Structured Quality Improvement Process Research Articles

Initiation of Palliative Care Referral from the Intensive Care Unit for Advanced Stage Metastatic Cancer Patients: A Quality Improvement Process from a Tertiary Referral Cancer Institute from South India.

Critically ill cancer patients in the intensive care unit (ICU) did not have any palliative care (PC) intervention as there was no PC referral from the ICU. The project aimed to initiate PC referral for at least 50% of progressive palliative intent cancer patients in intensive care to enhance communication with patients and caregivers. We included PC physicians, oncologists, and psychologists in the team for this project. We used the A3 problem-solving method of quality improvement (QI) and also used the Plan Do Check Act process. The first baseline assessment over 6 months of ICU deaths of patients who could have benefited from PC referral was collected; this made us realise that PC could have been initiated for some patients. Process maps of patient admission into the ICU and the process of their discharge were constructed. Analysis of root causes that were barriers to referral was examined. We made a PC trigger tool after team consultations and consensus and started using it to initiate PC referrals. PC discharge protocol was also initiated. Educational discussions were held with residents and nurses to ensure the continued use of the trigger tool. PC referral from intensive care slowly went up from 0% to beyond 50% by November 2019 and reached over 70% by March 2020; patients getting discharged had details of PC centres near their homes. Structured QI process and introducing the PC trigger tool led to the outcome of 50% PC referral for critically ill patients in ICU.

Establishment of a national quality improvement process on oxygen delivery index during cardiopulmonary bypass.

Targeted oxygen delivery during cardiopulmonary bypass (CPB) has received significant attention due to its influence on patient outcomes, especially in mitigating acute kidney injury. While it has gained popularity in select institutions, there remains a gap in establishing it globally across multiple centers. The purpose of this investigation was to describe the development of a quality improvement process of targeted oxygen delivery during CPB across hospitals throughout the United States. A systematic approach to utilize oxygen delivery index (DO2i) as a key performance indicator within hospitals serviced by a national provider of perfusion services. The process included a review of the current literature on DO2i, which yielded a target nadir value (272mL/min/m2) and an area under the curve (DO2i272AUC) cut off of 632. All data is displayed on a dashboard with results categorized across multiple levels from system-wide to individual clinician performance. From January 2020 through December 2022, DO2i data from 91 hospitals and 11,165 coronary artery bypass graft procedures were collected. During this period the monthly proportion of DO2i measurements above the target nadir DO2i272 ranged from 60.5% to 78.4% with a mean+/-SD of 70.8 +/- 4.2%. Binary logistic regression for the first 7months following monthly DO2i performance reporting has shown a statistically significant positive linear trend in the probability of achieving the target DO2i272 (p < .001), with a crude increase of approximately 7.8% for DO2i272AUC, and a 73.8% success rate (p < .001). A survey was sent to all individuals measuring oxygen delivery during CPB to assess why a target DO2i272 could not be reached. The two most common responses were an 'inability to improve CPB flow rates' and 'restrictive allogeneic red blood cell transfusion policies'. This study demonstrates that targeting a minimum level of oxygen delivery can serve as a key performance indicator during CPB using a structured quality improvement process.

Impact of a quality improvement intervention on neonatal mortality in a regional hospital in Burkina Faso

