Quality Improvement Metrics Research Articles

Improving the quality and guideline concordance of multidisciplinary gastric cancer care in a safety net hospital.

314 Background: Gastric cancer is a leading cause of cancer death worldwide and disproportionally affects people of East Asian and Latin American ethnicities. This study aimed to implement and evaluate an intervention to improve the quality and guideline concordance of multidisciplinary gastric cancer care at a public safety net hospital, Zuckerberg San Francisco General Hospital (ZSFG). Methods: A quality improvement (QI) intervention was developed and evaluated by pre-post comparison of clinical data. (1) An in-depth chart review of all patients with gastric adenocarcinoma in 2017-2019 (n=17) evaluated concordance with evidence-based guidelines and quality metrics. (2) Multidisciplinary meetings identified barriers to high quality care and established targets for improvement. (3) A clinical algorithm tailored for ZSFG was disseminated to standardize gastric cancer management. (4) A post-intervention chart review was conducted of all patients from 2021-2022 (n=22). (5) Descriptive statistics and pre-post comparison of QI metrics with Chi square and Kruskal Wallis tests were performed. Results: Pre-intervention clinical data and multidisciplinary input identified gaps in care: variation in provider knowledge and practices, rapidly evolving guidelines, limited access to advanced diagnostic modalities, and non-standardized surgical documentation. After implementation of a standardized approach to address these gaps, pre-post improvement was seen in rates of tumor board presentation (36.3% vs. 85.7%, P= 0.033), use of endoscopic ultrasound (9.09% vs. 64.2%, P= 0.017), pre-treatment nodal staging (27.2% vs. 78.5%, P= 0.030), receipt of neoadjuvant chemotherapy (20% vs. 80%, P=0.007 ), documentation of lymphadenectomy type (25% vs. 100%, P= 0.015), and a trend toward reduced time to PET/CT scan (median, 8.5 weeks pre vs 7.1 weeks post, P= 0.268). Conclusions: A QI intervention was successfully implemented to standardize gastric cancer care at ZSFG. Significant improvements were seen in all targeted metrics except time to outside PET scan. Potential confounders affecting pre-post care quality included personnel changes in a small workforce and the COVID-19 pandemic. Nevertheless, our intervention led to sustained improvements in practice patterns. We aim to replicate this success with other malignancies. Category Pre-Intervention Target Post-Intervention P value* Tumor Board% cM0 cases presented 36% (n=11) >90% 86% (n=14) 0.033 Endoscopic ultrasound (EUS)% cM0 cases referred for clinical staging 9% (n=11) >90% 64% (n=14) 0.017 Nodal staging (with EUS or PET) 27% (n=11) N/A 79% (n=14) 0.030 Receipt of neoadjuvant chemotherapy% eligible patients 20% (n=10) >80% 80% (n=10) 0.007 Surgery documentationLymphadenectomy type (i.e., D1 or D2) 25% (n=8) 100% 100% (n=7) 0.015 Time from diagnosis to PET/CT (median) 8.5 wks <5 wks 7.1 wks 0.268 *Chi square test, Kruskal-Wallis test.

Harmonizing Quality Improvement Metrics Across Global Trial Networks to Advance Paediatric Clinical Trials Delivery

BackgroundDespite global efforts to improve paediatric clinical trials, significant delays continue in paediatric drug approvals. Collaboration between research networks is needed to address these delays. This paper is a first step to promote interoperability between paediatric networks from different jurisdictions by comparing drivers for, and content of, metrics about clinical trial conduct.MethodsThree paediatric networks, Institute for Advanced Clinical Trials for Children, the Maternal Infant Child and Youth Research Network and conect4children, have each developed metrics to address delays and create efficiencies. We identified the methodology by which each network identified metrics, described the metrics of each network, and mapped consistency to come to consensus about core metrics that networks could share.ResultsMetric selection was driven by site quality improvement in one network (11 metrics), by network performance in one network (13 metrics), and by both in one network (five metrics). The domains of metrics were research capacity/capability, site identification/feasibility, trial start-up, and recruitment/enrolment. The network driven by site quality improvement did not have indicators for capacity/capability or identification/feasibility. Fifteen metrics for trial start up and conduct were identified. Metrics related to site approvals were found in all three networks. The themes for metrics can inform the development of ‘shared’ metrics.ConclusionWe found disparity in drivers, methodology and metrics. Tackling this disparity will result in a unified approach to addressing delays in paediatric drug approvals. Collaborative work to define inter-operable metrics globally is outlined.

