Quality Improvement Report Research Articles

Structured reporting in daily practice-status quo and future

Introduction and application of structured reporting in radiology private practice. Ultrasound (US), magnetic resonance imaging (MRI), computed tomography (CT), digital x‑ray (DR), mammography (MG). Structuring and predefinition of entire reports and report parts. Structured reporting in radiology presumably allows for higher report quality, reproducibility and easier access to data mining. Also the communication with the referring physicians can be improved. Although these advantages are well acknowledged, structured reporting does not prevail in private radiology practices. This article sheds light on the current situation of structured reporting in radiology private practice and provides information for the faltering implementation as well as perspective for individual potential solutions to overcome this situation. Structured reporting is not yet standard. Growing acceptance of structured reporting can be expected. The application of structured reporting can improve report quality. The use of structured reporting should be considered for common examinations.

An Acute Care Sepsis Response System Targeting Improved Antibiotic Administration.

Pediatric sepsis quality improvement in emergency departments has been well described and associated with improved survival. Acute care (non-ICU inpatient) units differ in important ways, and optimal approaches to improving sepsis processes and outcomes in this setting are not yet known. Our objective was to increase the proportion of acute care sepsis cases in our health system with initial antibiotic order-to-administration time ≤60 minutes by 20% from a baseline of 43% to 52% by December 2020. Employing the Model for Improvement with broad stakeholder engagement, we developed and implemented interventions aimed at effective intervention for sepsis cases on acute care units. We analyzed process and outcome metrics over time using statistical process control charts. We used descriptive statistics to explore differences in antibiotic order-to-administration time and inform ongoing improvement. We cared for 187 patients with sepsis over the course of our initiative. The proportion within our goal antibiotic order-to-administration time rose from 43% to 64% with evidence of special cause variation after our interventions. Of all patients, 66% experienced ICU transfer and 4% died. We successfully decreased antibiotic order-to-administration time. We also introduced a novel model for sepsis response systems that integrates interventions designed for the complexities of acute care settings. We demonstrated impactful local improvements in the acute care setting where quality improvement reports and success have previously been limited.

Crossing quartiles: Improving time to theatre for patients with hip fractures in a large UK district general hospital; A quality improvement report

BackgroundNeck of femur fractures are common injuries in the elderly population and carry significant morbidity and mortality. The introduction of a Best Practice Tariff (BPT) in 2010 laid out the criteria for optimising hip fracture care. These outcomes are audited annually by the National Hip Fracture Database. Meeting all six key targets attracts a financial uplift for each patient; one of these criteria is for an operation within 36 hours of admission. Local problemA large district general, seeing on average 551 hip fracture patients a year. In 2017, the trust was ranked 152/160 in England for meeting the 36-hour target to surgery, although theatre capacity was sufficient. The average time to theatre was 43.68 hours, significantly above the national average. BPT was only achieved in 45.7% of cases. MethodIn January 2018 an anaesthetic ‘hot week’ was introduced with the same anaesthetist responsible for the hip fracture lists to allow for continuity of care and timely identification of potential delays to surgery. Further responsibilities include attending trauma meeting, liaising with the orthopaedic and the orthogeriatric teams, and advising on medical optimisation of patients for theatre. ResultsComparing data for 2017 (pre-intervention) with 2018 (post-implementation), the following results in key measures were noted: Surgery within 36 hours increased from 54% to 87.5% of patients. Mean time to surgery fell from 43.68 hours to 25.11 hours. Attainment of BPT targets increased from 45.7% to 84%. Trust ranking went from 152nd to 20th for time to surgery and from 131st to 18th for meeting BPT. Rescheduled operations went from 126 to 31. As a result, mean length of stay reduced by 5.1 days. Mortality remained unchanged. ConclusionImplementation of an anaesthetic ‘hot week’ may help trusts improve times to theatre where sufficient theatre capacity is already in place.

