Quality Improvement Staff Research Articles

Reducing Dependence on General Anesthesia for Pediatric Oncology Outpatients Undergoing Repeated Lumbar Punctures

Introduction: A growing body of data has shown that higher cumulative anesthesia exposure is associated with neurocognitive impairment in children with chronic disease, including those with hematologic malignancies [Banerjee JAMA Oncology 2019]. To limit general anesthesia (GA) exposure alternative means of sedation and acceptance of alternatives by patients, families and providers need to be explored for children with acute lymphoblastic leukemia or lymphoma (ALL/LL) undergoing repeated lumbar punctures (LP) to deliver intrathecal (IT) chemotherapy. Methods: Patients age 1 to 25 years with ALL/LL treated at the Children's Hospital of Philadelphia main outpatient clinic (CHOP Main) and two CHOP satellite oncology offices (KOP, VOR) were analyzed for baseline rates of sedation for lumbar punctures. GA was defined as the use of intravenous (IV) propofol or an inhalational flurane. Moderate sedation was defined as IV fentanyl (maximum 2 mcg/kg dosing) for analgesia and midazolam (maximum 0.1 mg/kg) for anxiolysis. IV or oral midazolam only was considered mild sedation. We created a comprehensive quality improvement (QI) pathway to implement the use of mild/moderate sedation as a new Division of Oncology standard for LP-only procedures. Our QI goal was a 10% reduction in use of GA with concomitant measurement of outpatient clinic length of stay (LOS) as an additional metric. LOS was measured as time from triage to port de-access. Results: Our interdisciplinary QI team leveraged the CHOP QI framework utilizing tools that included a driver diagram (Figure 1) and impact/effort matrix to develop and prioritize interventions associated with achieving the QI goal. The Plan-Do-Study Act methodology was used to optimize the intervention. This required extensive collaboration with pediatric oncologists, nurse practitioners, nursing, child life, pharmacy, and QI staff to encourage methodology adoption and to optimize clinic workflow for maximal provider/patient participation and procedural efficiency. In the immediate period preceding the QI intervention (October 2019 to February 2020), baseline rates of GA use for across all 3 clinic sites were 73.1%, 15% (plus 34.6% deep sedation), and 24.7% at CHOP Main, KOP, and VNJ, respectively in 310 LP only procedures for patients with ALL/LL. After a delay in implementation due to COVID, the rate of GA usage at CHOP Main from May to July 2020 was reduced to 55.6% for 81 LPs (p=0.001) (Figure 2), while GA rates at the satellite clinics were unchanged. Decreased GA use at CHOP main was replaced by a significant increase in mild/moderate sedation (26.9% to 44.5%; p=0.001). Of the 18 newly diagnosed patients participating in the intervention to date, 16 receive their LPs with no or mild/moderate sedation. The median age of this cohort is 7 years of age with 6 patients ≤ 5 and 12 patients ≤ 10 years. The other two patients have medical syndromes deemed not conducive to replacing GA with moderate sedation. No child has experienced complications from moderate sedation or returned to GA due to sedation intolerance. Overall clinic LOS decreased significantly for all patients getting LPs (GA and sedation) (mean 4.88 hours vs 4.08 hours; p=0.033). An unintended benefit of the QI initiative is that the average LOS for patients receiving moderate sedation decreased from 6.67 hours to 4.15 hours (p=0.017) with the new streamlined clinic workflow. Conclusion: Baseline rates of sedation varied by oncology clinic site and appeared to align with ease of access to GA. GA is available in the oncology main clinic 3 days/week, and 73% of ALL/LL patients were using GA for LPs prior to the intervention. Since March 2020, nearly all patients with newly diagnosed ALL/LL are now undergoing LPs with no or mild/moderate sedation. Our data show that with appropriate education and preparation, LP with mild/moderate sedation is a feasible alternative to GA even for very young patients and reduces clinic LOS. We have expanded this QI intervention to include children with other newly-diagnosed cancers who require LPs and/or IT chemotherapy. Future directions include converting patients in ALL/LL maintenance and those undergoing other minimally invasive procedures from GA to moderate sedation. Disclosures Tasian: Incyte Corporation: Research Funding; Gilead Sciences: Research Funding; Aleta Biotherapeutics: Membership on an entity's Board of Directors or advisory committees. Rheingold:Pfizer: Research Funding.

