Quality Improvement System Research Articles

Leadership with Standardized Practise in TVET Institutions: A Quality System Improvement

Leadership with Standardized Practise in TVET Institutions: A Quality System Improvement

Biochar as bioretention systems for water quality improvement in Malaysia

Rapid urbanization and constant development of infrastructure in the civil engineering community has accelerated in the past decades. However, there has been a reduction of permeable surfaces for rainwater and surface runoff to escape, raising concerns regarding flooding and water quality especially in Malaysia where the tropical climate and heavy rainfall applies pressure on the bioretention systems. To lessen the issue, this paper will be looking into biochar’s benefits in bioretention systems focussing on the type of biochar which will be most suited in improving water quality. In particular, two types of biochar were compared such as rice husk biochar and palm biochar to be tested as bioretention system and different water samples were run through them. Various water quality parameter tests were conducted to evaluate biochar’s performance in reducing pollutants and contaminants from the water samples and thus enable to draw a conclusion on which is the most effective for bioretention use. With a deeper understanding of biochar’s capabilities and limitations, stormwater management strategies can be improved to make the construction industry more sustainable.

Promotion of early childhood development and mental health in quality rating and improvement systems for early care and education: A review of state quality indicators

In the United States (U.S.), quality rating and improvement systems (QRIS) are used by many states to incentivize quality in ECE and may be a viable lever for promoting early childhood development and mental health on a population level. We conducted a qualitative review of publicly available data on state QRIS indicators to better understand how states incorporate evidence-informed early childhood development and mental health promotion standards in QRIS. We systematically compared QRIS indicators for 41 U.S. states with child development and mental health promotion quality standards from Caring for Our Children National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs, 3rd Edition, as of March/April 2020. Of those, 39 states included at least one indicator consistent with child development or mental health promotion standards, including practices that can lead to early detection of developmental delays such as developmental monitoring, activities or curriculum addressing developmental domains, and regular communication and resource-sharing with parents/guardians. Opportunities exist within states for incorporating more specific guidance within indicators, such as use of childcare health consultants and advocates, validated screening tools, parent/guardian participation or input in developmental monitoring and screening, and staff training on family engagement. We found that in most states QRIS indicators offer guidance for ECE systems to support and monitor early development and foster mental health, with opportunities to enhance guidance. Findings point to QRIS as a viable opportunity for promotion of early childhood development and mental health standards in ECE systems.

Implementation of an ADALINE-Based Adaptive Control Strategy for an LCLC-PV-DSTATCOM in Distribution System for Power Quality Improvement

This study investigated the problem of controlling a three-phase three-wire photovoltaic (PV)-type distribution static compensator (DSTATCOM). In order to model, simulate, and control the system, the MATLAB/SIMULINK tool was used. Different controllers were applied to create switching pulses for the IGBT-based voltage source converter (VSC) for the mitigation of various power quality issues in the PV-DSTATCOM. Traditional control algorithms guarantee faultless execution or outcomes only for a restricted range of operating situations due to their present design. Alternative regulators depend on more resilient neural network and fuzzy logic algorithms that may be programmed to operate in a variety of settings. In this study, an adaptive linear neural network (ADALINE) was proposed to solve the control problem more efficiently than the existing methods. The ADALINE method was simulated and the results were compared with the results of the synchronous reference frame theory (SRFT), improved linear sinusoidal tracer (ILST), and backpropagation (BP) algorithms. The simulation results showed that the proposed ADALINE method outperformed the compared algorithms. In addition, the total harmonic distortions (THDs) of the source current were estimated under ideal grid voltage conditions based on IEEE-929 and IEEE-519 guidelines.

Implementing intact cord resuscitation in very preterm infants: feasibility and pitfalls.

