Support Quality Improvement Research Articles

Developing indicators and measures of high-quality for Australian general practice.

Rising health costs and health inequity are major challenges in Australia, as internationally. Strong primary health care is well evidenced to address these challenges. Primary Health Networks (PHNs) work with general practices to collect data and support quality improvement; however, there is no consensus regarding what defines high quality. This paper describes the development of an evidence-based suite of indicators and measures of high-quality general practice for the Australian context. We reviewed the literature to develop a suitable framework and revise quality assurance measures currently in use, then reviewed these in three workshops with general practitioners, practice managers, nurses, consumers and PHN staff in western Sydney. We used a descriptive qualitative research approach to analyse the data. A total of 125 evidence-based indicators were agreed to be relevant, and 80 were deemed both relevant and feasible. These were arranged across a framework based on the Quadruple Aim, and include structure, process and outcome measures. The agreed suite of indicators and measures will be further validated in collaboration with PHNs across Australia. This work has the potential to inform health systems innovation both nationally and internationally.

African Americans’ Hemodialysis Treatment Adherence Data Assessment and Presentation: A Precision-Based Paradigm Shift to Support Quality Improvement Activities

Rationale & ObjectiveThrice-weekly hemodialysis can result in adequate urea clearance; however, the morbidity and mortality rates of patients treated with maintenance dialysis remain unacceptably high, partly because of nonadherence. African Americans have a higher prevalence of kidney failure treated with dialysis, greater dialysis nonadherence, and higher odds of hospitalization. We hypothesized that more precise ways of assessing dialysis treatment adherence will reflect the severity of nonadherence, distinguish patterns of nonadherence, and inform the design of personalized behavioral interventions.Study DesignRetrospective cohort study.Setting & ParticipantsAfrican American patients receiving hemodialysis for >90 days.ExposureHemodialysis.OutcomeDialysis adherence.Analytical ApproachDialysis attendance data were displayed using a dot plot, categorized based on missed and shortened treatments, and examined for patterns. Descriptive characteristics were reported. In an exploratory analysis, associations between dialysis treatment adherence and participant characteristics were evaluated using ordinary least squares regression. An analysis was performed using missed minutes of dialysis and current metrics for measuring dialysis treatment adherence (ie, missed and shortened treatments).ResultsAmong 113 African American patients treated with dialysis, 47% were men; the median age was 57 years (interquartile range, 46-70 years), and the median dialysis vintage was 54 months (interquartile range, 22-90 months). With rows ordered based on the total missed minutes of dialysis, the dot plot displayed a decreasing gradient in the severity of nonadherence, with novel dialysis treatment adherence categories termed as follows: consistent underdialysis, inconsistent dialysis, and consistent dialysis. Distinct patterns of nonadherence and heterogeneity emerged within these categories. Older age was consistently associated with better adherence, as determined by the analyses performed using the total missed minutes of dialysis as well as missed and shortened treatments.LimitationsThe study findings, although replicable and paradigm-shifting, might be limited by the short timeline, focus on adherence data specific to African American patients treated with dialysis, and restriction to dialysis units affiliated with 1 academic center.ConclusionsThis study presents more precise and novel ways of measuring and displaying dialysis treatment adherence. The findings introduce a more personalized approach for evaluating actual dialysis uptake. Identification of unique patterns of adherence behavior is important to inform the design of effective behavioral interventions and improve outcomes for vulnerable African American patients treated with dialysis.

Investigating the patient food experience: Understanding hospital staffs' perspectives on what leads to quality food provision in Ontario hospitals.

