Quality Improvement Process Research Articles

Impact of Continuous Renal Replacement Therapy Initiation Time, Kidney Injury, and Hypervolemia in Critically Ill Children.

The mortality rate of pediatric patients who require continuous renal replacement therapy is approximately 42%, and outcomes vary considerably depending on underlying disease, illness severity, and time of dialysis initiation. Delay in the initiation of such therapy may increase mortality risk, prolong intensive care unit stay, and worsen clinical outcomes. In the pediatric intensive care unit of an urban level I trauma children's hospital, continuous renal replacement therapy initiation times and factors associated with delays in therapy were unknown. This quality improvement process involved a retrospective review of data on patients who received continuous dialysis in the pediatric intensive care unit from January 1, 2017, to December 31, 2021. The objectives were to examine the characteristics of the children requiring continuous renal replacement therapy, therapy initiation times, and factors associated with initiation delays that might affect unit length of stay and mortality. During the study period, 175 patients received continuous renal replacement therapy, with an average initiation time of 11.9 hours. Statistically significant associations were found between the degree of fluid overload and mortality (P < .001) and between the presence of acute kidney injury and prolonged length of stay (P = .04). No significant association was found between therapy initiation time and unit length of stay or mortality, although the average initiation time of survivors was 5.9 hours shorter than that of nonsurvivors. Future studies are needed to assess real time delays and to evaluate if the implementation of a standardized initiation process decreases initiation time.

Audit of an in-patient palliative care quality improvement process for patients with pancreatic ductal adenocarcinoma in a South African teaching hospital

Audit of an in-patient palliative care quality improvement process for patients with pancreatic ductal adenocarcinoma in a South African teaching hospital

Moving from Prove to Improve: A collaborative continuous quality improvement process for advancing clinical and translational science

Moving from <i>Prove</i> to <i>Improve</i>: A collaborative continuous quality improvement process for advancing clinical and translational science

Assessment of Quality Improvement and Patient Safety Resources, including Event Reporting Systems, in Graduate Medical Education Training Programs - An Institutional National Survey

Background Quality improvement (QI) and patient safety (PS) education were requirements implemented in 2017 by the Accreditation Council for Graduate Medical Education (ACGME) for residents and fellows. Trainees must receive training and experience in QI processes, including an understanding of healthcare disparities, but how training and experience occur remains largely unknown. Our study aimed to determine how institutions have integrated these requirements into medical education. Methods A Google Forms survey was emailed to the Designated Institutional Officials (DIOs) of 650 United States’ institutions with ACGME accredited programs in September 2021. The survey consisted of 34 multiple choice questions related to QI and PS parameters and the event reporting system (ERS); a Likert scale was used. Results More than half (n=392) of the emails were undeliverable, leaving only 258 possible responders; 51 responses were received, and all but one met the inclusion criteria of having at least one training program, which translated to a response rate of 19% (=50/257). The survey found that while 90% of institutions had an institutional QI/PS Committee, only 30% of these institutions also had a Graduate Medical Education-specific QI/PS Committee as well. Most institutions provided QI (88%) or PS training (94%), but only 71% and 83%, respectively, had mandatory training. Most institutions utilized an ERS (96%). While one of the less common methods was education on the ERS, approximately two-thirds of responding DIOs believed that by providing education on the ERS, resident/fellow participation in event reporting would improve, as well as contribute to their total education. Conclusions Further ERS education is warranted to encourage resident/fellow participation to develop various protocols related to QI and PS parameters.

The ASPiH Standards – 2023: guiding simulation-based practice in health and care

The ASPiH Standards 2023 provide a common framework within educational and healthcare sectors, bolstering quality assurance for simulation providers, regulators, professional bodies and commissioners. They endeavour to meet the current needs of simulation practitioners and learners, reflect the evolution of simulation practice, and account for emerging technologies. Therefore, they are applicable to any modality of simulation-based education and training as well as to translational and transformative simulation interventions, including the use of simulation for quality improvement processes, whether carried out at education centres, simulation facilities or at the point of care. The standards encourage adherence to core values of safety, equity, diversity and inclusion, sustainability, and excellence. They provide guidance for all simulation practitioners, highlighting key principles for planning, facilitation and evaluation of simulation activities, as well as recommendations for optimum resource management. Implementation of these standards will require consideration of how they apply to each individual context, and what outcome measures are most meaningful to demonstrate alignment.