Improvement of the management of anticoagulation in Atrial Fibrillation patients in the emergency and acute medical departments; a service quality improvement report

Atrial fibrillation (AF) is considered one of the main causes of ischemic stroke. The CHA2DS2VASC score can predict the stroke risk. Proper anticoagulation can significantly reduce such risk. Anticoagulation involves a risk of bleeding, which can be predicted by the HAS-BLED score. The non-documentation of both AF risk scores in the medical notes of patients presenting with acute or paroxysmal AF has alerted our team, for fear of missing administering the proper anticoagulation. A baseline audit showed that the CHA2DS2VASC score was documented in 27% of such patients, while the HAS-BLED score was documented in 5% of them. A quality improvement project was planned and included two PDSA cycles over a period of five months. The first cycle was based on raising the awareness of the junior doctors on risk assessment of AF patients and the importance of anticoagulation prescription. This involved educational posters, emails, and presentations. On the second cycle, the baseline audit showed a 69% improvement (from 27% to 46%) in the rate of CHA2DS2VASC score assessment and a 140% improvement (from 5% to 12%) in the rate of HAS-BLED scoring. However, the rate of anticoagulation prescription remained almost the same in both cycles (55% and 52%). A doctors’ survey showed that they are not quite comfortable prescribing long-term anticoagulation on acute care units because of the inadequate assessment of the bleeding risk, and the associated comorbidities that can disturb the action of the oral anticoagulants. They preferred to refer the patient to a specialised AF clinic for further assessment and prescription. On auditing the patient referral on discharge, it was found that 91% of the patient were seen at the AF clinic in 2 weeks. The remainders were referred to their GP for further assessment and prescription. That seemed to be a safer way of anticoagulation prescription for such patients.

Implementing Evidence-Based Interventions to Improve Vocational Recovery in Early Psychosis: A Quality-Improvement Report.

After young adults experience a first episode of psychosis, many express a need for help with education and employment. A quality improvement collaborative (QIC) launched in the Netherlands aimed to reinforce vocational recovery by improving participation in education and employment and by enhancing cognitive skills and self-management. This study examined methods used to implement interventions, barriers and facilitators, and implementation outcomes (fidelity, uptake, and availability). The Breakthrough Series was the model for change. Three evidence-based interventions were implemented to achieve targeted goals: individual placement and support (IPS), cognitive remediation, and shared decision making. Fidelity scores were obtained with fidelity scales. Eighty-five professionals and 332 patients representing 14 teams treating patients with early psychosis were included in the 24-month QIC. Of this group, 252 patients participated in IPS, 52 in cognitive remediation, and 39 in shared decision making. By month 22, teams attained moderate-to-high mean fidelity scores, with an average of 3.2 on a 4-point scale for cognitive remediation, 3.7 on a 5-point scale for IPS, and 4.9 on a 6-point scale for shared decision making. Over 24 months, use of a Breakthrough QIC to implement three interventions aimed at improving vocational recovery in teams delivering services for early psychosis yielded mixed results in terms of uptake and availability and moderate-to-high results in terms of fidelity. When implementing these types of interventions in this population, a multifaceted implementation model and a focused testing phase for computerized interventions appear needed, preferably with a maximum of two interventions implemented simultaneously.

Systematic Screening for Perinatal Mood and Anxiety Disorders to Promote Onsite Mental Health Consultations: A Quality Improvement Report.

Perinatal mood and anxiety disorders are the most common complication during pregnancy and postpartum. Screening, diagnosis, and treatment for these disorders are inhibited by limited mental health resources for patients and health care providers, lack of provider training, and time constraints. Systematic screening combined with onsite mental health consultation is an evidence-based method to increase timely diagnosis and treatment. The purpose of this quality improvement project was to promote and improve onsite mental health consultations through the implementation of a systematic screening guideline. The systematic screening guidelines included administration of the Patient Health Questionnaire-9 at the perinatal intake visit, the Edinburgh Perinatal Depression Scale between 28 and 32 weeks' gestation and again between 2 and 8 weeks postpartum. The guidelines included onsite mental health consultations for eligible women. Screening rates, attended onsite mental health consultations, and health care provider satisfaction and feedback surveys were collected over a 3-month period, before and after guideline implementation. Perinatal mood and anxiety disorder screening rates were significantly increased from 24.9% to 64.2% (P < .001) at the perinatal intake visit and in the third trimester from 0.3% to 32.8% (P < .001) with the implementation of a systematic screening guideline. Onsite mental health consultations significantly increased from 7.2% to 15.2% (P < .001). Perinatal care providers (n = 9, 100%) were satisfied with the screening guideline and reported that it added 5 minutes or less to their office visits. The implementation of a systematic perinatal mood and anxiety disorder screening guideline increased completed screenings in the perinatal period and increased the number of attended onsite mental health consultations. Systematic screening combined with onsite mental health consultation is a successful way to identify at-risk women and offer critical and convenient maternal mental health care without increasing the burden on perinatal care providers.

