Run Charts Research Articles

Large scale implementation of a medicines reconciliation care bundle in NHS GGC GP practices

Medicines reconciliation (MR) is an essential process for patient safety, promoting safer use of medicines with effective communication at the interface, particularly when patients are admitted and discharged from hospital....

Does an active adjustment of aerodynamic drag make sense?

The article concerns evaluation of the possible impact of the gap between the tractor and semitrailer on the aerodynamic drag coefficient. The aim here is not to adjust this distance depending on the geometrical shape of the tractor and trailer, but depending solely on the speed of articulated vehicle. All the tests have form of numerical simulations. The method of simulation is briefly explained in the article. It considers various issues such as the range and objects of tests as well as the test conditions. The initial (pre-adaptive) and final (after adaptation process) computational meshes have been presented as illustrations. Some of the results have been presented in the form of run chart showing the change of value of aerodynamic drag coefficients in time, for different geometric configurations defined by a clearance gap between the tractor and semitrailer. The basis for a detailed analysis and conclusions were the averaged (in time) aerodynamic drag coefficients as a function of the clearance gap.

Outcomes from an orientation model to reduce attrition in paediatric weight management.

We aimed to reduce attrition of newly referred patients in a paediatric weight management programme by implementing an orientation to address families' expectations and screen for and support behavioural and mental health problems and psychosocial stressors at programme outset. Orientation impact was monitored with run charts with percentages of scheduled encounters completed. Long-term impact was assessed by comparing patients in the initial 6 months of the orientation to a baseline group of referred patients during the same 6-month time interval in the prior year (Pre-Orientation Group). The outcome measure was programme attrition within 15 months. Groups were compared using Kaplan-Meier survival analysis and Cox proportional hazards regression modelling. Patients in the Orientation Group had a 23% increased odds of attrition compared to patients in the Pre-Orientation group (adjusted Hazard ratio, aHR 1.23; 95% confidence interval, CI: 1.01, 1.51) and shorter median duration of follow-up (2.0 vs. 2.9 months, P = 0.004). An increase in body mass index z-score of 1 unit resulted in a nearly fivefold increased odds of attrition (aHR 5.24; 95% CI: 2.95, 9.3). An orientation for new patients did not reduce attrition within 15 months. We suggest that ongoing retention strategies should be embedded into the treatment phase of the programme.

Improving Discharge Efficiency in Medically Complex Pediatric Patients.

Children with medical complexity have unique needs when facilitating transitions from hospital to home. Defining readiness for discharge is challenging, and preparation requires coordination of family, education, equipment, and medications. Our multidisciplinary team aimed to increase the percentage of medically complex hospital medicine patients discharged within 2 hours of meeting medical discharge goals from 50% to 80%. We used quality improvement methods to identify key drivers and inform interventions. Medical discharge goals were defined on admission for each patient. Interventions included implementation of a complex care inpatient team with electronic admission order set, weekly care coordination rounds, needs assessment tool, and medication pathway. The primary measure, percentage of patients discharged within 2 hours of meeting medical discharge goals, was followed on a run chart. The secondary measures, pre- and post-intervention length of stay and 30-day readmission rate, were compared by using Wilcoxon rank-sum and χ(2) tests, respectively. The percentage of medically complex patients discharged within 2 hours of meeting medical discharge goals improved from 50% to 88% over 17 months and sustained for 6 months. In preintervention-postintervention comparison, median length of stay did not change (3.1 days [interquartile range, 1.8-7.0] vs 2.9 days [interquartile range, 1.7-6.1]; P = .67) and 30-day readmission rate was not impacted (30.7% vs 26.4%; P = .51). Efficient discharge for medically complex patients requires support of a multidisciplinary team to proactively address discharge needs, ensuring patients are ready for discharge when medical goals are met.

Achieving Hand Hygiene Success With a Partnership Between Graduate Medical Education, Hospital Leadership, and Physicians.

