Continuous Quality Improvement System Research Articles

Three success factors for continual improvement in healthcare: an analysis of the reports of improvement team members

IntroductionThe objectives of the Breakthrough Series Collaborative are to close the gap between what we know and what we do, and to contribute to continuous quality improvement (CQI) of healthcare...

Understanding uptake of continuous quality improvement in Indigenous primary health care: lessons from a multi-site case study of the Audit and Best Practice for Chronic Disease project

BackgroundExperimentation with continuous quality improvement (CQI) processes is well underway in Indigenous Australian primary health care. To date, little research into how health organizations take up, support, and embed these complex innovations is available on which services can draw to inform implementation. In this paper, we examine the practices and processes in the policy and organisational contexts, and aim to explore the ways in which they interact to support and/or hinder services' participation in a large scale Indigenous primary health care CQI program.MethodsWe took a theory-driven approach, drawing on literature on the theory and effectiveness of CQI systems and the Greenhalgh diffusion of innovation framework. Data included routinely collected regional and service profile data; uptake of tools and progress through the first CQI cycle, and data collected quarterly from hub coordinators on their perceptions of barriers and enablers. A total of 48 interviews were also conducted with key people involved in the development, dissemination, and implementation of the Audit and Best Practice for Chronic Disease (ABCD) project. We compiled the various data, conducted thematic analyses, and developed an in-depth narrative account of the processes of uptake and diffusion into services.ResultsUptake of CQI was a complex and messy process that happened in fits and starts, was often characterised by conflicts and tensions, and was iterative, reactive, and transformational. Despite initial enthusiasm, the mixed successes during the first cycle were associated with the interaction of features of the environment, the service, the quality improvement process, and the stakeholders, which operated to produce a set of circumstances that either inhibited or enabled the process of change. Organisations had different levels of capacity to mobilize resources that could shift the balance toward supporting implementation. Different forms of leadership and organisational linkages were critical to success. The Greenhalgh framework provided a useful starting point for investigation, but we believe it is more a descriptive than explanatory model. As such, it has limitations in the extent to which it could assist us in understanding the interactions of the practices and processes that we observed at different levels of the system.SummaryTaking up CQI involved engaging multiple stakeholders in new relationships that could support services to construct shared meaning and purpose, operationalise key concepts and tools, and develop and embed new practices into services systems and routines. Promoting quality improvement requires a system approach and organization-wide commitment. At the organization level, a formal high-level mandate, leadership at all levels, and resources to support implementation are needed. At the broader system level, governance arrangements that can fulfil a number of policy objectives related to articulating the linkages between CQI and other aspects of the regulatory, financing, and performance frameworks within the health system would help define a role and vision for quality improvement.

Early Experiences of Employing Consumer-Providers in the VA

Following guidelines in the mental health strategic plan of the Department of Veterans Affairs (VA), VA began in 2005 to fund a number of new positions for consumer-providers (CPs)--that is, individuals with personal experience of serious mental illness who provide support services to others with serious mental illness, typically as clinical team members. This study explored the challenges of CP implementation in its early stages within the VA. Four focus groups were conducted with a total of 59 VA CPs and 34 VA supervisors from across the United States. Group notes were coded by using a modified grounded theory approach to generate themes. Data from the groups suggest that hiring and employing CPs within VA has been feasible, beneficial, and acceptable to a majority of teammates. CPs reported experiencing some role confusion and resistance and fears among professional staff about how CPs would fit in. The authors make three recommendations on the basis of the focus group findings. First, CPs, traditional staff, and administrators need to be adequately prepared so that CPs can be effectively incorporated into clinical teams. Second, training for CPs varies widely, and efforts should be made to determine the best training package. Third, systems that are considering using CPs should establish a continuous quality improvement system to help evaluate CPs' performance and patient outcomes and to gather data to improve the knowledge base about CPs and their functions. CPs provide a wide range of recovery-oriented services and are valued by staff and consumers.