Use of prescribing safety quality improvement reports in UK general practices: a qualitative assessment

BackgroundQuality improvement (QI) initiatives are increasingly used to improve the quality of care and reduce prescribing errors. The Royal College of General Practitioners (RCGP) and Clinical Practice Research Datalink (CPRD) QI initiative uses routinely collected electronic primary care data to provide bespoke practice-level reports on prescribing safety. The aim of this study was to explore how the QI reports were used, barriers and facilitators to use, long-term culture change and perceived impact on patient care and practices systems as a result of receiving the reports.MethodsA qualitative study using purposive sampling of practices contributing to the CPRD, semi-structured interviews and inductive thematic analysis. We interviewed general practitioners, pharmacists, practice managers and research nurses.ResultsWe conducted 18 interviews, and organised themes summarising the use of QI reports in practice: receiving the report, facilitators and barriers to acting upon the reports, acting upon the report, and how the reports contribute to a quality culture. Effective dissemination of reports, and a positive attitude to audit and the perceived relevance of the clinical topic facilitated use. Lack of time and failure to see or act upon the reports meant they were not used. Factors influencing use of the reports included the structure of the report, ease of identifying cases, and perceptions about coding accuracy. GPs and pharmacists used the reports to conduct case reviews and directly contact patients to discuss unsafe prescribing and patient medication preferences. Finally, the reports contributed to the development of a quality culture within practices through promoting audit activity and acting as a reminder of good prescribing behaviours, promoting future patient safety initiatives, contributing to continuing professional development and improving local networks.ConclusionsThis study found the reports facilitated individual case review leading to an enhanced sense of quality culture in practices where they were utilised. Our findings demonstrate that the reports were generally considered useful and have been used to support patient safety and clinical practice in specific cases.

The effects of trained observers (dofficers) and audits during a facility-wide COVID-19 outbreak: A mixed-methods quality improvement analysis

BackgroundIn response to a facility-wide COVID-19 outbreak, our tertiary acute care hospital implemented an evidence-based bundle of infection control practices including the use of audits and trained observers “dofficers” to provide real-time constructive feedback.MethodsWe trained furloughed staff to perform the role of dofficer. They offered support and corrective feedback on proper PPE use and completed 21-point audits during a 4-week intervention period. Audits tracked appropriate signage, placement and availability of supplies (equipment), correct PPE use, enhanced environmental cleaning, along with cohorting and social distancing rates. Audit data was used to provide weekly quality improvement reports to units.ResultsNine hundred and sixty two separate audits recorded 36,948 observations, over 7,696 observer-hours. The most common errors were with environmental cleaning and PPE use; the least common were with regards to equipment availability and cohorting and social distancing. Mean error rates decreased from 9.81% to 2.88% (P < .001). The largest reduction, 22.57%, occurred in the category of PPE doffing errors.ConclusionsDofficer led audits effectively identified areas for improvement. Feedback through weekly reports and real-time correction of PPE errors by dofficers led to statistically significant improvements; however, error rates remained high. Further research is needed establish if these relationships are causal.

Quality improvement report: setting up a hospital at night service, limitations of bleep filtering and using an electronic task management system

The ‘hospital at night’ concept was developed at a joint conference of the London Deanery and Clinical Staff in 2002, as an issue for education and service provision. At the...

