Successful Quality Improvement Research Articles

Measuring Stakeholder Engagement in Statewide Primary Care Cardiovascular Health Improvement Cooperatives.

Cardiovascular disease (CVD) remains a major national health challenge with significant disparities linked to socioeconomic status, race, ethnicity, sex, and geography, prompting federal efforts to build statewide primary care quality improvement (QI) cooperatives to improve heart health. To be effective, cooperatives require high levels of member engagement and leaders need ways to assess engagement. The objective of this study was to develop and validate a novel Cooperative Member Survey to assess cooperative member engagement and assess the value of the cooperative to members across three statewide heart health QI cooperatives. The 14-item survey included fixed-response and open-ended questions and was developed through multiple iterative rounds across the three cooperatives to gain consensus on the wording of final items using a Delphi process. The survey then was administered to the key stakeholders in the three cooperatives. Findings from both the quantitative and qualitative items were analyzed and reported based on frequencies and emerging themes. The survey was then analyzed to determine factor structure and validity. Analysis revealed a two-factor structure which the research team identified as: (1) Cooperative Engagement, consisting of 11 items that measured how well the cooperative functioned overall, and (2) Cooperative Value, consisting of two items that assessed the perceived value of mutual learning and respect within the cooperative. This two-factor structure indicated that the Cooperative Member Survey successfully captured both the practical aspects of how the cooperative operates and the members' perceived benefits of their involvement. Successful QI cooperatives not only require efficient operations but also a sense of shared value among members. These findings suggest that cooperatives designed to improve public health outcomes may benefit from focusing not only on practical aspects of engagement but also on cultivating mutual respect and collective learning.

‘We listened and supported and depended on each other’: a qualitative study of how leadership influences implementation of QI interventions

BackgroundThere is growing recognition in the literature of the ‘Herculean’ efforts required to bring about change in healthcare processes and systems. Leadership is recognised as a critical lever for implementation...

Developing and piloting a set of quality-of-care indicators for Romanian public hospitals as part of a national programme to fund quality

BackgroundHealthcare systems aim to enhance the health status and well-being of the individuals and populations they serve. To achieve this, measuring and evaluating the quality and safety of services provided and the outcomes achieved is essential. Like other countries, Romania faces challenges regarding the quality of care provided in its public hospitals. To address this, the Romanian Ministry of Health initiated reforms in 2022, including implementing a pay-for-performance model based on quality indicators. This paper presents a descriptive analysis of processes, methods, results and lessons learned from developing and piloting a set of Quality of Care indicators for Romanian public hospitals.MethodsWorld Health Organization’s Athens Office on Quality of Care and Patient Safety assisted Romania in developing and piloting a set of quality-of-care indicators for public hospitals. The development phase included defining indicator domains, identifying potential indicators across these domains, and defining the final indicator set. The piloting phase involved selecting and recruiting piloting hospitals, developing data collection and validation methods and tools, training hospital staff, and collecting and analysing indicator data. Piloting ended with an evaluation workshop. Mixed, quantitative and qualitative methods were used, including literature reviews, stakeholder consultation workshops, survey instruments developed for this study, modified Delphi panels and consensus-building meetings. National stakeholders were actively involved throughout the process.ResultsFour priority domains were defined for quality-of-care indicators for Romanian public hospitals: patient safety, patient experience, healthcare workforce training and safety, and clinical effectiveness. 25 core indicators were selected across these domains. During the pilot, hospitals achieved an average completion rate of 90% for data submission, with all domains rated equally relevant during post-pilot evaluations. Lessons included the need for supportive legislation, improved internal auditing practices and enhanced staff training, refinement of indicator data collection methods and alignment of indicators with hospital-specific contexts.ConclusionsThis work presents a significant stride in improving Romanian public hospitals’ quality of care and patient safety. It underscores the importance of high-level commitment, stakeholder engagement, and robust data practices in driving successful quality improvement efforts. Emphasising the role of data-driven and patient-centric approaches in achieving optimal healthcare outcomes, lessons learned offer insights for the continuation of quality improvement work in Romania but also for healthcare systems elsewhere.