Early Experiences of Employing Consumer-Providers in the VA

Following guidelines in the mental health strategic plan of the Department of Veterans Affairs (VA), VA began in 2005 to fund a number of new positions for consumer-providers (CPs)--that is, individuals with personal experience of serious mental illness who provide support services to others with serious mental illness, typically as clinical team members. This study explored the challenges of CP implementation in its early stages within the VA.Four focus groups were conducted with a total of 59 VA CPs and 34 VA supervisors from across the United States. Group notes were coded by using a modified grounded theory approach to generate themes.Data from the groups suggest that hiring and employing CPs within VA has been feasible, beneficial, and acceptable to a majority of teammates. CPs reported experiencing some role confusion and resistance and fears among professional staff about how CPs would fit in. The authors make three recommendations on the basis of the focus group findings. First, CPs, traditional staff, and administrators need to be adequately prepared so that CPs can be effectively incorporated into clinical teams. Second, training for CPs varies widely, and efforts should be made to determine the best training package. Third, systems that are considering using CPs should establish a continuous quality improvement system to help evaluate CPs' performance and patient outcomes and to gather data to improve the knowledge base about CPs and their functions.CPs provide a wide range of recovery-oriented services and are valued by staff and consumers.

Can auditing save us from a quality disaster?

Auditing of clinical laboratories is a recognized component of quality assurance practice. National regulatory standards, such as the U.S. Clinical Laboratory Improvement Amendments (CLIA), and international voluntary standards, such as those promulgated by the International Organization for Standardization (ISO), are used in the auditing. Professional organizations have long recognized the benefit of on-site, peer review. However, recent events in the U.S. question the validity of current auditing practices. To be effective, auditing must be part of a continuous quality improvement system and a key component of laboratory leadership.

Collecting Data Along the Continuum of Prevention and Care

Summary For the past 14 years, a team of applied social scientists and system analysts has worked with a wide variety of Community-Based Organizations (CBO's), other grassroots agencies and networks, and Medical Center departments to support resource, program, staff and data development and evaluation for hospital- and community-based programs and agencies serving FflV at-risk and affected populations. A by-product of this work has been the development, elaboration and refinement of an approach to Continuous Quality Improvement (CQI) which is appropriate for diverse community-based providers and agencies. A key component of our CQI system involves the installation of a sophisticated relational database management and reporting system (DBMS) which is used to collect, analyze, and report data in an iterative process to provide feedback among the evaluators, agency administration and staff. The database system is designed for two purposes: (1) to support the agency's administrative internal and external reporting requirements; (2) to support the development of practice driven health services and early intervention research. The body of work has fostered a unique opportunity for the development of exploratory service-driven research which serves both administrative and research needs.

Quality Management in Radiology: Historical Aspects and Basic Definitions

In today's extremely competitive economic environment, the quality management processes used by industrial companies have become commonplace at hospitals and are proving successful in improving quality and controlling costs. Continuous quality improvement (CQI) methods provide a relatively new way, compared with quality assurance (QA) and quality control (QC) methods, to improve the quality of health care. Continuous quality improvement should be considered a philosophy rather than simply a methodology; it assumes no endpoints in improvement efforts and does not attempt to replace the older concepts of QA and QC but rather to reap their benefits and take them to a higher conceptual level. Continuous quality improvement has 4 foci: (1) to determine and meet the needs of patients and customers, (2) to approach quality improvement holistically on the basis of the identification of the underlying cause of poor performance, (3) to apply fact-based management and scientific methodology, and (4) to empower its practitioners to improve quality on a daily basis. Health care institutions and radiology departments use a variety of CQI systems or models, including the model of the Joint Commission on Accreditation of Healthcare Organizations, the Six Sigma model, and the Model for Business Excellence of the European Foundation for Quality Management. The International Organization for Standardization 9000, which creates a suitable organizational environment for the implementation of a CQI system, can be considered an effective QA and QC method.

Why Do Physicians Who Treat Lung Cancer Get Sued?