The purpose of this study is to evaluate the feasibility of intact cord resuscitation (ICR) in very preterm infants using a custom-equipped mobile resuscitation trolley (LifeStart®). We collected maternal and neonatal data of all inborn infants < 32weeks eligible for ICR per our protocol over 9months from ICR implementation. We compared rates of ICR between the beginning and the end of the study period. We reviewed maternal and neonatal adverse events related to the procedure and direct outcomes. In order to assess potential quality improvements related to the procedure, we collected the same data in the infants born in the 9-month period preceding ICR implementation. Out of 44 infants born < 32weeks during the period, 27 were eligible for ICR. Failure to initiate ICR occurred in 9/27, exclusively in the first 5.5months of the study. In one infant, ICR was interrupted prior to 2min due to placental abruption. No ICR procedure had to be interrupted due to insufficient cord length. Among the 18 infants who completed ICR, cord clamping timing increased significantly over the study period, from 3.0 [2.5-3.5] to 4.2min [3.1-8.3] (p = 0.02). No significant maternal blood loss or wound complications were noted. No infant deaths were attributable to failure or direct consequence of ICR, and no infant experienced hypoxic respiratory failure (intubation, FiO2 ≥ 0.4), asphyxia (pH < 7.2), or blood pressure instability (< 2 SD) following stabilization. Hemoglobin level after cord clamping was higher in the ICR cohort than in the pre-implementation group. Seven out of 18 infants exposed to ICR had a temperature < 36.5°C on admission. Conclusion: ICR is feasible in very preterm infants. Temperature management requires special attention. Multidisciplinary simulation training before implementation and systematic post-implementation quality improvement meetings may significantly increase ICR program success. What is Known: • Because infants born < 32weeks often require cardiorespiratory resuscitation at birth, they are not offered delayed cord clamping in the majority of neonatal intensive care units. • Recently, fully equipped mobile trolleys have been developed in order to allow bedside resuscitation with an intact cord. What is New: • Variable timing of cord clamping based on the infant's transition and respiratory stability, i.e., "physiology-based cord clamping," is safely achievable in very preterm infants. • Intact cord resuscitation requires specific equipment, operational protocols, and a high level of preparation from both obstetrical and neonatal teams, with a learning curve that can be streamlined by multidisciplinary simulation training.

Youth Social and Emotional Learning in Quality-Enhanced, Out-of-School Time Programs

Researchers examined social and emotional learning (SEL) ratings for two samples of 559 and 406 predominantly elementary-age youth of color, who were enrolled in out-of-school time (OST) programs serving communities mostly of high socioeconomic need in Palm Beach County, Florida. Covering the 2019-2020 and 2020-2021 school years in the context of the COVID-19 pandemic, the study predicted that programs’ participation in an SEL quality enhancement project would positively impact youth SEL. This quality enhancement was expected to emerge alongside the positive effects of foundational program quality achieved through participation in the Palm Beach County Quality Improvement System, which includes an array of supports provided by Prime Time Palm Beach County, a nonprofit OST intermediary organization. Amid the challenges of the pandemic, evidence emerged to support the positive impact of foundational quality on youth in OST, as well as the positive impact of an enhanced focus on SEL.

Implementation of Quality Improvement System Applications Based on Study Program National Accreditation Standard

The problem that occurs in university study programs is when accreditation is carried out suddenly and unplanned in a structured application system. This condition has an impact on the less than optimal accreditation value. The purpose of this science and technology application is to implement the application of a quality improvement system for study programs based on national accreditation standards. The method of activity with the application of science and technology through the application of application systems, training activities, structured guidance. The target audience is all heads of study programs at the University of Silampari Lubuklinggau (Unpari). The results of the application of science and technology show that the application of a quality assurance system application based on national accreditation standards at universities has been carried out by all study programs and there are 4 (four) study programs that are ready to propose accreditation with national standards. Suggestions require leadership commitment and support from all lecturers for the provision of facilities and funds in accordance with national accreditation standards.

