Quality Management Team Research Articles

Warming Blanket Head Drapes and Trapped Anesthetic Gases: Understanding the Fire Risk

Polyethylene warming blanket head drapes are widely used to help surgical patients maintain normothermia. The OR quality management team at Froedtert Hospital, Milwaukee, Wisconsin, designed a quality improvement project using an intubation mannequin to determine whether a head drape used on an intubated patient would enhance the risk of ignition in the presence of an undetected anesthesia system gas leak. The team revealed several significant factors, including higher oxygen flow rate, the presence and application of the head drape, and not using the warming blanket blower, in the accumulation of oxidizers. Considerations for the surgical team when using the head drape include cutting a fenestration in the drape around the endotracheal tube or otherwise venting the drape, using the blanket blower, and having the anesthesia care provider frequently lift the head drape, thus minimizing the accumulation of trapped gases.

Putting the Kappa Statistic to Use

AbstractInter‐rater assessments of agreement are an essential criterion in the subjective evaluation of product quality. When assessments among raters demonstrate evidence of a lack of agreement (partial or total), there is a need to identify the source of disagreement. The objective being the reduction or mitigation of the influence different raters have on the assessment and the achievement of consistency among raters. The less influence that raters have on the assessment, the more confident one is in making critical to quality decisions. However, situations do exist in which user perceptions can be unreliable (not repeatable) and demonstrate poor correlation with engineered specifications. Quality management teams must be aware of this. When such situations exist, it is advisable to revisit the voice of the process as a reliable function of specification. Copyright © 2011 John Wiley & Sons, Ltd.

Certifying a university ENT clinic using the ISO 9001:2000 international standard

Against statutory duties to introduce quality management systems, the increased importance of this subject has led to numerous activities in various public health institutions. Following the International Standardization Organization (ISO 9001:2000) prerequisites, Frankfurt Goethe University Hospital ENT clinic staff introduced a quality management system. This paper aims to investigate this process. Designing, planning and implementing the quality management system is described. Under the supervision of an executive quality management board, clinic quality goals were defined. Thereafter, several quality management teams performed an actual state analysis as well as developing and realising improvement proposals. Finally a quality management manual containing binding standards and working instructions concerning all patient care, research and teaching aspects was written. Successful certification by a neutral body ascertained that the clinic's quality management system conformed to current national and international standards while restructuring and reform improved procedural efficiency. The paper shows that mplementing the quality management system requires considerable effort but patients as well as staff profit considerably from the innovation. On the whole, the positive impact on structure and workflow in a specialist clinic predominates. Therefore, implementing a quality management system in all the clinic's wards and departments is recommended.

Evolution of Quality at the Organ Center of the Organ Procurement and Transplantation Network/United Network for Organ Sharing

One of the goals of the Organ Center of the Organ Procurement and Transplantation Network/United Network for Organ Sharing is to increase the efficiency of equitable organ allocation in the United States. Recognizing the ever-growing need for organ donors and transplants, leaders at the Organ Center increased its commitment to quality improvement initiatives through the development of a quality management team in 2001. The Organ Center began to focus on ways to capture data on processes and pinpoint areas for improvement. As the collection and analysis of data evolved, the Organ Center embraced formal quality standards, such as improvement cycles. Using these cycles, the Organ Center has seen significant improvement. One initiative involving lifesaving heart, lung, and liver placement showed success by doubling the Organ Center's organ placement rate. Another project involving the validation of donor information demonstrated that the accuracy of organ allocation can be improved by 5% on a consistent basis. As stewards for the gift of life and leaders in organ allocation, the Organ Center uses continuous quality improvement to achieve the goal of increasing the efficiency of equitable organ allocation.

Evolution of quality at the Organ Center of the Organ Procurement and Transplantation Network/United Network for Organ Sharing

One of the goals of the Organ Center of the Organ Procurement and Transplantation Network/United Network for Organ Sharing is to increase the efficiency of equitable organ allocation in the United States. Recognizing the ever-growing need for organ donors and transplants, leaders at the Organ Center increased its commitment to quality improvement initiatives through the development of a quality management team in 2001. The Organ Center began to focus on ways to capture data on processes and pinpoint areas for improvement. As the collection and analysis of data evolved, the Organ Center embraced formal quality standards, such as improvement cycles. Using these cycles, the Organ Center has seen significant improvement. One initiative involving lifesaving heart, lung, and liver placement showed success by doubling the Organ Center's organ placement rate. Another project involving the validation of donor information demonstrated that the accuracy of organ allocation can be improved by 5% on a consistent basis. As stewards for the gift of life and leaders in organ allocation, the Organ Center uses continuous quality improvement to achieve the goal of increasing the efficiency of equitable organ allocation.