Does Central Statistical Monitoring Improve Data Quality? An Analysis of 1,111 Sites in 159 Clinical Trials

BackgroundCentral monitoring aims at improving the quality of clinical research by pro-actively identifying risks and remediating emerging issues in the conduct of a clinical trial that may have an adverse impact on patient safety and/or the reliability of trial results. This paper, focusing on statistical data monitoring (SDM), is the second of a series that attempts to quantify the impact of central monitoring in clinical trials.Material and MethodsQuality improvement was assessed in studies using SDM from a single large central monitoring platform. The analysis focused on a total of 1111 sites that were identified as at-risk by the SDM tests and for which the study teams conducted a follow-up investigation. These sites were taken from 159 studies conducted by 23 different clinical development organizations (including both sponsor companies and contract research organizations). Two quality improvement metrics were assessed for each selected site, one based on a site data inconsistency score (DIS, overall -log10P-value of the site compared with all other sites) and the other based on the observed metric value associated with each risk signal.ResultsThe SDM quality metrics showed improvement in 83% (95% CI, 80–85%) of the sites across therapeutic areas and study phases (primarily phases 2 and 3). In contrast, only 56% (95% CI, 41–70%) of sites showed improvement in 2 historical studies that did not use SDM during study conduct.ConclusionThe results of this analysis provide clear quantitative evidence supporting the hypothesis that the use of SDM in central monitoring is leading to improved quality in clinical trial conduct and associated data across participating sites.

Positive Effect of a Financial Incentive on Radiologist Compliance With Quality Metric Placement in Knee Radiography Reports

PurposeOngoing quality improvement (QI) processes in the authors’ department include the insertion of a Kellgren-Lawrence (KL) osteoarthritis grading template in knee radiography reports to decrease unnecessary MRI. However, uniform adoption of this grading system is lacking. Department-wide financial incentives were instituted to improve compliance with QI metrics. The purpose of this study was to evaluate the effect of a financial incentive on KL grading system use and to compare compliance rates of musculoskeletal (MSK) radiologists with those of general radiologists who were not financially incentivized to use KL grading. MethodsPercentages of all knee radiography reports containing KL grading with standardized follow-up recommendations were determined by querying the departmental radiology database before and after the introduction of the new quality-based financial incentive. Preincentive compliance rates for MSK and general radiologists were compared with an adoption period and two separate 6-month postincentive periods. ResultsIn total, 52,673 reports were retrospectively analyzed for KL grading use (41,670 reports interpreted by MSK radiologists and 11,003 interpreted by general radiologists). Increase in compliance was greatest among MSK radiologists’ reports during the incentivized adoption period (from 36.1% to 53.2%). This improvement was sustained among MSK radiologists and averaged 62.7% during the most recently studied postimplementation period. A lesser degree of improvement in compliance was observed in nonincentivized general radiologists’ reports (from 19.3% to 27.5%); during the postimplementation follow-up period, their compliance decreased to 26.5%. ConclusionsThe introduction of a financial incentive resulted in significantly increased adoption of QI practices with sustained improvement among incentivized MSK radiologists compared with nonincentivized general radiologists.

Canadian tertiary care pediatric massive hemorrhage protocols: a survey and comprehensive national review.