Background The neonatal period is the most vulnerable time in terms of a child’s survival, with mortality during this period accounting for approximately half of the deaths before the age of 5 years. The Neonatal Essential Survival Technology (NEST) project is a program aiming to reduce mortality by improving the quality of neonatal care in sub-Saharan Africa. This study presents the evaluation of the first phase of the NEST intervention program at Saint Camille Hospital Ouagadougou (HOSCO), Burkina Faso, in terms of the reduction in neonatal mortality. Methods This is a retrospective analysis, based on “pre-intervention” data collected in 2015, and “post-intervention” data collected in 2018, including all infants admitted to the neonatal unit of HOSCO. The intervention period (2016 and 2017) comprised a structured quality improvement process conducted by a multidisciplinary working group that focused on improving infrastructure, equipment, training and use of clinical protocols, team working within the neonatal unit and with other hospital departments, and communication with referring healthcare facilities. Mortality data were compared pre- vs. post-intervention using a logistic regression model. Results The analysis included 1427 infants in the pre-intervention period, and 819 post-intervention. In both time periods, more than 75% of admissions were infants with low birth weight, and nearly 50% were very low birth weight. Post-intervention, while there was a decrease in overall admission, the proportion of multiple births increased from 20% to 24% (p = .01). The overall mortality rate was 44.9% (641/1427) pre-intervention, and 42.2% (346/819) post-intervention (OR 0.90, 95% confidence interval (CI) 0.76–1.07; p = .23). Adjusting for clinically relevant factors, the intervention was not associated with a change in overall mortality (OR 1.39, 95% CI 0.91–2.12; p = .13), but was associated with a reduced likelihood of mortality in outborn infants compared to inborn infants (OR 0.57, 95% CI 0.36–0.92; p = .02). Conclusions The first phase of the NEST quality improvement program was associated with a decrease in mortality in outborn infants admitted to the neonatal unit at HOSCO. Long-term assessment is expected to provide a more comprehensive evaluation of the program in a low-income setting.

Improving Vitamin D Screening in a Pediatric Rheumatology Clinic Using Structured Quality Improvement Process.

Monitoring levels of 25-hydroxyvitamin D (25-OHD) is an integral part of bone health assessment in the general pediatric population, especially in at-risk populations such as children with juvenile idiopathic arthritis (JIA), childhood-onset systemic lupus erythematosus (c-SLE), and juvenile dermatomyositis (JDM). However, only 38% of the patients with JIA, c-SLE, and JDM receiving care at Nationwide Children's Hospital Rheumatology clinic in 2016 had a 25-OHD level ordered in the preceding year. The objective of this project was to increase the percentage of 25-OHD levels ordered in patients with JIA, c-SLE, and JDM from 38% to 80% in 11 months and sustain it for 6 months. A multidisciplinary team initiated a continuous improvement project utilizing the Lean Six Sigma methodology. The team diagrammed the clinical process and identified steps that needed improvement. In addition, the team completed a root cause analysis of the process and brainstormed subsequent countermeasures. The team did not meet the 80% target but did order a 25-OHD level on 61% of patients by the end of the study period compared to 38% at the start of the study (P value 0.001). The level was sustained after the study period, with 68% of these children having a 25-OHD level ordered. The team successfully improved the screening processes for vitamin D deficiency in a busy subspecialty clinic setting using Lean Six Sigma methodology.

Introducing Nurse-Led Patient Education Visits: Empowering Patients and Elevating Nursing Practice.

The literature includes multiple descriptions of successful nurse-led interventions, but the effects of nurse-led education on nurse and patient satisfaction in an executive health program are unknown. Nursing staff desire to practice more fully within their scope of licensure. Increased practice demands raised questions about whether nurse-led education would improve staff and patient satisfaction. A structured quality improvement process was used to design a nurse-led patient education program. Pilot measures included 5-point Likert scale patient and staff satisfaction surveys. Nurse burnout was also measured before and after the pilot. Patient satisfaction was high; 96% reported favorable satisfaction during the pilot, with sustained results over the following 3 years. Nurses' sense of achievement improved by 12 percentage points, and perception of making good use of skills and abilities increased by 39 percentage points. A nurse-led patient education intervention contributed to improved staff satisfaction while sustaining a positive patient experience.

Q-Tip: Using a Structured Quality Improvement Process to Generate High-Quality Family Satisfaction Data.

Q-Tip: Using a Structured Quality Improvement Process to Generate High-Quality Family Satisfaction Data.

Implementing clinic-wide depression screening for pediatric diabetes: An initiative to improve healthcare processes.