106. UTILITY OF A QUALITY DASHBOARD ESTABLISHED BY A RESIDENT QUALITY COUNCIL

Quality Improvement (QI) science focuses on how healthcare is delivered (process measures) and the results (outcome measures). Although instruction in QI methodology is recognized as an important part of a resident's education, maintaining resident engagement is a challenge. A Resident Quality Council (RQC) was established to (1) create and maintain a resident-generated and relevant quality dashboard, (2) enhance resident awareness of in-hospital QI initiatives, and (3) increase QI scholarly activity among residents. A RQC was established in 2017 consisting of five resident champions and three chief residents, mentored by program leadership, a Chief Quality Officer, and QI staff. To increase resident engagement a continuously updated resident-inspired dashboard, which highlighted both quality and operational standards, was created. Metrics were chosen based on resident feedback. Over 18 months, a lecture series was introduced into the residency curriculum which highlighted various QI initiatives with a special focus on process and outcome measures related to the dashboard. At the start of the 2019-2020 academic year, the RQC surveyed residents in regards to their level of QI engagement and the utility of the dashboard as part of the residency curriculum. The most relevant metrics, as reported, included asthma guidelines, length of stay, and number of safety events. There was a reported increase in understanding of a dashboard's utility from 15.8% to 78.3% (N = 23). 78% reported continued interest in the maintenance of a dashboard with resident-pertinent metrics and acknowledged that the dashboard contributed to their understanding of the significance of QI science. Lastly, 87% felt the knowledge presented to them through the dashboard directly resulted in their increased interest in in-hospital QI initiatives and their desire to partake in QI scholarly work. Establishment of an RQC has proven beneficial in promoting QI interest amongst residents. Resident-pertinent dashboard metrics have kept housestaff engaged and interested in expanding their QI fund of knowledge through QI-driven scholarly projects.

Ultrasound guidance for pediatric vein cannulation: an emergency nurse quality improvement initiative and registry

Background
 Between 10 and 25 percent of pediatric patients present to the emergency department (ED) with difficult to cannulate veins. Recent RCT evidence suggests that in pediatric patients assessed at being a predicted difficult IV start (by DIVA score of 3 or more), ultrasound guided catheter placement decreased the number of IV attempts, decreased time to successful IV placement, and improved first pass success, patient satisfaction, and catheter dwell time. Our QI project examines the specific learnings around ultrasound guided peripheral IV in pediatric patients and suggests opportunity for non-pediatric specialist hospitals to consider with the overall aim of minimizing IV attempts on all pediatric patients within our EDs.
 Building on a RCT led by Dr Curtis in pediatrics patients conducted at the Stollery from 2012-2014, a standardized ultrasound guided nurse performed procedure was implemented in 2016 at the University of Alberta and Stollery EDs, and expanded to the Royal Alexandra ED in 2017 and the Misericordia ED in 2019. Using the same education package and QI study methodology as previously reported in adult patients this study focused specifically on pediatric patients.
 Methods 
 A quality improvement (QI) registry was utilized to track complications and success of pediatric patients at all sites. The aim was to assess for program success, and improve education, training, and procedural success as required. Staff who had achieved independent practice voluntarily completed a tracking form whenever an ultrasound procedure occurred. Completed forms were assessed on a continual basis for any opportunities for improvement. Qualitative feedback was also obtained from informal interviews, a focus group, and a survey of the trained nurses. Feedback was thematically analyzed and grouped into themes for reporting.
 Results 
 There were no reported pediatric UGIV placed at the MCH and RAH during the study period. At the Stollery 126 cases were reported. Immediate insertion complications were noted in three cases as ‘pain or swelling at site’, and ‘unable to advance catheter’. In the first and second years of data collection the average number of traditional IV attempts prior to UGIV attempt decreased from 3.9 to 2.8; first ultrasound pass success increased from 65% to 86%; overall ultrasound success improved from 85% to 97.6% respectively. Increasing nurse skill was significant with a linear increase of first pass and overall success seen with increasing number of ultrasound starts: From 6-20 starts (54% first pass 64% overall success) through to >150 starts (97% first pass and 100% overall). QI staff feedback included ensure adequate pediatric specific supplies such as longer length small gauge catheters, and a procedural focus of patient, provider, and assistant set up. Location of IV placement was noted to change in a number of cases from hand and A/C to forearm.
 Advice and Lessons Learned 
 