Hemorrhage is the leading cause of pediatric death in trauma and cardiac arrest during surgery. Adult studies report improved patient outcomes using massive hemorrhage protocols (MHPs). Little is known about pediatric MHP adoption in Canada. After waived research ethics approval, we conducted a survey of Canadian pediatric tertiary care hospitals to study MHP activations. Transfusion medicine directors provided hospital/patient demographic and MHP activation data. The authors extracted pediatric-specific MHP data from requested policy/procedure documents according to seven predefined MHP domains based on the literature. We also surveyed educational and audit tools. The analysis only included MHPs with pediatric-specific content. The survey included 18 sites (100% response rate). Only 13/18 hospitals had pediatric-specific MHP content: eight were dedicated pediatric hospitals, two were combined pediatric/obstetrical hospitals, and three were combined pediatric/adult hospitals. Trauma was the most common indication for MHP activation (54%), typically based on a specific blood volume anticipated/transfused over time (10/13 sites). Transport container content was variable. Plasma and platelets were usually not in the first container. There was little emphasis on balanced plasma/platelet to red-blood-cell ratios, and most sites (12/13) rapidly incorporated laboratory-guided goal-directed transfusion. Transfusion thresholds were consistent with recent guidelines. All protocols used tranexamic acid and eight sites used an audit tool. Pediatric MHP content was highly variable. Activation demographics suggest underuse in nontrauma settings. Our findings highlight the need for a consensus definition for pediatric massive hemorrhage, a validated pediatric MHP activation tool, and prospective assessment of blood component ratios. A national pediatric MHP activation repository would allow for quality improvement metrics.

Consecutive Inpatient Hematology Consultation Service Utilization across 11 Years in the Medical Intensive Care Unit

INTRODUCTION The current understanding of hematology consultation service utilization is limited to four studies in the outpatient setting and zero in the inpatient setting. While training programs in non-hematology specialties (i.e., cardiology, infectious diseases, nephrology) invest in dual-trained specialty-intensivists, investments into dual-trained hematologist-intensivists are systematically underdeveloped. Despite the high clinical volume of hematology patients admitted to the Medical Intensive Care Unit (MICU), there is currently no characterization of hematology MICU service needs. We sought to begin to fill this gap by examining the volume of consecutive consultations, time to consultation, consult patient characteristics, type, and number of consult question per patient and consult categories originating in the MICU at the largest hospital in the United States (2023 Becker's Hospital Review). METHODS We conducted a retrospective observational study of consecutive patients 18 years of age or older who had an incident (i.e., de novo) hematology consultation while admitted to the MICU from February 2013 through March 2023 at a single academic center. Inclusion criteria included (1) age of ≥ 18, and (2) initial consultation generated during MICU admission. To ensure only incident hematology consultations originating in the MICU were examined, patients with consultation placed on the medical floor with subsequent transfer to the MICU, and re-consultations in the MICU for the same patient, were excluded. Each consult note was manually reviewed to determine the exact consultation query. Descriptive statistics collected for each patient included (1) baseline demographics, (2) labs from day of consultation, (3) time to consultation, (4) binary hospital discharge status (alive or dead), and (5) number and type of consult queries within each consult. For the latter, number of queries per each consult were also recorded (i.e., anemia and thrombocytopenia would be two independent queries), and each query was further adjudicated as pertaining to either classical or malignant hematology. Descriptive statistics were tabulated using Microsoft Excel and GraphPad 9.4.1. RESULTS Across 11 years of consecutive, incident consultations requested from the MICU, there were a total of 594 hematology consults with 776 total consultation queries. At time of consultation request, the median age of patients was 60 years, 47% were of female sex, and mean time to hematology consultation was 30 hours after initial MICU admission (Table 1). Of the queries, 75% pertained to classical and 25% to malignant hematology. Of the 776 consult queries, the top three overall hematology consultation queries were for thrombocytopenia (n=105), coagulopathy (n = 86), and lymphoproliferative disorders (n=77). The top three classical hematology queries were for thrombocytopenia (n=105), coagulopathy (n=86), and thrombosis (n = 76). The top three malignant hematology queries were for lymphoproliferative disorders (n=77), acute leukemia (n=48), and plasma cell dyscrasias (n=25) (Table 1). CONCLUSIONS To our knowledge, our study is the first to describe the volume of incident inpatient hematology consultations originating from the MICU. We found that classical hematology queries constitute three quarters of consultation volume, yet the existing literature on hematologic critical care focus only on quality improvement metrics for hematologic malignancies in the ICU. The development of quality metrics for classical hematology critical care management and identification of research are needed, particularly in the context of the identified national workforce shortage in classical hematology. Future work to examine intensivists' consultation queries originating from other intensive care units (i.e., surgical, cardiac, and neurological), would allow a data-driven evaluation of the service need for dual-trained hematologist-intensivists in the United States. The volume and complexity of classical hematology consults that arise in the ICU, as demonstrated in this study, in addition to frequent ICU consultations and admission for hematologic malignancies, highlights an area of both research and clinical practice that could support developing dual trained hematologist-intensivist to help protocolize and deliver safe and expedient care for all consult queries.