CHILD CARE IN THE UNITED STATES: MARKETS, POLICY, AND EVIDENCE

AbstractParticipation in non‐parental child care arrangements is now the norm for preschool‐age children in the U.S. However, child care services are becoming increasingly expensive for many families, and quality is highly uneven across providers and sectors, raising questions about the impact of child care costs and quality on parental employment and child development. The U.S. policy landscape is dominated by three policies that subsidize costs for low‐income families or attempt to improve the safety and quality of providers: the Child Care and Development Fund, regulations, and quality rating and improvement systems. In this paper, I provide a thorough review of the evidence on each policy, focusing on how they influence a wide range of family and provider outcomes. The paper begins with a detailed description of the structure and functioning of the child care market, using the most up‐to‐date data on families’ utilization of care services and provider characteristics. I then draw on a diverse set of studies across multiple fields to summarize the evidence on the impact of child care policy. In the final section of the paper, I offer recommendations for future research in each policy area.

Impact of Pulmonary Complications on Outcomes and Resource Use After Elective Cardiac Surgery.

To characterize the impact of pulmonary complications (PCs) on mortality, costs, and readmissions after elective cardiac operations in a national cohort and to test for hospital-level variation in PC. PC after cardiac surgery are targets for quality improvement efforts. Contemporary studies evaluating the impact of PC on outcomes are lacking, as is data regarding hospital-level variation in the incidence of PC. Adults undergoing elective coronary artery bypass grafting and/or valve operations were identified in the 2016-2019 Nationwide Readmissions Database. PC was defined as a composite of reintubation, prolonged (>24 hours) ventilation, tracheostomy, or pneumonia. Generalized linear models were fit to evaluate associations between PC and outcomes. Institutional variation in PC was studied using observed-to-expected ratios. Of 588,480 patients meeting study criteria, 6.7% developed PC. After risk adjustment, PC was associated with increased odds of mortality (14.6, 95% CI, 12.6-14.8), as well as a 7.9-day (95% CI, 7.6-8.2) increase in length of stay and $41,300 (95% CI, 39,600-42,900) in attributable costs. PC was associated with 1.3-fold greater hazard of readmission and greater incident mortality at readmission (6.7% vs 1.9%, P <0.001). Significant hospital-level variation in PC was present, with observed-to-expected ratios ranging from 0.1 to 7.7. Pulmonary complications remain common after cardiac surgery and are associated with substantially increased mortality and expenditures. Significant hospital-level variation in PC exists in the United States, suggesting the need for systematic quality improvement efforts to reduce PC and their impact on outcomes.

Using Family Narrative Reports to Identify Practices for Improving End-of-Life Care Quality

Patient experiences should be considered by healthcare systems when implementing care practices to improve quality of end-of-life care. Families and caregivers of recent in-patient decedents may be best positioned to recommend practices for quality improvement. To identify actionable practices that bereaved families highlight as contributing to high quality end-of-life care. We conducted qualitative content analysis of narrative responses to the Bereaved Family Surveys Veterans Health Administration inpatient decedents. Out of 5964 completed surveys in 2017, 4604 (77%) contained at least one word in response to the open-ended questions. For feasibility, 1500/4604 responses were randomly selected for analysis. An additional 300 randomly selected responses were analyzed to confirm saturation. Over 23% percent (355/1500) of the initially analyzed narrative responses contained actionable practices. By synthesizing narrative responses to the BFS in a national healthcare system, we identified 98 actionable practices reported by the bereaved families that have potential for implementation in QI efforts. Specifically, we identified 67 end-of-life practices and 31 practices in patient-centered care domains of physical environment, food, staffing, coordination, technology and transportation. The 67 cluster into domains including respectful care and communication, emotional and spiritual support, death benefits, symptom management. Sorting these practices by target levels for organizational change illuminated opportunities for implementation. Narrative responses from bereaved family members can yield approaches for systematic quality improvement. These approaches can serve as a menu in diverse contexts looking for approaches to improve patient quality of death in in-patient settings.