Food quality influences patient food satisfaction, which may subsequently affect food intake and recovery, influencing hospital costs. The present qualitative study aimed to gain an understanding of hospital staff/volunteers experiences of serving food in Ontario hospitals, perceptions of food quality and challenges to quality food provision. Sixteen Ontario hospitals participated. Semi-structured interviews (n = 64 participants) and focus groups (n = 24; 150 participants) were conducted. Transcripts were analysed using inductive thematic analysis. Four themes emerged: (1) Providing Good Quality Food (e.g., attributes that comprise the construct of meal quality, patients' expectations and desires from meals); (2) Individualising the Food and Mealtime Experience (e.g., processes to identify and cater to patients' needs and preferences); (3) Acknowledging Organisational Constraints (e.g., staffing, budget, etc.); and (4) Innovating Beyond Constraints (e.g., identifying innovation within potential modifiable and unmodifiable organisational constraints). Serving meals in hospital is complex because of organisational and patient factors; however, current efforts to serve quality food despite these complexities were uncovered in our investigation. Discussions highlighted current practices that promote food quality and strategies for improvement. Improving food quality and the hospital meal experience can support food intake and patient outcomes, as well as reduce waste and hospital associated costs. The findings can be used to support quality improvement measures aiming to serve high quality food that meets patients' expectations and nutritional needs.

Perspectives on developing and sustaining a small baby program

The Small Baby Program at Nationwide Children's Hospital was launched in 2004 in response to a need for better care for infants born extremely preterm. Standardization of care, decreased variability, multidisciplinary support, and robust research and quality improvement have allowed us to greatly improve our outcomes. In addition to the numerous medical and technological advances during this time, a strong commitment to kangaroo care and family-centered care have been integral to the growth and success of our program. The following review of the program aims to highlight the above areas while detailing the specific processes that have contributed to its ongoing success. Key areas of focus have been on respiratory management, neurodevelopmental care, and nutritional optimization. The implementation and continued refinement of the Small Baby Program has allowed us to improve the survival of extremely preterm infants, decrease certain morbidities, and improve long-term neurodevelopmental outcomes.

Addressing the Scottish burden of wounds through the Lens of Profound Knowledge.

The prevalence of wounds and the cost of treating them are increasing year on year. Improving the quality of wound care will improve patient outcomes and is a financial necessity. The Lens of Profound Knowledge is a tool that can be used to support quality improvement and identify where action is needed. It allows exploration of an organisation through four aspects-appreciate the system, understanding variation, psychology, and theory of knowledge-and working on all four aspects simultaneously is believed to increase the likelihood of achieving improvement. Improvements at and between all levels-microsystem (such as frontline services), mesosystem (health boards) and macrosystem (NHS Scotland)-would reduce variation in practice and prove to be both clinically and cost-effective. Given the rapidly growing population of people with unhealed wounds, wound care needs to be valued at all system levels and be adequately resourced.

“Doing our best for patient safety”: An international and interprofessional qualitative study with spinal manipulative therapy providers in community-based settings

BackgroundPatient safety research is expanding from hospitals to community-based healthcare settings. Knowledge gaps persist among manual therapy professions that may impede patient safety initiatives within musculoskeletal care settings. ObjectivesTo describe perceptions of patient safety among chiropractors and physiotherapists who provide spinal manipulation therapy (SMT). DesignQualitative descriptive study. MethodCross-sectional data were collected using the SafetyNET Survey to Support Quality Improvement. SMT providers (n = 705) in 3 countries completed surveys, with 84 providing written responses to an open-ended question about patient safety. Qualitative thematic analysis described providers’ perceptions about patient safety within their practice. ResultsSMT providers’ perceptions were influenced by professional, patient, and practice setting factors. Five themes and 10 supporting categories were developed. Doing Our Best for Patient Safety concerned Avoiding Mistakes and Prioritizing Safety.Putting Patients First focused on Developing Relationships and Individualizing Care.Working and Learning Together advocated for Interprofessional Communication and Collaborative Learning. Organizing Practice Processes emphasized Standardizing Procedures and Benchmarking Progress.Considering Practitioner Identity highlighted how Recognizing Difference among SMT providers and Challenging Fears of other healthcare professionals and patients about SMT were important for enhancing patient safety. ConclusionFindings align with World Health Organization guiding principles that the nature of healthcare settings influence patient safety strategies. Most responses focused on individual strategies to prevent adverse events. However, this approach may overlook the benefits of identifying and documenting adverse events, setting time to discuss adverse events with clinic members, standardizing clinical practices, and building transparent patient safety cultures across healthcare professions and settings.