Nosocomial infections: MRSA und CDAD as a challenge

Inadequate antibiotic prescribing and poor adherence to infection control guidelines are the main reasons for the development and spread of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (CD), the most important cause of antibiotic-associated diarrhoea (AD) and colitis. Both CDAD and MRSA infection are associated with significant morbidity, excess mortality and substantial consumption of resources. Increases in the incidence of both infections have been observed in Germany and represent a challenge to clinicians, infection control practitioners, quality management teams und hospital administration. Prudent use of antibiotics, in particular critical prescribing of fluoroquinolones and cephalosporins, is an important component in programmes aiming at an effective prevention of MRSA and CDAD. Other similarly important components are minimization of pathogen transmission between patients and healthcare personnel by isolation and contact precautions, early detection of MRSA carriers and MRSA decolonization treatment. It must be ascertained that patients nursed in isolation rooms receive medical care of similar high quality as all other patients. Over the last years, there has been no major breakthrough in therapy and outcomes in both CDAD and MRSA infection. Close collaboration between hospitals, nursing homes and primary care institutions will be critical for better control of MRSA and CDAD.

Measuring the cost of quality in a hotel restaurant operation

PurposeThe objective of this research is to apply the cost of quality (COQ) concepts in a hotel restaurant environment using the PAF (prevention, appraisal, and failure costs) model. Then use the percentage of sales approach to evaluate the significance of the COQ measures in the PAF model.Design/methodology/approachThis research involved reviewing available literature on the COQ framework. Then through the process of interviews and secondary data collection, an analysis of the COQ measures in the PAF model was accomplished.FindingsWhile researchers suggested that the COQ should be 2 to 4 percent of sales, the actual findings were 12 to 16 percent over a two‐year period. These findings help the restaurant quality management team to reevaluate the quality of food and services, and provide justification for more investment in prevention activities.Practical implicationsThe practical implication from this study was that an investment in prevention activities in the PAF model for the restaurant did lead to reduction in failure costs (internal and external) and appraisal costs.Originality/valueThis study demonstrates that the COQ measures used in the PAF model can improve the quality of food and services provided to the restaurant customers, and therefore, result in improvement in overall profitability.

Implementation of Online Radiology Quality Assurance Reporting System for Performance Improvement: Initial Evaluation

To evaluate an online system developed and implemented for reporting and managing quality assurance (QA) events occurring in a radiology department. This HIPAA-compliant study had institutional review board approval; informed consent was not required. Using repeated plan-do-study-act cycles, a radiology quality management team applied a 10-step process to implement an online reporting system. The system permits remote submission of cases by staff members. The number of weekly submissions to the system over a 9-month period was evaluated and compared with that for the preceding 6 months by using the Mann-Whitney test. Sources and nature of data, actions initiated, and final outcomes were also analyzed. Recorded data included forum of discussion, dimension of care, action items, monitoring of follow-up and compliance, and notification status. During the first 9 months of implementation, 605 cases were submitted (mean, 21.4 cases per week), a significant increase (P < .005) compared with the preceding 6 months (mean, 3.2 cases per week). Cases, which were submitted by residents (121 cases [20.0%]), fellows (94 cases [15.5%]), faculty members (319 cases [52.7%]), or technologists (54 cases [8.9%]), reported technical (33.1%) or administrative (8.0%) issues. The 329 clinical cases (54.4%) included 60 errors in communication (18.2%), 67 errors in interpretation (20.4%), 78 diagnostic delays (23.7%), 99 missed diagnoses (30.1%), and 54 procedural complications (16.4%); some cases were in more than one category. Twenty-three cases (3.8%) resulted in submission-related QA projects, and 69 cases (11.4%) resulted in individuals or sections of the hospital undergoing additional training. A secure online QA reporting system promotes reporting of QA events and serves as a database for identifying and managing trends, initiating performance improvement projects, and providing feedback to staff members who submit cases.