QLTI-08. THE COLUMBIA NEURO-ONCOLOGY RESEARCH DASHBOARD: A WEB-BASED TOOL TO ASSESS CLINICAL TRIAL RECRUITMENT AND ACCRUAL METRICS

Abstract BACKGROUND Insufficient trial participation is a recognized barrier to drug development. Research has focused on patient and physician-associated factors, yet few institutions assess the impact of trial availability, referral patterns, and patient eligibility. Screening logs provide a rough estimate of candidate pools but tell us nothing about patients who are not screened, let alone why. To better understand site-specific barriers and effectively assess efforts to overcome them, real-time, data-driven metrics are essential. METHODS To address this need, we created The Columbia Neuro-Oncology Clinical Research Dashboard (CRD), a web-based tool designed to capture all patients presenting to our faculty practice with newly diagnosed or recurrent CNS tumors and track their participation -- or lack thereof -- in interventional trials. From 7/2022 - 9/2022, we experimented with several iterations of the CRD, adjusting the platform and variables in response to user feedback. To pilot the final design, we started with a limited sample of high-grade glioma patients seen at Columbia University Irving Medical Center's Neuro-Oncology Faculty Practice from 9/1/2022 - 1/1/2023. During this period, 62 patients were tracked, allowing for further refinements to improve functionality and data capture. When populated, the CRD was easily queried for important quality improvement metrics including accrual rates, time from presentation to study initiation and grounds for screen failure. It also captured the percentage of patients who were not offered a trial and the cited reasons. Inclusion of demographics and referral patterns provided additional dimensions to the data. NEXT STEPS: The CRD has met its preliminary aims. It provides a user friendly and accessible interface for data capture. With appropriate staffing and implementation processes in place, it has real potential to inform our efforts to improve patient accrual and diversity with real-time metrics. Subsequent efforts will focus on these aspects of the project.

Measuring Potentially Avoidable Acute Care Transfers From Long-Term Care Homes in Quebec: a Cross Sectional Study.

Potentially avoidable emergency department transfers (PAEDTs) and hospitalizations (PAHs) from long-term care (LTC) homes are two key quality improvement metrics. We aimed to: 1) Measure proportions of PAEDTs and PAHs in a Quebec sample; and 2) Compare them with those reported for the rest of Canada. We conducted a repeated cross-sectional study of residents who were received at one tertiary hospital between April 2017 and March 2019 from seven LTC homes in Quebec, Canada. The MedUrge emergency department database was used to extract transfers and resident characteristics. Using published definitions, PAEDTs and PAHs were identified from principal emergency department and hospitalization diagnoses, respectively. PAEDT and PAH proportions were compared to those reported by the Canadian Institute for Health Information. A total of 1,233 transfers by 692 residents were recorded, among which 36.3% were classified as being potentially avoidable: 22.8% 'PAEDT only', 11.6% 'both PAEDT & PAH', and 1.9% 'PAH only'. Shortness of breath was the most common reason for transfer. Pneumonia was the most common diagnosis from the 'both PAEDT & PAH' category. PAEDTs and PAHs accounted for 95% and 37% of potentially avoidable transfers, respectively. Among 533 hospitalizations, 31.3% were PAHs. These proportions were comparable to the rest of Canada, with some differences in proportions of transfers due to congestive heart failure, urinary tract infection, and implanted device management. PAEDTs far outweigh PAHs in terms of frequency, and their monitoring is important for quality assurance as they may inform LTC-level interventions aimed at their reduction.

SAP BusinessObjects in Medical Informatics.

