Quality Improvement Specialists Research Articles

Development and validity testing of a matrix to evaluate maturity of clinical pathways: a case study in Saskatchewan, Canada

BackgroundHealthcare systems are transforming into learning health systems that use data-driven and research-informed approaches to achieve continuous improvement. One of these approaches is the use of clinical pathways, which are tools to standardize care for a specific population and improve healthcare quality. Evaluating the maturity of clinical pathways is necessary to inform pathway development teams and health system decision makers about required pathway revisions or implementation supports. In an effort to improve the development, implementation, and sustainability of provincial clinical pathways, we developed a clinical pathways maturity evaluation matrix. To explore the initial content and face validity of the matrix, we used it to evaluate a case pathway within a provincial health authority in Saskatchewan, Canada.MethodsBy using iterative consensus-based processes, we gathered feedback from stakeholders including patient and family partners, policy makers, clinicians, and quality improvement specialists, to rank, retain, or remove enablers and sub-enablers of the draft matrix. We tested the matrix on the Chronic Pain Pathway (CPP) for primary care in a local pilot area and revised the matrix based on feedback from the CPP development team leader.ResultsThe final matrix contains five enablers (i.e., Design, Ownership and Performer, Infrastructure, Performance Management, and Culture), 20 sub-enablers, and three trajectory definitions for each sub-enabler. Supplemental documents were created for six sub-enablers. The CPP scored 15 out of 40 possible points of maturity. Although the pathway scored highest in the Design enabler (10/12), it requires more attention in several areas, specifically the Ownership and Performer and the Performance Management enablers, each of which scored zero. Additionally, the Infrastructure and Culture enablers scored 2/4 and 3/8 points, respectively. These areas of the CPP are in need of improvement in order to enhance the overall maturity of the CPP.ConclusionsWe developed a clinical pathways maturity matrix to evaluate the various dimensions of clinical pathways’ development and implementation. The goals of this initial work were to develop and validate a tool to assess the maturity and readiness of new or existing pathways and to track pathways' revisions and improvements.

Improving symptom screening rates for patients with head and neck cancer.

e23246 Background: Effective symptom management in cancer care relies on regular and accurate reporting using validated patient-reported outcome measures (PROMs), such as the Edmonton Symptom Assessment System (ESAS). The ESAS measures nine common cancer symptoms, rating them on a scale from 0 to 10 to improve monitoring and communication regarding patient symptoms and prevent adverse outcomes such as emergency department visits. There is a need to enhance completion rates to ensure that head and neck cancer (HNC) symptoms are effectively addressed. High completion rates provide valuable data for cancer centers and clinicians to intervene early and support patients through their cancer journey. This makes it an important target for quality improvement (QI) with wide-ranging implications for patient outcomes and care quality. Our objectives were to: Investigate underlying reasons for poor ESAS completion rates. Lay the groundwork for strategic interventions aimed at bolstering symptom screening among HNC patients. Methods: This was a QI project targeting the HNC patient population at a regional cancer centre (RCC). Our approach included stakeholder engagement meetings alongside the expertise of QI specialists. Comprehensive data collection was conducted to analyze symptom screening rates and identify potential barriers to ESAS completion. We tracked ESAS completion on weekly HNC clinic days from 2022-2023 via manual and automated chart abstraction. Patient, staff, and volunteer interviews, along with direct clinic observations, provided data for Ishikawa diagrams, facilitating a root cause analysis. Results: We identified a marked decline in ESAS completion rates, steadily decreasing from an average of 29.4% during the 2022-2023 fiscal year to an average of 7.6% between April-November 2023, with rates dropping as low as 3.3% in September 2023. Root cause analysis pinpointed several barriers to ESAS completion, including the transition from paper-based assessments used during the pandemic to electronic formats, low patient awareness of the purpose of symptom screening, perceived lack of value in screening by patients and staff, and the absence of direct guidance from staff in helping patients complete their ESAS. Variable communication practices and inconsistencies in registration staff directing patients to kiosks was also observed. Improving infrastructure and support for volunteer services was identified as a potential solution, which may optimize their effectiveness in symptom screening roles. Conclusions: The project has laid the foundation for targeted QI interventions aimed at improving ESAS screening adherence. By addressing the identified barriers, this work endeavors to re-engage patients in active symptom reporting and to integrate this critical aspect of care into the daily routine of the outpatient hospital setting, thereby enhancing the overall management of HNC symptoms.