Engaging physicians in hand hygiene programs is a challenge faced by many academic medical centers. Partnerships between education and academic leaders present opportunities for effective collaboration and improvement. The authors developed a robust hand hygiene quality improvement program, with attention to rapid-cycle improvements, including all levels of staff and health care providers. The program included a defined governance structure, clear data collection process, educational interventions, rapid-cycle improvements, and financial incentive for staff and physicians (including residents and fellows). Outcomes were measured on patients in all clinical areas. Run charts were used to document compliance in aggregate and by subgroups throughout the project duration. Institutional targets were achieved and then exceeded, with sustained hand hygiene compliance >90%. Physician compliance lagged behind aggregate compliance but ultimately was sustained at a level exceeding the target. Successfully achieving the institutional goal required collaboration among all stakeholders. Physician-specific data and physician champions were essential to drive improvement.

Promoting the role of patients in improving hand hygiene compliance amongst health care workers

Hand hygiene is one of the fundamental measures necessary for reducing healthcare-associated infections. The adherence of health care workers to safe hand hygiene practices is low worldwide, despite evidence showing...

Quality monitoring of billets distribution in mechanised sugarcane planting

The mechanised farming operations, especially sugarcane mechanised planting, have diverse sources of variation that may harm the agronomic performance of the crop and destabilise the process, causing failure to meet operational goals. Accordingly, this study aimed to assess the quality of sugarcane mechanised planting in two operating shifts, on the left and right furrows, using statistical quality control tools. Mechanised planting was conducted in a farming area in the municipality of Monte Alto, Sao Paulo (SP), Brazil. The statistical design used was completely randomised, with plots subdivided in space, wherein 80 sampling points (replicates) were recorded during the day and night shifts, divided into 40 replicates on the left furrow and 40 replicates on the right furrow. The quality variables and/or indicators assessed regarding the performance of the mechanised set were the number of billets m -1 , total number of shoots m -1 , number of viable shoots m -1 , percentage of viable shoots, and billets consumption (Mg ha -1 ), for both furrows and operating shifts. The combined use of run charts and control charts has become essential to monitor the mechanised planting process more stringently, leading to greater reliability in decision-making and thereby improving future operations. The operation quality of mechanised sugarcane planting is affected by day and night shifts and is lower during the night period for all quality indicators, especially the left furrow.

P136: A quality improvement initiative to optimize appropriate testing for venous thromboembolism in the emergency department

Introduction: Venous thromboembolism (VTE) is a common diagnostic consideration among patients presenting to the emergency department (ED) and often requires the use of diagnostic testing. A normal d-dimer (DD) blood test can exclude VTE and eliminate the need for costly imaging and the associated contrast medium and radiation exposure. The purpose of this quality improvement initiative was to increase the use of DD testing for patients with a low and intermediate clinical pretest probability of VTE, increase the use of ventilation perfusion scans (VQ) as an alternative to CT pulmonary angiogram (CTPA) and decrease the use of CTPA and venous doppler ultrasound (VDUS) at St. Michael’s hospital. Methods: A multispecialty team developed an ED specific algorithm set for appropriate VTE testing that were posted on the ED online portal along with a poster in each zone of the ED after an ED launch campaign with request for feedback. A run chart was used to track DD, CTPA, VQ and VDUS utilization. Two-sided T-test comparison was conducted to compare pre- and post-implementation utilization. Results: Physician feedback was positive regarding the use of: DD in VTE intermediate risk patients and the VTE algorithm set. Feedback was negative for DD turnaround time. We found a significant increase in DD use (77 tests per month to 93; p=0.013), but no significant change in the use of CTPA (27.3 per month to 30; p=0.38), VDUS, or VQ. Number of monthly ED visits remained constant. Conclusion: This intervention increased DD utilization, but measuring appropriateness will require prospective collection of clinical pre-test probability. Integrated risk stratification and decision aids into computer physician order entry may be necessary to track and improve appropriateness.

Local Pharmacy Partnership to Prevent Pediatric Asthma Reutilization in a Satellite Hospital.