Electronic health record (EHR) generates a large amount of data filled with opportunities to enhance documentation compliance, quality improvement, and other metrics. Various software tools exist, but many clinicians are unaware of them. Our institution switched from a hybrid of paper and multiple small EHRs to one all-inclusive EHR system. We faced significant challenges beyond the typical new software deployment phase that affected our departmental regulatory compliance, quality measures, and research initiatives. We aimed to navigate these issues through the use of medical informatics. We used a multidimensional database software analysis tool called SAP BusinessObjects® (SAP SE. Released 2020. SAP BusinessObjects, Version 14.2.8.3671. Waldorf, Germany) to design automated queries for the patient database to generate various reports for our department. As a result, We improved our anesthesia documentation non-compliance from 13-17% of all cases to 4% within months. We have also used this tool to automatically generate various reports such as preoperative beta-blocker administrations, caseloads, case complications, procedure logs, and medication records. Even today many departments rely on manual checks for even the most basic documentation and quality metric compliance, which can be time consuming and costly. Using medical informatics tools is a highly efficient alternative. Fortunately, many software tools exist within most modern EHR packages, and most people can learn to use these tools productively.

Breast Cancer Care in Kenya – A Hybrid Approach to Clinical Data Management

Background: High-quality data is essential for guiding clinical decision-making, quality improvement initiatives, national and local policy recommendations, and outcomes measurement and reporting. In Kenya, EHRs have been implemented in several disease- and goal-specific care modules, but their post-implementation usage remains low and precludes scale-up. Maintenance costs, attitudinal-behavioral limitations, and workflow interference have limited EHR implementation in other LMIC. While continued investigation will likely refine future EHR functionality, creative solutions are needed in the meantime to supplement these efforts. The aim of this study is to describe the creation and implementation of clinical forms for the secondary development of a prospective database in a multidisciplinary breast clinic.
 Methods: We developed clinical forms and corresponding RedCAP instruments, through the following steps: (1) multidisciplinary needs assessment and plan; (2) collaborative drafting of forms; (3) iterative clinical piloting and revision; (4) harmonization of forms with RedCAP instruments; and (5) administrative approval for clinical use.
 Results: The needs assessment identified challenges related to documentation of clinical encounters. Five clinical forms were created and edited over a period of 6 months, corresponding to ten RedCAP instruments with 469 fields. These tools capture data with potential for use as quality improvement metrics, including ECOG status, clinical and pathologic staging, barriers to care, disease status and progression, treatments and other interventions, among others.
 Conclusion: We hypothesize that insight gained from EHR implementation in LMIC can be applied on a small scale to generate high-quality data and facilitate care in the absence of widespread EHR usage. These tools will be used both to develop a prospective database and to retroactively migrate legacy data for outcomes analysis of the multidisciplinary breast clinic at Moi Teaching and Referral Hospital in Eldoret, Kenya. Following administrative approval, a formative evaluation will be conducted during the clinical implementation phase in a hybrid effectiveness-implementation trial.

65 &THRIVE: TRANSFORMING OLDER ADULT CARE IN THE EMERGENCY DEPARTMENT

Abstract Kaiser Permanente Los Angeles Medical Center’s (LAMC) Utilization Management Department expanded our geriatric initiative throughout the hospital with emphasis in the Emergency Department (ED). The ED is the first point of patient contact in the hospital, early identification and initiation of interventions needed for potential discharge barriers will assist in timely discharges. LAMC obtained Geriatric ED Accreditation (GEDA) Level 2 this year, the first in the Los Angeles County to achieve this title. This was done by implementing ten new policies with quality improvement (QI) metrics, conducting age sensitivity trainings for our staff, and enhancing our ED rooms to be geriatric friendly. Two of the ten interventions in our ED include 1) volunteers to provide support to our geriatric patients prevent functional decline, prevent delirium and readmission rates, and 2) palliative care consults initiated in the ED prevent suffering and promote the best possible quality of life for patients who are facing a serious illness. Between 2020 and 2021, there has been a 15% increase for the census of 65+ patients. 21% increase of number of older adults with ED readmissions, and a 13% increase in number of older adults staying in the ED for more than 8 hours. With the increasing older adult population, we see a rise in our admission and readmissions of older adults in our ED. This indicates a need for geriatric specialized care and Kaiser plans to obtain GEDA for all Southern California Hospitals.

How do we measure organisational wellness? Development of a comprehensive patient-centred and employee-centred visual analytical solution

BackgroundDashboards are visual information systems frequently employed by healthcare organisations to track key quality improvement and patient safety performance metrics. The typical healthcare dashboard focuses on specific metrics, disease processes...