Exception reporting: an effective way to increase compliance leading to improvements in working conditions for junior doctors

In 2016, the new junior doctors contract introduced exception reporting (ER) to monitor extra hours worked, report patient safety, rostering and training concerns. Unfortunately, from discussions with foundation doctors, there seems to be a reluctance to engage with ER. This quality improvement project aims to identify reasons for reluctance among foundation doctors to engage with ER and implement changes to address these barriers with a view to improve rates of ER. Questionnaires regarding ER were distributed to all foundation doctors at a district general hospital. Following this, a leaflet was created and disseminated to all doctors providing guidance on ER and addressing several issues highlighted by the questionnaire. Foundation doctors were re-surveyed to assess for improvement. We found a significant improvement (p<0.05) in proportion of overtime exception reports filled from 20.3% to 33.9%. The most common barriers identified were apprehension of meeting with the consultant to discuss reports, insufficient senior encouragement and fear of appearing inefficient. An increased awareness and understanding of ER through the leaflet achieved an improvement in rates of ER. The insight gained from this quality improvement report can be applied across other trusts to improve compliance with the ER system nationwide, in order to safeguard staff wellbeing and thereby improve patient safety.

Quality Assessment of the Literature on Quality Improvement in PICUs: A Systematic Review.

To synthesize the literature describing quality improvement in PICUs and to appraise the quality of extant research. We searched the PubMed, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials databases between May and June 2020. Peer-reviewed articles in English that report quality improvement interventions in PICUs were included. Titles and abstracts were screened, and articles were reviewed to determine whether they met quality improvement criteria. Data were abstracted using a structured template. The quality of the included articles was assessed using the Quality Improvement Minimum Quality Criteria Set and scored on a scale of 0-16. Of the 2,449 articles identified, 158 were included in the analysis. The most common targets of quality improvement interventions were healthcare-associated infections (n = 17, 10.8%), handoffs (n = 15, 9.5%), rounds (n = 13, 8.2%), sedation/pain/delirium (n = 13, 8.2%), medication safety (n = 11, 7.0%), and unplanned extubation (n = 9, 5.7%). Of the six domains of healthcare quality described by the Institute of Medicine, patient-centeredness and timeliness were infrequently addressed, and none of the studies addressed equity. The median quality score based on the Quality Improvement Minimum Quality Criteria Set was 11.0 (25-75th interquartile range, 9.0-13.0). Although the quantity and quality of articles have been increasing, only 17% of the studies were deemed "high quality," having a score between 14 and 16. Only eight articles (5%) cited Standards for QUality Improvement Reporting Excellence guidelines for reporting quality improvement works. The number of publications, including high-quality publications, on quality improvement interventions in PICUs has been increasing. However, low-quality articles continue to be published, even in recent years. Therefore, there is room for improvement in the quality of reporting.

Implementation of a Clinical Pharmacist in a Hemodialysis Facility: A Quality Improvement Report

Rationale & ObjectiveHemodialysis (HD) patients have complicated disease states, placing them at higher risk for medication-related problems, medication discrepancies, and nonadherence. The objective of this study is to evaluate the impact of a clinical pharmacist in a single HD facility by assessing the efficacy of medication reconciliation in HD patients and evaluating the potential impact on a single health care system.Study DesignRetrospective study.Setting & ParticipantsGreenfield Health Systems, a wholly owned subsidiary of Henry Ford Health System, operates 14 HD facilities throughout Southeast Michigan. The West Pavilion facility is located in Detroit, MI. Patients with end-stage kidney disease included in the study had a minimum of 4 encounters with the clinical pharmacist or pharmacy interns between August 2017 and October 2018.ExposureA clinical pharmacist performed medication reconciliation and medication reviews with HD patients to assess medication-related problems and identify gaps in care. Interventions made by the pharmacist were prespecified through a collaborative practice agreement.OutcomesTo evaluate the impact of a clinical pharmacist in an HD facility by assessing the efficacy of medication reconciliation in HD patients and evaluating the potential impact on this health system through an estimated cost avoidance.Analytical ApproachDescriptive statistics were used to collect medication-related problems and classified based on a modified Hepler-Strand approach.ResultsThere were 1,403 medication-related problems, with an average of 8.96 medication-related problems per patient. Adherence was the most common medication-related problem (31%). Antihypertensive medication was the most common drug class in which the pharmacist intervened (37%), followed by vitamin D analogues and calcimimetics (29%). A projected total of US $447,355 was saved.LimitationsRetrospective analysis of observational data and descriptive statistics with the potential for residual bias and confounding.ConclusionsPharmacists in HD facilities have a positive influence on HD patients through medication management that results in cost savings.