Building a Better Simulation to Improve Outcomes in High-Risk Obstetric Emergencies

Simulation is considered the gold standard in training obstetric staff members to respond to high-risk clinical emergencies such as hemorrhage and hypertension. Simulations provide an opportunity for staff to practice skills in a low-risk environment while identifying process breakdowns and practice gaps and supporting quality improvement. A narrow focus on skills alone fails to address key components of interdisciplinary collaboration and communication as well as the holistic experience of the patient and her family.

Health Outcomes Management Evaluation-A National Analysis of Dutch Heart Care.

AimsA group of heart centres in the Netherlands have been at the forefront internationally to implement the principles of value-based healthcare. This study aims to give an up-to-date assessment of outcome-based quality improvement in 2020 at a national level in Dutch heart care.Methods and resultsPhysicians and healthcare professionals for each participating hospital filled out a questionnaire with 26 detailed questions on quality improvement and organization of care. In total, 20 hospitals participated; 11 heart centres with thoracic surgery and 9 without thoracic surgery. Results show that outcome reports are actively used within the heart centres to support quality improvement initiatives. In 50% of the centres, apart from physicians, also nurses and hospital management are involved. For 60% of the heart centres, outcome measurement is embedded in strategy and annual plans. The stage of development of supporting IT infrastructure (outcome measurement in the Electronic Health Record and dashboards) is very diverse. A wide range of different learning strategies supports outcome-based quality improvement.ConclusionHealth outcomes have become a relevant element in quality improvement and organization of Dutch heart centres. Earlier research shows that in 2012–2016 heart centres focused mainly on measuring outcomes. Now in 2020, heart centres are more able to actually use the acquired insights based on these measurements to initiate improvement projects. The diversity in how this is done indicates that this field is still strongly developing and shows potential for heart centres to share best practices in the implementation of value-based healthcare.

Systemic constellations applied in organisations: a\xa0systematic review

This article—published in the Journal Gruppe. Interaktion. Organisation.— presents a systematic overview of the current empirical evidence of the effectiveness of the systemic constellation method when applied in organisations.Although the systemic constellation method is increasingly used for team coaching, organisational development and transformation processes, among others, scientific evidence on the effectiveness and quality of this method is still scarce. This may hamper the broader implementation of a potentially useful approach. Altogether, ten electronic databases were searched up to January, 2020. Multiple languages, qualitative and quantitative designs, and academic and grey literature were included. The search resulted in the identification of 79 potentially relevant publications, seven of which were prospective and 13 were retrospective effectiveness studies in terms of organisational outcomes. Only two of the seven prospective studies used a controlled design. This review concludes that the empirical evidence on the systemic organisational constellation method points toward a potentially effective intervention in the organisational context. However, it is too early to make firm conclusions as the number of studies was small and quality of the studies was low in general.The present systematic review summarises the literature on the systemic constellation method applied in organisations. It offers coaches and consultants insights into the method from a scientific perspective and describes potential mechanisms of action regarding the intervention. The results of the review provide a solid basis for future research and give directions for new studies to support quality improvement and help us better understand the factors influencing effectiveness.

Quality improvement in practice—part 1: creating learning systems

Applying quality improvement methods to solve complex quality issues involves people deeply. People discover solutions, test and adapt ideas, thereby giving them autonomy and control over the system in which they work. Focusing quality improvement on what matters most for staff and service users creates the opportunity to bring a deeper sense of meaning and connection to purpose, both of which are integral to joy in work. When applying quality improvement at scale within large organisations or systems, bringing teams together in learning systems can provide a critical structure to build skills, collaborate and learn from one another. This article describes the core elements of learning systems designed to support quality improvement and joy in work, illustrated through two examples. The framework can be applied at different levels of a system, including the individual, the team and the organisation, or even to a large improvement effort across organisational boundaries. The next article in this series will discuss the application of the joy in work framework to healthcare settings.