Framework for health care quality and evidence-based practice in radiology departments: A regional study on radiographer's perceptions

IntroductionThe main goals of this study were to describe, in an integrated and multidimensional way, the conditions related to the quality of care in radiology departments from Algarve (Portugal), to assess the perspective of radiographers on the use of scientific evidence in clinical practice and to validate a model that characterizes the conditions for continuous improvement. MethodsA cross sectional study was performed in four radiology departments from public and private healthcare facilities from Algarve region (Portugal). A paper-based survey was sent to all radiographers to assess the quality systems implemented in their radiology departments and their perspective on the use of scientific evidence in clinical practice. ResultsIn total, 62 radiographers (61.4%) completed the survey. The quality dimensions that obtained the highest degree of compliance were the existence of quality assurance and improvement activities (43.0%), existence of standards in clinical practice of radiographers (42.7%) and the existence of special provisions (37.6%). The quality dimension related to patient's involvement was the one with the lowest level of compliance. Moreover, from the radiographers perspective, positive responses were obtained related to evidence-based actions (83.0%), sources of evidence (76.0%) and the significance of research activities (74.0%). ConclusionThese findings suggest that a new framework based on four factors (Support for Information; Organizational Capability to Technical Quality of Care; Patient Involvement and Evidence-Based Radiology), should be considered in the establishment of strategic policies that better define the provision of diagnostic procedures and professional practices in radiology departments from Algarve region, based on quality improvement systems and better patient safety. Implications for PracticeThere is a need to include patients in the decision-making process, to involve radiographers in quality assurance and improvement activities and to implement quality monitoring mechanisms within radiology departments under study.

Signal quality enhancement in multiplexed communication systems based on the simulation model of the optimum technical specifications of Raman fiber optical amplifiers

Abstract Raman optical amplifiers have more reliability than the repeater in the optical communication networks. In the optical amplifier, the transmission equals the gain bandwidth of the amplifiers. The optical amplifier has functionalities such as WDM amplification (gain equalization), gain control (rapidly variation of the gain), inter-stage access (compensation in the dispersion rate). This paper presents the optimum technical specifications of fiber Raman optical amplifiers (FROAs) with average power system for signal quality improvement in multiplexed systems. The signal has upgraded to a max. Q-factor of 11.47 applied along 1000 m as a range through the free-space optical (FSO) communication channel that has an attenuation rate of 10 dB/km. Our suggested system has clarified the best Q-factor that is greatly increased to reach 49.36 in the presence of the pump laser. The multiplexed communication systems signal quality is enhanced by the percentage ratio of 39.65%.

The validity and reliability of quality improvement and accreditation system instrument in managing childcare center

&lt;span lang="EN-US"&gt;Quality improvement and accreditation system (QIAS) instrument was developed to determine the quality management practices level in childcare centers in Malaysia. This study was conducted in Kedah, Penang, and Kelantan to intricate the reliability and validity of the instrument. Exploratory factor analysis (EFA) and item reliability analysis have been used to measure the level of reliability and authenticity of the questionnaires. Further, inter-rater reliability (IRR) test was used to obtain expert confirmation of the reliability, validity and credibility of the instrument. All the seven constructs possessed high reliability index value between 0.87–0.92. Similarly, EFA analysis showed that there are seven dimensions exist in the QIAS instrument with factor loading ranged from 0.64–0.88. The findings also showed that the variance explained in the data is 64.46% with Eigenvalue more than 1. These results reflecting that all the item are accepted with a high verification. In addition, a very high reliability coefficient value, α=0.93 and inter-rater reliability of 91% indicated a high level of agreement and reliability among field evaluators. The results proved that this QIAS instrument had high validity and reliability and was capable to measure the quality management practices level in Malaysian childcare center.&lt;/span&gt;

The effects of a high quality state-run preschool program as rated by a Quality Rating and Improvement System on children's school readiness

The goal of this study was to evaluate the effects of attending a state-run preschool program that is rated as “higher quality” on a state's Quality Rating and Improvement System (QRIS) for children's outcomes in prekindergarten and kindergarten. It was expected that children who attended higher QRIS-rated programs would demonstrate greater gains in school readiness skills relative to children who received similar subsidies but attended lower-rated programs in the prekindergarten year. However, because there is little to base a hypothesis on with regard to longitudinal associations, we had no a priori hypotheses regarding potential effects into the fall and spring of kindergarten. Participants included 2 cohorts (N = 516; 50% female, Mage = 4.80 years). Data were collected on school readiness outcomes in the fall and spring of prekindergarten and kindergarten. Results suggested that participating in the higher-rated program was related to gains in language during the prekindergarten year that persisted into kindergarten. Findings indicated that children who participated in the program experienced greater gains in their math, literacy, and school readiness in kindergarten. However, the majority of the effects were generally small, albeit positive.

