comfortable in application of research methods (74.3%). Encouraging feedback was obtained from the audience. They stated that they had benefited from the workshop and felt more prepared and motivated to indulge in scholarly activities. The study shows improvement in research-related knowledge of clinical residents attending a 1-day training workshop. We recommend inclusion of such workshops in the curriculum of residents for skill building and enhanced indulgence in research activities in order to prepare them as future leaders in quality improvement, health policy, and hospital administration.

Which Attributes of Credibility Matter for Quality Improvement Projects in Hospital Care—A Multiple Case Study among Hospitalists in Training

Healthcare professionals have to give substance to the role of a champion in order to successfully lead quality improvement (QI) initiatives. This study aims to unravel how hospitalists in training shape their role as a champion within the context of QI projects in hospital care and why some are more effective in leading a QI project than others. We focus on the role of credibility, as it is a prerequisite for fulfilling the role of champion. This multiple-case study builds upon 23 semi-structured interviews with hospitalists in training: quality officers and medical specialists. We first coded data for each case and then described the different contexts of each case in detail to enable comparison across settings. We then compared the cases and contrasted the attributes of credibility. Four attributes of credibility emerged and were identified as essential for the hospitalist in training to succeed as a champion: (1) being convincing about the need for change by providing supportive clinical evidence, (2) displaying competence in their clinical work and commitment to their tasks, (3) generating shared ownership of the QI project with other healthcare professionals, and (4) acting as a team player to foster collaboration during the QI project. We also identified two contextual factors that supported the credibility of the hospitalist in training: (1) choosing a subject for the QI project that was perceived as urgently required by the group of stakeholders involved, and (2) being supported by the board of directors and other formal and informal leaders as the leader of a QI project. Further research is needed to gain a deeper understanding of the relationship between credibility and sustainability of change.

Getting Ahead: A Resident Led Quality Improvement Project to Increase Diabetic Nephropathy Screening in an Underserved Hispanic-Predominant Population.

Diabetes is the leading cause of end-stage renal disease (ESRD) in the United States (US), with 37 million having chronic kidney disease. Despite national guidelines recommendations for diabetic nephropathy screening with urine albumin-to-creatinine ratio (UACR), less than 50% receive full screening.Our Internal Medicine residents led a quality improvement project to increase diabetic nephropathy screening rate with UACR in our resident clinic by 50% in one academic year. We conducted the resident-led quality improvement project from July 2021 to April 2022. We reviewed the electronic medical records (EMR) from our clinic pre-intervention July 2020 to June 2021 and compared this to post intervention July 2021 to March 2022 determining the nephropathy screening rates in patients with diabetes. Our interventions included resident education, pre and post surveys to test foundational knowledge, adding UACR in the affordable laboratory order form and establishing normal reference range of UACR in the EMR. We collected 217 patients with diabetes, 27% were uninsured, 38% had Medicare/Medicaid and 90% identified as Hispanic. Comparing pre to post intervention, there was a significant change of 45 (20.7%) vs 71 (32.7%) patients screened for diabetic nephropathy with a UACR. The correct average score of knowledge-based questions was 82% on the pre survey, which increased to 88% in the post survey. Our study showed promising results on improving diabetic nephropathy screening. The comprehensive approach including resident education about diabetic nephropathy screening with UACR and more so facilitating the order set in the EMR were key to achieve this goal.

Co-designing person-centred quality indicator implementation for primary care in Alberta: a consensus study

BackgroundWe aimed to contribute to developing practical guidance for implementing person-centred quality indicators (PC-QIs) for primary care in Alberta, Canada. As a first step in this process, we conducted stakeholder-guided prioritization of PC-QIs and implementation strategies. Stakeholder engagement is necessary to ensure PC-QI implementation is adapted to the context and local needs.MethodsWe used an adapted nominal group technique (NGT) consensus process. Panelists were presented with 26 PC-QIs, and implementation strategies. Both PC-QIs and strategies were identified from our extensive previous engagement of patients, caregivers, healthcare providers, and quality improvement leaders. The NGT objectives were to: 1. Prioritize PC-QIs and implementation strategies; and 2. Facilitate the participation of diverse primary care stakeholders in Alberta, including patients, healthcare providers, and quality improvement staff. Panelists participated in three rounds of activities. In the first, panelists individually ranked and commented on the PC-QIs and strategies. The summarized results were discussed in the second-round face-to-face group meeting. For the last round, panelists provided their final individual rankings, informed by the group discussion. Finally, we conducted an evaluation of the consensus process from the panelists’ perspectives.ResultsEleven primary care providers, patient partners, and quality improvement staff from across Alberta participated. The panelists prioritized the following PC-QIs: ‘Patient and caregiver involvement in decisions about their care and treatment’; ‘Trusting relationship with healthcare provider’; ‘Health information technology to support person-centred care’; ‘Co-designing care in partnership with communities’; and ‘Overall experience’. Implementation strategies prioritized included: ‘Develop partnerships’; ‘Obtain quality improvement resources’; ‘Needs assessment (stakeholders are engaged about their needs/priorities for person-centred measurement)’; ‘Align measurement efforts’; and ‘Engage champions’. Our evaluation suggests that panelists felt that the process was valuable for planning the implementation and obtaining feedback, that their input was valued, and that most would continue to collaborate with other stakeholders to implement the PC-QIs.ConclusionsOur study demonstrates the value of co-design and participatory approaches for engaging stakeholders in adapting PC-QI implementation for the primary care context in Alberta, Canada. Collaboration with stakeholders can promote buy-in for ongoing engagement and ensure implementation will lead to meaningful improvements that matter to patients and providers.

