Quality Improvement Methods Research Articles

Increasing Follow-up for Adolescents With Depressive Symptoms.

Prompt follow-up for positive depression screen results is important in providing high-quality care for adolescents. We sought to improve follow-up within 30 days for adolescents (≥12 years) with Patient Health Questionnaire-9 scores ≥10, or those with a positive question 9, from 25% to 40%. We conducted a quality improvement project at 6 primary care locations serving ∼33,300 patients (70% Black, 7.3% Hispanic, 80% Medicaid-enrolled). Our team identified key drivers and iteratively tested interventions, including contacting patients after antidepressant medication initiation, scheduling patients for follow-up during index visits, collaborating with integrated psychologists to expedite therapy for higher-risk patients, and reaching out to patients without scheduled follow-ups. Pre-intervention, 13.3% (589 of 4427) of adolescent encounters met the criteria for follow-up within 30 days, and 25.8% had a documented follow-up within 30 days. During the intervention period, 12.3% (764 of 6224) of adolescent encounters met the criteria for follow-up within 30 days, and the mean follow-up rate increased to 43.1%. By monitoring process measures, we scheduled follow-up visits for 18.9% of patients during the index encounter. Outreach to the remainder led to 32.6% of these patients completing follow-up. Our balancing measure of monitoring integrated psychology visit volumes remained stable. The application of quality improvement methods in primary care practices increased the frequency of follow-up care for high-risk adolescents after a positive depression screen.

Improving implementation and team communication by integrating a cystic fibrosis transition readiness (CF R.I.S.E.) program into electronic health records.

The cystic fibrosis (CF) Responsibility. Independence. Self-care. Education. (R.I.S.E.) program was developed to provide assessment and education, supporting transition readiness for people with cystic fibrosis (pwCF). Lack of integration within electronic health records (EHR) was a barrier to implementation of CF R.I.S.E. University of Michigan was able to integrate CF R.I.S.E. into EHR. To improve implementation and EHR documentation of CF R.I.S.E. module completion by pwCF across two (CF) programs from baseline (10.5%) to 75% per month in 6 months (January through June 2023). Two CF programs utilized quality improvement (QI) methods and tools and ad hoc support by a CF Learning Network (QI) specialist. Eligibility included pwCF ≥16 years old seen in CF clinics who accepted CF R.I.S.E. Beginning January 2, 2023, programs met in biweekly, virtual meetings to discuss implementation. Deidentified data were collected monthly tracking modules completed by pwCF and number of team members engaging with CF R.I.S.E. and documenting in EHR. Data timelines were baseline (November-December 2022), project period (January-June 2023), and post-project (July-December 2023). Completion rates increased from baseline (10.5%) to 48% (range 33% to 81%) through December 2023. During the project, an average 7.7 team members completed an average 19.2 modules per month. Post-project, an average 8 team members completed an average 16.5 modules per month. This collaboration demonstrated how utilization of EHR allowed for successful CF R.I.S.E. improvement at both programs. Shared software utilization and QI initiatives may be a way to facilitate timely dissemination of best practices through learning health systems.

14 Exploring factors contributing to Secondary Traumatic Stress in residents during a child maltreatment paediatrics rotation

Abstract Background Secondary Traumatic Stress (STS) refers to the distress and emotional disruption experienced by individuals caring for those who have experienced trauma. STS is increasingly recognised in child serving professions, especially in medical trainees and clinicians working in Child Maltreatment Paediatrics (CMP). Paediatric resident physicians are typically of younger age, work long hours in stressful conditions, and have limited CMP experience. This makes them particularly vulnerable to experiencing STS. In addition to affecting the wellbeing of trainees, STS can impede performance at work and affect patient care. Thus, it is important to understand and mitigate the development of STS among paediatric trainees during their CMP rotation. Objectives This study aims to identify key factors contributing to STS among medical residents at a tertiary care paediatric hospital during a CMP rotation. Design/Methods Qualitative interviews and focus groups were conducted to explore the experiences and perceptions of CMP trainees, staff physicians, and psychologists. Quality Improvement methods including a Fishbone diagram (figure 1), 5-whys analysis, and Pareto analysis (figure 2) were used to analyze the factors that contribute to residents developing STS symptoms. Results Our analysis revealed the following themes contributing to STS symptoms in paediatric residents: (1) limited awareness and education on STS symptoms, (2) lack of planned case debriefing, (3) residency-related burn out, (4) limited experience in CMP, (5) hidden curriculum of residency, and (6) limited opportunity to discuss STS symptoms. Conclusion Our study identified factors related to both limited knowledge around STS, and limited opportunities to debrief cases that may contribute to the development of STS among residents. These factors can, in part, be addressed on a program level. This aligns with existing STS literature which emphasizes implementing program level strategies to support professionals in addition to prioritizing self-care. Next steps involve implementing targeted interventions within the rotation to help mitigate STS effects on trainees.