Does Central Monitoring Lead to Higher Quality? An Analysis of Key Risk Indicator Outcomes

BackgroundCentral monitoring, which typically includes the use of key risk indicators (KRIs), aims at improving the quality of clinical research by pro-actively identifying and remediating emerging issues in the conduct of a clinical trial that may have an adverse impact on patient safety and/or the reliability of trial results. However, there has to-date been a relative lack of direct quantitative evidence published supporting the claim that central monitoring actually leads to improved quality.Material and MethodsNine commonly used KRIs were analyzed for evidence of quality improvement using data retrieved from a large central monitoring platform. A total of 212 studies comprising 1676 sites with KRI signals were used in the analysis, representing central monitoring activity from 23 different sponsor organizations. Two quality improvement metrics were assessed for each KRI, one based on a statistical score (p-value) and the other based on a KRI’s observed value.ResultsBoth KRI quality metrics showed improvement in a vast majority of sites (82.9% for statistical score, 81.1% for observed KRI value). Additionally, the statistical score and the observed KRI values improved, respectively by 66.1% and 72.4% on average towards the study average for those sites showing improvement.ConclusionThe results of this analysis provide clear quantitative evidence supporting the hypothesis that use of KRIs in central monitoring is leading to improved quality in clinical trial conduct and associated data across participating sites.

No Quick Fixes: Integrating Population Health Education and Quality Improvement in a Large Residency Program.

The intersection of population health (PH), quality improvement (QI), and health disparities is increasingly a focus in graduate medical education. However, it remains unclear how trainees may best improve disparities within clinical training environments. We integrated PH education for residents participating in a practical QI experience in a continuity clinic serving an underserved population. We analyzed whether PH education increased confidence in creating care plans and implementing team-based care strategies after selection of one of three QI metrics with known health disparities led to improvement. Posteducational session, attendees had odds of confidence in creating care plans 10.0 (95% confidence interval [CI] 4.6-21.7) times the presession period, whereas nonattendees' confidence was unchanged (OR 1.63, 95% CI 0.78-3.4). Residents participating in the QI project did not have higher confidence in creating a care plan at baseline (20% vs. 9.6%, p = .09) nor any additional shift in confidence versus other residents (p = .57). There were no differences in QI metric performance rate trends for residents choosing a specific QI metric versus those that did not (p > .33 for all comparisons). PH didactics can increase resident confidence around PH topics. However, translating such learning into outcomes and improved health equity may require dedicated efforts across residency training.

A survey of stroke-related capabilities among a sample of US community emergency departments.

ObjectivesMost acute stroke research is conducted at academic and larger hospitals, which may differ from many non‐academic (ie, community) and smaller hospitals with respect to resources and consultant availability. We describe current emergency department (ED) and hospital‐level stroke‐related capabilities among a sample of community EDs participating in the Emergency Quality Network (E‐QUAL) stroke collaborative.MethodsAmong E‐QUAL‐participating EDs, we conducted a survey to collect data on ED and hospital stroke‐related structural and process capabilities associated with quality of stroke care delivery and patient outcomes. EDs submitted data using a web‐based submission portal. We present descriptive statistics of self‐reported capabilities.ResultsOf 154 participating EDs in 30 states, 97 (63%) completed the survey. Many were rural (33%); most (82%) were not certified stroke centers. Although most reported having stroke protocols (67%), many did not include hemorrhagic stroke or transient ischemic attack (45% and 57%, respectively). Capability to perform emergent head computed tomography and to administer thrombolysis were not universal (absent in 4% and 5%, respectively). Access to neurologic consultants varied; 18% reported no 24/7 availability onsite or remotely. Of those with access, 48% reported access through telemedicine only. Admission capabilities also varied with patient transfer commonly performed (79%).ConclusionStroke‐related capabilities vary substantially between community EDs and are different from capabilities typically found in larger stroke centers. These data may be valuable for identifying areas for future investment. Additionally, the design of stroke quality improvement interventions and metrics to evaluate emergency stroke care delivery should account for these key structural differences.

Leveraging financial incentives and behavioural economics to engage physicians in achieving quality-improvement process measures.