Minimal information exists on why malpractice actions are filed against physicians who treat lung cancer. To review currently available data on lung cancer malpractice litigation to develop litigation-avoidance strategies. A retrospective review of a publicly available database containing verdicts and settlements of malpractice cases. Data were then compared to the Physician Insurers Association of America (PIAA) Lung Cancer Study, which was published in 1992. The PIAA report is considered the best available data on malpractice and lung cancer. There were 89 patients in the current study and 213 patients in the PIAA study. Physicians are most often sued by patients in their 50s (mean age, 58.9 years; range, 34 to 80 years [current study]; vs 55 years; range, 17 to 75 years [PIAA study]). Primary care physicians (60% cases in the current study vs 33% cases in the PIAA study) and radiologists (20% cases in the current study vs 55% cases in the PIAA study) were named as defendants in > 75% of suits. Failure to diagnosis lung cancer was the most common reason physicians were sued (80% case in the current study vs 23.3% cases in the PIAA series). Despite the similarity in litigation profiles, the mean award to plaintiffs, in constant dollars, increased from $172,271 in the PIAA study to $632,261 in the current study. (1) Recommended strategies to avoid litigation depend on physician subspecialties. While primary care physicians would benefit most from setting up a chest radiograph tracking system, radiologists would benefit most from initiating a continuous quality improvement system to substantially decrease the misinterpretation rate of chest radiographs. (2) Over the past 12 years, there appears to have been a substantial increase in awards to patients with lung cancer who sue their physicians. However, this finding may be artificial because of differing study design. Further investigation on this subject is recommended.

Quality based social insurance coverage and payment of the application of a high cost medical therapy: the case of spinal cord stimulation for chronic non-oncologic pain in The Netherlands

This article describes a project in which a national continuous quality improvement system and a payment scheme were explicitly linked, while introducing an expensive treatment (Spinal Cord Stimulation (SCS)) in the social health insurance benefit package, in The Netherlands. By linking a national CQI system and a payment scheme in a conditional financing policy a steering instrument for future control of the quality of neuromodulation treatment through SCS is created.

An institutional system to monitor and improve the quality of residency education.

This study sought to investigate whether an institution's Graduate Medical Education Committee (GMEC) could develop a system of continuous quality improvement of its residency programs using an annual survey provided by the institution for all residents. Beginning in 2000, residents were surveyed annually about their educational and work environments. The GMEC determined standards of performance for the items on the survey based on four areas commonly cited by the Accreditation Council for Graduate Medical Education: supervision, feedback/evaluation, scholarly time, and duty hours. Residency program directors submitted action plans to improve those areas rated below the standard by the residents in the program. The 2000 survey served as baseline. In 2001, residency programs met the standard for 55.2% of the items, and 18 programs submitted 67 action plans. In 2002, programs met the standard for 80.6% of the items. For the items below standard, programs showed improvement in 14.9% and declined in 4.5% of the items compared with baseline. Six of the 18 programs had accreditation site visits during the study period. Five received no citations in the targeted areas. The sixth program was visited three months after it developed action plans for its six deficient areas. It received citations for two of the six areas. An institution that sponsors residency programs can develop and sustain an effective system to continuously monitor and evaluate its programs and improve the educational quality as evidenced by successful accreditation decisions.

Developing a National Continuous Quality Improvement System for Neuromodulation Treatment in the Netherlands

Because neuromodulation was not included in the national health insurance system, the Dutch Neuromodulation Group (DNG) developed national standards and a continuous quality improvement (CQI) system for consistency in application of neuromodulation techniques and in the quality of outcomes. A stepwise approach was used in which the following ten steps were taken: (1) selected participating medical specialists and their centers, (2) described the treatment protocol, (3) collected data in a national database, (4) organized feedback sessions for the DNG, (5) formulated quality indicators, (6) adjusted the process of treatment, (7) formalized the structure of the DNG, (8) defined responsibilities, (9) established procedures for future development, and (10) made agreements with payers. Making reimbursement for expensive health care interventions contingent on a national CQI system created a powerful financial incentive to continuously provide effective care in an efficient manner.

A public health perspective on the transport of evidence-based practices.