An interprofessional postgraduate quality improvement curriculum: results and lessons learned over a 5-year implementation

ABSTRACT Problem Quality Improvement (QI) is interprofessional by nature; however, most academic QI programs occur in silos and do not leverage the opportunity to bring interprofessional learners together. Intervention To evaluate QI competencies of physician, nursing, pharmacy, behavioral health, and social work residents after participating in a longitudinal QI curriculum. Lessons learned are shared to guide educators in developing QI curriculum for interprofessional learners. Context Cohorts of graduate students over 5 years participated in a QI curriculum that aligned with each professions’ core quality competencies. Residents engaged in didactics and experiential learning in primary care clinics. Impact All learners (N = 74) demonstrated improvement in QI knowledge measured by the QIKAT-R and applied their skills demonstrated by completion of a QI project presented at the Institute for Healthcare Improvement annual forums. Participation in QI curriculum resulted in knowledge and skill improvement. Lessons learned An experiential QI curriculum is a natural place to bring diverse post-graduate learners together to improve QI knowledge and skills. Successful QI curriculum goals are to (a) align projects with institutional and stakeholder goals, (b) include coaches to promote teamwork and project management, (c) narrow project scope, (d) develop an improvement mindset that failures are learning opportunities, and (e) address needs for data access.

Reviewing healthcare quality improvement initiatives: Best practices in management and leadership

This research paper explores best practices in management and leadership for healthcare quality improvement. Emphasizing the critical role of effective leadership, the study examines transformational leadership, interdisciplinary collaboration, and ethical considerations. Technological integration is identified as a critical enabler. Findings underscore the significance of patient-centric approaches and the need for enhanced training programs. Implications for healthcare practice and policy include prioritizing ongoing leadership education, integrating patient perspectives, and strategically investing in technology. The research highlights the interconnectedness of these elements in driving successful quality improvement initiatives. As healthcare systems strive for continuous enhancement, implementing these best practices promises to elevate patient outcomes, foster collaborative cultures, and contribute to the ongoing transformation of healthcare delivery. Keywords: Healthcare Quality Improvement, Leadership Best Practices, Transformational Leadership, Interdisciplinary Collaboration, Technological Integration.

Improving Inpatient Colonoscopy Bowel Preparation: A Successful Quality Improvement Project.

Inadequate inpatient bowel preparation can lead to repeat procedures, prolonged hospital stays, and increased financial burden. In this quality improvement project, the authors developed an electronic medical record (EMR)-based order set with precise instructions and anticipatory guidance for inpatient bowel preparation before colonoscopy. The current study is a nonrandomized intervention study. The authors compared 2 groups: an intervention group using a newly developed, consensus-based, standardized EMR bowel preparation order set and a control group using previously existing EMR bowel preparation orders. Bowel preparation outcomes were followed over the course of 16 months. The aim was to improve inpatient colonoscopy bowel preparation, as evaluated by the Boston Bowel Preparation Scale, procedure delays, and length of hospital stay. We additionally evaluated the groups' demographics and patient-level factors. A total of 459 inpatient colonoscopies were evaluated over a 16-month period. The intervention group consisted of 227 inpatient colonoscopies, while the control group consisted of 232. The intervention group showed superior Boston Bowel Preparation Scale score and decreased length of hospital stay. The number of adequate bowel preparations increased in the intervention group when compared to the control group from 77% to 86%. The creation of an EMR-based order set is a low-cost and sustainable action that can be easily implemented throughout a hospital system.

Developing a Sustainable Quality Improvement Program in an Academic Center: The Experience of an Adolescent Unit.

Successful quality improvement (QI) efforts use a comprehensive, institutional QI framework and professional development, but literature describing implementing QI frameworks in Adolescent Medicine practices is sparse. We aimed to implement and increase the number of formally structured QI projects (primary aim) and the number of projects achieving a centerline (CL) shift (secondary aim) in our hospital's Adolescent Medicine Clinic. We used formal QI methodology to improve health outcomes by increasing the number of faculty with formalized QI education, creating interdisciplinary QI teams, and improving staff motivation. QI education was mandatory for Adolescent Medicine fellows and pediatric residents and encouraged for faculty and staff. The Divisional QI leadership team attended monthly meetings to review key driver diagrams, run and control charts, and receive intervention updates. All providers and staff received monthly updates, and the Hospital Quality and Safety Committee received biannual updates. We used run charts to share progress with primary and secondary aims. Since Q3 2014, the Adolescent Medicine team consistently achieved the primary aim of having 5 active projects in process, with 9 projects from Q1 2018-Q4 2020. For the secondary aim, a target of 50% of active QI projects attaining a sustained centerline shift was achieved in Q2 2018 and maintained in 16 of 20 quarters since. Clinicians can use QI methodology to improve health outcomes while facilitating professional development. For this initiative to succeed, institutional leadership must provide an infrastructure prioritizing meaningful QI involvement.

