Quality Improvement System Research Articles

1189-P: Real-World Factors Associated with Use of Basal Insulin and Hypoglycemia in the Inpatient Setting

Per current guidelines, our institution advocates using basal-bolus insulin regimens for inpatient hyperglycemia. However, it is a challenging practice in the real-world setting. Hypoglycemia is an unwanted consequence and a national quality metric for hospitals. We sought to characterize the factors around use of basal insulin and hypoglycemic events (HE) in our hospital system for quality improvement and to develop preventative strategies. Between April-June 2018, 4130 admissions receiving basal insulin (glargine, NPH, or Mixed 70/30, 75/25) were retrospectively reviewed for HE, defined as glucose <70 mg/dl. ICU and non-ICU patients were included. Insulin infusion or insulin pump therapy was excluded. Median age was 66 years, 48% were male and median A1C was 7.8%. In the entire cohort, 22% (923) had >/= 1 HE. Of those, 76% had 1-3 HE and 24% had >/= 4 HE per admission. The frequency of basal insulins were 75% glargine, 18% NPH, and 6% Mixed. Within 24 hours of the first HE, insulin dose was decreased in 42% receiving glargine, 66% NPH, and 59% mixed insulin by an average of 23%, 23% and 11%, respectively. Oral antidiabetic agents (OADs) were used concurrently in 16% of admissions with HE, of which sulfonylureas (SU) represented 43%, metformin 25%, and DPP-4i 26%. At the time of the HE, patients were on an oral diet in 73% of admissions, TPN or tube feeds in 6%, and NPO in 12%. In 75% of the HE, basal insulin was administered without the use of guideline-based hospital order sets and 83% of HE did not have an endocrinology consultation. Our analysis demonstrates several key issues that need to be addressed around the recommended practice of basal insulin in the hospital setting. Among them, inadequate response in dose reduction after the first HE, underutilization of standardized order sets, concurrent use of OADs, particularly SU, add risk for HE. Endocrinology consultation is low, and the complicated nature of a basal-bolus insulin regimen as well as the many variables involved remain real world challenges. Disclosure A. Pandya: None. S. Nguyen: None. V. Saldivar: None. A.R. Sadhu: None.

Implementing a multi-site cardiac arrest quality improvement initiative

Background: 
 Medical cardiac arrest care in Edmonton Zone Emergency Departments does not undergo structured quality monitoring or continuous improvement. Prior to this work, quality indicators had not been selected, nor had tracking or reporting activities been undertaken. This work brings the Edmonton Zone EDs to the forefront of the continuous quality improvement recommendations made by Heart and Stroke Canada and the American Heart Association that are believed to improve both patient outcomes and overall system performance.
 For this project quality indicator development and implementation takes three perspectives: patients and families, frontline staff and the health care system. This work is informed by the Institute for Healthcare Improvement, the National Institute of Science and the International Liaison Committee on Resuscitation’s work on Systems of Care and Continuous Quality Improvement for Emergency Cardiovascular Care. This work is motivated by the desire to improve patient/family experience and outcome, provider experience while improving system performance.
 
 Implementation: 
 An iterative process identified the lowest resource/highest impact areas for improvement. This process was informed through a Delphi survey conducted by the Alberta Cardiac Arrest Stakeholders group and stakeholder engagement. Four areas for improvement were identified: support of patients and families, support of staff, improvement in care metrics, and system level interventions. Support of patients and families was accomplished through the development of an advisory network, by linking families with existing supports, and through the implementation of a bereavement package. Supporting staff was accomplished through the development of a formal and informal debriefing processes. Improving clinical care was accomplished through the integration of chest compression feedback devices into clinical care. Improvements at the system level will be accomplished through the creation of a cardiac arrest registry.
 
 Evaluation Methods:
 Mixed methods approaches are used to evaluate this project. Post cardiac arrest quality track forms are being filled out. Chest compression feedback device data was obtained through simulated patient-care scenarios, staff experiences were obtained through a structured survey. Clinically chest compression data was collected from the feedback devices by Clinical educators, through tracking forms, and pre-and-post surveys of frontline staff measuring burnout and occupational stress are underway. Data is being collected in a local registry to generate accurate incidence and survival rates. Eventual post-implementation interviews with providers, survivors and families will be conducted.
 