Barriers and facilitators to health professionals' engagement in quality improvement initiatives: a mixed-methods systematic review.

Quality improvement (QI) initiatives in healthcare are crucial for enhancing service quality and healthcare outcomes. The success of these initiatives depends on the active engagement of healthcare professionals, which can be influenced by several factors within the healthcare system. This systematic review synthesized the factors influencing healthcare professionals' engagement in QI projects, focusing on identifying both barriers and facilitators. A mixed methods systematic review (MMSR) was conducted using the JBI methodology for MMSR. Databases such as MEDLINE, CINAHL, Scopus, and Embase were searched for studies that explored barriers and facilitators to QI engagement of health professionals in the clinical setting. Methodological quality was assessed using the Mixed-Methods Appraisal Tool (MMAT). The extracted data were synthesized using the JBI convergent integrated approach to MMSR. Eighteen studies (seven qualitative, nine quantitative, and two mixed-methods) published between 2007 and 2023 were included in the review. The analysis revealed barriers and facilitators to engagement in QI initiatives at different levels of the health system. At the QI program level, the engagement of health professionals to QI was influenced by the approach to QI, evidence underpinning the QI initiative, QI knowledge and training, and access to QI specialists. At the health professional level, barriers and facilitators were related to their organizational role, motivation, perceptions about QI, and collaborations with individuals and groups. At the organizational level, factors related to culture and climate, leadership, available resources (including human resource and workload, infrastructure, and incentives), and institutional priorities influenced health professionals' participation in QI. This review highlights the complex interplay of organizational, individual, and QI program level factors that influence the engagement of healthcare professionals in QI. Overcoming these complex barriers and leveraging facilitators is crucial for enhancing participation in QI efforts. The findings underscore the need for a multi-level strategy that focuses on creating a conducive organizational culture, providing robust leadership, and ensuring adequate resources and training for healthcare professionals. Such strategies hold the potential to enhance the effectiveness and sustainability of QI initiatives in healthcare settings.

A Practical Guide to Building, Evaluating and Refining a Multi-Sector Community-Based Integrated Care Model for Seniors

Background: Integrated care models that bring together health and social care services in the communities where people live are necessary to meet people’s needs in an effective, person-centred, and sustainable manner. However, designing, implementing, and evaluating these models remain challenging particularly given the complexity of need, services, and partnerships.
 Objectives: Over the last three years, we utilized a learning health system approach to design, implement, evaluate, and revisit our integrated care model that aims to integrate health and social care for seniors, with a focus on those facing socioeconomic or other challenges. The Community Wellness Hub is an alliance of health and social service providers that coordinate and deliver services to seniors. The Hub is located in affordable housing buildings and provides services to individuals who reside in the building and surrounding area. The aim is to enable members to lead healthy and fulfilling lives in the community by proactively addressing health and wellness needs and reducing health crises requiring acute care. Services provided are an intersection of three systems: health care, housing, and social care, spanning 15 organizations. 
 In this workshop, we share the journey of the Community Wellness Hub from inception to date. We will reflect on facilitators, challenges, and learnings in three main areas: building and implementing the hub, evaluating the implementation, and enacting the results of the evaluation.
 Proposed Audience: Proposed participants include policy makers, program designers, evaluators, quality improvement specialists, patients, and caregivers as well as researchers interested in designing and evaluating complex integrated care initiatives.
 Structure: 
 •The first 5-10 minutes of the workshop will be a round table introduction
 •Then 5 minutes for introducing the Community Wellness Hub and the agenda of the workshop to the participants 
 •The last 10 minutes will be for summarizing the lessons learned and take-home messages. Similarities and variations amongst jurisdictions will be reflected on based on the participants
 •Then the rest of the time will be divided into three equal parts. The first will cover the creation of the hub, then the evaluation and finally enacting of the evaluation results into actionable steps. Each of the three sections will start by an open question inviting the audience to work in small groups to answer this question. These questions are: what are the key elements when creating a hub model via a partnership that spans health, social and community care? How to evaluate the implementation of an integrated hub model? How to enact the evaluation results?
 •After each group discussion, we will connect to reflect on the various approaches. Following that the presenters will share the approach they used within the hub highlighting resources, methods, tools, and practical tips.
 Outcome: By the end of the workshop, participants are expected to have learned some practical tips around designing, implementing, evaluating and utilizing the evaluation results in the context of integrating health and social care that may be applied to their local programs or initiatives.