In our previous work, providing medications in-hand at discharge was a key strategy to reduce asthma reutilization (readmissions and emergency revisits) among children in a large, urban county. We sought to spread this work to our satellite hospital in an adjacent county. A key initial barrier was the lack of an outpatient pharmacy on site, so we sought to determine if a partnership with community pharmacies could improve the percentage of patients with medications in-hand at discharge, thus decreasing reutilization. A multidisciplinary team partnered with community pharmacies. Using rapid-cycle improvement methods, the team aimed to reduce asthma reutilization by providing medications in-hand at discharge. Run charts were used to display the proportion of patients with asthma discharged with medications in-hand and to track 90-day reutilization rates. During the intervention period, the median percentage of patients with asthma who received medications in-hand increased from 0% to 82%. A key intervention was the expansion of the medication in-hand program to all patients. Additional changes included expanding team to evening stakeholders, narrowing the number of community partners, and building electronic tools to support key processes. The mean percentage of patients with asthma discharged from the satellite who had a readmission or emergency department revisit within 90 days of their index admission decreased from 18% to 11%. Impacting population-level asthma outcomes requires partnerships between community resources and health providers. When hospital resources are limited, community pharmacies are a potential partner, and providing access to medications in-hand at hospital discharge can reduce asthma reutilization.

Analytics 1.0, 2.0, 3.0

Analytics 1.0, 2.0, 3.0

Theoretical Study on the Electronic Structures, Magnetic Properties and Corrosion-Resistant Ability of NinAl (n=1-8, 12) Clusters

The growth behavior, electronic structures and magnetic properties for NinAl (1-8,12) clusters were investigated detailedly using the selected density functional method (BPW91/LanL2DZ). The change of binding energies show that bimetallic clusters are more stable based on the computed bond energy of Al-Ni, which is bigger than that of Ni-Ni. The strong peaks of Ni5Al in run chart of binding energies, HOMO–LUMO gap, fragmentation energy, the second-order energy and the ionization potential indicate that the stability of bimetallic cluster is optimal when the doping of aluminum is 16.7 atomic percent. At the same time, the hardness analysis of bimetallic clusters shows that Ni5Al cluster has excellent corrosion resistance ability. In addition, the magnetic moment of NinAl (n=1-8,12) clusters decrease obviously comparing with pure nickel clusters because of the s-p-d hybridization between aluminum atom and nickel atom.

Achieving behaviour change for detection of Lynch syndrome using the Theoretical Domains Framework Implementation (TDFI) approach: a study protocol.

BackgroundLynch syndrome is an inherited disorder associated with a range of cancers, and found in 2–5 % of colorectal cancers. Lynch syndrome is diagnosed through a combination of significant family and clinical history and pathology. The definitive diagnostic germline test requires formal patient consent after genetic counselling. If diagnosed early, carriers of Lynch syndrome can undergo increased surveillance for cancers, which in turn can prevent late stage cancers, optimise treatment and decrease mortality for themselves and their relatives. However, over the past decade, international studies have reported that only a small proportion of individuals with suspected Lynch syndrome were referred for genetic consultation and possible genetic testing. The aim of this project is to use behaviour change theory and implementation science approaches to increase the number and speed of healthcare professional referrals of colorectal cancer patients with a high-likelihood risk of Lynch syndrome to appropriate genetic counselling services.MethodsThe six-step Theoretical Domains Framework Implementation (TDFI) approach will be used at two large, metropolitan hospitals treating colorectal cancer patients. Steps are: 1) form local multidisciplinary teams to map current referral processes; 2) identify target behaviours that may lead to increased referrals using discussion supported by a retrospective audit; 3) identify barriers to those behaviours using the validated Influences on Patient Safety Behaviours Questionnaire and TDFI guided focus groups; 4) co-design interventions to address barriers using focus groups; 5) co-implement interventions; and 6) evaluate intervention impact. Chi square analysis will be used to test the difference in the proportion of high-likelihood risk Lynch syndrome patients being referred for genetic testing before and after intervention implementation. A paired t-test will be used to assess the mean time from the pathology test results to referral for high-likelihood Lynch syndrome patients pre-post intervention. Run charts will be used to continuously monitor change in referrals over time, based on scheduled monthly audits.DiscussionThis project is based on a tested and refined implementation strategy (TDFI approach). Enhancing the process of identifying and referring people at high-likelihood risk of Lynch syndrome for genetic counselling will improve outcomes for patients and their relatives, and potentially save public money.

Implementation of a Preventive Services Bundle in Academic Pediatric Primary Care Centers.