Virtual Nutrition Counseling in Pediatric Primary Care: An Integrated Approach to the Prevention and Management of Pediatric Obesity.

Given the rising prevalence of pediatric obesity, new approaches to the delivery of targeted nutrition counseling to not only prevent but also treat pediatric obesity are needed. The integration of a dietitian virtually was a successful quality improvement measure in this academic pediatric primary care clinic. The virtual dietitian provided age-appropriate nutrition counseling at well-child visits from 9 months to 6 years of age. Dietary counseling was also provided for children with overweight and obesity regardless of age. Vegetable, fruit, snack, and dairy intake was assessed in children who received counseling versus those who had traditional well childcare. Improved dairy habits were noted in the counseling cohort. A decrease in body mass index was not demonstrated in the patients with obesity or overweight; however, patient and provider satisfaction was quite high with this novel quality improvement measure. Virtual nutrition counseling can be easily integrated to facilitate a comprehensive pediatric medical home.

Quality improvement and outcomes for neonates with hypoxic-ischemic encephalopathy: obstetrics and neonatal perspectives

Despite significant improvement in perinatal care and research, hypoxic ischemic encephalopathy (HIE) remains a global healthcare challenge. From both published research and reports of QI initiatives, we have identified a number of distinct opportunities that can serve as targets of quality improvement (QI) initiatives focused on reducing HIE. Specifically, (i) implementation of perinatal interventions to anticipate and timely manage high-risk deliveries; (ii) enhancement of team training and communication; (iii) optimization of early HIE diagnosis and management in referring centers and during transport; (iv) standardization of the approach when managing neonates with HIE during therapeutic hypothermia; (v) and establishment of protocols for family integration and follow-up, have been identified as important in successful QI initiatives. We also provide a framework and examples of tools that can be used to support QI work and discuss some of the perceived challenges and future opportunities for QI targeting HIE.

Quality improvement efforts directed at optimal umbilical cord management in delivery room

Delayed or deferred cord clamping (DCC) and umbilical cord milking (UCM) benefit all infants by optimizing fetal-neonatal transition and placental transfusion. Even though DCC is recommended by almost all maternal and neonatal organizations, it has not been universally implemented. There is considerable variation in umbilical cord management practices across institutions. In this article, we provide examples of successful quality improvement (QI) initiatives to implement optimal cord management in the delivery room. We discuss a number of key elements that should be considering among those undertaking QI efforts to implement DCC and UCM including, multidisciplinary team collaboration, development of theory for change, mapping of the current and ideal process and workflow for cord management, and creation of a unit-specific evidence-based protocol for cord management. We also examine important strategies for implementation and provide suggestions for developing a system for measurement and benchmarking.

Quality improvement in public–private partnerships in low- and middle-income countries: a systematic review

BackgroundPublic–private partnerships (PPP) are often how health improvement programs are implemented in low-and-middle-income countries (LMICs). We therefore aimed to systematically review the literature about the aim and impacts of quality improvement (QI) approaches in PPP in LMICs.MethodsWe searched SCOPUS and grey literature for studies published before March 2022. One reviewer screened abstracts and full-text studies for inclusion. The study characteristics, setting, design, outcomes, and lessons learned were abstracted using a standard tool and reviewed in detail by a second author.ResultsWe identified 9,457 citations, of which 144 met the inclusion criteria and underwent full-text abstraction. We identified five key themes for successful QI projects in LMICs: 1) leadership support and alignment with overarching priorities, 2) local ownership and engagement of frontline teams, 3) shared authentic learning across teams, 4) resilience in managing external challenges, and 5) robust data and data visualization to track progress. We found great heterogeneity in QI tools, study designs, participants, and outcome measures. Most studies had diffuse aims and poor descriptions of the intervention components and their follow-up. Few papers formally reported on actual deployment of private-sector capital, and either provided insufficient information or did not follow the formal PPP model, which involves capital investment for a explicit return on investment. Few studies discussed the response to their findings and the organizational willingness to change.ConclusionsMany of the same factors that impact the success of QI in healthcare in high-income countries are relevant for PPP in LMICs. Vague descriptions of the structure and financial arrangements of the PPPs, and the roles of public and private entities made it difficult to draw meaningful conclusions about the impacts of the organizational governance on the outcomes of QI programs in LMICs. While we found many articles in the published literature on PPP-funded QI partnerships in LMICs, there is a dire need for research that more clearly describes the intervention details, implementation challenges, contextual factors, leadership and organizational structures. These details are needed to better align incentives to support the kinds of collaboration needed for guiding accountability in advancing global health. More ownership and power needs to be shifted to local leaders and researchers to improve research equity and sustainability.