 Results:
 A patient/family advisor network has been established. Survivor and families can be connected with the Bystander Support Network and the Heart and Stroke Foundation portal through the bereavement packages being offered at one of the QI sites. Two sites have developed staff debriefing processes: an interdisciplinary Critical Incident Stress Management (CISM) team at one site, and referral to an existing CISM team at two other sites. Chest compression feedback is being used at two sites, staff feedback has been positive. One site is tracking resuscitation metrics which are being used to guide and evaluate the interventions: continued improvement in chest compression quality has been noted. Data analytics are being used at all sites to identify additional opportunities to improve resuscitation care and efforts are underway to expand data collection to other sites and to unify pre-hospital and in-hospital cardiac arrest data.
 
 Advice and Lessons Learned:
 
 Pre-intervention data would have allowed for more meaningful comparisons in patient care. Efforts should be put into identifying what these measures could be.
 High levels of staff engagement at one site appear to have influenced the uptake of chest compression feedback. Effort should identify key stakeholders and gain buy in to increase uptake
 There are significant barriers to unifying pre-hospital and in-hospital cardiac arrest data. It is our belief that a continuous record offers some greatest opportunity to collect data on resuscitation care. Efforts should focus on building a linkage between these data sources and creating a shared data set.

Helping Unlock Better Care (HUB|C) using quality improvement science in community pharmacies - An implementation method.

Community pharmacists' optimal scope of practice extends far beyond traditional dispensing or compounding, and health promotion or chronic disease management services based in the pharmacy can generate significant social and economic value. But, with many competing demands and performance expectations from patients, payers, and policymakers, many pharmacies face challenges when introducing, maintaining, optimizing, or integrating their service offerings. Quality Improvement (QI) science may provide a practical change management framework for pharmacy professionals to lead their teams in embracing optimal scope and in making pharmacy-based services more feasible and attractive for all parties. To build community pharmacies' capacity for continuous QI (CQI) and to understand how the implementation of CQI is best achieved in this setting. Community pharmacies will undertake a process of change within one or more existing pharmacy services. Participatory action research principles will empower these sites to identify their own opportunities for improvement, generate change ideas, and trial and study those ideas in practice, using a QI system built on the Model for Improvement and Plan-Do-Study-Act (PDSA) cycles. An external Quality Facilitator will consult and train an internal Change Champion and other pharmacy staff to use QI tools and strategy. Mixed methods will be used to explore changes in pharmacy service quality, and to understand the experience of the pharmacy professionals taking part in the QI process. To assess the capacity and willingness of community pharmacies to undertake self-directed QI initiatives, with the support of an external Quality Facilitator and an established QI approach. Understandings surrounding the transferability of this process, including further scale-up, and the production of additional change management tools are additional potential outcomes of this work.

Can We Move the Needle on School Mental Health Quality Through Systematic Quality Improvement Collaboratives?

Learning collaboratives (LCs) have often been used to improve somatic health care quality in hospitals and other medical settings, and to some extent to improve social services and behavioral health care. This initiative is the first demonstration of a national, systematic LC to advance comprehensive school mental health system quality among school district teams. Twenty-four districts representing urban, rural, and suburban communities in 14 states participated in one of two 15-month LCs. Call attendance (M = 73%) and monthly data submission (M = 98% for PDSA cycles and M = 65% for progress measures) indicated active engagement in and feasibility of this approach. Participants reported that LC methods, particularly data submission, helped them identify, monitor and improve school mental health quality in their district. Qualitative feedback expands quantitative findings by detailing specific benefits and challenges reported by participants and informs recommendations for future research on school mental health LCs. Rapid-cycle tests of improvement allowed teams to pursue challenging and meaningful school mental health quality efforts, including mental health screening in schools, tracking the number of students receiving early intervention (Tier 2) and treatment (Tier 3) services, and monitoring psychosocial and academic improvement for students served.

Aligning Graduate Medical Education Improvement Projects With Merit Incentive-Based Payment System Requirements via Functional Outcome Measures.