Youth with type 1 diabetes (T1D) endorse high rates of depressive symptoms, which can significantly impair self-management, glycemic control, and quality of life. Current guidelines recommend annual depression screening for all adolescents with T1D, but few models exist to implement screening procedures across clinics in this population. The primary aim of this project was to increase depression screening from 0% to 80% in four clinics, and to describe the structured quality improvement process to reach this goal. All patients aged 12 to 21 years old with T1D at four participating clinics in a Midwestern hospital system were eligible to participate. Using a two-stage process, patients were administered the Patient Health Questionnaire (PHQ-2 plus PHQ-9 if positive) annually. Rates of depression screening by clinic site, rates of positive depression screens, social worker documentation of follow-up care, and associations with diabetes-related health outcomes were analyzed. Over 2 years, average depression screening rates increased from 0% to 75% across all clinics, and 89% of patients with a positive screen met with a social worker for a targeted mental health assessment. At initial screening, 7.6% of patients screened positive for at-risk depressive symptoms on the PHQ-2 and from that group, 6.7% additionally screened positive on the PHQ-9. Annual depression screenings were feasibly implemented across four clinics and the use of real-time data listening and automated processes facilitated successful implementation. Future directions include further automation, targeted training and billing mechanisms, dissemination to non-metropolitan clinics, and further assessment of depression screening tools for adolescents with T1D.

Abstract WP388: Improvement of Adherence to Performance Measures in Patients With Acute Ischemic Stroke by Using Automatic Extraction of Electronic Medical Records: Baseline Characteristics of the Network of Shanghai Stroke Service System (4S)

Introduction: Several stroke quality control and outcome projects have demonstrated the success in improving stroke care quality through structured process. However, Chinese healthcare systems are challenged with its overwhelming numbers of patients, limited resources and large regional disparities. This study aims to Improve quality of stroke care to address regional disparities. Methods: The Shanghai Stroke Service System (4S) was established as a regional network for stroke care quality improvement in Shanghai. The 4S registry uses a web-based database that automatically extracts data from structured electronic medical records. Thirty-six hospitals including 10 regional stroke centers and 25 district stroke centers. Registry began enrolling all patients with diagnosed acute ischemic stroke (AIS) in 2017. Primary outcome is to evaluate the differences in quality metrics performance before and after the implementation structured quality improvement process. Results: Among 14461 patients with AIS registered, patient’s average age was 73 years old with 4958 women (34.2%) in 2017. Compared to the data from the previous registry, web-based database enrolled more patients (3175 in 2014, 4815 in 2015, 12387 in 2016, p&lt;0.001). With the best use of resource(Table1), AIS patients in 4S were more likely to receive performance measures than those of previous registry (composite measure 83%, Figure 1A). A trend of gradually decreased hospital mortality and rate of unplanned re-admission within 30 days was observed in 4S hospitals (Figure 1B). Conclusions: The study has helped to identify areas stroke care deficiencies and improvement. Despite of challenges of healthcare in China, 4S proved the feasibility and potentially effective as a regional stroke network model for quality improvement. This model could be duplicated at other large cities or regions in China. Clinicaltrials.gov Identifier NCT02735226

Metabolomic state as early indicator of responsiveness to therapy in the acute phase of septic shock

Medical patients whose care needs exceed what is feasible on a general ward, but who do not clearly require critical care, may be admitted to an intermediate care unit (IMCU). Some IMCU patients deteriorate and require medical intensive care unit (MICU) admission. In 2012, staff in the Johns Hopkins IMCU expressed concern that patient acuity and the threshold for MICU admission were too high. Further, shared triage decision-making between residents and supervising physicians did not consistently occur.To improve our triage process, we used a 4Es quality improvement framework (engage, educate, execute, evaluate) to (1) educate residents and fellows regarding principles of triage and (2) facilitate real-time communication between MICU residents conducting triage and supervising physicians.Among patients transferred from the IMCU to the MICU during baseline (n = 83;July–December 2012) and intervention phases (n = 94;July–December 2013), unadjusted mortality decreased from 34% to 21% (p = 0.06). After adjusting for severity of illness, admitting diagnosis, and bed availability, the odds of death were lower during the intervention vs. baseline phase (OR 0.33; 95%CI 0.11–0.98).Using a structured quality improvement process targeting triage education and increased resident/supervisor communication, we demonstrated reduced mortality among patients transferred from the IMCU to the MICU.