Facilitated Process Improvement: An Approach to the Seamless Linkage Between Evidence and Practice in CKD

Two common strategies for guideline implementation are preformed practice improvement tools, such as flowcharts, and process reengineering by total quality management (TQM) teams. Prespecified tools fail to accommodate local circumstances, TQM requires an unrealistic level of local commitment, and neither has a proven track record for success. We describe an alternative approach termed facilitated process improvement (FPI), a systematic exploration of potential modifications to systems of care, and its application to the implementation of an evidence-based chronic kidney disease (CKD) guideline, focusing on individuals not yet requiring renal replacement therapy. The FPI steps followed by the implementation work group to develop a set of implementation tools for the Renal Physicians Association Advanced CKD Guideline included: (1) developing functional specifications of processes, including actions and prerequisites required; (2) investigating processes of care in a variety of site types to understand processes and reasons for failures; (3) developing practical tools corresponding to root causes of failures of processes and subprocesses; and (4) developing a meta-tool to tailor local selection of tools. Formal needs assessment identified processes of care related to 3 major tasks: identify patients, develop and communicate patient-specific management plan, and implement plan. Subtasks were identified to address root causes of failures, and, for each, tools were modified from existing or developed de novo by the work group, which further developed an organized management approach that uses 4 categories of tools: (1) assessment tools identify opportunities for improvements; (2) tailoring tools, a unique feature of this approach, determine which tools are applicable; (3) implementation tools identify patients and communicate and implement management plan; and (4) evaluation tools assess the impact of implementation. The work group, in collaboration with community clinicians, patients, and CKD and tool experts, developed and used FPI to provide a range of tools in a fashion that supports and simplifies local assessment, tailoring, implementation, and evaluation. With the formative work completed, practitioners whose practice improvement experience level and other resources may be limited will find it more feasible and practical to provide optimal advanced CKD management without the demands of conventional TQM or continuous quality improvement.

Decreasing Adverse Drug Events Associated with Lepirudin and Argatroban for the Treatment of Heparin-Induced Thrombocytopenia.

Purpose: Case reports, as well as our anecdotal experience, revealed frequently elevated activated partial thromboplastin time (aPTT) levels in some patients on the direct thrombin inhibitors (DTI) lepirudin and argatroban when dosed according to the FDA-approved guidelines in the Product Inserts. We analyzed our institution's experience with these agents to determine if dosing guidelines need reconsideration.Methods: A retrospective chart review was conducted under the auspices of the pharmacy quality management team, with IRB approval. Cases were from the pharmacy database of all patients that received lepirudin or argatroban from September 2002 through March 2004. Sixty-six cases were identified and reviewed.Results: Patients were treated with the DTI for Heparin Induced Thrombocytopenia, with or without thrombosis (HIT, HITT), based on a decline of platelet count on heparin by 50% or to <100,000/uL (70%, n=46), and/or a positive HIPA ELISA (27%, n=18). 39 patients received lepirudin and 27 patients argatroban. The mean dose of the DTI which resulted in a therapeutic aPTT (55–80 sec) was calculated for each patient. The mean lepirudin dose resulting in therapeutic aPTT was 0.071 mg/kg/hr with 35 (90%) of patients requiring less than the recommended dose of 0.15mg/kg/hr. Only 4 (10%) patients had a mean dose at or above the recommended dose. 19 (49%) patients required 0.05 mg/kg/hr or lower. The mean argatroban dose resulting in therapeutic aPTT was 1.52 mcg/kg/min. 18 (67%) of patients required less than the recommended dose, 4 (15%) patients had a dose equal to the recommended, and only 5 (18%) had a mean dose above the recommended dose. aPTT levels were therapeutic or supratherapeutic a majority of the time in both groups, even though the dosing of the two DTI was overall lower than the recommended dosing. Furthermore, for many of the patients with both agents, there was a poor correlation between the dose of the DTI and the resulting aPTT, making it difficult to predict the resulting aPTT for a given dose adjustment of the DTI. Lastly, twenty occurrences of written prescription errors in five patients receiving argatroban were identified. These errors were due to the confusion between the dosing of argatroban as mcg/kg/min and not mg/kg/hr. The incorrect dose of argatroban was not dispensed to any patient.Conclusion: The DTI, Lepirudin and argatroban, used for HIT/HITT lack specific dosing titration guidelines, yet they require careful dosing and close monitoring for safe use. As with any acute anticoagulant, they carry a significant risk of life-threatening hemorrhage. Results of this study suggest that current dosing recommendations for both agents are too high, and that for safer use with lower risk of hemorrhage, the dosing guidelines need to be lowered. And while it is not likely that the prescribing errors for argatroban will be administered by pharmacy departments and nurses, the appropriateness of dosing the agent as mcg/kg/min as opposed to the more typical mg/kg/hr should be addressed, at least by greater physician education and possibly by altering the product insert. This study also supports that both lepirudin and argatroban should be considered high-alert medications requiring special attention by experienced clinicians.