Successful Water Quality Improvement Practices of a Campus’s River in Ningbo Based on Water Replenishment and Circulation Since Year 2017

Rivers play a critical role in regional water quality, but from time to time concentration of surface water pollutants can easily exceed both national and local water standards. This study debates the feasibility and effectiveness of utilizing the natural treatment potential of flowing river water by replenishing treated sewage effluent and forced circulating. The research combines field experiments and laboratory analyses to assess the impact of this approach on water quality. Theoretical simulation with one-dimension modeling recommended by China’s national standard of “Code of Practice for Computation on Allowable Permitted Assimilative Capacity of Water Bodies” (GB/T 25173-2010) indicates that the target campus river water’s cycle flowing contributes to the further removal of key pollutants from treated sewage, resulting in the improvement of campus river’s water quality downstream along its forced circulation. NH3-N and CODMn levels of the campus’s river water were notably reduced and met the planning water qualities as expected.

Improving Hurricane Preparedness Among Galveston County Older Adults: Description of a Successful Community-Based Quality Improvement Model.

Older adults are at high risk of experiencing injury, exacerbations of their chronic conditions, and death when evacuations are ordered because of hurricanes or natural disasters. The Homebound seniors residing in Galveston County are at a particularly high risk of morbidity and mortality during evacuations for hurricanes. This paper described the impact of a quality improvement intervention designed and implemented by nurse practitioners during the 2022 and 2023 hurricane season. The education program aimed at increasing the hurricane preparedness of the home-bound patients. Of these patients, 190 returned pre and post surveys. Interventions showed a 43% increase in patients having an evacuation plan in the event of a hurricane, 633% increase in STEAR registration, 16% increase in patients having access to emergency supplies, and 34% increase in patients having an emergency contact list with up-to-date medication list. All improvements on hurricane preparedness items were significant (p < .0001) except for the need for assistance in case of an evacuation. Our findings suggest a need for continuous hurricane preparedness education in the community to ensure safe evacuation, improve hurricane preparation, and increase the number of seniors who registered with the State of Texas Emergency Assistance Registry.

IDENTIFYING, DEVELOPING, AND IMPLEMENTING CARE PLANS CONSISTENT WITH GOALS, PRIORITIES, AND PREFERENCES

Abstract NASEM’s first recommendation to reform nursing home (NH) care is to deliver comprehensive, person-centered, equitable care that ensures residents’ health, quality of life, and safety, promotes autonomy, and manages risks. The NH Code of Federal Regulations requires person-centered care (PCC). However, while there are existing structures (i.e. MDS 3.0) to support care planning clinical needs, most NHs lack tools and procedures to systematically identify and provide care that aligns with resident goals, priorities, and preferences (GPPs). This is especially true for GPPs that reflect personhood and the human desire for autonomy. Our subcommittee aims to change the culture of care planning in NHs to integrate residents and families in co-developing holistic, person-centered care plans that centralize residents’ GPPs in ways that promote and support personhood. Our subcommittee will develop and test a) a standardized GPP care planning process that includes enhanced approaches to identification, documentation, communication, and implementation of resident GPPs; b) a repository of tools to support identification and documentation of resident GPPs; and c) training to prepare staff to understand and recognize resident GPPs. We will collaborate with other Moving Forward Committees to develop approaches to evaluating and measuring quality in care planning with inclusion of health information technology . When completed, the proposed work will provide evidence of successful and feasible quality improvement approaches to care planning resident GPPs that can augment existing federal requirements and can inform future policy changes or guidance to surveyors.