 The key for staff to transition to procedural competance was to ensure initial and ongoing oportunities to place many ultrasound guided IVs (i.e. when time allows in all patients with non-optimal IV placement locations or with non-easy predicted tradititional IV starts)
 Further work is required at non specilaist hospitals with trained staff to increase ultrasound guided use in pedatric patients
 At all particapting sites work continues on unit level QI to minimize the number of IV attempts on all pedatric patients as well as work towards a cohort of available staff that are comforable and competent with ultrasound that can provide 24/7 unit coverage. (with limited numbers of trained staff there is increase burden on these staff to assist others while also completing their own nursing assignment.

Optimizing delivery to meet demand for integrative medicine services in an academic hospital setting: A pilot study

ContextA rapidly growing body of evidence shows the positive benefits of integrative medicine (IM) services for patients in hospital-based settings. IM therapies, such as acupuncture, massage, meditation and relaxation, and animal-assisted therapy, reduce symptom burden of pain, anxiety, and stress and increase sense of well-being and satisfaction in hospitalized patients. Current challenges facing hospitals are to move beyond proof-of-concept studies and to provide hospital-based IM therapies. ObjectiveThe aim of our quality improvement project was to develop, implement, and evaluate a feasible, scalable, hospital-based “best practice” model for increasing demand for IM services and optimizing their delivery. DesignA multidisciplinary team convened to use quality improvement tools to outline a process for providing IM services. SettingA large academic medical center in the Midwestern United States. ParticipantsIM leadership staff, IM providers, nurses, hospital team members, support staff, and quality improvement staff. InterventionsAfter determining baseline levels of demand and service delivery, we sought to (1) increase nursing staff awareness of available IM services; (2) improve communication between IM providers and nurses; and (3) reinforce communication at the level of nurse supervisors, patients, and family members. Main Outcome MeasuresWe recorded the numbers and types of IM services ordered at baseline and postimplementation and determined the new delivery rate of requested services. ResultsWe noted an increase in the number of IM orders, percentage of delivered IM services, and percentage of patients who reported that IM services improved their hospital stay.

Hypertension and Diabetes Quality Improvement in a Practice Transformation Network.

The Garden Practice Transformation Network in Maryland brought together primary and specialty practices working toward value-based models and efficient care delivery. Practices were provided with coaching and live and multimedia education regarding practice transformation and quality improvement. Coaches supported practices in multipronged approaches to quality improvement. Practice champions and clinical staff were trained on appropriate documentation of blood pressure (BP) and diabetes measures, and new workflows to optimize care delivery. Quality improvement staff were trained in extracting data from electronic health records, providing feedback to practice clinicians, and reporting to Practice Transformation Network staff. Final measurement of BP control was 66%, and final measurement of blood glucose control was 28%. Quality improvement activities in a practice transformation network led to the delivery of high-quality care and quality improvement.

Initiating and Implementing Social Determinants of Health Data Collection in Community Health Centers

Successfully incorporating social determinants of health (SDH) screening into clinic workflows can help care teams provide targeted care, appropriate referrals, and other interventions to address patients' social risk factors. However, integrating SDH screening into clinical routines is known to be challenging. To achieve widespread adoption of SDH screening, we need to better understand the factors that can facilitate or hinder implementation of effective, sustainable SDH processes. The authors interviewed 43 health care staff and professionals at 8 safety net community health center (CHC) organizations in 5 states across the United States; these CHCs had adopted electronic health record (EHR)-based SDH screening without any external implementation support. Interviewees included staff in administrative, quality improvement, informatics, front desk, and clinical roles (providers, nurses, behavioral health staff), and community health workers. Interviews focused on how each organization integrated EHR-based SDH screening into clinic workflows, and factors that affected adoption of this practice change. Factors that facilitated effective integration of EHR-based SDH screening were: (1) external incentives and motivators that prompted introduction of this screening (eg, grant requirements, encouragement from professional associations); (2) presence of an SDH screening advocate; and (3) maintaining flexibility with regard to workflow approaches to optimally align them with clinic needs, interests, and resources. Results suggest that it is possible to purposefully create an environment conducive to successfully implementing EHR-based SDH screening. Approaching the task of implementing SDH screening into clinic workflows as understanding the interplay of context-dependent factors, rather than following a step-by-step process, may be critical to success in primary care settings.