Using focus groups to evaluate and strengthen public health nursing population-focused interventions.

Nebraska Health Connection Access Medicaid's (NHC AM) public health nursing (PHN) population-focused practice model is designed to provide enrollment, education, and PHN case management interventions for the Medicaid Managed Care population. Evaluation and continuous improvement of these interventions are, in part, completed through a collaborative effort between NHC AM and a quality management team at the University of Nebraska Medical Center College of Nursing. Focus group methodology was used to access non-English-speaking populations to evaluate and strengthen population-focused PHN interventions.

Innovative Workplace Practices and Occupational Injuries and Illnesses in the United States

This article studies the consequences of organizational innovations on occupational injuries and illnesses in the American private sector over the past 20 years. High-performance workplace practices such as total quality management, job rotation and autonomous work teams can damage workplace health and safetythey can increase the intensity of work both in manufacturing and tertiary industries, and some practices can even be incompatible with the design and the assinirlation of safety rules. Using surveys on organizational changes in the USA, management literature and BLS-OSHA data, we show for 26 sectors that the adoption of high-performance practices seems correlated to a dramatic increase in occupational injuries and illnesses.

Management fads: Emergence, evolution, and implications for managers

Executive Overview Management fads often get a lot of attention. Should managers be concerned about the latest management fad, or is it just a waste of time?1 Considerable interest has been shown in the literature about management fads and fashions. Journal and newspaper articles abound,2 and professional books have been written on the subject.3 Unlike many literature-based, academic concepts, these fads and fashions are well known by practicing managers. This article focuses on five management fads of the late 20th century, each one representative of a management trend of a specific decade: MBO (1950s), sensitivity training (1960s), quality circles (1970s), total quality management (1980s), and self-managed or self-directed teams (1990s). In each case, this article explores the origin of the fad through its evolution into mainstream management practice. Further, each fad is examined to determine relevance to current management practice. The article offers practical guidelines for managers regarding which fads to embrace and when.

The adoption of innovative work practices in service establishments

Using data from the 1994 US National Establishment Survey, the author investigates differences between manufacturing and service establishments in the use of five innovative work practices: total quality management, self-managed teams, job rotation, job sharing and flextime. Service establishments are more likely to use job sharing and flextime. Manufacturing establishments are more likely to use total quality management and self-managed teams. These results hold when controlling for establishments’ business strategies, worker demographics, institutional connections and use of technology. Determinants of adoption of total quality management, self-managed teams and flextime also varied by sector.

Eliciting and mapping qualitative preferences to numeric rankings in group decision making

Group work is becoming the norm in organizations. From strategy planning committees to quality management teams, organizational members are collaborating on problem solving. One area of team support that is often desired is the scoring and ranking of decision alternatives on qualitative/subjective domains, and the aggregation of individual preferences into group preferences. In this paper we present a new conceptual approach to qualitative preference elicitation and aggregation. This approach is based on well established decision analysis techniques. It significantly advances the state of the art of group decision making by addressing four common limitations: (1) the inability to deal with vagueness of human decision makers in articulating preferences; (2) difficulties in mapping qualitative evaluation to numeric estimates; (3) problems in aggregating individual preferences into meaningful group preference; and (4) the lack of simple user friendly techniques for dealing with a large number of decision alternatives. Our approach is easy to implement in stand alone personal computers and groupware. We illustrate this with a real-world problem.

Work Organization, Technology, and Performance in Customer Service and Sales

The author analyzes the strengths and weaknesses of Total Quality Management and Self-Managed Teams, as compared to mass production approaches to service delivery, among customer service and sales workers in a large unionized regional Bell operating company. Participation in self-managed teams was associated with a statistically significant improvement in self-reported service quality and a 9.3% increase in sales per employee. When combined with new technology, teams boosted sales an additional 17.4%. These effects persisted over time. Total Quality Management, by contrast, did not affect performance. This study represents a “strong test” of the efficacy of teams because theory predicts weak outcomes for self-managed teams among service and sales employees in establishments where technology and organizational structure limit opportunities for self-regulation, the nature of work and technology do not require interdependence, and downsizing creates pervasive job insecurity—conditions found at the company studied here.