Pharmacy-driven performance improvement initiative to increase compliance with intravenous smart pump drug error reduction systems at a large urban academic medical center.

Smart pump dose error reduction systems (DERS) reduce errors for intravenous (IV) administration medications by warning users of order, calculation, and programming errors. The purpose of this performance improvement initiative was to increase IV smart pump DERS usage from 77% to 95% at a large, urban academic medical center. A pharmacy-led team with nurses, physicians, and quality improvement specialists executed interventions from July 2020 through April 2022 to increase DERS compliance. A discovery phase (phase I) was followed by 6 Plan-Do-Study-Act (PDSA) cycles created to address barriers to DERS utilization. Phase I revealed that problems involving the DERS library and bedside nurse training were the major drivers of noncompliance. Phase II consisted of 3 system-level PDSA cycles, and phase III included 3 focused group PDSA cycles. Data were collected monthly from the smart pump reporting software by the informatics pharmacist and analyzed by the team to assess compliance rates in response to the corresponding interventions. The median DERS compliance increased from 77% to 83% over the 2-year period, which correlates with approximately 109,000 additional infusions run on DERS each year within our institution. The implementation of a DERS problem reporting tool accessed through the medication administration record resulted in the most pronounced improvement. DERS compliance improved following system-level sustainable interventions, although further PDSA cycles are needed to meet the goal DERS utilization rate of 95%. The results of this study may help other institutions attempting to improve DERS utilization create targeted interventions.

CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity

IntroductionThe WHO Surgical Safety Checklist (SSC) is a communication tool that improves teamwork and patient outcomes. SSC effectiveness is dependent on implementation fidelity. Administrative audits fail to capture most aspects...

Lessons learned from a multiagency community mental health centre quality improvement learning collaborative in New Hampshire

Background/Aims Community mental health centres in the US often struggle to implement the evidenced-based metrics and measurement processes required for quality reporting initiatives. Through the co-design and facilitation of a learning collaborative, all 10 community mental health centres in New Hampshire agreed on the goal of demonstrating measurement alignment and improvement across three behavioural health metrics related to depression and suicide risk, aiming for a screening rate of at least 85% in a year. Methods The learning system framework and Lean Six Sigma define, measure, analyse, improve and control methodologies were used to increase participation and improve quality reporting. Teams were asked to participate in both a group learning collaborative and individual centre facilitation sessions, working with a quality improvement specialist. Reported measures were compared with subsets of the population data and between centres. Outliers were identified for potential reporting inaccuracies and opportunities for improvement. Results All 10 community mental health centres were able to accurately report screening results on all three measures. After 12 months, 70% of the teams were able to reach the group-determined goal of at least 85% of eligible patients being screened in one measure, 40% of the teams met the benchmark in two measures and 20% of the teams were able to meet the benchmark in all three measures. Conclusions Early investment by community mental health centre leadership through the development of a shared aim and project outcomes is essential to support learning and achieve positive outcomes. Quality improvement specialists are vital for facilitation of shared learning and practice across organisations.

Teacher Competencies and School Improvement Specialist Coaching (SISC+) Programme in Malaysia as a Model for Improvement of Quality Education in China

The focus for Chinese citizens to pursue study in Malaysia is based on quality improvement in the Malaysian education system, especially in the teacher quality and school improvement specialist coaching (SISC+) program implemented in the Malaysian school system. The role of teacher’s competencies, such as teacher enthusiasm, which involves the invoking of passion and excitement in students and the participation of teachers, are the most positive teaching activity associated with the gratification of specific lessons. As a model to attract foreign students, especially from China, it is important to review the Ministry’s SISC+ plan and determine if teaching competencies among teachers can positively impact the system. The purpose of this study is to examine how teacher competencies influence the SISC+ Coaching program (Guidance) in rural high schools in Malaysia. The novelty of this research lies in measuring teachers’ competencies in three dimensions: communication skills, skills in teaching strategies, and methods and teaching-involvements skills within a framework. This study employed a quantitative method consisting of a questionnaire with a five-point Likert scale. The instruments were taken from a questionnaire developed by the Malaysia Ministry of Education (MOE) for the coaching of SISC+ (16 questions), while the measurement of teachers’ competencies (22 questions) was performed using a questionnaire from past literature. A total of 186 teachers from six Malaysia secondary schools were involved in the study and the data were analyzed using SEM PLS. The findings revealed that out of all the three competency dimensions (communication, policy, process, and methodology, and student involvement), only teacher communication skills with learners had a major effect on the SISC+ coaching program. The findings also showed that the contact capabilities with students appeared to favor the SISC+ method. Thus, the study contributes to the creation of new knowledge with empirical tests, along with several practical implications for research on teaching competency development.