The WHO essential medicines list AWaRe book: from a list to a quality improvement system

Antibiotics are often prescribed inappropriately, either when they are not necessary or with an unnecessarily broad spectrum of activity. AWaRe (AccessWatchReserve) is a system developed by WHO to classify antibiotics based on their spectrum of activity and potential for favouring the development of antibiotic resistance (Access: narrow spectrum/low potential for resistance; Watch: broader spectrum/higher potential for resistance; Reserve: last resort antibiotics to use very selectively). The WHO target is that by 2023, at least 60% of prescribed antibiotics globally should be from the Access category. The WHO AWaRe Book aims to improve empiric antibiotic prescribing by providing simple guidance for common infections based on the principles of AWaRe in alignment with the Model Lists of Essential Medicines for adults and children.

A replicable, open-source, data integration method to support national practice-based research & quality improvement systems

ObjectivesThe Epilepsy Learning Healthcare System (ELHS) was created in 2018 to address measurable improvements in outcomes for people with epilepsy. However, fragmentation of data systems has been a major barrier for reporting and participation. In this study, we aimed to test the feasibility of an open-source Data Integration (DI) method that connects real-life clinical data to national research and quality improvement (QI) systems. MethodsThe ELHS case report forms were programmed as EPIC SmartPhrases at Mass General Brigham (MGB) in December 2018 and subsequently as EPIC SmartForms in June 2021 to collect actionable, standardized, structured epilepsy data in the electronic health record (EHR) for subsequent pull into the external national registry of the ELHS. Following the QI methodology in the Chronic Care Model, 39 providers, epileptologists and neurologists, incorporated the ELHS SmartPhrase into their clinical workflow, focusing on collecting diagnosis of epilepsy, seizure type according to the International League Against Epilepsy, seizure frequency, date of last seizure, medication adherence and side effects. The collected data was stored in the Enterprise Data Warehouse (EDW) without integration with external systems. We developed and validated a DI method that extracted the data from EDW using structured query language and later preprocessed using text mining. We used the ELHS data dictionary to match fields in the preprocessed notes to obtain the final structured dataset with seizure control information. For illustration, we described the data curated from the care period of 12/2018–12/2021. ResultsThe cohort comprised a total of 1806 patients with a mean age of 43 years old (SD: 17.0), where 57% were female, 80% were white, and 84% were non-Hispanic/Latino. Using our DI method, we automated the data mining, preprocessing, and exporting of the structured dataset into a local database, to be weekly accessible to clinicians and quality improvers. During the period of SmartPhrase implementation, there were 5168 clinic visits logged by providers documenting each patient’s seizure type and frequency. During this period, providers documented 59% patients having focal seizures, 35% having generalized seizures and 6% patients having another type. Of the cohort, 45% patients had private insurance. The resulting structured dataset was bulk uploaded via web interface into the external national registry of the ELHS. ConclusionsStructured data can be feasibly extracted from text notes of epilepsy patients for weekly reporting to a national learning healthcare system.