Effluent quality improvement in sequencing batch reactor-based wastewater treatment processes using advanced control strategies.

The treatment of wastewater is highly challenging due to large fluctuations in flowrates, pollutants, and variable influent water compositions. A sequencing batch reactor (SBR) and modified SBR cycle-step-feed process (SSBR) configuration are studied in this work to effectively treat municipal wastewater while simultaneously removing nitrogen and phosphorus. To control the amount of dissolved oxygen in an SBR, three axiomatic control strategies (proportional integral (PI), fractional proportional integral (FPI), and fuzzy logic controllers) are presented. Relevant control algorithms have been designed using plant data with the models of SBR and SSBR based on ASM2d framework. On comparison, FPI showed a significant reduction in nutrient levels and added an improvement in effluent quality. The overall effluent quality is improved by 0.86% in FPI in comparison with PI controller. The SSBR, which was improved by precisely optimizing nutrient supply and aeration, establishes a delicate equilibrium. This refined method reduces oxygen requirements while reliably sustaining important biological functions. Focusing solely on the FPI controller's performance in terms of total air volume consumption, the step-feed SBR mechanism achieves an excellent 11.04% reduction in consumption.

Ductal Stenting in Low-Resource Environments.

Duct-dependent pulmonary circulation has traditionally been addressed by the Blalock-Taussig-Thomas shunts (BTTS). Recently, catheter-based alternatives such as ductal stenting have emerged as a particularly advantageous option, especially in resource-constrained settings. This article delves into the nuances of ductal stenting within low-resource environments, highlighting its relative ease of application, reduced morbidity, and cost-effectiveness as key factors in its favor. Comparisons in mortality between the two procedures are however likely to be confounded by selection biases. Ductal stenting appears to be particularly beneficial for palliating older infants and children with cyanotic congenital heart disease and diminished pulmonary blood flow who present late. Additionally, it serves as a valuable tool for left ventricular training in late-presenting transposition with an intact ventricular septum. A meticulous pre-procedure echocardiographic assessment of anatomy plays a pivotal role in planning access and hardware, with additional imaging seldom required for this purpose. The adaptation of adult coronary hardware has significantly enhanced the technical feasibility of ductal stenting. However, challenges such as low birth weight and sepsis specifically impact the performance of ductal stenting and patient recovery in low-resource environments. There is potential for systematic application of quality improvement processes to optimize immediate and long-term outcomes of ductal stenting. There is also a need to prospectively examine the application of ductal stenting in low-resource environments through multi-center registries.

Academic program enhancement supporting the success of undergraduate nursing students and graduates

Nursing program administrators, faculty, academic success coaches, and remediation specialists have implemented many interventions in support of baccalaureate nursing students' retention and graduates' NCLEX-RN® first-time pass rates. A private university's undergraduate nursing program's team incorporated additional evidence-based interventions aimed improving students' achievement of benchmarks following a 3-year decline in NCLEX-RN pass rates. Interventions expanded the prelicensure academic program's activities using a continuous quality improvement approach. A simulation center was constructed and a director was hired. A consultant also facilitated faculty engagement in curricular revisions. A new position, coordinator tutor/remediation specialist, was filled and the academic success coach launched interventions that complemented an initial and subsequent strategies for success initiative. New interventions were trialed and evaluated and became integral to students' and graduates' success. The academic success coach's commitment to students' achievements promoted their engagement in interventions. Pass rates increased and were sustained. Examples of interventions, supported by evidence, are presented in tables for review. A logic model depicts components of the program plan and its interventions as augmented by prospective strategies and remediation interventions. Continuous quality improvement processes will continue. Students and graduates have commented positively on the benefits of the assorted, success-promoting interventions.