Quality Improvement Specialists' Experiences of Implementing an Assessment of Patients' Experiences in South Korea

Quality Improvement Specialists' Experiences of Implementing an Assessment of Patients' Experiences in South Korea

Practice Facilitation Improves Adolescent Reproductive Health Preventive Services in Primary Care.

Provision of reproductive health preventive services to adolescents is critical given their high rates of sexually transmitted infections and unintended pregnancies. Pediatricians are well positioned to provide these services but often face barriers. With this project, we aimed to build quality improvement (QI) capacity within pediatric practices to improve adherence to national guidelines for adolescent reproductive health preventive services. In 2016, an accountable care organization overseeing health care delivery for low-income children in the Midwestern United States used practice facilitation, a proven approach to improve health care quality, to support pediatric practices in implementing reproductive health QI projects. Interested practices pursued projects aimed at providing (1) sexual risk reduction and contraceptive counseling (reproductive health assessments [RHAs]) or (2) etonogestrel implants. QI specialists helped practices build key driver diagrams and implement interventions. Outcome measures included the proportion of well-care visits with RHAs completed and number of etonogestrel insertions performed monthly. Between November 1, 2016, and December 31, 2019, 6 practices serving >7000 adolescents pursued QI projects. Among practices focused on RHAs, the proportion of well-care visits with completed RHAs per month increased from 0% to 65.8% (P < .001) within 18 months. Among practices focused on etonogestrel implant insertions, overall insertions per month increased from 0 to 8.5 (P < .001). Practice facilitation is an effective way to increase adherence to national guidelines for adolescent reproductive health preventive services within primary care practices. Success was driven by practice-specific customization of interventions and ongoing, hands-on support.

Mobilizing Elders: An Interprofessional Effort

Older adults often experience functional decline during hospitalization as a result of immobility. Such decline has associated adverse outcomes, including gait instability, falls, pressure injuries, delirium, and new nursing home admissions. Our objective was to create an effective and sustainable in-hospital mobility program through enhanced interdisciplinary cooperation in an Acute Care of the Elderly (ACE) unit. An interdisciplinary team at UNC’s 25-bed ACE unit planned and delivered enhanced patient mobility beginning in July 2020. We used an input-process-output model to design and analyze an intervention based on enhanced collaboration. Inputs included a mobility taskforce which was comprised of physicians, nurses, physical and occupational therapists, and quality improvement specialists. Through regular meetings, each taskforce member contributed to the study design and were empowered to identify barriers to implementation. Outputs included stakeholder engagement and mobility rates. Early results show a doubling in mobility rates over a 6-month period with consistent and enthusiastic stakeholder engagement. Observations of such benefits include: a) stakeholder inclusion from each discipline ensured implementation that was pragmatic and easily incorporated into the daily workflow; b) mobility champions regularly disseminated information to their respective disciplines, leading to changes using a quality improvement process; and c) barriers to implementation were rapidly identified, and mobility champions were motivated to find solutions, allowing cohesive incorporation of a broad spectrum of priorities. An interprofessional team model is effective to mobilize hospitalized older adults, potentially reducing adverse hospital outcomes. Successful implementation of such programs is dependent on interprofessional collaboration.

Development and Evaluation of Best Practice Alerts: Methods to Optimize Care Quality and Clinician Communication.

Development and Evaluation of Best Practice Alerts: Methods to Optimize Care Quality and Clinician Communication.

Systems engineering analysis of diagnostic referral closed-loop processes

BackgroundClosing loops to complete diagnostic referrals remains a significant patient safety problem in most health systems, with 65%–73% failure rates and significant delays common despite years of improvement efforts, suggesting...

Quality Improvement Education in the Era of COVID-19: A Pivot Toward Virtual Education.

Quality Improvement Education in the Era of COVID-19: A Pivot Toward Virtual Education.