First-year implementation of mailed FIT colorectal cancer screening programs in two Medicaid/Medicare health insurance plans: qualitative learnings from health plan quality improvement staff and leaders

BackgroundColorectal cancer screening rates remain low, especially among certain racial and ethnic groups and the uninsured and Medicaid insured. Clinics and health care systems have adopted population-based mailed fecal immunochemical testing (FIT) programs to increase screening, and now health insurance plans are beginning to implement mailed FIT programs. We report on challenges to and successes of mailed FIT programs during their first year of implementation in two health plans serving Medicaid and dual eligible Medicaid/Medicare enrollees.MethodsThis qualitative descriptive study gathered data through in-depth interviews with staff and leaders at each health plan (n = 10). The Consolidated Framework for Implementation Research, field notes from program planning meetings between the research team and the health plans, and internal research team debriefs informed interview guide development. Qualitative research staff used Atlas.ti to code the health plan interviews and develop summary themes through an iterative content analysis approach.ResultsWe identified first-year implementation challenges in five thematic areas: 1) program design, 2) vendor experience, 3) engagement/communication, 4) reaction/satisfaction of stakeholders, and 5) processing/returning of mailed kits. Commonly experienced challenges by both health plans related to the time-consuming nature of the programs to set up, and complexities and delays in working with vendors. We found implementation successes in the same five thematic areas as well as four additional areas of: 1) leadership support, 2) compatibility with the health plan, 3) broader impacts, and 4) collaboration with researchers. Commonly experienced successes included the ability to adapt the mailed FIT program to the individual health plan culture and needs, and the synchronicity between the programs and their organizational missions and goals.ConclusionsBoth health plans successfully adapted mailed FIT programs to their own culture and resources and used their strong quality management resources to maximize success in overcoming the time demands of setting up the program and working with their vendors. Mailed FIT programs administered by health plans, especially those serving Medicaid- and dual eligible Medicaid/Medicare-insured populations, may be an important resource to support closing gaps in colorectal cancer screening among traditionally underserved populations.

A systematic review exploring the content and outcomes of interventions to improve psychological safety, speaking up and voice behaviour

BackgroundHaving psychologically safe teams can improve learning, creativity and performance within organisations. Within a healthcare context, psychological safety supports patient safety by enabling engagement in quality improvement and encouraging staff to speak up about errors. Despite the low levels of psychological safety in healthcare teams and the important role it plays in supporting patient safety, there is a dearth of research on interventions that can be used to improve psychological safety or its related constructs. This review synthesises the content, theoretical underpinnings and outcomes of interventions which have targeted psychological safety, speaking up, and voice behaviour within a healthcare setting. It aims to identify successful interventions and inform the development of more effective interventions.MethodsA key word search strategy was developed and used to search electronic databases (PsycINFO, ABI/Inform, Academic search complete and PubMed) and grey literature databases (OpenGrey, OCLC WorldCat, Espace). Covidence, an online specialised systematic review website, was used to screen records. Data extraction, quality appraisal and narrative synthesis were conducted on identified papers.ResultsFourteen interventions were reviewed. These interventions fell into five categories. Educational interventions used simulation, video presentations, case studies and workshops while interventions which did not include an educational component used holistic facilitation, forum play and action research meetings. Mixed results were found for the efficacy or effectiveness of these interventions. While some interventions showed improvement in outcomes related to psychological safety, speaking up and voice, this was not consistently demonstrated across interventions. Included interventions’ ability to demonstrate improvements in these outcomes were limited by a lack of objective outcome measures and the ability of educational interventions alone to change deeply rooted speaking up behaviours.ConclusionTo improve our understanding of the efficacy or effectiveness of interventions targeting psychological safety, speaking up and voice behaviour, longitudinal and multifaceted interventions are needed. In order to understand whether these interventions are successful, more objective measures should be developed. It is recommended that future research involves end users in the design phase of interventions, target both group and organisational levels, ensure visible leader support and work across and within interdisciplinary teams.Prospero registration numberCRD42018100659.

Using Lean Six Sigma to improve rates of day of surgery admission in a national thoracic surgery department.