Quality improvement efforts to address racial and ethnic disparities in patients with peripheral vascular disease and chronic limb-threatening ischemia

IntroductionRacial and ethnic disparities in care have been documented among patients who present with chronic limb-threatening ischemia (CLTI), the most severe form of peripheral artery disease (PAD). This scoping review was designed to explore the different types of quality improvement (QI) initiatives that have been set up to address disparities in access to care and treatment outcomes for this vulnerable patient population. MethodsA systematic search of the MEDLINE, Embase, and CINAHL databases was performed to identify articles that evaluated QI programs, care processes, or outcomes established to address disparities in access and treatment among non-White and ethnic minority patients with PAD and/or CLTI. This search was limited to studies published in the English language after 1990, and abstracts were screened and abstracted by the authors. The review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines for scoping reviews. ResultsOur search yielded six articles published between 1990 and 2023 that reported on QI initiatives designed to address some aspect of differential care among non-White patients with different types of PAD including CLTI. QI protocols were primarily focused on addressing disparities in the care of non-White patients with diabetic foot infections and/or adherence to guidelines for patients with CLTI. Findings from these studies identified potential for improvement through multidisciplinary care teams and algorithm-based treatment protocols that emphasize the importance of medication compliance, timely revascularization, and frequent follow-up. Nevertheless, data between studies were heterogeneous, and there were limited protocols that specifically focused on measures to mitigate differential access for non-White patients with PAD or CLTI. ConclusionsThere has been a paucity of QI initiatives and processes established to address disparities in access to care and treatment outcomes for non-White and ethnic minority patients with PAD and/or CLTI. More hospital and community-based programs are needed to improve access to vascular surgery care for this vulnerable patient population.

Turnaround Time of the Hematology Results of Cancer Patients During the COVID-19 Pandemic: An Opportunity to Initiate a Quality Improvement Process.

Turnaround time (TAT) is a crucial clinical parameter that reflects the performance of a laboratory especially in the context of oncology and the COVID-19 pandemic. Based on the Lean Six Sigma methodology, we performed a retrospective analysis of the TAT of the complete blood count (CBC) of cancer patients with the aim of reducing this delay in the future. Overone month of the COVID-19 pandemic, a retrospective evaluative audit was carried out on the TAT of the CBC in an oncology department. The root causes of failures of the overall analysis process were detected. The initiation of an improvement approach was implemented through the creation of an improvement flowchart and a new requestform. The hospital information system (HIS) datawere exported to Microsoft Excel® (Microsoft Corporation, Redmond, Washington, United States). Using the collected data, the mean, standard deviation, median, and interquartile range were calculated using IBMSPSSStatistics for Windows, Version 23, (Released 2015; IBM Corp., Armonk, New York, United States). All time intervals were expressed in minutes. Among 263 intra-laboratory TATs analyzed, the median intra-lab TAT was 56 minutes (interquartile range (IQR): 36-80minutes). A total of 82% of the analyses were performed in less than 90 minutes with a predominance of the interval 30-59at 42.9%. The main causes of failures were essentially the lack of time stamping of the samples as well as the lack of real-time communication between the biologists and the clinicians. The proposed improvement model is currently being approved by all practitioners whose main items are as follows: At the clinical department level, distinguish the request forms but also the labels of the samples of the oncology hospital by a particular color, indication of clinical signs andsampling time on the request forms and on the HIS. At the laboratory level, create a specific chain for oncology department samples, alarmnotification on the HIS, and rapid telecommunication of results for vital situations. The intra-lab TAT of our study is biologically acceptable. Because our work is limited by the phases outside the control of the laboratory, it should lead to a continuous improvement project.

Continuous quality improvement project to reduce the downtime of medical linear accelerators: A case study at Zhejiang Cancer Hospital

ObjectiveTo analyse and continually improve existing issues in the quality improvement process of medical linear accelerators (LINACs) and enhance the quality control management of LINACs. MethodsData were collected from eight LINACs (sourced from three manufacturers) at Zhejiang Cancer Hospital using Excel diaries between January 2019 and December 2020. The data description and analysis were performed using the analytic hierarchy process, SPSSAU and Excel software, and mean-time-to-repair (MTTR)/mean-time-between-failure (MTBF) metrics. Continuous quality improvement was executed using the quality control circle (QCC) quality management method. ResultsAfter quality improvement, the risk frequency of ‘LINAC down’ events decreased by 43.63% and downtime was reduced by 40.45%. The weight of downtime risk improved by 73.69%. The MTTR recovery value increased by 31.90%, and MTBF reliability increased by 2.97 h. The simulation results demonstrated that the proposed quality improvement measures could effectively decrease the frequency and duration of downtimes, consequently extending the normal operational time of LINACs. ConclusionTransitioning from instant repair to preventative maintenance can enhance the operational efficiency of equipment and yield economic benefits for hospitals. The QCC method and the event risk evaluation model are effective in reducing the downtime of LINACs and improving their quality control management.