A Practical Guide to Creating a Pareto Chart as a Quality Improvement Tool.

Quality is always a hot topic in healthcare, and the ultimate goals are to maintain a high level of patient satisfaction and improve the financial aspects.[1] These two goals are rapidly changing, and they could be affected by many of the surrounding factors. When a healthcare organization faces a problem in achieving these two goals, it is important to understand the causes and immediately start the appropriate interventions. One principle of quality improvement in healthcare is to do it right the first time,[2,3] so it is important to do the right intervention promptly by targeting the most vital contributing factors that led to the problem at hand. By nature, healthcare organizations are complicated, also have been described as a complex adaptive system,[4] which is one of the most difficult systems to understand and manage because one problem could be linked to many contributing factors at the same time.The concept of the Pareto principle was developed in the 19th century by the economist Vilfredo Pareto,[5] who noticed that 80% of the land in Italy was owned by just 20% of the population.[6] Moreover, he found that 80% of production usually came from only 20% of the companies. This led him to a general hypothesis that 80% of the results are originated from 20% of the factors or causes that influence the results.[7] The Pareto principle, which is also known as the rule of 20/80, has become an important quality tool, recognized by the American Society for Quality (ASQ) as one of seven basic quality tools for process improvement.[8]A Pareto chart enables a quality improvement specialist to make informed decisions and prioritize the appropriate interventions to achieve the desired goal.[5] The main concept behind the Pareto chart is that the weights or effects of the contributing factors that lead to specific outcomes are not equal, so identifying the highly weighted factors and working on them first will shorten the time needed to reach the desired outcome, thus saving effort and unnecessary costs. In 1937, the 80/20 concept was crystallized by Joseph M. Juran, a pioneer in the field of quality improvement, who added the cumulative line at the top of the chart to make it easier to judge the impact that each factor has on the desired outcome. He also came up with the terms “vital few” and “trivial many,” which are used to categorize the factors based on their weight.[9]Figure 1 shows an example of a Pareto chart that was used to identify causes of medication errors.When planning a quality improvement project, the Pareto chart is mainly used in the phase of problem identification, but a Pareto chart is also helpful in the data analysis and outcome evaluation phase, after conducting a specific intervention. Pareto chart presents the data in a visual manner, which may be suitable for communicating information about the problem to upper management when seeking their support or action.[5,10,11] Vice versa, if there is a desirable outcome that needs to be maintained, a Pareto chart could be used to identify the so-called vital few contributing factors that must be maintained to sustain the desired outcome.A Pareto chart is a bar graph with frequency on the left side (y-axis), percentage on the right side (z axis), and contributing factors are arranged in descending order by frequency on the x-axis. The line that reflects the cumulative percentage of the factors is a key component of the Pareto chart; when the line reaches ≥ 80%, this means that all of the previously added up factors represent 20% of the causes (i.e., the vital few). If you focus on these causes, then you will be able to reach the desired outcome most efficiently. After that, you can direct your effort toward the remaining factors (i.e., the trivial many). Keep in mind that the 80/20 rule is a rough guide about typical distributions based on the Pareto principle, so the numbers are not exact and the total may not add up to 100%. The Pareto chart effectively highlights that the weights or effects of the contributing factors that lead to specific outcome are not equal.A great way to understand the Pareto principle is by making your Pareto chart. Start by identifying the problem or situation that needs to be improved. Then, identify the factors that contribute to the problem and their respective frequency. Enter the data in a spreadsheet (e.g., Microsoft Excel) and create your own Pareto chart as follows.Now you have Pareto chart ready, and it should be similar to Figure 1.In conclusion, a Pareto chart is a useful tool that could be used in many phases of quality improvement projects, serving many functions. Applying the Pareto concept to quality improvement projects in a healthcare setting will reduce time, costs, and efforts.

Dissemination of Evidence-Based Recommendations for Sickle Cell Disease to Primary Care and Emergency Department Providers in North Carolina: A Cost Benefit Analysis.