Work Organization, Technology, and Performance in Customer Service and Sales

The author analyzes the strengths and weaknesses of Total Quality Management and Self-Managed Teams, as compared to mass production approaches to service delivery, among customer service and sales workers in a large unionized regional Bell operating company. Participation in self-managed teams was associated with a statistically significant improvement in self-reported service quality and a 9.3% increase in sales per employee. In combination with new technology, teams boosted sales 17.4%. These effects persisted over time. Total Quality Management, by contrast, did not affect performance. This study represents a strong test of the efficacy of teams because theory predicts weak outcomes for self-managed teams among service and sales employees in establishments where technology and organizational structure limit opportunities for self-regulation, the nature of work and technology do not require interdependence, and downsizing creates pervasive job insecurity-conditions found at the company studied here.

United Resource Networks: how compliance issues affect a managed care transplant network

UNITED Resource Networks provides access to the nations’s leading medical delivery systems specializing in transplantation. The United Resources Networks Transplant Network was established in 1987 by contracting the transplant centers for United Healthcare. In 1991, URN began providing its national organ and tissue transplant network to non-United Healthcare payors. The URN Transplant Network is currently utilized by over 1400 customers including HMOs, indemnity carriers, self-funded employer groups, and resource distributors, such as reinsurers, stop-loss carriers, managing general underwriters (MGUs), and utilization and case management groups. Presently, there are 49 participating medical centers with over 123 solid-organ or tissue transplant programs in the URN Transplant Network. Transplant programs qualify for inclusion in the Transplant Network by undergoing a thorough program-credentialing process that evaluates the clinical and practical criteria shown in Table 1. Programs included in the Network undergo annual and ongoing evaluation by the URN Quality Management Team. Changes in team or physician leadership, specific patient or client concerns, or changing trends in clinical outcomes or administrative services are closely monitored to assure the standards for which a program was chosen for the Network are being maintained. In addition, Patient Satisfaction Surveys are performed and shared with the contracted centers on a routine basis. United Resource Networks negotiates global transplant package rates, which include evaluation, organ or tissue procurement, pretransplant and inpatient care, professional fees, ancillary services, and up to 12 months’ follow-up care for various transplant categories. United Resource Networks recently announced a Pediatric Transplant Network that was formed using criteria relating specifically to pediatric patients. In addition, URN provides a variety of strategic educational conferences and seminars throughout the year. Offerings include three Transplant Conferences for Payor Medical Directors, two Courses in Transplantation for Case Managers, and an Annual National Clinical Conference, which brings payors and providers together to discuss the changing trends in transplantation.

Overview of Gluten-Sensitive Enteropathy (Celiac Sprue)

Author: Amy E. Inman-Felton, RD, Quality Management and Research Team, The American Dietetic Association, and Owner, Quality Nutrition Services, Leawood, Kansas. Reviewers: Therese Beaudette, MS, RD, Editor, Seminars in Nutrition, Englewood, Colo; Merri Lou Dobler, MS, RD, Food Writer, The Spokesman-Review, Spokane, Wash; Carol Ireton-Jones, PhD, RD, Director, Nutrition Program Management, Coram Health Care, Carrollton, Tex; Elvira Q. Johnson, MS, RD, Director, Nutrition Services, Cambridge Health Alliance, Cambridge, Mass; Robert Kushner, MD, Director, Wellness Institute, Northwestern Memorial Hospital, Chicago, III; Karen G. Smith, MS, RD, FADA, Director of Support Services Systems, Morrison Health Care, Smyrna, Ga; Guenter Spanknebel, MD, Associate Professor, Department of Medicine, Digestive Diseases Division, University of Massachusetts Medical Center, Worcester. Editor's note: To obtain an electronic version of this protocol, E-mail your request tojgilbre@eatright.org.

Improving the Timing of Antimicrobial Prophylaxis through a Total Quality Management Approach

Studies have shown that the optimal time to give preoperative prophylactic antibiotics is within 2 hours prior to the incision. An initial study of perioperative antibiotic use at our institution revealed significant deficiencies both in the timing and the charting of preoperative antibiotics. In response to these findings, a multidisciplinary total quality management team was formed. This team identified several key problems related to the timing and documentation of preoperative antibiotics. Accordingly, our institution's method of prophylactic antibiotic delivery and administration was revised, and a program to educate appropriate staff was formulated. Following these interventions, a second study found that the number of preoperative antibiotic doses given at the proper time improved from 86% in the previous study to 98%, and that the number of doses properly charted improved from 84% to 94%.