Combinatorial Method for Quality Improvement of the Thrust Plate – A Case Study

Aim: This research aims to mitigate defects in the turning operation of thrust plates used in fighter jet fuel tank assemblies, thereby reducing the rejection rate and improving overall quality. This aligns with the aerospace industry's reliability goals. Background: The thrust plate is a critical component in fighter jet fuel tank assembly, transmitting engine thrust to the airframe. Quality compromises in this component can impair jet performance. It was observed that the thrust plate had a rejection rate of about 2.9% due to various defects. This real- world scenario underscores the importance of our study on the thrust plate and its potential impact on the aerospace industry. The rejection rate underscores its significance and potential for patent by quality improvement in turning of the thrust plate. Objective: The objective is to mitigate turning operation defects on the thrust plate to reduce rejection rates, aligning with aerospace industry reliability goals. Methods: Experimentation encompassed four pivotal factors: turning speed, feed rate, cutting depth, and tool inserts, implemented through Taguchi's Orthogonal Array technique. Grey Relational Analysis was utilized to optimize parameters in thrust plate turning. Specifically, this paper targeted the enhancement of its diameter, surface roughness, and tool life. Results: A single coefficient for the multiple responses, i.e., grey relational grade, has been determined, and optimum levels for the parameters have been identified. Confirmation experiments with the optimal factor level combination were carried out on a sample of thrust plates, and no rejections were observed. Conclusion: An experimental design based on Taguchi’s orthogonal array approach was used to conduct the experiments. The Grey Relational Analysis has been applied to analyze the experimental results and optimize the turning operation process parameters for the responses thrust plate diameter, tool life, and surface roughness. With this, the rejection of the thrust plate has been considerably reduced.

Improving Patient Wait Times on the First Day of Radiotherapy Treatment

Long wait times on starting day of radiotherapy (day 1) can cause dissatisfaction among both patients and healthcare providers. Reducing these wait times will decrease stress and decongest hospital facilities especially in current coronavirus disease 2019 times. A multidisciplinary core team was formed during the Stanford-India Collaborative Quality Improvement training to reduce the median wait times on day 1 of treatment from 6 to 4.5 hours (a 25% reduction). Several factors were identified on the fishbone diagram, and key causes were identified using a Pareto chart and action prioritization matrix. The Plan-Do-Study-Act Cycle strategy was undertaken for the identified interventions. The outcome measure was time from arrival at the hospital to entry into a treatment room. Data were obtained from time charts at various stations and electronic records. The secondary measures were visual analog scale (VAS) scores, 80th percentile wait times, and the day-2 delay percentage. The balancing measure was “new errors” due to interventions. The interventions included the completion of all administrative tasks not needing patients' presence on the day before day 1. Baseline data from 198 patients and postintervention data from 160 patients were compared and analyzed. The median wait time at baseline, which was 6 hours, was reduced to 4.2 hours. The VAS score showed 70.4, 67.7, and 71.9% satisfaction for the resident physician, therapists, and patients, respectively. The 80th percentile wait times reduced from 8 to 5.7 hours; and the day 2 starting rate decreased from 22.5 to 2.04%, with no new errors reported. Radiotherapy day 1 wait times can be safely decreased, leading to improved satisfaction among patients and healthcare providers, by utilizing classic quality improvement methods and tools.