Development of the Motivational Interviewing Coach Rating Scale (MI-CRS) for health equity implementation contexts.

The field of implementation science emphasizes efficient and effective fidelity measurement for research outcomes and feedback to support quality improvement. This paper reports on such a measure for motivational interviewing (MI), developed with rigorous methodology and with diverse samples. Using item response theory (IRT) methods and Rasch modeling, we analyzed coded (a) recordings (n = 99) of intervention sessions in a clinical trial of African American adolescents with obesity; (b) standard patient interactions (n = 370) in an implementation science study with youth living with HIV; and (c) standard patient interactions (n = 172) in a diverse community sample. These methods yielded a reliable and valid 12-item scale on several indicators using Rausch modeling including single construct dimensionality, strong item-session maps, good rating scale functionality, and item fit after revisions. However, absolute agreement was modest. The 12 items yielded thresholds for 4 categories: beginner, novice, intermediate and advanced. The 12-item Motivational Interviewing Coach Rating Scale is the first efficient and effective fidelity measure appropriate with diverse ethnic groups, with interventions that are MI only or interventions that integrate MI with other interventions, and with adolescents and families as well as adults. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Quality Improvement Education in the Era of COVID-19: A Pivot Toward Virtual Education.

Quality Improvement Education in the Era of COVID-19: A Pivot Toward Virtual Education.

Challenges of Research on Person-Centered Care in General Practice: A Scoping Review.

Background: Delivering person-centered care is one of the core values in general practice. Due to the complexity and multifaceted character of person-centered care, the effects of person-centered care cannot be easily underpinned with robust scientific evidence. In this scoping review we provide an overview of research on effects of person-centered care, exploring the concepts and definitions used, the type of interventions studied, the selected outcome measures, and its strengths and limitations.Methods: Systematic reviews on person-centered care compared to usual care were included from Pubmed, Embase, and PsycINFO. The search was conducted in February 2021. Data selection and charting was done by two reviewers.Results: The literature search yielded 481 articles. A total of 21 full-text articles were assessed for eligibility for inclusion. Four systematic reviews, published between 2012 and 2018, were finally included in this review. All reviews used different definitions and models and classified the interventions differently. The explicit distinction between interventions for providers and patients was made in two systematic reviews. The classification of outcomes also showed large differences, except patient satisfaction that was shared. All reviews described the results narratively. One review also pooled the results on some outcome measures. Most studies included in the reviews showed positive effects, in particular on process outcomes. Mixed results were found on patient satisfaction and clinical or health outcomes. All review authors acknowledged limitations due to lack of uniform definitions, and heterogeneity of interventions and outcomes measures.Discussion: Person-centered care is a concept that seems obvious and understandable in real life but is complex to operationalize in research. This scoping review reinforces the need to use mixed qualitative and quantitative methods in general practice research. For spreading and scaling up person-centered care, an implementation or complexity science approach could be used. Research could be personalized by defining therapeutic goals, interventions, and outcome variables based on individual preferences, goals, and values and not only on clinical and biological characteristics. Observational data and patient satisfaction surveys could be used to support quality improvement. Integrating research, education, and practice could strengthen the profession, building on the fundament of shared core values.

Standardizing Care of Neuro-oncology Patients Using a Customized Electronic Medical Record Toolkit.

ObjectiveTo develop and implement a customized toolkit within the electronic medical record (EMR) to standardize care of patients with brain tumors.Patients and MethodsWe built a customized structured clinical documentation support toolkit to capture standardized data at office visits. We detail the process by which this toolkit was conceptualized and developed. Toolkit development was a physician-led process to determine a work flow and necessary elements to support best practices as defined by the neuro-oncology clinical team.ResultsWe have developed in our EMR system a customized work flow for clinical encounters with neuro-oncology patients. In addition to providing a road map for clinical care by our neuro-oncology team, the toolkit is designed to maximize discrete data capture. Several hundred fields of discrete data are captured through the toolkit in the context of our routine office visits. We describe the characteristics of patients seen at our clinic, the adoption of the toolkit, current initiatives supported by the toolkit, and future applications.ConclusionThe EMR can be effectively structured to standardize office visits and improve discrete data capture. This toolkit can be leveraged to support quality improvement and practice-based research initiatives at the point of care in a neuro-oncology practice.