ObjectiveThe aim of this study is to improve rates of day of surgery admission (DOSA) for all suitable elective thoracic surgery patients.DesignLean Six Sigma (LSS) methods were used to enable improvements to both the operational process and the organizational working of the department over a period of 19 months.SettingA national thoracic surgery department in a large teaching hospital in Ireland.ParticipantsThoracic surgery staff, patients and quality improvement staff at the hospital.Intervention(s)LSS methods were employed to identify and remove the non-value-add in the patient’s journey and achieve higher levels of DOSA. A pre-surgery checklist and Thoracic Planning Meeting were introduced to support a multidisciplinary approach to enhanced recovery after surgery (ERAS), reduce rework, improve list efficiency and optimize bed management.Main Outcome Measure(s)To achieve DOSA for all suitable elective thoracic surgery patients in line with the National Key Performance Indicator of 75%. A secondary outcome would be to further decrease overall length of stay by 1 day.ResultsOver a 19 month period, DOSA has increased from 10 to 75%. Duplication of preoperative tests reduced from 83 to <2%. Staff and patient surveys show increased satisfaction and improved understanding of ERAS.ConclusionsUsing LSS methods to improve both operational process efficiency and organizational clinical processes led to the successful achievement of increasing rates of DOSA in line with national targets.

Web Exclusive. Annals for Hospitalists Inpatient Notes - Reaching for Higher Value in Health Care by Bringing Together Clinicians and Researchers-The Michigan Program on Value Enhancement.

Web Exclusives19 November 2019Annals for Hospitalists Inpatient Notes - Reaching for Higher Value in Health Care by Bringing Together Clinicians and Researchers—The Michigan Program on Value EnhancementGeoffrey D. Barnes, MD, MSc and Eve A. Kerr, MD, MPHGeoffrey D. Barnes, MD, MScMichigan Program on Value Enhancement, Michigan Medicine Quality Department and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan (G.D.B., E.A.K.)Search for more papers by this author and Eve A. Kerr, MD, MPHMichigan Program on Value Enhancement, Michigan Medicine Quality Department and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan (G.D.B., E.A.K.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M19-2980 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Hospitalists frequently serve as clinical leaders of quality improvement (QI) projects. Their first-hand knowledge of clinical care processes and breadth of clinical expertise make them perfectly suited for these roles. In many health systems, these clinical QI leads are paired with QI staff or “performance improvement coaches” who have process expertise in one or more QI methodologies (e.g., Lean).However, even with a clinician-QI staff partnership, many well-intentioned QI projects are limited by suboptimal design and analysis. Hospitalists who work in this space should consider collaborating with health services researchers who can assist with rigorous preintervention assessments, innovative intervention design, ...

Zap it track it: the application of Lean Six Sigma methods to improve the screening system of low-grade mucinous neoplasms of the appendix in an acute hospital setting.

To improve the number of patients receiving annual computed tomography (CT) scan and tumour markers, who are diagnosed with low-grade mucinous neoplasms (LAMN). A pre-/post-intervention design was employed using Lean Six Sigma methods to identify gaps in the screening system and to develop and implement solutions for a more robust, auditable screening programme. The patients diagnosed with LAMN of the appendix referred to the acute hospital and are enrolled in the screening service. Consultant colorectal surgeons, cancer nurse specialist, colorectal medical team and quality improvement staff. Diagnostic tools identified gaps in the current process. A set of improvements were implemented to standardize the pathway for referral and surveillance of patients, provide information on the condition and treatment and standardize and track information received by patients and their referring hospital. Pre and post-intervention outcome measures were taken for the number of patients who receive an annual CT of thoracic, abdomen and peritoneum and tumour markers and number of patients who receive information and contact details. At baseline, of the 28 patients that met the inclusion criteria only 61% had a correct follow-up. Following the implementation of improvements, 78% of patients had correct follow-up and 90% had received information. Gaps in the current cancer screening system were identified and improvements implemented a reduced number of patients having an incorrect follow-up. Findings are applicable across all precancerous screening systems irrespective of the type of malignancy. The methods used empowered patients and fostered an interdisciplinary team approach to care.

Nursing roles for in-hospital cardiac arrest response: higher versus lower performing hospitals

BackgroundGood outcomes for in-hospital cardiac arrest (IHCA) depend on a skilled resuscitation team, prompt initiation of high-quality cardiopulmonary resuscitation and defibrillation, and organisational structures to support IHCA response. We examined...