Reducing Patient Care Delays in Radiation Oncology Via Optimization of Insurance Pre-Authorization: Reducing Delays via Optimization of Pre-Auth

Purpose/ObjectivesDifficulties and delays in insurance pre-authorization (pre-auth) can negatively impact patient care, resulting in postponing, modifying, or even cancelling radiation therapy for patients. We aimed to perform a root cause analysis for pre-auth delays in our department and implement solutions to optimize our workflow. Our primary objectives were to decrease mean time for clinical treatment plan (CTP) completion, and for number of cases delayed/denied, by 50% each. Materials/MethodsWe performed a root cause analysis for pre-auth delays, and used the PDSA & A3 quality improvement methods. We sampled ∼2 cases per disease site (19 cases from July – Aug 2022) to determine the baseline. Countermeasures included: 1) optimizing our CTP templates per disease site to contain the specific clinical information required for pre-auth, 2) formalizing earlier completion of CTPs in our Care Path®, and 3) formalizing the pre auth workflow in our Care Path®. We tracked various metrics, including mean time for CTP completion, % usage of our Care Path®, % usage of revised CTP templates, mean time until pre-auth initiated & completed, and % of cases delayed/denied. Two-tailed T-tests and Chi-squared tests were used to generate p-values comparing mean values and percentages, respectively. Results495 patients completed CT simulation in our department between October 2022 and February 2023. Mean time for CTP completion (Day 0 = day of CT simulation scheduling) improved from 16 days at baseline to 4 days (p<0.001). Care Path® usage improved from 16% to 97% (p<0.001), as did usage of our revised CTP templates, from 0% to 97% (p<0.001). The mean time from insurance pre-auth initiation to completion improved from 5 days to 1 day. The percent of cases that were delayed/denied was reduced significantly from 32% to 8% (p<0.001). ConclusionsImproving timeliness and details of CTP documentation and pre-auth by using our Care Path® and optimizing CTP templates improved efficiency of insurance pre-auth completion and reduced the number of cases delayed/denied.

The Quality Improvement Review Board: An Innovative Approach to Oversight of Projects That Do Not Meet Criteria of Human Subject Research.

This article describes the development of an institutional quality improvement review board (QIRB) as an effective and efficient method for reviewing and overseeing institutional quality improvement (QI) initiatives. QI projects involve the systematic collection and analysis of data and the implementation of interventions designed to improve the quality of clinical care and/or educational programs for a distinct population in a specific setting. QI projects are fundamentally distinct from human subjects research (HuSR); however, the differences between them are subtle and highly nuanced. Determining whether a project meets the definition of QI or qualifies as HuSR, thus requiring institutional review board (IRB) review, can be confusing and frustrating. Nevertheless, this distinction is highly consequential due to the heavy regulatory requirements involved in HuSR and IRB oversight. Making the correct determination of a project's regulatory status is essential before the project begins. Project leaders may not realize that their work meets the definition of HuSR and, therefore, might conduct the project without appropriate IRB review. Therefore, best practices dictate that project leaders should not decide which type of institutional review is appropriate for their projects. In addition, when QI project teams attempt to disseminate the results of their work, documentation of formal review and approval is generally required by peer-reviewed journals and professional organizations. However, institutional review mechanisms are rarely available. Projects that do not meet the definition of HuSR fall outside the purview of IRBs and most institutions do not have an alternative review body. This creates frustration for both project leaders and IRB administrators. Apart from IRB review, a separate process for reviewing QI projects offers several benefits. These include (1) relieving the burden on busy IRB staff; (2) promoting scholarly activity; (3) protecting the institution, project leaders, and participants from HuSR conducted outside of appropriate IRB review; and (4) promoting rigorous QI methods.

Centralized vs. Decoupled Dual-arm Planning Taking into Account Path Quality

The aim of coordinated planning is to avoid robot-to-robot collisions in a multi-robot system, and there are two standard solution approaches: centralized planning and decoupled planning. Our first contribution is a decoupled planning approach that ensures C2\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\varvec{\\mathcal {C}^2}$$\\end{document}-continuous control commands with zero velocities and zero accelerations at the start and goal. We benchmark our decoupled approach with a centralized approach. Contrary to literature, we show that for a standard motion planning pipeline, such as the one used by MoveIt!, centralized planning is superior to decoupled planning in dual-arm manipulation: It has a lower computation time and a higher robustness. Our second contribution is an optimization that minimizes the rotational motion of an end-effector while considering obstacle avoidance. We derive the analytic gradients of this optimization problem, making the algorithm suitable for online motion planning. Our optimization extends an existing path quality improvement method. Integrating it into our decoupled approach overcomes its shortcomings and provides a motion planning pipeline that is robust at up to 99.9 % with a planning time of less than 1 s and that computes high-quality paths.