Quality Indicators for the Diagnosis and Management of Sudden Sensorineural Hearing Loss.

Sudden sensorineural hearing loss (SSNHL) is an ideal entity for quality indicator (QI) development, providing treatment challenges resulting in variable or substandard care. The American Academy of Otolaryngology-Head and Neck Surgery recently updated their SSNHL guidelines. With SSNHL demonstrating a large burden of illness, this study sought to leverage the updated guidelines and develop QIs that support quality improvement initiatives at an individual, institutional, and systems level. Candidate indicators (CIs) were extracted from high-quality SSNHL guidelines that were evaluated using the Appraisal of Guidelines for Research and Evaluation II tool. Each CI and its supporting evidence were summarized and reviewed by a nine-member expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs using the modified RAND Corporation-University of California, Los Angeles appropriateness methodology. Fifteen CIs were identified after literature review. After the first round of evaluations, the panel agreed on 11 candidate indicators as appropriate QIs with 2 additional CIs suggested for consideration. An expert panel meeting provided a platform to discuss areas of disagreement before final evaluations. The expert panel subsequently agreed upon 11 final QIs as appropriate measures of high-quality care for SSNHL. The 11 proposed QIs from this study are supported by evidence and expert consensus, facilitating measurement across a wide breadth of quality domains. With the recently updated SSNHL guidelines, and a greater focus on quality improvement opportunities, these QIs may be used by healthcare providers for targeted quality improvement initiatives.

Requirements for a Dashboard to Support Quality Improvement Teams in Pain Management.

Pain management is often considered lower priority than many other aspects of health management in hospitals. However, there is potential for Quality Improvement (QI) teams to improve pain management by visualising and exploring pain data sets. Although dashboards are already used by QI teams in hospitals, there is limited evidence of teams accessing visualisations to support their decision making. This study aims to identify the needs of the QI team in a UK Critical Care Unit (CCU) and develop dashboards that visualise longitudinal data on the efficacy of patient pain management to assist the team in making informed decisions to improve pain management within the CCU. This research is based on an analysis of transcripts of interviews with healthcare professionals with a variety of roles in the CCU and their evaluation of probes. We identified two key uses of pain data: direct patient care (focusing on individual patient data) and QI (aggregating data across the CCU and over time); in this paper, we focus on the QI role. We have identified how CCU staff currently interpret information and determine what supplementary information can better inform their decision making and support sensemaking. From these, a set of data visualisations has been proposed, for integration with the hospital electronic health record. These visualisations are being iteratively refined in collaboration with CCU staff and technical staff responsible for maintaining the electronic health record. The paper presents user requirements for QI in pain management and a set of visualisations, including the design rationale behind the various methods proposed for visualising and exploring pain data using dashboards.

Patient-Reported Experience Measures in Stroke Care: A Systematic Review.

Patient-reported experience measures (PREMs) assess patients' perception of health care. We aimed to identify all reported PREMs for stroke care and critically appraise psychometric properties of PREMs validated for patients with stroke. Studies on the development, validation, or utilization of PREMs for adult patients with stroke were systematically identified. The Consensus-Based Standards for the Selection of Health Measurement Instruments criteria were used to appraise psychometric performance. We included 18 studies, examining 13 PREMs. Two PREMs had been developed for stroke care: Consumer Quality Index: Cerebrovascular Accident and Riksstroke. Consumer Quality Index: Cerebrovascular Accident was given a positive psychometric assessment, but its length and limited language applicability impede clinical implementation. Riksstroke was appraised as doubtful. Eleven PREMs were generic. The psychometric performance of 5 generic PREMS, validated for patients with stroke, received conflicting assessments. Six generic PREMs had not been validated in patients with stroke and were therefore not assessed for instrument performance. Thirteen PREMs have been published for use in stroke care. The stroke-specific Consumer Quality Index: Cerebrovascular Accident has favorable psychometric performance but lacks practical feasibility. Other PREMs have inadequate or unknown psychometric properties. This indicates the need for developing stroke-specific PREMs to support quality improvement and enhance patient-centered care.