A quality improvement approach to optimizing infusion wait times.

61 Background: Long wait times are a common and occasionally unavoidable experience for patients receiving chemotherapy infusions. It unfavorably impacts patient satisfaction and clinic efficiency. Our primary objective was to evaluate the impact of infusion clinic process changes on patient wait times within a Plan, Do, Study, Act (PSDA) framework. Methods: A multi-disciplinary team, consisting of oncology, nursing, pharmacy, quality improvement, and support staff, met to have brainstorming sessions, make surveys, and conduct time studies to analyze our current process (Plan). A Pareto chart created using survey results showed communication issues were likely causing the largest modifiable impact on our wait times. A common source of miscommunication was whether patients are waiting on labs results for treatment. Beginning March 2019, patients not requiring labs on the day of treatment were assigned to a separate scheduling title to designate them as priority for vital signs and review by pharmacy (Do). Upon clinic check-in, these patients now have vitals signs collected immediately and pharmacy is notified of their arrival to begin chemotherapy preparation. Results: Baseline as well as prospective wait time data was collected from 30 clinic days (360 patient wait times) from chart reviews and timestamp data available in the electronic medical record (EMR). Results were analyzed (Study) using Statistical Process Control (SPC) charts to allow for early detection of improvement. Pre-implementation wait times averaged 1 hour and 37 minutes. Post implementation wait times average 1 hour and 16 minutes (Act). This change was significant based on a shift visible on the SPC chart. Our balancing measure of wait times for all patients did not increase compared to baseline (2 hours and 15 minutes). No significant correlation was observed between average daily wait times and the day of the week or the number of patients treated that day at baseline. Conclusions: Implementation of a new clinic scheduling title and workflow reduced wait times for patients not requiring labs on the day of treatment without increasing wait times for patients requiring labs. Additional PDSA cycles will be conducted for further reductions in wait times for all patients at our site.

Impact Assessment of a Comprehensive Department Quality Improvement Program Reporting System

The value of patient safety organizations (PSO) such as RO-ILS has become clear with the implementation and maturation of these initiatives. In the field of radiation oncology, RO-ILS serves as a valuable collective resource to identify safety concerns through centralized reporting of incidents that occur as participating centers. Within our department we developed an internal reporting system to capture not only incidents but also issues impacting on safety or quality of care across the full spectrum of severity. The goal was to identify and address both major but also more mundane events and concerns that never-the-less impact our goal of providing safe high quality care. Here we review the findings of our program over the first year following implementation. We hypothesized that a comprehensive reporting program would serve to identify focus areas for quality improvement through engagement of all staff in this process. We developed a custom quality improvement portal for use by all department members. The portal was designed to align with RO-ILS to facilitate event submission. The portal is accessed through a desktop icon or through the electronic information management system. Staff submitting events provide information on type of event, step in work flow it occurred, and at which step it was identified. Events are reviewed weekly by a multi-disciplinary Quality Improvement Team (QIT) who assigns events to champions who report back findings at a future QIT meeting. Based on champion recommendations and QIT discussion corrective actions are implemented. Serious events requiring submission to the hospital safety reporting system or deemed of sufficient interest for reporting to RO-ILS are identified and submitted. From December 15, 2017 through December 31, 2018 387 events were submitted. Physicists (41%), RTT’s (34%) and MDs (14%)were staff most commonly submitting however submissions were received from staff representative of all categories including nursing, dosimetry, administration, and engineering. Events occurred most commonly at treatment (tx) planning (19%), tx delivery (17%) pre-tx QA review (16%) and on-tx (15%). Events were identified most commonly at pre-tx review (25%), on-tx (25%), or tx delivery (15%). The most common event types were operational/process improvement (57%) and unsafe condition (27%). Most common precipitating factors were communication (28%), organizational management (20%) and human factors (20%). The most common event type and factor pairing was operational/process improvement and communication (17%). The QIP led to 24 new or modified policies and procedures. A robust QIP focused on submission of incidents and issues across the full spectrum of severity of quality/safety is an effective way to engage department staff in quality improvement. The QIP program facilitated identification of diverse issues leading to targeted interventions to improve quality and safety in our department.

What Words Convey: The Potential for Patient Narratives to Inform Quality Improvement.