The Merit-based Incentive Payment System (MIPS) is a requirement for all physicians for value-based reporting. Medicare has approved registries as a mechanism for MIPS reporting. Concurrently, residencies continue to abide by the Accreditation Council for Graduate Medical Education's (ACGME's) curriculum requirement of utilizing/practicing quality improvement (QI).The objectives of this study were as follows: (1) incorporate a meaningful functional outcome measure into an electronic health record (EHR) to track spine functional outcomes; (2) generate a report containing covariables extracted from the EHR system to provide trackable data for current and future resident QI projects/investigations; and (3) establish an infrastructure to align ACGME QI initiatives with the MIPS requirements. This pilot study and retrospective analysis successfully demonstrates how a meaningful functional outcome measure can be incorporated into the EHR system for QI. Moreover, it demonstrates successful establishment of infrastructure for alignment of QI projects for ACGME residency requirements with MIPS requirements.

Finding Analysis of Medical Device Manufacturer Audit in Suzhou Industrial Park for the Last Three Years

Common findings are to be found from 144 different type of medical device manufacturers' audit reports which are from Jan. 2017 to Jun. 2019. Advise is to be provided for medical device manufacturers on continual improvement. Classify and analyze the on-site audit findings from different type of medical device manufacturers. The frequency of findings from chapter production management, buildings and facilities, quality control are comparatively high. The key to improve the quality management system is to cultivate the staff sense of continual improvement of quality system, improve the staff ability of finding and solving problems, encourage staff participation in quality system, fit the quality system on product realization.

“Quality” assurance features in state-funded early childhood education: A policy brief

Most states in the U.S. now have some form of publicly funded Pre-Kindergarten. This brief asks what they have done to ensure the quality of their programs. It does so by mapping state adoption of three popular program quality assurance features: Early Learning Standards, Kindergarten Entry Assessments, and Tiered Quality Rating and Improvement Systems. We find that all three are now widespread across the American states, despite little research on their effects. We suggest that these quality assurance features need to be subjected to rigorous evaluation tied to their effectiveness in improving student outcomes.

Cohort study of neonatal resuscitation skill retention in frontline healthcare facilities in Bihar, India, after PRONTO simulation training

BackgroundUse of simulation in neonatal resuscitation (NR) training programmes has increased throughout low-income and middle-income countries. Many of such programmes have demonstrated a positive impact on NR knowledge and skill...

An Improved-SRF Strategy for Distribution Grid Connected SPV System for Power Quality Improvement under Non-linear Load Conditions

In few decades, non-conventional energy sources have been consider as the most encouraging source for off-grid power generation. It is challenging task to generate power with renewable sources integrated with grid with improved power quality. In this paper, an improved current control strategy is propose for photovoltaic grid connected system for empowerment of power quality. Also a hybrid PLL is propose in this paper which detects the phase angle with high accuracy. Due to the utilization of power electronic devices, harmonics are produce in system and this one is the major concern which creates the power quality issues. It is also difficult to compensate the effects imposes on system due to non-linear loads. Thus, the priority of this paper goes for the improvement of power quality by simply reducing total harmonic distortion (THD) with maintaining balance source under non-linear load condition. This paper includes some improved features of synchronous reference frame method which leads to a low THD. The propose method is simulated in matlab environment to reveal its fruitfulness.

Simplifying quality rating systems in early childhood education

High-quality preschool experiences can promote children’s short- and long-term development, yet many children in the United States still lack access to high-quality care. Many states have turned to Quality Rating and Improvement Systems (QRIS) in an attempt to solve this problem. Unfortunately, recent empirical work has shown that most QRIS ratings are not linked to either program quality or children’s learning gains, leading to calls for reform. In particular, in recent years there have been calls to simplify QRIS and focus accountability on a smaller set of quality measures that are linked to children’s development. This exploratory study probes the potential of such an approach, comparing how a single measure of quality compares to a set of commonly-used QRIS indicators (e.g. teacher education, an observational measure of teacher-child interactions, classroom size/ratio, opportunities for family involvement, etc.). Our findings—that a QRIS system based on an observational measure of the quality of teacher-child interactions alone is equally effective at predicting children’s learning gains as a more complex set of indicators—align with recent calls for second generation QRIS that use fewer, but more powerful indicators. Implications for research and policy are discussed.