Factors Influencing Patient Experience in Primary Healthcare Clinics within the eThekwini Municipality in KwaZulu-Natal

Patient experience is seen as a fundamental measure for healthcare evaluation, which fuels the debate regarding the most relevant factors influencing patient experience. Limited empirical knowledge exists concerning the factors that influence patient experience from the users’ perspective in South Africa. This study addresses the research gap by determining the factors influencing patient experience among primary healthcare users in Waterloo, Grove-End and Stonebridge communities in the eThekwini Municipality of KwaZulu-Natal. The study is quantitative, descriptive and cross-sectional, and utilises a self-administered questionnaire that was distributed among 280 primary healthcare users. They strongly agreed (> 90%) that all the factors presented in the study are contributors to their patient experience. The factor analysis determined the relevance of the factors as perceived by the respondents. It was found that the doctor’s role (0.970), clinic cleanliness (0.943), coordination and continuity of care (0.943), and waiting time (0.914) are the most significant influencers of patient experience. Education (0.898), nurses (0.882), medication (0.854) and the quality of care (0.853) serve as moderate influencers. Access (0.745), family/friend involvement (0.722) and the physical state of the infrastructure (0.714) are mild influencers of patient experience. Patient-centred care (0.639), management effectiveness (0.637), communication (0.596) and information (0.443) were non-influencers of patient experience. User experience is multifaceted and each factor represents a varying level of influence. It is recommended that a patient-experience framework should be developed that can be linked to improvement initiatives within South Africa in an effort to support quality improvement.

Data missingness in the Michigan NEMSIS (MI-EMSIS) dataset: a mixed-methods study

ObjectiveThe study was done to evaluate levels of missing and invalid values in the Michigan (MI) National Emergency Medical Services Information System (NEMSIS) (MI-EMSIS) and explore possible causes to inform improvement in data reporting and prehospital care quality.MethodsWe used a mixed-methods approach to study trends in data reporting. The proportion of missing or invalid values for 18 key reported variables in the MI-EMSIS (2010–2015) dataset was assessed overall, then stratified by EMS agency, software platform, and Medical Control Authorities (MCA)—regional EMS oversight entities in MI. We also conducted 4 focus groups and 10 key-informant interviews with EMS participants to understand the root causes of data missingness in MI-EMSIS.ResultsOnly five variables of the 18 studied exhibited less than 10% missingness, and there was apparent variation in the rate of missingness across all stratifying variables under study. No consistent trends over time regarding the levels of missing or invalid values from 2010 to 2015 were identified. Qualitative findings indicated possible causes for this missingness including data-mapping issues, unclear variable definitions, and lack of infrastructure or training for data collection.ConclusionsThe adoption of electronic data collection in the prehospital setting can only support quality improvement if its entry is complete. The data suggest that there are many EMS agencies and MCAs with very high levels of missingness, and they do not appear to be improving over time, demonstrating a need for investment in efforts in improving data collection and reporting.

Improving Educational Quality through Optimizing the Potential of Educational Institutions in Indonesia

The quality of education in an educational institution will be greatly influenced by the potential of educational institutions and the governance system. The existing potential must be optimized to support quality improvement. Likewise, the education governance system will develop well when it is implemented through a good system by professional managers. The system has been designed in detail by the government which was stipulated by the Minister of National Education Regulation No. 19 of 2007 concerning "Education Management Standards by Primary and Secondary Education Units". This regulation was prepared by the government to regulate a good, balanced and sustainable governance system.The problem is determined to what extentthe ability of educational institutions to optimize the potential of the institution and optimizing inputs, processes, outputs and outcomes, starting from planning, organizing, actuiting, and controlling. This paper will discuss the improving educational quality through optimizing the potential of educational institutions in Indonesia in order to achieve shared ideals for a better educational future.