Enhancing Quality of Congenital Heart Care Within Resource-Limited Settings.

Over 90% of the world's children with congenital heart disease (CHD) are born in the resources poor settings of low- to middle-income countries (LMICs). The shortfall in human and material resources and dysfunctional health systems leads to poor quality of care (QoC) which contributes substantially to suboptimal outcomes of patients with CHD in LMICs. Notwithstanding these challenges, it is possible to develop a quality improvement (QI) framework that can have a significant impact on outcomes and prevent a number of deaths. In this review, we examine the common barriers to implementing effective QI processes in LMICs. Using examples of successful QI initiatives in LMIC, we propose a broad framework that focuses on simple, yet effective measures involving cohesive efforts of all key participants guided and nurtured by a leadership that strongly values QoC.

Implementation of the Acute Care for Elders Strategy to Improve the Quality of Care Transitions in Quebec and Ontario: a Retrospective Multiple Case Study.

In 2016, two Canadian hospitals participated in a quality improvement (QI) program, the International Acute Care for Elders (ACE) Collaborative, and sought to adapt and implement a transition coach intervention (TCI). Both hospitals were challenged to provide optimal continuity of care for an increasing number of older adults. The two hospitals received initial funding, coaching, educational materials, and tools to adapt the TCI to their local contexts, but the QI project teams achieved different results. We aimed to compare the implementation of the ACE TCI in these two Canadian hospitals to identify the factors influencing the adaptation of the intervention to the local contexts and to understand their different results. We conducted a retrospective multiple case study, including documentary analysis, 21 semi-structured individual interviews, and two focus groups. We performed thematic analysis using a hybrid inductive-deductive approach. Both hospitals met initial organizational goals to varying degrees. Our qualitative analysis highlighted certain factors that were critical to the effective implementation and achievement of the QI project goals: the magnitude of changes and adaptations to the initial intervention; the organizational approaches to the QI project implementation, management, and monitoring; the organizational context; the change management strategies; the ongoing health system reform and organizational restructuring. Our study also identified other key factors for successful care transition QI projects: minimal adaptation to the original evidence-based intervention; use of a collaborative, bottom-up approach; use of a theoretical model to support sustainability; support from clinical and organizational leadership; a strong organizational culture for QI; access to timely quality measures; financial support; use of a knowledge management platform; and involvement of an integrated research team and expert guidance. Many of the lessons learned and strategies identified from our analysis will help clinicians, managers, and policymakers better address the issues and challenges of adapting evidence-based innovations in care transitions for older adults to local contexts.

Tracheostomy care quality improvement in low- and middle-income countries: A scoping review

Tracheostomy is a lifesaving, essential procedure performed for airway obstruction in the case of head and neck cancers, prolonged ventilator use, and for long-term pulmonary care. While successful quality improvement interventions in high-income countries such as through the Global Tracheostomy Collaborative significantly reduced length of hospital stay and decreased levels of anxiety among patients, limited literature exists regarding tracheostomy care and practices in low and middle-income countries (LMIC), where most of the world resides. Given limited literature, this scoping review aims to summarize published tracheostomy studies in LMICs and highlight areas in need of quality improvement and clinical research efforts. Based on the PRISMA guidelines, a scoping review of the literature was performed through MEDLINE/PubMed and Embase using terms related to tracheostomy, educational and quality improvement interventions, and LMICs. Publications from 2000–2022 in English were included. Eighteen publications representing 10 countries were included in the final analysis. Seven studies described baseline needs assessments, 3 development of training programs for caregivers, 6 trialed home-based or hospital-based interventions, and finally 2 articles discussed development of standardized protocols. Overall, studies highlighted the unique challenges to tracheostomy care in LMICs including language, literacy barriers, resource availability (running water and electricity in patient homes), and health system access (financial costs of travel and follow-up). There is currently limited published literature on tracheostomy quality improvement and care in LMICs. Opportunities to improve quality of care include increased efforts to measure complications and outcomes, implementing evidence-based interventions tailored to LMIC settings, and using an implementation science framework to study tracheostomy care in LMICs.