Quality Improvement in Itself Changes Your Thinking: Lessons From Disseminating Quality Improvement Methods Through a Multisite International Collaborative Palliative Care Project in India.

Seven major palliative care (PC) centers in India were mentored through the Palliative Care-Promoting Assessment and Improvement of the Cancer Experience (PC-PAICE) by US and Australian academic institutions to implement a quality improvement (QI) project to improve the accessibility and quality of PC at their respective centers. The objective was to evaluate the experiences of teams in implementing QI methods across diverse geographical settings in India. A quota sampling approach was used to elicit perspectives of local stakeholders at each site. The Consolidated Framework for Implementation Research informed development of a semistructured interview guide. Analysis leveraged deductive and inductive approaches. We interviewed 44 participants (eight organizational leaders, 12 clinical leaders, and 24 team members) at seven sites and identified five themes. (1) Implementing QI methods enabled QI teams to think analytically to solve a complex problem and to identify resources. (2) Developing a problem statement by identifying specific gaps in patient care fostered team collaboration toward a common goal. (3) Making use of QI tools (eg, A3 process) systematically provided a new, straightforward QI toolkit and improved QI teams' conceptual understanding. (4) Enhancing stakeholder engagement allowed shared understanding of QI team members' roles and processes and shaped interventions tailored to the local context. (5) Designing less subjective processes for patient care such as assessment scales to identify patient's symptomatic needs positively changed work practices and culture. Engaging and empowering multiple stakeholders to use QI methods facilitated the expansion and improvement of PC and cancer services in India. PC-PAICE demonstrated an efficient, effective way to apply QI methods in an international context. The impact of PC-PAICE is being magnified by developing a cadre of Indian QI leaders.

Strategies for enabling physician leadership and involvement in quality improvement: a scoping review

Background: The importance of physician advocacy and leadership in quality improvement (QI) in health care is well recognized, but achieving physician involvement is challenging. The purpose of this scoping review was to describe strategies used in physician-led QI models/approaches that include learning about the science of improvement and may enable physician QI capability, participation, and leadership. Methods: Articles were identified through electronic searches of MEDLINE, Embase, CINAHL, and Scopus, and reference lists were reviewed. For each model/approach, descriptions of strategies were extracted and the frequency of each strategy was determined. Thematic analysis was conducted. Results: Eleven articles representing nine unique models/approaches were included. From these, 20 enabler strategies were identified, and eight themes emerged: dedicated support staff; operational alignment and leader support; evidence-informed care; sharing QI to encourage QI; financial investment; formal QI leader role and responsibility; physician mentorship; and QI capability. No model/approach included all the strategies, and the number of strategies aligned with each theme varied. Heterogeneity in reporting physician-led QI approaches and broad use of the term “physician-led” increased search complexity. Conclusion: Comprehensive models/approaches that encourage physicians to participate in and lead QI while learning the science of improvement have not yet been developed. Research on physician QI participation and strategy evaluation, including effectiveness, is required. This review offers a road map of enabler strategies that can be used to support future models.

Collaborative GI Fellow Project: Improving the Consent Process With an Informational Video Prior to Outpatient Colonoscopy

Informed consent is central to the ethical and legal conduct of endoscopic procedures.1 The consent process should allow patients time to make a considered decision about their care. Consent for elective colonoscopy is often obtained immediately prior to colonoscopy, after patients have taken bowel prep and arranged time off, which may compel patients to proceed.2 Moreover, in our center, <5% of patients review printed procedural information sent out in advance. We therefore performed a GI Fellow led quality improvement study of a pre-procedure informational colonoscopy video and assessed its association with patient satisfaction.

GetFIT for CRC: Nurse Practitioner–Led Program to Improve Colorectal Cancer Screening

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States. This program evaluation was conducted to assess the outcomes of a nurse practitioner–led quality improvement program to increase CRC screening in primary care using the logic model framework. The GetFIT for CRC program consisted of applying a multifaceted intervention to reduce barriers to CRC screening via fecal immunochemical testing (FIT), thereby increasing FIT compliance. FIT completion rates rose to 65.4% 6 months postimplementation, showing special cause variation based on Institute for Healthcare Improvement rules. The increase in completion rates continues to be sustained at 58.5% 12 months after implementation.

Evaluation of the introduction of QOF quality improvement modules in English general practice: early findings from a rapid, qualitative exploration of implementation

BackgroundA 2018 review of the English primary care pay-for-performance scheme, the Quality and Outcomes Framework, suggested that it should evolve to better support holistic, patient-centred care and leadership for quality...