Improving Screening for Social Determinants of Health in an Outpatient Complex Care Clinic.

Families of children with medical complexity (CMC) may face challenges related to Social Determinants of Health (SDoH). Although standardized SDoH screening has been implemented in numerous medical settings, there has been limited study of screening among CMC. Our global aim is to improve access to institutional and community resources for families of CMC with identified needs. Here, we aimed to establish SDoH screening for families in our outpatient Complex Care Center and attain a screening rate of 80%. A multidisciplinary team in our clinic used quality improvement methods to implement and study an expanded SDoH screen, which included 3 questions specific to the needs of CMC (ie, emergency planning, social support, and medical equipment concerns). Interventions, informed and refined by 5 key drivers, were tested over a 12-month period. A statistical process control chart tracked key outcome and process measures over time. SDoH screening sustained a mean of 80% after implementation during the study period. Incorporating registration staff in screen distribution was our most impactful intervention. At least 1 SDoH concern was identified on 56% of screens; concerns specific to CMC and mental health were most frequently reported. A total of 309 responses to positive screens were reported in total. Successful implementation of an expanded, tailored SDoH screen revealed a multitude of social needs specific to families of CMC that otherwise may not have been recognized. Our team continues to develop and distribute resources to address identified needs.

Understanding a new wrinkling behavior of annular grooved panel during flexible free incremental sheet forming

Wrinkling behavior of sheet metal by inappropriate process parameters and the resultant variation of thickness and microstructure during incremental sheet forming (ISF) have significant impact on forming stability and geometric profile. The wrinkling-related mechanism is yet to be well understood, which make it difficult to effectively control wrinkling defects during ISF. In the present work, the wrinkling behavior and related mechanism of a typical annular grooved panel are investigated during a novel flexible free ISF process. Experiments demonstrate that during this ISF process, the sheet material sequentially undergoes 4 deformation modes: contacting state under plane strain condition, contracting state with only elastic deflection, thickening state under uniaxial compression condition, and wrinkling state where the circumferential compressive stress exceeds the critical wrinkling stress. The evolution of these deformation modes is dominantly caused by the increasing of edge contraction and circumferential stress, which are induced by the bending moment from the forming tool and auxiliary sheets. Based on the mechanism, an analytical model is developed to predict the wrinkling behavior, by which the corresponded sheet thickness, bending moment, circumferential compressive stress and critical wrinkling stress during the wrinkling process could be comprehensively calculated. Experimental results validate that the analytical model can accurately predict the wrinkling behavior under different process parameters, material properties and auxiliary sheet materials. Through microstructural characterization, numerical simulation and analytical modeling, the influence of process parameter and material property on wrinkling behavior is systematically investigated, along with the variation of sheet thickness and microstructure under different wrinkling modes. This work enhance a deep understanding of wrinkling behavior during ISF process, thereby providing effective methods for process optimization and quality improvement.

Developing Clinical Judgment During Transition to Practice With Rapid-Cycle Deliberate Practice Simulation.

New-to-practice nurses (NPNs) make more errors than their experienced peers, affecting patient safety and contributing to sentinel events. Additionally, new nurses have a high attrition rate in their first year of practice. Simulation-based education may bridge the gap between education and practice by supporting the development of clinical judgment of NPNs. With quality improvement methods, an intradisciplinary team implemented a quality improvement project to improve NPNs' clinical judgment skills. A multipatient simulation that used rapid-cycle deliberate practice gave NPNs an opportunity to refine clinical decision-making and communication skills. In total, 24 NPNs participated in the pilot simulation. Pre- and postsurvey scores using the simulation effectiveness tool-modified showed self-reported improvement in clinical judgment and communication skills, among other competencies. Rapid-cycle deliberate practice simulation may support the development of essential nursing competencies, along with increased confidence and enhanced psychological safety among NPNs. [J Contin Educ Nurs. 202x;5x(x):xx-xx.].