Structured Reporting Using CEUS LI-RADS for the Diagnosis of Hepatocellular Carcinoma (HCC)-Impact and Advantages on Report Integrity, Quality and Interdisciplinary Communication.

Simple SummaryContrast-enhanced ultrasound (CEUS) is an increasingly accepted imaging modality for visualizing hepatocellular carcinoma (HCC) and is recommended as a secondary imaging option by most leading hepatology societies. In recent years, the use of structured reporting (SR) has been recommended by several societies to standardize report content and improve report quality of various diagnostic modalities when compared to conventional free-text reports (FTR). Our single-center study aimed to evaluate the use of SR using a CEUS LI-RADS software template in CEUS examinations of 50 HCC patients. SR significantly increased report integrity, satisfaction of the referring physicians, linguistic quality and overall report quality compared to FTR. Therefore, the use of SR in CEUS examinations of HCC patients may represent a valuable tool to facilitate clinical decision-making and improve interdisciplinary communication in the future.Background: Our retrospective single-center study aims to evaluate the impact of structured reporting (SR) using a CEUS LI-RADS template on report quality compared to conventional free-text reporting (FTR) in contrast-enhanced ultrasound (CEUS) for the diagnosis of hepatocellular carcinoma (HCC). Methods: We included 50 patients who underwent CEUS for HCC staging. FTR created after these examinations were compared to SR retrospectively generated by using template-based online software with clickable decision trees. The reports were evaluated regarding report completeness, information extraction, linguistic quality and overall report quality by two readers specialized in internal medicine and visceral surgery. Results: SR significantly increased report completeness with at least one key feature missing in 31% of FTR vs. 2% of SR (p < 0.001). Information extraction was considered easy in 98% of SR vs. 86% of FTR (p = 0.004). The trust of referring physicians in the report was significantly increased by SR with a mean of 5.68 for SR vs. 4.96 for FTR (p < 0.001). SR received significantly higher ratings regarding linguistic quality (5.79 for SR vs. 4.83 for FTR (p < 0.001)) and overall report quality (5.75 for SR vs. 5.01 for FTR (p < 0.001)). Conclusions: Using SR instead of conventional FTR increases the overall quality of reports in CEUS examinations of HCC patients and may represent a valuable tool to facilitate clinical decision-making and improve interdisciplinary communication in the future.

The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly.

Background: Suboptimal care transitions increases the risk of adverse events resulting from poor care coordination among providers and healthcare facilities. The National Transition of Care Coalition recommends shifting the discharge paradigm from discharge from the hospital, to transfer with continuous management. The patient centered medical home is a promising model, which improves care coordination and may reduce hospital readmissions. Methods: This is a quality improvement report, the geriatric patient-aligned care team (GeriPACT) at Tennessee Valley Healthcare System (TVHS) participated in ongoing quality improvement (Plan, Do, Study, Act (PDSA)) cycles during teamlet meetings. Post home discharge follow-up for GeriPACT patients was provided by proactive telehealth communication by the Registered Nurse (RN) care manager and nurse practitioner. Periodic operations data obtained from the Data and Statistical Services (DSS) coordinator informed the PDSA cycles and teamlet meetings. Results: at baseline (July 2018–June 2019) the 30-day all-cause readmission for GeriPACT was 21%. From July to December 2019, 30-day all-cause readmissions were 13%. From January to June 2020, 30-day all-cause readmissions were 15%. Conclusion: PDSA cycles with sharing of operations data during GeriPACT teamlet meetings and fostering a shared responsibility for managing high-risk patients contributes to improved outcomes in 30-day all-cause readmissions.