Intermediate care to intensive care triage: A quality improvement project to reduce mortality

PurposeMedical patients whose care needs exceed what is feasible on a general ward, but who do not clearly require critical care, may be admitted to an intermediate care unit (IMCU). Some IMCU patients deteriorate and require medical intensive care unit (MICU) admission. In 2012, staff in the Johns Hopkins IMCU expressed concern that patient acuity and the threshold for MICU admission were too high. Further, shared triage decision-making between residents and supervising physicians did not consistently occur. MethodsTo improve our triage process, we used a 4Es quality improvement framework (engage, educate, execute, evaluate) to (1) educate residents and fellows regarding principles of triage and (2) facilitate real-time communication between MICU residents conducting triage and supervising physicians. ResultsAmong patients transferred from the IMCU to the MICU during baseline (n=83;July–December 2012) and intervention phases (n=94;July–December 2013), unadjusted mortality decreased from 34% to 21% (p=0.06). After adjusting for severity of illness, admitting diagnosis, and bed availability, the odds of death were lower during the intervention vs. baseline phase (OR 0.33; 95%CI 0.11–0.98). ConclusionsUsing a structured quality improvement process targeting triage education and increased resident/supervisor communication, we demonstrated reduced mortality among patients transferred from the IMCU to the MICU.

Fostering evidence-based quality improvement for patient-centered medical homes: Initiating local quality councils to transform primary care.

Although the patient-centered medical home endorses quality improvement principles, methods for supporting ongoing, systematic primary care quality improvement have not been evaluated. We introduced primary care quality councils at six Veterans Health Administration sites as an organizational intervention with three key design elements: (a) fostering interdisciplinary quality improvement leadership, (b) establishing a structured quality improvement process, and (c) facilitating organizationally aligned frontline quality improvement innovation. Our evaluation objectives were to (a) assess design element implementation, (b) describe implementation barriers and facilitators, and (c) assess successful quality improvement project completion and spread. We analyzed administrative records and conducted interviews with 85 organizational leaders. We developed and applied criteria for assessing design element implementation using hybrid deductive/inductive analytic techniques. All quality councils implemented interdisciplinary leadership and a structured quality improvement process, and all but one completed at least one quality improvement project and a toolkit for spreading improvements. Quality councils were perceived as most effective when service line leaders had well-functioning interdisciplinary communication. Matching positions within leadership hierarchies with appropriate supportive roles facilitated frontline quality improvement efforts. Two key resources were (a) a dedicated internal facilitator with project management, data collection, and presentation skills and (b) support for preparing customized data reports for identifying and addressing practice level quality issues. Overall, quality councils successfully cultivated interdisciplinary, multilevel primary care quality improvement leadership with accountability mechanisms and generated frontline innovations suitable for spread. Practice level performance data and quality improvement project management support were critical. In order to successfully facilitate systematic, sustainable primary care quality improvement, regional and executive health care system leaders should engage interdisciplinary practice level leadership in a priority-setting process that encourages frontline innovation and establish local structures such as quality councils to coordinate quality improvement initiatives, ensure accountability, and promote spread of best practices.