Background: Sickle cell disease (SCD) is a genetic condition affecting primarily individuals of African descent, who happen to be disproportionately impacted by poverty and who lack access to health care. Individuals with SCD are at high likelihood of high acute care utilization and chronic pain episodes. The multiple complications seen in SCD contribute to significant morbidity and premature mortality, as well as substantial costs to the healthcare system.Objectives: SCD is a complex chronic disease resulting in the need for primary, specialty and emergency care. Many providers do not feel prepared to care for individuals with SCD, despite the existence of evidence-based guidelines. We report the development of a SCD toolbox and the dissemination process to primary care and emergency department (ED) providers in North Carolina (NC). We report the effect of this dissemination on health-care utilization, cost of care, and overall cost-benefit.Methods: The SCD toolbox was adapted from the National Heart, Lung, and Blood Institute recommendations. Toolbox training was provided to quality improvement specialists who then disseminated the toolbox to primary care providers (PCPs) affiliated with the only NC managed care coordination system and ED providers. Tools were made available in paper, online, and in app formats to participating managed care network practices (n=1 800). Medicaid claims data were analyzed for total costs and benefits of the toolbox dissemination for a 24-month pre- and 18-month post-intervention period.Results: There was no statistically significant shift in the number of outpatient specialty visits, ED visits or hospitalizations. There was a small decrease in the number of PCP visits in the post-implementation period. The dissemination resulted in a net cost-savings of $361 414 ($14.03 per-enrollee per-month on average). However, the estimated financial benefit associated with the dissemination of the SCD toolbox was not statistically significant.Conclusions: Although we did not find the expected shift to increased PCP visits and decreased ED visits and hospitalizations, there were many lessons learned.

Building Successful Models in Primary Care to Improve the Management of Adult Patients with Obesity.

Although several obesity clinical practice guidelines are available and relevant for primary care, a practical and effective medical model for treating obesity is necessary. The aim of this study was to develop and implement a holistic population health-based framework with components to support primary care-based obesity management in US health care organizations. The Obesity Care Model Collaborative (OCMC) was conducted with guidance and expertise of an advisory committee, which selected participating health care organizations based on prespecified criteria. A committee comprising obesity and quality improvement specialists and representatives from each organization developed and refined the obesity care framework for testing and implementing guideline-based practical interventions targeting obesity. These interventions were tracked over time, from an established baseline to 18 months post implementation. Ten geographically diverse organizations, treating patients with diverse demographics, insurance coverage, and health status, participated in the collaborative. The key interventions identified for managing obesity in primary care were applicable across the 4 OCMC framework domains: community, health care organization, care team, and patient/family. Care model components were developed within each domain to guide the primary care of obesity based on each organization's structure, resources, and culture. Key interventions included development of quality monitoring systems, training of leadership and staff, identifying clinical champions, patient education, electronic health record best practice alerts, and establishment of community partnerships, including the identification of external resources. This article describes the interventions developed based on the framework, with a focus on implementation of the model and lessons learned.

A generative co-design framework for healthcare innovation: development and application of an end-user engagement framework

Plain English summaryBackgroundContinual improvements to health systems, products, and services are necessary for improvements in health. However, many of these improvements are not incorporated into everyday practice. When designing new health systems, products, and services, involving members of the healthcare community and the public with personal healthcare experience can help to make sure that improvements will be useful and relevant to others like them.MethodsTogether with healthcare workers and family members with healthcare experience, we developed and applied a step-by-step guide to involving those with personal experience in the design of health system improvements.ResultsOur guide has three phases— ‘Pre-Design’, ‘Co-Design’, and ‘Post-Design’. This paper describes each of these phases and illustrates how we applied them to our own project, which is to use virtual healthcare methods to improve care for children with chronic healthcare conditions and their families. In our own work, we found that healthcare workers and family members with personal healthcare experiences were able to use their knowledge and creativity to help us imagine how to improve care for children with chronic healthcare conditions and their families. We have created action items from these family member- and healthcare worker-identified needs, which we will use to shape our virtual healthcare system.ConclusionsThis paper may be useful for those seeking to involve members of the healthcare community and the public in the creation of better healthcare systems, products, and services.BackgroundChallenges with the adoption, scale, and spread of health innovations represent significant gaps in the evidence-to-practice cycle. In the health innovation design process, a lack of attention paid to the needs of end-users, and subsequent tailoring of innovations to meet these needs, is a possible reason for this deficit. In the creative field of health innovation, which includes the design of healthcare products, systems (governance and organization mechanisms), and services (delivery mechanisms), a framework for both soliciting the needs of end-users and translating these needs into the design of health innovations is needed.MethodsTo address this gap, our team developed and applied a seven-step methodological framework, called A Generative Co-Design Framework for Healthcare Innovation. This framework was developed by an interdisciplinary team that included patient partners.ResultsThis manuscript contributes a framework and applied exemplar for those seeking to engage end-users in the creative process of healthcare innovation. Through the stages of ‘Pre-Design’, ‘Co-Design’, and ‘Post-Design’, we were able to harness the creative insights of end-users, drawing on their experiences to shape a future state of care. Using an expository example of our own work, the DigiComp Kids project, we illustrate the application of each stage of the Framework.ConclusionsA Generative Co-Design Framework for Healthcare Innovation provides healthcare innovators, applied health science researchers, clinicians, and quality improvement specialists with a guide to eliciting and incorporating the viewpoints of end-users while distilling practical considerations for healthcare innovation and design.