Integration of IPC/WASH critical conditions into quality of care and quality improvement tools and processes: Bangladesh case study

Unsafe patient care in hospitals, especially in low- and middle-income countries, is often caused by poor infection prevention and control (IPC) practices; insufficient support for water, sanitation, and hygiene (WASH); and inadequate waste management. We looked at the intersection of IPC, WASH, and the global initiative of improving health care quality, specifically around maternal and newborn care in Bangladesh health facilities. We identified 8 primary quality improvement and IPC/WASH policy and guideline documents in Bangladesh and analyzed their incorporation of 30 subconditions under 5 critical conditions: water; sanitation; hygiene; waste management/cleaning; and IPC supplies, guidelines, training, surveillance, and monitoring. To determine how Bangladesh health care workers implemented the policies, we interviewed 33 informants from 16 public and private facilities and the national level. Bangladesh’s 8 primary guidance documents covered 55% of the 30 subconditions. Interviews showed that Bangladesh health facility staff generally rely on eight tools related to quality improvement (five); IPC (two); and supportive supervision (one) plus a robust supervision mechanism. The stakeholders identified a lack of human resources and environmental hygiene infrastructure and supplies as the main gaps in providing IPC/WASH services. We concluded that the Bangladesh government had produced substantial guidance on using quality improvement methods to improve health services. Our recommendations can help identify strategies to better integrate IPC/WASH in resources including standardizing guidelines and tools within one toolkit. Strategizing with stakeholders working on initiatives such as universal health coverage and patient safety to integrate IPC/WASH into quality improvement documents is a mutually reinforcing approach.

Voltage quality improvement method based on adaptive power control of photovoltaic inverter

Abstract With the increasing penetration rate of distributed photovoltaics in the distribution network in China, the energy pressure has been effectively alleviated. However, the voltage over-limit problem of its parallel outlets cannot be ignored. Therefore, this paper put forward a power control method with photovoltaic inverters which is adaptive. First, the principle of photovoltaic voltage overstepping the limit is analyzed, and second, an adaptive control tactic is brought up for the disturbance of the volatile load of photovoltaic output. Finally, combined with the analysis and verification of simulation examples, the results show that the proposed strategy can effectively improve the voltage quality of the grid and prove the effectiveness of the proposed strategy.

The quality improvement method for detecting attacks on web applications using pre-trained natural language models

The quality improvement method for detecting attacks on web applications using pre-trained natural language models

SiC MOSFET Gate Oxide Quality Improvement Method in Furnace Thermal Oxidation with Lower Pressure Control

We have investigated carbon behavior resulting from pressure control in furnace thermal oxidation process and evaluated the effect on gate oxide quality resulting from this pressure control. In order to investigate the potential reduction of carbon defects by reducing CO and CO2, an analysis of oxidized SiC wafers was conducted. To evaluate the effect of pressure control related carbon component change during thermal oxidation, QBD characteristic was evaluated in SiC MOS Capacitance. The analysis results revealed on observable decrease in carbon at the SiO2/SiC interface and the SiO2 layer. The QBD results shown that improved at lower pressure better than those obtained in the general pressure.

Statistical Process Control – A Method for Continuous Quality Improvement

Statistical Process Control – A Method for Continuous Quality Improvement

Image Quality Restoration on Historical Artifacts Using Histogram Equalization and Contrast Stretching Methods

This research was carried out to improve the image quality of historical artifacts that experience quality degradation such as noise, unclear or dark image contrast, and poor sharpness. Contrast Stretching and Histogram Equalization are image quality improvement methods to expand and even out image grayscale. This research aims to build a system for improving image quality on historical artifacts using contrast stretching and histogram equalization methods. The sample used in this research is RGB image data with 10 test images in .jpg format, while the process uses the Matlab programming language. The results of improving image quality using the contrast stretching and histogram equalization methods from sample 1 to image sample 10 showed the best results in test image_citra_1 with contrast stretching results based on PSNR = 32.61 dB and MSE = 35.86 Db and PSNR = 19.13 Db and MSE = 794.76 in histogram equalization calculations.