For the past 25 years, health care providers and health system administrators have sought to improve care by surveying patients about their experiences. More recently, policymakers have acted to promote this learning by deploying financial incentives tied to survey scores. This article explores the potential of systematically elicited narratives about experiences with outpatient care to enrich quality improvement. Narratives were collected from 348 patients recruited from a nationally representative Internet panel. Drawing from the literature on health services innovation, we developed a two-part coding schema that categorized narrative content in terms of (a) the aspects of care being described, and (b) the actionability of this information for clinicians, quality improvement staff, and health system administrators. Narratives were coded using this schema, with high levels of reliability among the coders. The scope of outpatient narratives divides evenly among aspects of care currently measured by patient experience surveys (35% of content), aspects related to measured domains but not captured by existing survey questions (31%), and aspects of care that are omitted from surveys entirely (34%). Overall, the narrative data focused heavily on relational aspects of care (43%), elaborating on this aspect of experience well beyond what is captured with communication-related questions on existing surveys. Three-quarters of elicited narratives had some actionable content, and almost a third contained three or more separate actionable elements. In a health policy environment that incentivizes attention to patient experience, rigorously elicited narratives hold substantial promise for improving quality in general and patients' experiences with care in particular. They do so in two ways: by making concrete what went wrong or right in domains covered by existing surveys, and by expanding our view of what aspects of care matter to patients as articulated in their own words and thus how care can be made more patient-centered. Most narratives convey experiences that are potentially actionable by those committed to improving health care quality in outpatient settings.

Abstract TP376: Barriers and Facilitators to Obtaining the “New” Goal Blood Pressure for Patients With Ischemic Stroke - A Mixed Methods Analysis from the Veterans Health Administration

Introduction: The 2017 ACC/AHA updated hypertension guideline recommends a “new” goal blood pressure (BP) of &lt;130/80 mmHg for stroke survivors. Little is known regarding the perceived barriers and facilitators to implementing this recommendation and whether Veterans Health Administration medical centers (VAMCs) routinely achieving this degree of post-stroke BP control. Methods: Chart review was conducted to determine the numbers of patients with hypertension who obtained ACC/AHA (i.e., &lt;140/90 mmHg) and Joint National Committee (JNC)-8 recommended BP goals (i.e., 130/80 mmHg). Thematic analysis was performed on 27 semi-structured qualitative interviews with providers, hospital and clinic administrators, and quality improvement staff conducted February-April 2018 at two diverse VAMCs. Interviews were conducted prior to the start of a CAre Transition and Hypertension (CATcH) improvement intervention. Code descriptions of “opinions regarding ‘new’ BP guidelines,” “barriers to BP management,” and, “facilitators to BP management” were compared across sites and among providers. A multidisciplinary team conducted consensus-based coding of transcripts. Results: In the sixteen-months prior to the implementation of CATcH, facility-level pass rates for BP control were: 50% (18/36) patients at Site 1 and 64% (16/25) at Site 2 had obtained old goal BP, whereas 28% (10/36) at Site 1 and 20% (5/20) at Site 2 obtained new goal BP. Barriers and facilitators of bp management were identified at the patient-, provider-, and facility-levels (Table). Similar themes were seen across sites. Conclusions: Pre-intervention pass rates for bp need to improve. Multiple barriers and facilitators at the patient-, provider-, and systems-levels have been considered in designing the CATcH intervention, which seeks to incorporate the 2017 ACC/AHA hypertension guidelines into routine clinical care and improve on current facility-level performance.

Synonym-Based Word Frequency Analysis to Support the Development and Presentation of a Public Health Quality Improvement Taxonomy.

Researchers and analysts have not completely examined word frequency analysis as an approach to creating a public health quality improvement taxonomy. To develop a taxonomy of public health quality improvement concepts for an online exchange of quality improvement work. We analyzed documents, conducted an expert review, and employed a user-centered design along with a faceted search approach to make online entries searchable for users. To provide the most targeted facets to users, we used word frequency to analyze 334 published public health quality improvement documents to find the most common clusters of word meanings. We then reviewed the highest-weighted concepts and categorized their relationships to quality improvement details in our taxonomy. Next, we mapped meanings to items in our taxonomy and presented them in order of their weighted percentages in the data. Using these methods, we developed and sorted concepts in the faceted search presentation so that online exchange users could access relevant search criteria. We reviewed 50 of the top synonym clusters and identified 12 categories for our taxonomy data. The final categories were as follows: Summary; Planning and Execution Details; Health Impact; Training and Preparation; Information About the Community; Information About the Health Department; Results; Quality Improvement (QI) Staff; Information; Accreditation Details; Collaborations; and Contact Information of the Submitter. Feedback about the elements in the taxonomy and presentation of elements in our search environment from users has been positive. When relevant data are available, the word frequency analysis method may be useful in other taxonomy development efforts for public health.