HUMAN FACTOR IN THE QUALITY IMPROVEMENT SYSTEM OF AIRCRAFT MAINTENANCE

The subject matter of the article is the analyzes of the human factor in the quality improvement system of maintenance markers, which are aimed to evaluate the completeness of amount of work completed by the responsible party and technology of work performance as provided for by an engineering order, the goal is compare the results of the work of various operators and teams with established standards or against each other, for justification of measures aimed at quality improvement, evaluation of these measures effectiveness. On the basis of the purpose of the quality indicators and the methods for their determination, there are distinguished – initial quality evaluation, composite quality measures and overall quality level. Each type of maintenance quality evaluation has corresponding fields of application and calculation procedure. The methods used are semi-Markov processes with a finite set of states, a generalized structured method, the use of game theory, construction and analysis of cause and effect graphs, and situation assessment tree graph. Results. Taking into consideration the constant complication of aviation technique (AT), by means of new technologies introduction, new requirements are being put forward for the ground support personnel, and as the result, the price for aircraft failure has risen. That’s why, the reduction of failures amount through the fault of maintenance personnel due to the psychological characteristics of their activities is among the priority tasks with regards to flight safety. This goes to prove that the influence of the human factor on the quality and effectiveness of aircraft maintenance has not been fully studied in world wide aeronautical science. Conclusions. In general, the problem of improving the quality of professional activities of maintenance operators is complex and research should concern the entire aspect of the factors affecting its performance

Baseline Cardiopulmonary Resuscitation Skill Performance of Nursing Students Is Improved After One Resuscitation Quality Improvement Skill Refresher.

This article reports the results of baseline cardiopulmonary resuscitation (CPR) skills performance measurements from 467 nursing students. All participants had completed a CPR course. Baseline measurements were compared to performance after one 10-minute refresher training session on the Resuscitation Quality Improvement system. Significant improvements were made after the computer- and practice-based refresher. Findings suggest that staff developers should evaluate the use of audio and visual feedback devices to improve the quality of CPR provided by clinical staff.

Building, scaling, and sustaining a learning health system for surgical quality improvement: A toolkit.

This article describes how to start, replicate, scale, and sustain a learning health system for quality improvement, based on the experience of the Michigan Surgical Quality Collaborative (MSQC). The key components to operationalize a successful collaborative improvement infrastructure and the features of a learning health system are explained. This information is designed to guide others who desire to implement quality improvement interventions across a regional network of hospitals using a collaborative approach. A toolkit is provided (under Supporting Information) with practical information for implementation.

Detection of colorectal adenomas with a real-time computer-aided system (ENDOANGEL): a randomised controlled study

Colonoscopy performance varies among endoscopists, impairing the discovery of colorectal cancers and precursor lesions. We aimed to construct a real-time quality improvement system (ENDOANGEL) to monitor real-time withdrawal speed and colonoscopy withdrawal time and to remind endoscopists of blind spots caused by endoscope slipping. We also aimed to evaluate the effectiveness of this system for improving adenoma yield of everyday colonoscopy. The ENDOANGEL system was developed using deep neural networks and perceptual hash algorithms. We recruited consecutive patients aged 18-75 years from Renmin Hospital of Wuhan University in China who provided written informed consent. We randomly assigned patients (1:1) using computer-generated random numbers and block randomisation (block size of four) to either colonoscopy with the ENDOANGEL system or unassisted colonoscopy (control). Endoscopists were not masked to the random assignment but analysts and patients were unaware of random assignments. The primary endpoint was the adenoma detection rate (ADR), which is the proportion of patients having one or more adenomas detected at colonoscopy. The primary analysis was done per protocol (ie, in all patients having colonoscopy done in accordance with the assigned intervention) and by intention to treat (ie, in all randomised patients). This trial is registered with http://www.chictr.org.cn, ChiCTR1900021984. Between June 18, 2019, and Sept 6, 2019, 704 patients were randomly allocated colonoscopy with the ENDOANGEL system (n=355) or unassisted (control) colonoscopy (n=349). In the intention-to-treat population, ADR was significantly greater in the ENDOANGEL group than in the control group, with 58 (16%) of 355 patients allocated ENDOANGEL-assisted colonoscopy having one or more adenomas detected, compared with 27 (8%) of 349 allocated control colonoscopy (odds ratio [OR] 2·30, 95% CI 1·40-3·77; p=0·0010). In the per-protocol analysis, findings were similar, with 54 (17%) of 324 patients assigned ENDOANGEL-assisted colonoscopy and 26 (8%) of 318 patients assigned control colonoscopy having one or more adenomas detected (OR 2·18, 95% CI 1·31-3·62; p=0·0026). No adverse events were reported. The ENDOANGEL system significantly improved the adenoma yield during colonoscopy and seems to be effective and safe for use during routine colonoscopy. Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Hubei Province Major Science and Technology Innovation Project, and the National Natural Science Foundation of China.

