Rapid-cycle Quality Improvement Research Articles

Improving Chronic Kidney Disease Care in Primary Care Practices: An Upstate New York Practice-based Research Network (UNYNET) Study

With the prevalence of chronic kidney disease (CKD) in the United States rising from 10% to 13%, implementation of the evidence-based Kidney Disease Outcomes Quality Initiative guidelines, which were developed for the delay of progression of CKD, is of increasing importance in primary care offices. Previous studies have shown limited knowledge and uptake of Kidney Disease Outcomes Quality Initiative guidelines by primary care physicians. CKD and its complications are still largely under-diagnosed and under-treated. A multifaceted quality improvement study was undertaken to test if these guidelines could be implemented to improve CKD care in underserved practices. Using a combination of practice enhancement assistants, computer decision-making support, and academic detailing, we sought to increase physician awareness and care of CKD in 2 inner-city practices. Using these 3 modalities, a rapid-cycle quality improvement process was implemented. One hundred eighty-one patients met the inclusion criteria of having a glomerular filtration rate <60. This represented a 100% sample of patients with CKD at baseline. Recognition of CKD improved significantly from 30 (21%) to 114 (79%) (P < .001). Diagnosis of anemia also increased significantly from 26 (33%) to 53 (67%) (P < .001). Angiotensin-converting enzyme inhibitor and aspirin use did not change significantly (P = .31 and P = .233, respectively). Changes in medications that did show significance were metformin use, which decreased 50% from 12 to 6 patients (P < .001), and nonsteroidal anti-inflammatory drug use, which decreased 41% from 23 to 14 patients (P < .001). Mean glomerular riltration rate increased significantly from 45.75 to 47.34 (P < .001). Recognition and treatment of CKD and its complications can be markedly improved in primary care offices using a combination of practice enhancement assistants, computer decision-making support, and academic detailing. A significant rise in glomerular riltration rate, although small, was a surprising and encouraging result. Larger studies in a more geographically spread region are needed to confirm these preliminary results.

Meadville Medical Center's Experience With the Accelerating Best Care in Pennsylvania Project: Lessons Learned and Future Directions

This paper demonstrates that the staff of a community hospital can learn a system of quality improvement (QI) and subsequently apply it to new challenges within the organization. Team members from Meadville Medical Center (MMC), a rural hospital in Northwestern Pennsylvania, participated in the Accelerating Best Care in Pennsylvania project to learn rapid-cycle QI methodology. The team applied this method to 2 areas that were identified as opportunities for improvement. The projects included increasing compliance with deep vein thrombosis prophylaxis in a hospital unit, and the administration of pneumococcal vaccinations on another unit. Compliance was 100% by the end of the initial measurement period. Improvements made to protocols and processes during the course of the projects have been extended successfully throughout the hospital. In response to the positive feedback and results, MMC created a similar system for teaching and implementing rapid-cycle QI and has applied it to additional projects with success.

Improving Delivery of Clinical Preventive Services: A Multi-Year Journey

Adults in the United States typically do not receive all recommended clinical preventive services (CPS) for which they are eligible, missing opportunities for prevention and/or early detection. A multi-year quality improvement initiative targeting CPS delivery in a fee-for-service ambulatory care network is described. Since 1999, HealthTexas Provider Network (HTPN) has implemented multiple initiatives to increase CPS delivery, including a flowsheet, a physician champion model, physician- and practice-level audit and feedback, and rapid-cycle quality improvement training. From 2000 to 2006, "recommended or done" CPS delivery increased from 68% to 92%, and "done" from 70% to 86% (2001 to 2006). "Perfect care" composite performance increased from 0.19 to 0.51 (2001 to 2006). Long-term, multistrategy approaches can achieve substantial sustained improvement in CPS delivery throughout a large ambulatory care provider network.