Understanding What Older People Value in the Design of a Community-Based Healthy Ageing Program, a Qualitative Study

Older people who are wanting to support their own ability to age well may benefit from attending community-based group programs. However, many of these programs are designed and implemented by health professionals without direct input from older people, which may limit the opportunity to ensure such programs are authentically meeting the needs of this population group. A qualitative approach, using an interpretative phenomenological analysis (IPA), was undertaken with seven (six female and one male) participants, aged between 62 and 80 years to explore the experiences of participating in a pilot Ageing Well Program. Interviews were transcribed and analysed according to IPA principles. Three themes emerged from the analysis of the interview data: (1) The value of focusing on different aspects of ageing; (2) Learning new knowledge; and (3) Transferring skills to everyday life. Participants in the pilot of the Ageing Well Program highlighted that those aspects of the Program, such as the focus on adding value through targeting multiple aspects of ageing, as well as developing strategies to successfully learn, apply, and translate new knowledge into their everyday lives, were beneficial and supported engagement. However, future programs would benefit from the inclusion of clear and coherent written material to provide an aide in remembering the strategies and new information learnt during the Program. Findings support the importance and value of engaging with older people to assist with the development of community-based programs that are authentically designed to align with the expectations of older people, through a process of quality improvement.

Practitioner research as a pathway to educational leadership

ABSTRACT ‘Educational Leadership’ is embedded in [country] early childhood policy. What the role is, who should do it and why educators are hesitant about becoming leaders however, remains ambiguous. According to the national curriculum framework and teacher standards, more research about the work of educators is needed. The reported research aimed to investigate whether long-term, enquiry-based professional learning, utilizing practitioner research, could lead to quality improvement. Practitioner Research engaged educators in investigating and improving practice in a continuous process of quality improvement. Research topics were pedagogical in nature, designed to be enabling of ‘educational leadership’ for quality improvement. Action Research was used by practitioner researchers to investigate ways to improve pedagogical quality. University researchers also used meta-research to investigate the action research processes. Focus groups and mentor statements revealed unexpectedly that the Educational Leader role was pivotal in the relationship between professional learning, practitioner research and quality. Strengthened Educational Leader identities emerged as participants gained research skills and evidence for designing and implementing pedagogical change. Knowledge building facilitated strengthened engagement of educator teams. This was transformational, informing the case for change and further exploration of practitioner research as a workforce strategy for quality improvement and staff retention.

Clinical Inquiry and Problem Identification.

This is the second article in a new series designed to provide readers with insight into educating nurses about evidence-based decision-making. It builds on AJN's award-winning previous series-Evidence-Based Practice, Step by Step and EBP 2.0: Implementing and Sustaining Change (to access both series, go to http://links.lww.com/AJN/A133). This follow-up series will address how to teach and facilitate learning about the evidence-based practice (EBP) and quality improvement (QI) processes and how they impact health care quality. This series is relevant for all nurses interested in EBP and QI, especially DNP faculty and students. The brief case scenario included in each article describes one DNP student's journey.