Previous studies have documented poor rates of delivery of preventive services, 1 of the core services provided in the primary care medical home setting. We aimed to increase the reliability of delivering a bundle of preventive services to patients 0 to 14 months of age from 58% of patient visits to 95% of visits. The bundle includes administration of routine vaccinations, offering influenza vaccination, completed lead screening, completed developmental screening tool, screening for maternal depression and food insecurity, and documentation of gestational age. The setting was 3 academic pediatric primary care clinics that serve 31,000 patients (>90% Medicaid). Quality improvement methodology was used and key driver diagram was determined. Patient "Ideal Visit Flow" and the Responsible, Accountable, Support, Consulted, and Informed Matrix were developed to drive accountability for components of the ideal flow. Plan, Do, Study, Act cycles were used to develop successful interventions. The percent of patients seen who received all bundle elements for which they were eligible was plotted weekly on a run chart, and statistical process control methods were used to determine a significant change in performance. The preintervention percentage of patient visits ages 0 to 14 months receiving all preventive service bundle elements was 58%. The postintervention percentage is 92%. Innovative redesign led to improvement in percentage of patients age 0 to 14 months who received the entire preventive services bundle. Key elements for success were multidisciplinary site-specific teams, redesigned visit flow, effective communication, and resources for data and project management.

Implementation of an Inpatient Pediatric Sepsis Identification Pathway.

Early identification and treatment of severe sepsis and septic shock improves outcomes. We sought to identify and evaluate children with possible sepsis on a pediatric medical/surgical unit through successful implementation of a sepsis identification pathway. The sepsis identification pathway, a vital sign screen and subsequent physician evaluation, was implemented in October 2013. Quality improvement interventions were used to improve physician and nursing adherence with the pathway. We reviewed charts of patients with positive screens on a monthly basis to assess for nursing recognition/physician notification, physician evaluation for sepsis, and subsequent physician diagnosis of sepsis and severe sepsis/septic shock. Adherence data were analyzed on a run chart and statistical process control p-chart. Nursing and physician pathway adherence of >80% was achieved over a 6-month period and sustained for the following 6 months. The direction of improvements met standard criteria for special causes. Over a 1-year period, there were 963 admissions to the unit. Positive screens occurred in 161 (16.7%) of these admissions and 38 (23.5%) of these had a physician diagnosis of sepsis, severe sepsis, or septic shock. One patient with neutropenia and septic shock had a negative sepsis screen due to lack of initial fever. Using quality improvement methodology, we successfully implemented a sepsis identification pathway on our pediatric unit. The pathway provided a standardized process to identify and evaluate children with possible sepsis requiring timely evaluation and treatment.

Using run charts for cardiovascular disease risk assessments in general practice.

INTRODUCTION Run charts are quality improvement tools. AIM To investigate the feasibility and acceptability of run charts displaying weekly cardiovascular disease (CVD) risk assessments in general practice and assess their impact on CVD risk assessments. METHODS A controlled non-randomised observational study in nine practices using run charts and nine control practices. We measured the weekly proportion of eligible patients with completed CVD risk assessments for 19 weeks before and after run charts were introduced into intervention practices. A random coefficients model determined changes in CVD risk assessment rates (slope) from pre- to post- intervention by aggregating and comparing intervention and control practices' mean slopes. We interviewed staff in intervention practices about their use of run charts. RESULTS Seven intervention practices used their run chart; six consistently plotting weekly data for >12 weeks and positioning charts in a highly visible place. Staff reported that charts were easy to use, a visual reminder for ongoing team efforts, and useful for measuring progress. There were no significant differences between study groups: the mean difference in pre- to post-run chart slope in the intervention group was 0.03% more CVD risk assessments per week; for the control group the mean difference was 0.07%. The between group difference was 0.04% per week (95% CI: -0.26 to 0.35, P = 0.77). DISCUSSION Run charts are feasible in everyday general practice and support team processes. There were no differences in CVD risk assessment between the two groups, likely due to national targets driving performance at the time of the study.

Reducing Overutilization of Testing for Clostridium difficile Infection in a Pediatric Hospital System: A Quality Improvement Initiative.