Taming Wicked Problems in Modern Health Care Systems

IN ORDER TO BE MOST EFFECTIVE, health care systems need to be able to prioritize not just the provision of technologically advanced and potentially curative care but also the psychosocially advanced and compassionate palliative care. However, it is well known that modern health care systems are socially complex organizations often fraught with perverse incentives and internal conflicts that serve as fertile grounds for wicked problems. The concept of “wicked problems”1 was originally proposed by Horst Rittel who stratified problems into tame or wicked problems. Tame problems are problems that have a definitive solution that can be identified using linear methods of problem solving involving the classic steps of data gathering, data analysis, solution formulation, and solution implementation (Fig. 1). Once the solution is implemented, the tame problem will usually be solved. For example, dirty hands often spread infection and frequent hand washing decreases spread of infection. In stark contrast to tame problems, wicked problems are those that cannot be solved using the standard linear methods of problem solving. In fact, wicked problems are characterized2 by the following: Wicked problems have incomplete, contradictory, and changing requirements and complex interdependencies that are often unique to the local setting of the problem. The stake holders of a wicked problem often have radically different world views for both understanding the problem and approaching its solution. The intricacies of a wicked problem are often not well understood until after formulation and trial of a solution. Every implemented solution to a wicked problem usually has consequences, and may even uncover additional problems deeply embedded in the structure of care. Wicked problems require adaptive solutions that are tailored to work in the local setting and need to be implemented by a group of local stakeholders and champions who are well acculturated in their organizational culture. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) study is a seminal study that identified and wrestled with a wicked palliative care problem that was (and still often is) widely prevalent in our health care system. The study was originally designed to improve end-of-life decision making and reduce the frequency of mechanically supported, painful, and needlessly prolonged process of dying. The phase 1 of SUPPORT identified problems in communication and an increased frequency of aggressive treatments in the face of terminal illness. In an effort to solve these (wicked) problems, the phase II of the study used specifically trained nurses to facilitate patient–physician communication and advance care planning. The solution attempted in the phase 2 of the SUPPORT did not solve the problem, but in fact exposed new aspects of the wicked problem which were deeply and insidiously rooted in the culture of modern biomedicine. Thus understandably the problem refused to lend itself to the traditional linear mode of problem solving. As Dr Lynne states in her pioneer essay, “SUPPORT’s authoritative defeat of prognostic information and shared decision-making as a strategy for reform pushed me to seek other strategies.” The use of the rapid cycle quality improvement process is certainly one of the more effective ways of taming wicked problems, as wisely identified by Dr Lynn. The intrinsically recurrent and iterative nature of the plan-do-study-act (PDSA) engine empowers local Pioneers in Palliative Care

Overcoming Barriers to Oxygen Saturation Targeting

To reduce hyperoxia in very low birth weight infants who receive supplemental oxygen, the Children's Mercy Hospital neonatal respiratory quality improvement committee introduced the potentially better practice of oxygen saturation targeting and identified strategies to overcome barriers to implementation of this practice. Using rapid-cycle quality improvement projects, this center adapted an oxygen saturation targeting protocol and tracked hourly oxygen saturation as measured by pulse oximetry in very low birth weight infants who received supplemental oxygen. The percentage of time in the range of 90% to 94% of oxygen saturation as measured by pulse oximetry increased from 20% to an average of 35% after implementation of the protocol. The percentage of time with oxygen saturation as measured by pulse oximetry >98% dropped from 30% to an average of 5% to 10%. A well-planned strategy for implementing oxygen saturation targeting can result in a sustained change in clinical practice as well as change in the culture of the NICU regarding the use of oxygen.

Disease Management in Primary Care: Rapid Cycle Quality Improvement of Asthma Care

Disease Management in Primary Care: Rapid Cycle Quality Improvement of Asthma Care

Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: before and after study

Problem Despite lack of evidence that enteral feeding tubes benefit patients with dementia, and often contrary to the wishes of patient and family, patients with dementia who have difficulty swallowing...

A rapid-cycle collaborative model to promote guidelines for acute myocardial infarction.

This American College of Cardiology (ACC) Acute Myocardial Infarction (AMI) Guidelines Applied in Practice (GAP) collaborative in Michigan represented ACC's third initiative, in partnership with local health care coalitions and the Michigan Peer Review Organization. The GAP Pilot Project formed the basis for this project, which supported caregivers' efforts to improve their processes and consistently apply the evidence-based guidelines for AMI care. The Institute for Healthcare Improvement (IHI) Breakthrough Series model of improvement was modified to merge the GAP Pilot Project's design with a rapid-cycle quality improvement model. The collaborative included learning sessions that focused on five phases--planning, tool implementation, monitoring tool use, remeasurement, and results--and on increasing tool use rates in each phase. Building on the work of two previous efforts, the ACC AMI GAP projects yielded substantial collective knowledge. Developing and fostering a collaborative culture allowed hospital teams to avoid barriers or overcome them successfully based on others' experiences and collectively solve problems, and it shortened the learning curve and accelerated QI.