Background:Dedicated quality-improvement (QI) initiatives within health care systems are of clear benefit, and physicians respond to financial incentivization. The Canadian health care system often lacks this lever, and many financially incentivized QI programs rely on traditional economic principles. We describe our evaluation of financial incentivization for the implementation of QI process metrics in a department of surgery at a Canadian academic hospital system and its impact over a 4-year period.Methods:Quality-improvement processes informed by extant QI incentivization literature and guided by the principles of behavioural economics were implemented within our institution’s Department of Surgery. Disbursement of supplemental government funding was modified to be contingent on the ability of divisions within the department to meet predefined QI metrics, including regular multidisciplinary meetings, morbidity and mortality rounds with documented feedback of systemic issues to division members, reviews of adverse events, and implementation of annual patient experience projects. We evaluated the effect of the QI processes from 2015/16 to 2018/19.Results:There was a significant increase in the number of divisions that satisfied all the QI metrics over the study period, from 2 (28%) in 2015/16, to 5 (71%) in 2016/17, to 7 (100.0%) in 2017/18 and 2018/19 (p < 0.01). The application of behavioural economics principles, such as reward versus penalty payoff, loss aversion, payment separation, aligning of values, and relative social ranking, was important to the outcome of the study.Conclusion:Incentivizing QI activities in the Canadian health care system is possible and led to improvement in QI processes as a whole in our department. This paper lays out a method of financial reimbursement to facilitate engagement of physicians and establishment of a foundation of important QI processes and measures within a department.

A Novel Approach to Pediatric Heart Failure Quality Improvement within the ACTION Network

<h3>Purpose</h3> Children hospitalized with heart failure (HF) face a high risk of mortality, prolonged length of stay, high resource utilization, and are at heightened risk for 30-day readmission. There is enormous opportunity to improve outcomes and survival in pediatric HF, a field where there is wide practice variation and minimal standardization of care. Accurate and reliable data collection is a crucial step to establish effective quality improvement (QI) initiatives. Such a resource in the pediatric HF population is lacking, partly due to the significant data collection burden. This pilot project aimed to establish a pediatric HF QI platform with reliable and efficient data collection through central data abstraction supplemented with administrative data. <h3>Methods</h3> All children hospitalized with acute decompensated HF across 6 centers that participate in both the ACTION network and Pediatric Health Information System (PHIS) were identified for inclusion (6/2019 - 7/2020). Centers submitted a brief "face sheet" for each patient, the hospital discharge summary, and the PHIS patient identifier. Data was abstracted from the discharge summaries centrally at the data coordinating center. Additional data pertaining to each hospitalization was extracted from PHIS. Data collected included in-hospital mortality, medication use at discharge, length of stay, ICU days, inotrope use, TPN use, resource utilization, readmission rates, and the need for ECMO, VAD, mechanical ventilation, or dialysis. <h3>Results</h3> A total of 227 patients with 309 HF hospitalizations were included in this pilot study. Using a strategy of central data abstraction and supplementation with administrative data to minimize center data collection burden, pediatric HF quality improvement metrics were able to be generated and developed into a heart failure dashboard (Figure). <h3>Conclusion</h3> We present a novel approach to pediatric HF data collection that minimizes center effort while providing a valuable platform for future QI efforts.

Use of a Quality Scorecard to Enhance Quality and Safety in Community Hospital Newborn Nurseries

To implement a quality improvement (QI) scorecard as a tool for enhancing quality and safety efforts in level 1 and 2 community hospital nurseries affiliated with Nationwide Children's Hospital. A QI scorecard was developed for data collection, analytics, and reporting of neonatal quality metrics and cross-sector collaboration. Newborn characteristics were included for risk stratification, as were clinical and process measures associated with neonatal morbidity and mortality. Quality and safety activities took place in community hospital newborn nurseries in Ohio, and education was provided in both online and in-person collaborations, followed by local team sessions at partner institutions. Baseline (first 12months) and postbaseline comparisons of clinical and process measures were analyzed by logistic regression, adjusting for potential confounders. In logistic regression models, at least 1 center documented improvements in each of the 4 process measures, and 3 of the 4 centers documented improvements in compliance with glucose checks obtained within 90minutesof birth among at-risk infants. Collaborative QI projects led to improvements in perinatal metrics associated with important outcomes. Formation of a center-driven QI scorecard is feasible and provides community hospitals with a framework for collecting, analyzing, and reporting neonatal QI metrics.