Re-engaging students in medical school accreditation: the independent student analysis action (ISA2) approach

This article was migrated. The article was marked as recommended. Background: Student satisfaction with key aspects of a medical school program plays a major role in an institution's accreditation in the United States (US). There is limited evidence regarding how to best engage students in responding to areas of lower student satisfaction that are identified through the national Liaison Committee on Medication Education (LCME) accreditation self-study process. Methods: We present a student-led innovation to promote greater levels of student engagement throughout Harvard Medical School's re-accreditation experience, which we refer to as the Independent Student Analysis Action (ISA2) process. This innovation built directly upon the Independent Student Analysis (ISA) survey, which is expected by the LCME for accreditation. The ISA2 process allowed medical student leaders to leverage ISA results to identify 11 priority areas that had relatively lower levels of satisfaction and subsequently coordinate focused, time-limited ISA2 working groups to address these problematic areas. These working groups then presented their solutions to the student body, and a follow-up survey gauged satisfaction with these areas in light of the changes made. Results: The ISA2 process engaged over 110 students, faculty, and staff. The majority of the student body completed the follow-up survey, which demonstrated higher levels of satisfaction with these previously problematic areas as identified in the original ISA survey. Further, 96% of students reported being satisfied with the ISA2 process as a mechanism for utilizing student feedback in the ISA to create meaningful institutional changes. Conclusions: The ISA2 served as a powerful convening mechanism for engaging a large number of students in our institution's re-accreditation efforts. Other medical schools looking to involve students in their continuous quality improvement systems and accreditation experience may benefit from reviewing and customizing this model to their institution's needs.

Should all paediatric appendicectomies be performed in a specialist or high-volume setting?

Acute appendicitis is a common surgical emergency in children. The majority of appendicectomies in children are performed by general surgeons, rather than specialist paediatric surgeons. To assess the impact of hospital specialization, hospital volume, and surgeon volume on outcomes for children undergoing appendicectomy in Ireland. NQAIS (National Quality Assurance and Improvement System) data for all appendicectomies performed on children in Ireland between January 2014 and November 2017 was examined. Hospitals were categorized as specialist paediatric centres (SPCs), high-volume general (HVGHs), moderate-volume general (MVGHs), or low-volume general (LVGHs) by annual case volume. Similarly, surgeons were categorized as high-volume (HVSs), moderate-volume (MVSs), or low-volume (LVSs) by annual volume. Data relating to patient demographics, type of surgery (open/laparoscopic/laparoscopic converted to open), length of stay (LOS), mortality, admission to critical care, and readmission rates were collected and analysed. About 9593 appendicectomies were performed in 21 hospitals by 134 surgeons. Patients in SPCs had lowest overall rates of laparoscopic surgery (48% v 66% (HVGHs) v 70% (MVGHs) v 57%(LVGHs), p< 0.001). In SPCs 30-day readmission rates were lower for younger children (5.3% for 5-8-year olds v 6.7% (HVGHs) v 7.3%(MVGHs) v 10.5% (LVGHs), p= 0.023). HVSs performed more laparoscopic appendicectomies on younger patients (0-4years: 40% v 6% (MVSs) v 17%(LVSs), p< 0.001) but performed the least on older children (13-16years: 76% v 82%(MVSs) v 82%(LVSs), p< 0.001). Children younger than 8years undergoing appendicectomy in HVGHs or SPCs, or by HVSs, have marginally better outcomes. In older children, marginally shorter in-hospital stays and higher laparoscopic rates are seen in those looked after outside of high-volume or specialist units. Our results show that nonspecialist centres provide an essential, and safe, service to paediatric patients with acute appendicitis.