Robust Control Chart Application in Semiconductor Manufacturing Process

Statistical Process Control (SPC) charts are frequently used in the semiconductor manufacturing environment to monitor process quality and detect special-cause variations, hence, to take corrective actions when necessary. The important aspects of control charts to consider on production floors are identifying the primary objective of implementing control charts, the type of data to monitor and the most appropriate control limits to establish. When the quality data is a type of attribute data like the proportion of defectives from a production lot, a p-chart approach is most suitable. In p-chart applications, although the assumption of normally distributed process data is not mandatory, the widespread practice is to assume the normal distribution of process data when establishing the control limits. Yet again, the reality of industrial settings is that process data are most likely influenced by outliers, resulting in highly skewed distributions. This paper addresses these issues by proposing robust SPC charting techniques to detect special-cause variations in the semiconductor manufacturing processes. Here, we present a case study of a semiconductor company in Malaysia, Dominant Opto Technologies Sdn. Bhd. to propose three robust statistical approaches for monitoring the proportion of defectives in production lots. We apply M-estimates, median, and interquartile range to calculate the upper control limits (UCL) and found that robust estimators are more effective in detecting early process deterioration and capturing the out-of-control (OOC) conditions better than traditional control charts. By proposing robust methods, this study enlightens the practical aspects of process quality improvement for real-life manufacturing setups. Because a high OOC rate may impact manufacturing productivity, we recommend the decision-makers choose the types of control charts based on the implications of each robust approach toward quality and productivity. The significance of this study includes providing insights into setting up the appropriate attribute control charts for detecting defective proportions for professionals and SPC researchers working in these areas.

High positive predictive value 22q11.2 microdeletion screening by prenatal cell-free DNA testing that incorporates fetal fraction amplification.

22q11.2 deletion syndrome (DS) is a serious condition with a range of features. The small microdeletion causing 22q11.2DS makes it technically challenging to detect using standard prenatal cfDNA screening. Here, we assess 22q11.2 microdeletion clinical performance by a prenatal cfDNA screen that incorporates fetal fraction (FF) amplification. The study cohort consisted of patients who received Prequel (Myriad Genetics, Inc.), a prenatal cfDNA screening that incorporates FF amplification, and met additional eligibility criteria. Pregnancy outcomes were obtained via a routine process for continuous quality improvement. Samples with diagnostic testing results were used to calculate positive predictive value (PPV). 379,428 patients met study eligibility criteria, 76 of whom were screen-positive for a de novo 22q11.2 microdeletion. 22 (29.7%) had diagnostic testing results available, and all 22 cases were confirmed as true positives, for a PPV of 100% (95% CI 84.6%-100%). This performance was based on cases that ranged broadly across FF (5.9%-41.1%, mean 23.0%), body mass index (22.3-44.8, mean 29.9), and gestational age at testing (10.0w-34.6w, median 12.7w). Ultrasound findings in screen-positive pregnancies were consistent with those known to be associated with 22q11.2DS. 22q11.2 microdeletion screening that incorporates FF amplification demonstrated high PPV across both general and high-risk population cohorts.

Magnitude and associated factors of postoperative mortality among patients who underwent surgery in Ethiopia: systematic review and meta-analysis.

Postoperative mortality is one of the six surgical indicators identified by the Lancet Commission on Global Surgery for monitoring access to high-quality surgical care. This study aimed to assess the magnitude and associated factors of postoperative mortality among patients who underwent surgery in Ethiopia. This systematic review and meta-analysis were conducted based on the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Ten studies were included in this Systematic review and meta-analysis. The risk of bias for each study was assessed using the Joanna Briggs Institute quality appraisal scale. Publication bias was checked using a funnel plot and Egger's regression test. Heterogeneity across studies was assessed by I2 statistics. STATA version 17 software was used for analysis. A random effect model and the DerSimonian-Laird method of estimation was used to estimate the pooled magnitude of postoperative mortality. Odds ratios with 95% CIs were calculated to determine the associations of the identified factors with postoperative mortality. The results revealed that the pooled magnitude of postoperative mortality among patients who underwent surgery in Ethiopia was 4.53% (95% CI :3.70-5.37). An American Society of Anesthesiologists score greater than or equal to III [adjusted odds ratio (AOR): 2.45, 95% CI: 2.02, 2.96], age older than or equal to 65 years (AOR: 3.03, 95% CI: 2.78, 3.31), and comorbidity (AOR: 3.28, 95% CI: 1.91, 5.63) were significantly associated with postoperative mortality. The pooled magnitude of postoperative mortality among patients who underwent surgery in Ethiopia was high. The presence of comorbidities, age older than 65 years, and ASA physical status greater than III were significantly associated with postoperative mortality. Therefore, the Ministry of Health and other concerned bodies should consider quality improvement processes.