Study objectives included addressing overuse of Clostridium difficile laboratory testing by decreasing submission rates of nondiarrheal stool specimens and specimens from children ≤12 months of age and determining resultant patient and laboratory cost savings associated with decreased testing. A multifaceted initiative was developed, and components included multiple provider education methods, computerized order entry modifications, and automatic declination from laboratory on testing stool specimens of nondiarrheal consistency and from children ≤12 months old. A run chart, demonstrating numbers of nondiarrheal plus infant stool specimens submitted over time, was developed to analyze the initiative's impact on clinicians' test-ordering practices. A p-chart was generated to evaluate the percentage of these submitted specimens tested biweekly over a 12-month period. Cost savings for patients and the laboratory were assessed at the study period's conclusion. Run chart analysis revealed an initial shift after the interventions, suggesting a temporary decrease in testing submission; however, no sustained differences in numbers of specimens submitted biweekly were observed over time. On the p-chart, the mean percentage of specimens tested before the intervention was 100%. After the intervention, the average percentage of specimens tested dropped to 53.8%. Resultant laboratory cost savings totaled nearly $3600, and patient savings on testing charges were ∼$32 000. Automatic laboratory declination of nondiarrheal stools submitted for CDI testing resulted in a sustained decrease in the number of specimens tested, resulting in significant laboratory and patient cost savings. Despite multiple educational efforts, no sustained changes in physician ordering practices were observed.

Improving Documentation Timeliness: A "Brighter Future" for the Electronic Medical Record in Resident Clinics.

Electronic medical records have many observed benefits but may cause work disruption, resulting in delayed documentation completion. The purpose of this project was to improve compliance with institutional standards of documentation of well child checks for residents and attendings without increasing stress. This project was completed at Children's Hospital Primary Care Clinic at Vanderbilt, which is staffed by 74 residents, supervised by 17 attendings. A longitudinal observational study using convenience sampling for the last full week of each month from October 2010-January 2012 was planned. Baseline documentation completion rates were assessed, then age-specific, structured data-entry forms were introduced beginning in March 2011. Run charts were created for completion data for all clinic visits in the sample. Physician self-report of satisfaction with and stress related to documentation was assessed through pre- and postintervention surveys. Data were derived for an average of 231 patient visits per month. The median percentage of documentation or attestations completed within the institutional standards increased from 54.7% to 78.9% for residents and from 38.2% to 83.5% for attendings. Physicians reporting high satisfaction with documentation increased from 20.5% to 85.7% (P < .01) for residents and from 11.1% to 76.9% (P < .01) for attendings. Residents reporting high stress with documentation decreased from 59.1% to 28.6% (P < .02). Use of age-specific, structured data-entry forms achieved marked improvement in documentation timeliness, but there is still room for improvement. The authors are now teaching computer-based documentation in exam rooms and instituting accountability measures.

Implementation of Postoperative Respiratory Care for Pediatric Orthopedic Patients.

At our institution, one-fifth of pediatric patients undergoing hip and spine surgery require prolonged oxygen supplementation, most likely due to postoperative atelectasis. Using quality improvement methodology, we aimed to implement an innovative postoperative respiratory care algorithm for hip and spine surgery patients, with a global aim of improving respiratory outcomes. A multidisciplinary team developed a care algorithm that relied on an activated respiratory therapist (RT) and engagement of patients and families. The algorithm was implemented via multiple rapid tests of change. Process measures representing the beginning and end of the care algorithm were plotted on standard run charts. We evaluated the association of algorithm implementation with a primary outcome of prolonged (>10 hours) oxygen supplementation via a quasi-experimental design using Fisher's exact and t tests. The team successfully implemented the algorithm, with a reliability to process of 80%. Key interventions included education of RTs, a daily huddle, and implementation of automated orders. Among all hip and spine patients, algorithm implementation was associated with a small, non-statistically significant decrease in prolonged oxygen use (21% to 16%). Among patients with underlying chronic conditions, there was a significant decrease in prolonged oxygen use from 22% to 6% after algorithm implementation (P = .04). We implemented an innovative respiratory care algorithm in hip and spine surgery patients by empowering RTs and engaging families to participate in care. We found that this approach was associated with decreased prolonged oxygen use in patients with chronic underlying conditions.

Implementation of HIV treatment as prevention strategy in 17 Canadian sites: immediate and sustained outcomes from a 35-month Quality Improvement Collaborative

BackgroundRapid scale-up of effective antiretroviral therapy (ART) is required to meet global targets to eliminate new HIV infections and AIDS-related deaths. Yet, gaps persist in all nations striving for these...

The Wisdom of Crowds.

The Wisdom of Crowds.