Improving eye screening practice among pediatric rheumatology patients receiving hydroxychloroquine.

Hydroxychloroquine (HCQ) is commonly used in the treatment of various autoimmune diseases related to its many benefits and favorable safety profile. Although HCQ retinopathy was considered to be uncommon, a prevalence of 7.5% was described in a recent study making early detection critical. The most updated screening guidelines by the American Academy of Ophthalmology were published in 2016; however, it lacked pediatric-specific recommendations and the overall compliance with screening guidelines was poor in previous studies. We developed a quality improvement (QI) initiative aiming to create institutional screening recommendations. Additionally, to increase eye screening in pediatric rheumatology clinic for patients receiving HCQ from 65% to 85% in 12 months and to sustain that rate for at least 6 months. We formed a multidisciplinary team of pediatric rheumatologists and ophthalmologists, clinical pharmacist, clinic nurses, QI specialist, quality data technician and administrative staff. We included patients receiving HCQ and who were evaluated at Nationwide Children's Hospital rheumatology clinic. A key driver diagram was formulated to identify barriers to compliance and determine possible interventions. Main interventions included summarizing screening guidelines in a step by step algorithm, increasing awareness of these guidelines among patients and providers, improving collaboration and communication with ophthalmologists, and initiating pre-visit planning. Baseline performance data included 164 patients. Fifty-four (33%) of those patients were at high risk for HCQ retinopathy. Of them, 50% were on HCQ dose of >5 mg/kg/day and 31.5% had been taking HCQ for ≥5 years. Two center line shifts were noticed over the course of the project. The target of 85% compliance was reached in February 2019 and was sustained until December 2019. Our study highlights the importance of interdisciplinary communication to increase awareness of screening guidelines among medical providers and patients. Pre-visit planning played a major role in identifying patients and opportunities for optimizing eye screening in patients at risk for HCQ retinopathy. Collaboration between rheumatologists and ophthalmologists is crucial in managing patients on HCQ. The implementation of same-day eye screening allowed this collaboration to be more efficient. Future efforts are being directed at monitoring and improving utilization of the effective interventions.

Promoting Pediatric Preventive Visits Through Quality Improvement Initiatives in the Primary Care Setting

To evaluate whether quality improvement (QI) capacity-building in affiliated primary care practices could increase well care visit uptake. Partners For Kids (PFK) is an accountable care organization caring for pediatric Medicaid beneficiaries in Ohio. PFK QI specialists recruited practices to develop QI projects around increasing well care visit rates (proportion of eligible children with well care visits during calendar year) for children aged 3-6years and adolescents. The QI specialists supported practice teams in implementing interventions and collecting data through monthly or bimonthly practice visits. Ten practices, serving more than 26 000 children, participated in QI projects for a median of 8.5months (IQR 5.3-17.6). Well care visit rates in the QI-engaged practices significantly improved from 2016 to 2018 (P<.001 for both age groups). Over time, well care visit rates for 3- to 6-year-old children increased by 11.8% (95% CI 5.4%-18.2%) in QI-engaged practices, compared with 4.1% (95% CI 0.1%-7.4%) in non-engaged practices (P=.233). For adolescents, well care visit rates increased 14.3% (95% CI -2.6% to 31.2%) compared with 5.4% (95% CI 1.8%-9.0%) in QI-engaged vs non-engaged practices over the same period (P=.215). Although not statistically significant, QI-engaged practices had greater magnitudes of rate increases for both age groups. Through practice facilitation, PFK helped a diverse group of community practices substantially improve preventive visit uptake over time. QI programs in primary care can reach patients early to promote preventive services that potentially avoid costly downstream care.