Do Early Care and Education Programs Improve When Enrolled in Quality Rating and Improvement Systems? Longitudinal Evidence from One System

ABSTRACT Quality rating and improvement systems (QRISs) are designed to assess, improve, and communicate the quality of early care and education programs. Using administrative data, we investigated whether providers that participated in a county-level QRIS saw increases to their global quality (tier) rating, domain-specific quality ratings, and scores on an observation measure of classroom quality. Research Findings: On average, participating providers increased their overall tier ratings; this pattern was particularly true for providers with lower initial tier ratings. We found more consistent evidence of increases on indicators of structural quality components (e.g., teacher and director qualifications), and limited evidence of improvement on process quality indicators (e.g., measure of teacher–child interaction). This finding suggests structural quality improvements may be driving global tier rating changes. In addition, providers saw average increases on a measure of classroom quality, with larger increases seen in domains that measure classroom organization and emotional support. Practice and Policy: We discuss implications for how QRISs can promote quality improvement for participating providers and suggest avenues for future research.

The cost of a first and second hospital-wide accreditation in Flanders, Belgium.

Hospital accreditation is a popular and widely used quality control and improvement instrument. Despite potential benefits, ques-tions are raised whether it constitutes appropriate use of hospitals' limited financial resources. This study aims to calculate the cost of preparing for and undergoing a first and second accreditation by the Joint Commission International or Qualicor Europe in acute-care hospitals. All (n = 53) acute-care hospitals in Flanders (Belgium) were invited to participate and report on the costs in preparing for and undergoing a first and/or second accreditation cycle. To measure costs, a questionnaire with six domains and 90 questions was developed based on literature review, policy documents and a multidisciplinary expert group. All costs were recalculated to 2020 euro to correct for inflation and reported as medians with interquartile range. A total of 25 hospitals (47%) participated in the study. Additional investments and direct operational costs for a first accreditation cycle amounted to 879.45 euro (interquartile range: 794.81) per bed and 3.8 full-time equivalent (FTE) per hospital additional new staff members were recruited for coordination and implementation of the trajectory. A second accreditation survey costed remarkably less with a total cost of extra investments and direct operational cost of 222.88 euro (interquartile range: 244.04) per bed and less investment in additional staff (1.50 FTE). Most of the costs were situated in consulting costs and investments in infrastructure. The median total extra cost (direct operational cost and additional investments) amounted to 0.2% of the hospital's operating income for a first accreditation cycle and 0.05% for a second cycle. A first accreditation cycle requires a strong financial commitment of hospitals, as many costs result from the preparation in the years prior to an accreditation survey. A second survey is less expensive for hospitals, but still requires a considerable effort in terms of budget and staff. Policy makers should be aware of these significant costs as hospitals are operating with public resources and budget is scarce. The identification of these costs is a necessary building block to evaluate cost-effectiveness of accreditation versus other quality improvement systems and the continuation of these accreditation systems and their costs needs further study and a thorough debate.

Novel Laparoscopic System for Quality Improvement and Increased Efficiency

Novel Laparoscopic System for Quality Improvement and Increased Efficiency

Protocol for a proof-of-concept study evaluating systematic quality improvement with Realtime event support (SQUIRES)

Introduction: Quality improvement (QI) in healthcare results in better patient outcomes, healthcare system performance, and professional development. One target of QI initiatives in the perioperative period is surgical site infections (SSI), for which several risk factors have been identified. Reliable administration of indicated surgical antibiotic prophylaxis is a modifiable factor of particular relevance. We hypothesize that a novel telemedicine-augmented quality improvement program will improve administration of surgical antibiotic prophylaxis. Objectives: The objective of this QI study is to evaluate the utility of a telemedicine-augmented QI initiative on administration of timely surgical antibiotic prophylaxis. The incidence of SSI will also be reported for multiple surgical services. Methods: This will be a multi-center prospective before-and-after proof-of-concept study. Patients undergoing a surgical procedure across seven operating room facilities at four hospitals in the BJC Healthcare System will be included. Approximately 40,000 patients over an eight-month period will be enrolled. This eight-month period will include a baseline observational phase, an education intervention phase, an intervention phase employing real-time event detection with associated guidance from a remote telemedicine center, and a subsequent observational phase. The primary outcome will be administration of on-time surgical antibiotic prophylaxis throughout the trial. Other outcomes will include incidence of SSIs. Registration Information: This trial is registered on clinicaltrials.gov, NCT04983329 (30th July 2021).