A quality improvement project to establish accuracy in completing Early Warning Score chart and appropriate clinical response depending on the score in acute care wards at Asiri Surgical Hospital

Failure or delay in recognition of acutely deteriorating patients in acute care ward setting leads to preventable morbidity, cardiac arrest, and death. Assessment and responding to Early Warning Score (EWS) adapted from National Early Warning Score 2 is implemented at Asiri Surgical Hospital to capture these patients early and escalate their care appropriately. Though a colour-coded EWS chart and a hospital policy are available, gaps in accurate recording, monitoring, and triggering were reported. Thus, a quality improvement project was conducted with the aim of establishing more than 80% accuracy in completing the EWS chart and appropriate clinical response to EWS score in acute care wards at Asiri Surgical Hospital by August 2022.A multidisciplinary team performed a series of Plan-Do-Study-Act cycles focusing on correct documentation and calculation of EWS score and appropriate monitoring and escalation of care. Key drivers for hindering the pathway were identified and addressed. Over the course of the project, correct recording improved from 81.25% to 99.4%, accurate calculation of total EWS score had improved from 79% to 88%, patients who received recommended monitoring as triggered by EWS score improved from 78.8% to 84.6% and escalation of care when EWS score is 5 or more improved from 70.9% to 91.7%.A step improvement in the clinical response to a deteriorating patient in the acute care ward setting at Asiri Surgical Hospital was attained by the successful quality improvement project involving the frontline care providers.

Reducing Central Line-Associated Bloodstream Infections in a Burn Intensive Care Unit: Using a Business Framework for Quality Improvement.

Central line-associated bloodstream infections (CLABSIs) pose a unique risk in burn patients, with rates of infection 2-3 times that of other Intensive Care Unit (ICU) populations. Here we present a detailed account of our experience in reducing CLABSI rates utilizing a business framework called the Four Disciplines of Execution (4DX). The Burn ICU CLABSI rate had risen to the 90th percentile nationally when compared to other burn units on the National Healthcare Safety Network. We applied the 4DX framework. This is a four-step method which includes creating a Wildly Important Goal, establishing measurable and accomplishable process measures, creating a scoreboard, and using a weekly meeting to provide accountability. Process changes included both physician and nursing practices. The physicians changed the criteria for when to order blood cultures, as well as requiring attending approval for cultures. The nurses engaged in a peer-observation practice improvement for "scrub the hub" and line dressing conditions and improved their own expertise for peripheral IV placement. The multidisciplinary team initiated a daily review of line indications to ensure removal as soon as possible. Overall, the CLABSI rate decreased from 7.39 infections per 1000 line days to 2.29 infections per 1000 line days over 1 year. We subsequently achieved over 635 days without a CLABSI. In conclusion, the 4DX was a successful quality improvement technique in our healthcare context. Because of the simplicity of implementation, we think it is broadly applicable in the healthcare setting.

Quality Improvement Campaign Improved Utilization of Rapid Sequence MRI for Diagnosis of Pediatric Appendicitis

Appendicitis is the most common indication for emergency general surgery in the pediatric population. Computed tomography (CT) or magnetic resonance imaging (MRI) may be used for diagnosis when ultrasound findings are equivocal. However, CT involves unnecessary radiation exposure if MRI is available. After introducing a rapid sequence MRI (rsMRI) appendicitis protocol at our institution, CT was still preferentially used. We therefore implemented a quality improvement (QI) campaign to reduce the rate of CTs and increase the rate of rsMRI. Here, we assess the effectiveness of the QI campaign while evaluating potential barriers to using rsMRI. We conducted a mixed methods study, first performing stakeholder interviews which informed the design of a QI campaign initiated in May 2021 and a midway feedback survey in December 2021. A retrospective cohort study was then performed of children evaluated for appendicitis at our institution between January 1, 2016, and April 30, 2022. CT and rsMRI rates were compared before and after QI campaign implementation. There was a significant decrease in rate of CTs and increase in rate of rsMRIs performed following the initiation of the QI campaign (p<0.0001). The rate of CT scans decreased by a factor of 0.4 while the rate of rsMRI increased by a factor of 9.5. A successful QI campaign was initiated at our institution, resulting in decreased utilization of CT and increased use of rsMRI for the evaluation of suspected appendicitis. These results highlight the potential impact of QI projects. III.