Pancreatic Computed Tomography Standardised Reporting Templates: Can We Improve Report Quality in Pancreatic and Peri-ampullary Malignant Tumours?

Accurate pancreatic/periampullary cancer staging and resectability assessment is vital to optimise patient care and where appropriate, surgical management and outcomes. Our tertiary hepato-pancreatico-biliary surgical centre receives referrals from several local hospitals. Imaging is performed and reported locally prior to referral, with subsequent heterogeneity of practice in protocolling and reporting prior to specialist GI radiologist review for multi-disciplinary team meeting (MDTM). Use of reporting templates has the potential to reduce heterogeneity and improve report quality and, ultimately, patient outcomes.

Improving SCD compliance in trauma patients at Kings County Hospital Center: a quality improvement report

Venous thromboembolism (VTE) is the fourth most commonly reported complication in trauma patients. For these patients, thromboprophylaxis is a standard of care. Patient compliance with sequential compression devices (SCDs), a...

Overcoming challenges to removing inappropriate penicillin allergy labels: A quality improvement report.

Over 3 months, we provided monthly education to internal medicine residents and distributed resources regarding penicillin-allergy history taking. Allergy information in the electronic record was updated more often during the intervention compared to the period before the intervention (16.1% vs 10.9%; P = .02). Education and interdepartmental collaboration have the potential to affect provider behavior.

Care bundles for improving outcomes in patients with COVID-19or related conditions in intensive care - a rapid scoping review.

Care bundles for improving outcomes in patients with COVID-19or related conditions in intensive care - a rapid scoping review.

Sustaining compliance with hand hygiene when resources are low: A quality improvement report.

Sustainability of hand hygiene is challenging in low resource settings. Adding ownership and goal setting to the WHO-5 multimodal intervention may help sustain high compliance. To increase and sustain compliance of nursing and medical staff with hand hygiene in a tertiary referral center with limited resources. A quality improvement initiative was conducted over two years (2016-2018). After determining baseline compliance rates, the WHO-5 multimodal intervention was implemented with staff education and training, system change, hospital reminders, direct observation and feedback, and hospital safety climate. Additionally, the medical staff was responsible for continuous surveillance of compliance (ownership) until rates above 90% were achieved and sustained (goal setting). Of 2987 observations collected between August 2016 and April 2018, 1630 (54.5%) were before, and 1357 (45.5%) were after patient encounters. The average overall compliance with hand hygiene was sustained at 94% for nursing and medical staff. Two instances of drops below 90% were associated with incidence of nosocomial Rotavirus infections. There were no similar infections during intervention periods with compliance rates above the set goal. Analysis using p-charts revealed significant improvement in compliance rates from baseline (χ2 (1) = 7.94, p = 0.005). Adding ownership and goal setting to the WHO-5 multimodal intervention may help achieve, and sustain high rates of compliance with hand hygiene. Involving health care workers in quality improvement initiatives is feasible, durable, reliable, and cheap, especially in settings with limited financial resources.

Evaluating Environmental Impact Assessment report quality in South African national parks

This research evaluates Environmental Impact Assessment (EIA) report quality for a selected sample of development projects in South African national parks. It applies an adapted version of an international EIA report quality review package to 24 developments within 10 national parks, across three EIA regimes. The results suggest good EIA report quality across all four quality review areas, with improvement over time, but also highlight particular weaknesses in terms of dealing with waste and, to a lesser extent, with significance and mitigation. To build on this research, the development of a sector-specific EIA report quality review package is recommended, with more emphasis on the strategic context, waste and water-related aspects. The conclusion is that EIA is well positioned to remain an important decision support instrument for developments within national parks. Conservation implications: The results show that EIA reports for developments in South African national parks are generally of sufficient quality for decision-making that benefits conservation. However, weaker performance regarding waste, significance determination, water-related impacts and a lack of consideration of strategic context requires a conservation-specific EIA report quality review package to improve report quality in the areas of weakness and thereby increase the value of EIA as an instrument for environmental governance and sustainable development in conservation areas.