Preventability of injury-related morbidity & mortality at four hospitals in Cameroon: A systematic approach to trauma quality improvement.

Adverse events reviews are a fundamental component of trauma quality improvement (QI) that facilitate the correction of systemic issues in care. Although injury-related mortality in Cameroon is substantial, to our knowledge, opportunities for QI have not been formally assessed. Thus, a formal review of adverse events in Cameroonian trauma patients was implemented as a first step toward identifying targets for systems modification. A QI committee composed of multidisciplinary experts at four hospitals in Cameroon was formed to review adverse events including deaths among trauma patients from 2019 to 2021. Events were discussed at newly established morbidity and mortality conferences and committee meetings to identify contributing factors and overall preventability. During 50 meetings, 95 adverse events were reviewed, including 58 deaths (61%). Other adverse events were delays in diagnosis/treatment (22%) and surgical site infections (17%). Overall, 34 deaths (59%) were classified as preventable, 21% potentially preventable, and 21% not preventable. Over half (52%) of the 46 preventable or potentially preventable deaths occurred in the emergency department (ED); while brain injury (57%), respiratory failure (41%), and hemorrhage (39%) were the most frequent physiologic factors associated with mortality. Contributory factors identified include lack of a structured approach to patient management, absence of continuous training for personnel, and locally adapted protocols. Basic improvements in evaluation and management of life-threatening issues in the ED can significantly reduce the high rate of preventable trauma-related deaths across Cameroon. Formal trauma QI methods can be utilized in low-resource environments to determine mortality root causes and identify intervention targets.

Towards environmentally sustainable healthcare: using quality improvement to deliver a net zero NHS

The healthcare industry is a major contributor to climate change globally. There is growing interest in using quality improvement methods to improve the sustainability of healthcare. East London NHS Foundation Trust uses quality improvement as its approach to solving complex problems. This article uses a case study methodology to describe how the trust's programme of sustainability used quality improvement at both systemic and local levels to support the organisation to reduce direct greenhouse gas emissions by 40% by 2025 and indirect emissions by 40% by 2036. Using quality improvement in a structured way enabled staff and service users to consider their contribution to sustainability and develop, test and measure ideas that were within their control. This led to an organisational reduction in gas emissions of 37% and CO2 emissions by 14% in winter months. At a local level, three case studies showcase the accomplishments of teams who successfully reduced medication waste by 66.2kg CO2e per year, reduced spending on single-use plastics by 54% and lowered CO2 emissions by 10798kg per year through the return of walking aids. Supporting structures for the programme included active and visible participation from senior stakeholders, with service users and carers involved at both strategic and operational levels, and tracking data over time. Future work should focus on creating a change package of ideas to serve as a blueprint to scale up these initiatives across the organisation.

Using Behavioral Insights to Strengthen Strategies for Change. Practical Applications for Quality Improvement in Healthcare.

For over 30 years, quality improvement (QI) methods have been used as a means of increasing the quality and safety of healthcare services, but with mixed success. One explanation highlighted in the literature for this outcome is the overemphasis on technical elements of change, and a failure to fully appreciate the human side of change. Behavioral insights (BI) is an approach that utilizes knowledge and tools from a broad range of scientific disciplines, such as neuroscience and behavioral psychology, to support behavior change. The aim of this paper is to explore the possibility of supplementing QI methods with tools and understanding from BI. We outline a practical case that involved applying aspects BI methods into a QI program aimed at reducing the use of intravenous antibiotics in patients accessing services at a busy university hospital in Copenhagen, Denmark. We exemplify how to use BI tools to guide the analysis of staff behaviors during standard clinical processes and develop targeted interventions aimed at increasing actions and behaviors more aligned to best clinical practice. Outcomes suggest that it is possible to combine the models and methods from BI and QI in a way that is helpful in focusing attention on the human side of change when developing strategies for change. Potential psychological barriers identified from the analysis included the following: 'default inertia,' 'decision complexity,' 'risk aversion,' and biases related to confidence, confirmation, and omission. Future quality improvement projects could benefit from integrating models and tools from BI to guide and support behavior change.