Quality Improvement Training in a Variety of Cancer Care Delivery Settings: Experiences From a Comprehensive Cancer Center, an Academic Medical Center, and Community Practices.

Training clinical and supportive staff in quality improvement (QI) theory and use of QI tools has the potential to improve oncology care delivery. We report our combined experience of providing training to oncologists in a variety of local settings and assess the effect of the training on individual participants and for institutions. Multidisciplinary oncology teams at a comprehensive cancer center, an academic medical center, and community practices were led through experiential QI training that spanned several months. The curriculum included didactic training sessions that attendees applied to their local project-based work and that required plan-do-study-act cycles. The curriculum was adapted to the smaller practice setting through use of a workbook and a reduced focus on quantitative methods. All teams were supported by coaches and provided final presentations to leadership. The self-rated abilities of trainees to use 15 QI tools were assessed with a pre/post training survey that had five response categories (information, skill, knowledge, understanding, and wisdom). Local institutional and external project presentations were tracked. During 7 years, 129 trainees participated in 56 QI projects. All of the 15 QI tools had 80% of trainees rate themselves in the top three categories (knowledge, understanding, and wisdom) after the training; none met this threshold before. Multiple projects were presented in institutional and external settings. Most projects targeted three of the four domains of the ASCO Quality Oncology Practice Initiative certification program standards. We implemented and sustained QI training programs in a variety of cancer delivery settings. The flexible training model should be easily adoptable by others.

Abstract 180: Nursing Roles for In-Hospital Cardiac Arrest Response: A Qualitative Study

Introduction: Survival and favorable clinical outcomes for in-hospital cardiac arrest (IHCA) are highly dependent on a skilled resuscitation team, prompt initiation of high quality CPR and defibrillation, and organizational structures to support resuscitation care. While nurses are generally involved in resuscitation efforts, the purpose of this study was to examine their specific roles and factors that affect their contributions during an IHCA response. Methods: We conducted a qualitative study at 9 hospitals participating in the AHA Get-With-The-Guidelines Resuscitation registry. Purposeful sampling was used to select hospitals that vary in terms of geography, academic status, and risk-standardized IHCA survival. Participants included nurses, physicians, respiratory therapists, pharmacists, quality improvement staff, hospital administrators, and other staff, yet discussion of the nursing function was prominent across all stakeholder groups. Qualitative thematic text analysis was used to identify the distinct types of nursing roles in relation to IHCA and how these roles were supported across sites. Results: We conducted semi-structured interviews with 158 individuals at 9 hospitals. Nurses were identified as an integral part of the IHCA response at all sites, with three major IHCA nursing roles identified: bedside first responder, rapid response or code team member, and leader. There were distinct differences across sites in support for nurses in these different roles with regard to educational training and competency, organizational engagement, and empowerment (Table). Conclusion: Nurses are a critical component of effective IHCA response and processes, including diverse roles as bedside first responders, code team members, and leadership for resuscitation care. Mentoring and empowering frontline nurses and ensuring that clinical competency and training needs for IHCA care specific for nurses is essential for resuscitation care.

Map-enabled experiential review: A novel approach to engaging healthcare staff in quality improvement

A common barrier to continuous and sustainable improvement in many organisations is the lack of staff engagement with quality improvement. In the healthcare sector, the failure to engage staff with quality has been associated with preventable patient harm, which persists despite more than two decades of emphasis on safety and quality in this sector. This paper describes a novel approach — map-enabled experiential review (MEER) — that has significant potential to address staff engagement issues and produce meaningful improvement outcomes. The MEER approach uses map-based simulation of organisational processes to enable structured conversations among staff about their daily implementation of those processes as a means of identifying and addressing latent safety threats and other areas for improvement.