Quality improvement in critical access hospitals: addressing immunizations prior to discharge.

Many patients hospitalized in critical access hospitals (CAHs) are at high risk for influenza and pneumonia. These hospitalizations may represent a missed opportunity to address immunizations. Addressing these missed immunizations could provide an opportunity for CAHs to gain practical experience in data-driven quality improvement. To improve documentation and delivery of influenza and pneumococcal immunizations prior to hospital discharge and provide CAHs with quality improvement experience. We recruited 17 CAHs in Kansas to participate in a rapid-cycle quality improvement project to address inpatient immunizations. Each hospital identified patient discharges on a monthly basis and abstracted medical records to see if the patient's immunization status had been assessed and if patients had been vaccinated prior to discharge. Documentation of influenza immunization status improved from 17% of admissions at baseline to 62% at follow-up (P < 0.001). Documentation of pneumococcal immunization status increased from 36% at baseline to 51% at follow-up (P < 0.001). Documentation of immunizations was significantly higher among the 8 hospitals that developed standard charting forms for recording immunization status (P < 0.01). Despite improved documentation of immunization status, at remeasurement only 3.4% received an influenza vaccination and 1.3% received a pneumococcal vaccination prior to discharge. Critical access hospitals can effectively participate in quality improvement activities, but increased involvement of medical staff or standing immunization orders may be needed to improve actual vaccine administration prior to discharge.

Obstacles to collaborative quality improvement: the case of ambulatory general medical care.

To assess the effectiveness of inter-site collaboration and report-card style feedback of quality measures on quality improvement in the outpatient setting and to identify major barriers to improvement. A collaborative quality improvement effort consisting of a large cross-sectional data collection effort (chart reviews and patient surveys), feedback of comparative quality of care data to improvement teams, and collaboration between sites. Eleven primary care sites in the Boston area. Quality improvement teams at each site with physician leaders. Education about techniques of rapid-cycle quality improvement, coaching of on-site teams, and report-card style feedback of comparative site-specific quality of care data. Multiple quality improvement projects were undertaken through this collaboration. However, though we were careful to educate teams on methods of continuous quality improvement and to name specific clinical leaders, the degree of collaboration and quality improvement fell short of expectations. Major impediments to improvement included lack of team members' time and resources, lack of incentives, and unempowered team leadership. The primary obstacle to collaboration was the diversity of sites and inability of teams to create interventions that were relevant to other sites. Despite ample quality of care data, quality improvement education, and a structured collaborative process, achieving quality improvement in the ambulatory setting is still a difficult challenge. Organizations need to find ways of overcoming the obstacles faced by improvement teams in order to maximize quality improvement.

Finding the Key to Reform in End-of-Life Care

We conducted an observational cohort study to determine if hospital-based, reinforcing regulatory and educational interventions could encourage physicians to discuss end-of-life (EOL) care with their patients. Specifically, we measured the effect of (1) administrative prompts to encourage discussions about EOL care and (2) a mandatory educational seminar focusing on EOL issues. Study subjects were patients consecutively admitted to the medicine service who faced an anticipated 3-year mortality rate of at least 50%. The main study endpoint was the frequency of documented EOL discussions between physicians and patients. In the inception cohort of 184 patients, physicians discussed EOL care with 64 patients (34.8%), and in the follow-up cohort of 121 patients, 41 individuals (33.9%) had documented discussions regarding EOL issues (P = 0.90). Actual Do Not Resuscitate(DNR) orders were written for 53 patients (28.8%) in the inception cohort and for 33 persons (27.3%) in the follow-up cohort (P = 0.71), We conclude that enhanced, mutually reinforcing regulatory and educational efforts focusing on EOL care proved ineffectual at promoting either discussions about EOL issues or the use of DNR orders.