A quality improvement project to decrease emergency department and medical intensive care unit transfer times

ObjectiveTo reduce transfer time of critically ill patients from the emergency department (ED) to the medical intensive care unit (MICU). DesignA prospective, observational study assessing preimplementation and postimplementation of quality improvement interventions in a tertiary academic medical center. InterventionsA team of frontline health care professional including ED, MICU, and supporting services using the clinical microsystems approach mapped out existing practice patterns, determined causes for delays, and used the Plan-Do-Study-Act to test changes.Measurements and Main ResultsThe team identified multiple issues that contributed to delays. These included poor coordination between transport services, respiratory therapy, and nursing in transferring patients from the ED as well delays in identification and transfer of stable MICU patients. These interventions reduced transfer time from 4.2 (3.4-5.7) hours to 2.2 (1.4-3.1) hours (median [interquartile range]; P < .001). Hospital length of stay decreased from 9.9 ± 9 to 8.3 ± 7 days (P < .03). ConclusionA team made up of frontline health care professionals using a structured quality improvement process and implementing multifaceted, multistage interventions, reduced transfer delays, and length of stay. Added benefits included engagement among members of the 2 microsystems and a more cohesive approach to patient care.

THU0403 Switching to IV Zoledronate for Osteoporosis Results in Recurrent Annual Drug Cost-Savings – Results of a Quality Improvement Project

BackgroundAnnual IV zoledronate has been shown to be the most effective bisphosphonate in fracture prevention. It is therefore first-choice now when starting new IV therapy in our department when osteoporosis...

Reducing Deep Sedation and Delirium in Acute Lung Injury Patients

Deep sedation and delirium are common in the ICU. Mechanically ventilated patients with acute lung injury are at especially high risk for deep sedation, delirium, and associated long-term physical and neuropsychiatric impairments. We undertook an ICU-wide structured quality improvement project to decrease sedation and delirium. Prospective quality improvement project in comparison with a retrospective acute lung injury control group. Sixteen-bed medical ICU in an academic teaching hospital with pre-existing use of goal-directed sedation with daily interruption of sedative infusions. Consecutive acute lung injury patients. A "4Es" framework (engage, educate, execute, evaluate) was used as part of the quality improvement process. A new sedation protocol was created and implemented, which recommends a target Richmond Agitation Sedation Scale score of 0 (alert and calm) and requires failure of intermittent sedative dosing prior to starting continuous infusions. In addition, twice-daily delirium screening using the Confusion Assessment Method for the ICU was introduced into routine practice. Sedative use and delirium status in acute lung injury patients after implementation of the quality improvement project (n = 82) were compared with a historical control group (n = 120). During the quality improvement vs. control periods, use of narcotic and benzodiazepine infusions were substantially lower (median proportion of medical ICU days per patient: 33% vs. 74%, and 22% vs. 70%, respectively, both p < 0.001). Further, wakefulness increased (median Richmond Agitation Sedation Scale score per patient: -1.5 vs. -4.0, p < 0.001), and days awake and not delirious increased (median proportion of medical ICU days per patient: 19% vs. 0%, p < 0.001). Through a structured quality improvement process, use of sedative infusions can be substantially decreased and days awake without delirium significantly increased, even in severely ill, mechanically ventilated patients with acute lung injury.

Educating fellows in practice-based learning and improvement and systems-based practice: The value of quality improvement in clinical practice

IntroductionIn 1999, the Accreditation Council for Graduate Medical Education identified 6 general competencies in which all residents must receive training. In the decade since these requirements went into effect, practice-based learning and improvement (PBLI) and systems-based practice (SBP) have proven to be the most challenging competencies to teach and assess. Because PBLI and SBP both are related to quality improvement (QI) principles and processes, we developed a QI-based curriculum to teach these competencies to our fellows. MethodsThis experiential curriculum engaged our fellows in our neonatal intensive care unit's (NICU's) structured QI process. After identifying specific patient outcomes in need of improvement, our fellows applied validated QI methods to develop evidence-based treatment protocols for our neonatal intensive care unit. ResultsThese projects led to immediate and meaningful improvements in patient care and also afforded our fellows various means by which to demonstrate their competence in PBLI and SBP. Our use of portfolios enabled us to document our fellows' performance in these competencies quite easily and comprehensively. DiscussionGiven the clinical and educational structures common to most intensive care unit–based training programs, we believe that a QI-based curriculum such as ours could be adapted by others to teach and assess PBLI and SBP.