Racial Disparities in Time to Start of Definitive Radiation Treatment for Patients With Locally Advanced Cervical Cancer

<h3>Purpose/Objective(s)</h3> Chemoradiation (CRT) is the curative standard for patients with locally advanced cervical cancer (LACC). The impact of time to start of definitive treatment has not been well defined. To further elucidate quality improvement metrics, we investigated factors that may influence start time to CRT or radiation (RT) and its impact on recurrence and survival outcomes. <h3>Materials/Methods</h3> Patients with LACC treated with definitive CRT or RT at our institution between 2015 and 2020 were retrospectively identified. Time to treatment initiation (TTI) was defined as the number of days from date of diagnosis (via biopsy) to start date of RT treatment. The cohort was stratified by the median TTI - within 75 (early) or ≥ 75 days (delayed). Multivariable logistic regression was conducted to examine factors associated with delayed TTI. Secondary endpoints of locoregional failure (LRF), overall survival (OS), and distant failure (DF) were evaluated in multivariable Cox and Fine-Gray models. <h3>Results</h3> We identified 143 patients with LACC who underwent definitive CRT or RT with a median follow up of 18 months. 71 (49.7%) patients had TTI < 75 days (median 53, range 2-74 days) and 72 (50.3%) patients had TTI ≥ 75 days (median 91, range 75-472 days). The delayed cohort had a higher proportion of Hispanic patients (51.4% vs 31.0%, <i>P</i> = 0.04). Both cohorts had similar distributions of other patient, tumor, and treatment related variables. In multivariable logistic regression examining the sociodemographic and clinical factors associated with delayed TTI, only race was a significant predictor as Hispanic women were 2.62 times more likely to undergo delayed TTI (OR 95% CI 1.14-6.00, <i>P</i> = 0.03) than non-Hispanic White women. Non-Hispanic women of other races (Black, Asian, mixed) comprised 18.2% of our cohort and had similar odds (<i>P</i> = 0.58) of undergoing delayed TTI as non-Hispanic White women. In multivariable models, delayed TTI was not associated with inferior LRF, OS, or DF. Similarly, Hispanic race was not associated with inferior outcomes on these endpoints. <h3>Conclusion</h3> In our study, patients with LACC were more likely to receive delayed definitive treatment of ≥ 75 days if they were Hispanic. This disproportionate delay in treatment at a high volume, academic cancer center represents an opportunity for exploration of patient-, physician-, and system-centered factors in order to counteract this disparity. Further studies examining the presence of similar disparities in delay to definitive treatment for locally advanced cervical cancer at other institutions and settings are warranted.

Using CAHPS patient experience data for patient-centered medical home transformation.

To examine how primary care practices use the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and its patient-centered medical home (PCMH) items during their PCMH transition. Qualitative study of practices' use of patient experience data during PCMH transformation, based on a random sample of primary care practices engaged in PCMH transformation, stratified by region, practice size, PCMH recognition history, and use of the CAHPS PCMH survey. We interviewed 105 practice leaders from 294 sampled practices (36% response rate) and used content analysis to identify themes about uses of patient experience data for practice improvement during PCMH transformation. Patient experience data were used primarily to assess and track improvements toward PCMH goals and as quality improvement (QI) metrics. CAHPS measures were used most often to discuss best practices, share data with patient advisory councils, and improve provider performance. The CAHPS PCMH survey helped practices improve patient-centeredness, particularly in coordinating care and supporting patient self-management and communication. The CAHPS PCMH items that assisted practices most were about patient self-management and provider referrals. Most practice leaders using the CAHPS PCMH survey felt that its items were actionable for standardizing PCMH changes or making structural changes. Practices administering CAHPS surveys focused on a more diverse set of QI areas. CAHPS surveys were considered actionable for PCMH transformation and used in standardizing and coordinating care. The CAHPS PCMH items were considered integral to the continuous QI needed for moving beyond formal PCMH recognition and maximizing transformation. This supports the National Committee for Quality Assurance's recommendation to administer the CAHPS or CAHPS PCMH survey for PCMH transformation.