175 Benchmarking MICHR’s Clinical and Translational Science production as a continuous quality improvement initiative.

OBJECTIVES/GOALS: In line with NCATS funding requirements, the Michigan Institute for Clinical and Health Research (MICHR) established a continuous quality improvement (CQI) process and used the process to guide the implementation of a benchmarking project to evaluate and set goals for MICHR’s production of Clinical and Translational Science manuscripts. METHODS/STUDY POPULATION: We aimed to increase the number of Clinical and Translational Science papers MICHR produces and to set a reasonable goal for improvement. Benchmarking was used to obtain a baseline and inform the identification of a reasonable goal for improvement. 11 Peer institutions were identified with similar funding levels. 1,225 Publications from 2022 for all 12 CTSAs were obtained from NIH Reporter. All publications were reviewed by title to identify probable CTS content. Two staff reviewers confirmed a total of 108 CTS publications across all CTSAs, and coded each paper to characterize the theoretical approach, method (quantitative and/or qualitative), analytic method and topic. All publications that were selected for benchmarking were also tracked and compared using Altmetrics for Institutions and Overton platforms. RESULTS/ANTICIPATED RESULTS: A total of 108 CTS publications were produced by 12 benchmarked CTSAs in 2022; of those, 70% (77) regarded research infrastructure, 37% (41) regarded research methods, and 15% (16) regarded clinical care. Over half, 53% (58), of the benchmarked papers are empirical research papers; of those, 67% (39) used quantitative methods, 28% (16) used qualitative methods, and 5% (3) used mixed methods. A clear majority of the benchmarked papers, 70% (76), provided only descriptive analyses, 18% (19) provided inferential analyses, and 12% (13) provided predictive analyses. We identified an opportunity to produce more manuscripts with descriptive analyses of research infrastructure. In the long-term, we saw an opportunity to produce predictive analyses of translational initiatives designed to impact clinical care. DISCUSSION/SIGNIFICANCE: The benchmarking results helped MICHR identify goals for its production of Clinical and Translational Science to fill gaps in the field. Expanding the scope of this benchmarking project might achieve greater interrater reliability using larger representative sets of publications drawn from institutions across the CTSA Consortium.

Dual‐beam lasers meet challenges of the automotive industry

AbstractThe challenges of transport electrification require the adoption of new manufacturing techniques. Lasers excel in most difficult tasks due to their ability to deliver energy with great precision, and their temporal and spatial control. Dual‐beam, adjustable mode beam (AMB) technology enables the versatile spatial control of laser energy deposition, providing wide process windows for defect‐free welding and focal spot positioning. The AMB technology improves process quality and speed in dissimilar material welding, copper welding and in structural aluminum welding across many applications in the automotive industry – from the production of batteries and drivetrains to structural body parts.

Evaluation of a Quality Improvement Process for Health-System Retention of Long Acting Growth Factors Prescriptions in the Pediatric Oncology Population

OBJECTIVE Granulocyte-colony stimulating factor (GCSF) products are often used in pediatric patients with malignant diagnoses to reduce the time that the patient is neutropenic. Long-acting GCSF products have been shown to be non-inferior to daily dosing of GCSF products, and are becoming more desired by patients and families. Insurance companies often require a prior authorization prior to approving the use of the long-acting GCSF products. This process has proven challenging leading to treatment delays and missed doses. The purpose of this study is to evaluate a quality improvement process for the prescribing and dispensing of long-acting GCSF to better serve pediatric patients within a single health care system. METHODS This is a single-center, retrospective chart review with the purpose of collecting data to compare prescription retention before and after the improvement intervention. Study timeline includes all doses of long-acting GCSF prescribed for pediatric oncology patients between June 2020–June 2021 compared with July 2021–March 2022. On June 30, 2021, educational information was provided to the appropriate stakeholders regarding the change in practice. RESULTS A total of 31 patients were included in the review, with 22 patients prior to the intervention (115 prescriptions), and 9 patients after the intervention (43 prescriptions). There was a 37.8% increase in health system prescription retention (15.7% vs 53.5%). CONCLUSIONS Pharmacist directed long-acting GCSF prescription destination and a dedicated prior-authorization team led to an increase in prescription retention for patients regardless of payer mandated outpatient pharmacy.