3D Technologies as the Future of Spatial Planning: the Example of Krakow

The main goal of the paper is to make a general assessment of the application of 3D technologies in spatial planning. It was performed with the city of Krakow as the case study. The paper describes the outline of the spatial planning system in Poland and the planning conditions of Krakow. The data obtained from laser scanning for Krakow are also briefly characterized. The possibility of using these data for locating high-rise buildings in terms of the protection of Krakow’s panorama and within two programs “IT system of the Country’s Protection Against Extreme Hazards” (ISOK) and “Integrated spatial data monitoring system for air quality improvement in Krakow” (MONIT-AIR) were analyzed in the paper. The main result of the research is the assessment of what studies or measurements may be used to meet particular spatial planning needs or requirements.

Primary care initiatives focused on the secondary prevention and management of chronic pain: a scoping review of the Australian literature

The aim of this scoping review was to identify initiatives focused on the secondary prevention and management of chronic pain in Australian primary care to understand options available to Primary Health Networks and to identify evidence gaps. The Medline, EMBASE, Cumulative Index to Nursing and Allied Health Literature and Cochrane databases, as well as relevant websites, were searched for eligible records published from 2007 to 2018. Initiative characteristics and outcomes evaluated were extracted and synthesised. In all, 84 initiatives from 167 published and grey literature records were identified, including: (1) consumer initiatives that aimed to improve access to multidisciplinary care, health literacy and care navigation (n=56); (2) health professional capacity building initiatives that aimed to ensure health professionals are skilled and provide best-practice evidence-based care (n=21); and (3) quality improvement and health system support initiatives (n=7). Evidence gaps were found relating to initiatives addressing the secondary prevention of chronic pain, those targeting vulnerable and regional populations, health professional capacity building initiatives for all primary health care providers and quality improvement and system support initiatives. Addressing evidence gaps related to effectiveness, cost-effectiveness and implementation should be the focus for future chronic pain initiatives in primary care settings.

Early Childhood Education and Child Care in Arizona : Is Availability Alone Sufficient?

With many states increasingly adopting Quality Rating and Improvement Systems (QRIS) to rate their early childhood education (ECE) and child care programs, researchers question the use of these systems. Specifically, they are trying to understand the value of information provided by QRIS ratings and the implications QRIS ratings have on the quality of and access to ECE and child care programs for families. In this study, we attempt to understand the value of QRIS ratings when they are provided for families at the household level. To do so we take a close look at the relationship between availability of programs rated by the Quality Improvement and Rating System (QIRS) in Arizona and demographics of the communities they serve, and compare the utilization of the programs in communities with varying demographic compositions. While we find that more high-quality ECE and child care programs are available for children that are Hispanic, Black, and eligible for free and reduced-price lunch, we also find that families underutilized those programs. We argue that this underutilization might be due to a variety of barriers that the families are experiencing and believe that efforts should be directed to work with families and assist them in understanding their enrollment options.

Influence of quality credentialing programs on teacher characteristics in center-based early care and education settings

Considerable evidence relates the quality of early childhood education (ECE) to children’s developmental outcomes, with teacher qualifications often cited as a critical ingredient for high-quality care. As a result, quality credentialing programs—including Quality Rating and Improvement Systems (QRIS) and the National Association for the Education of Young Children (NAEYC) Early Learning Program—are increasingly prominent vehicles for improving program quality. This study combines a randomized resume audit study with administrative data on provider participation in QRIS (N = 5607) and NAEYC (N = 10,553) to examine whether these quality credentialing programs influence provider behavior during the teacher hiring process. While NAEYC-accredited providers are strongly attracted to job applicants with ECE work experience, education, and other professional credentials, QRIS participants are not.