A public health perspective on the dissemination of empirically supported treatments is articulated, and the implications of this perspective for the foci of dissemination efforts and research are discussed. Strategies targeting multiple levels of the practice context, including payers and policy makers, will likely be needed to cultivate and sustain the demand for evidence-based treatments and to support the implementation of such treatments with fidelity. A continuous quality improvement system is recommended to document and improve the implementation and outcomes of evidence-based treatments delivered in community practice settings.

2.2 Continuous quality improvement.

Continuous quality improvement (CQI) can be envisaged as a circular process of goal-setting, followed by external and internal evaluations resulting in improvements that can serve as goals for a next cycle. The need for CQI is apparent, because of public accountability, maintaining European standards and the improvement of dental education. Many examples are known where recommendations from both external and internal evaluation are used for the improvement of dental education. Unfortunately, the implementation of the recommendations is inconsistent, rarely systematic and usually not transparent. This section agreed that it is essential to apply CQI in a structured, systematic and transparent way if we are to improve and maintain the quality of dental education. A model is proposed which includes three aspects: a) the process of CQI; b) the subjects to which CQI should be applied; and c) the management tools to govern CQI. It is stressed, that CQI is a process that can be applied in any dental school irrespective of curriculum or educational approach within the relevant context of the country or the region. The approach needs to recognize the complexity and the need to balance a quality improvement with accountability. A CQI system is also constrained in any organization by the attitudes and values of the staff. Inevitably there has to be a wide range in the application of CQI. Nevertheless, an agreed model on CQI might enhance convergence towards higher standards of dental education. The process of CQI can be supported by developments in information and communication technology (ICT): collection of data, identifying the steps in CQI, formats of reports, etc. The section was set, as one of its tasks, to advise on the development of a network based on a number of case studies on the application of CQI in dental education.

A model of efficient and continuous quality improvement in a clinical setting.

To establish a system of Continuous Quality Improvement (CQI) which does not require substantial resources in a clinical setting. A busy department of obstetrics and gynaecology. The system is based on seven elements: (i) comprehensive accumulation of data; (ii) involvement of all faculty members and the majority of residents; (iii) continuous monitoring of processes within the organization; (iv) application of clinical indicators; (v) file review system; (vi) task force approach for evaluation of processes within the organization; and (vii) intervention measures. Quality of contents of files and documentation, satisfaction of customers (patients, family members), trends of clinical indicators, effect of task force work, incidence of complaints. Inadequate documentation was noted in 14.6% before, and 4% 1 year after the initiation of the CQI program. Task force work in a variety of projects led to a substantial improvement in measured outcome. The absolute and relative numbers of complaints against the department decreased from 44 in 1993, to 27 in 1994, 20 in 1995 and 16 in 1996. In terms of the percentage of complaints directed against the hospital these figures represent 12.4, 9.6, 6.9 and 5.4% for 1993, 1994, 1995 and 1996 respectively. Our proposed CQI system has proved to be highly efficient and requires only minimal additional resources.

An introduction to ethics.

An introduction to ethics.

The Computer-Based Patient Record as a CQI Tool in a Family Medicine Center

In 1994 the Department of Family Medicine (DFM) at the Medical University of South Carolina (MUSC) developed an innovative infrastructure for continuous quality improvement (CQI) which capitalized on its existing computer-based patient record (CPR) system. The CPR is a key element in all components of the DFM patient care CQI activities. Computerized record reviews, online queries, and special reports provide the background information needed to establish CQI projects and, in some cases, diagnose the cause. Any data entered into the CPR, including progress notes text, is searchable for use by the quality improvement teams. The most compelling aspect of DFM's CPR-based CQI system is the use of quality control charts that are regularly generated by the research division from CPR data. These charts allow the CQI teams to determine whether any changes in the process measurements are due to chance causes or are caused by specific interventions introduced to improve the process. Four ongoing improvement projects that rely on CPR data and use electronically created control charts are discussed--optimizing the treatment of acute bronchitis, improving adherence to practice guidelines for patients with adult onset diabetes mellitus, improving the recognition and treatment of tobacco abuse, and improving blood pressure control in patients with hypertension. Each improvement project has a unique set of goals and objectives, against which the project's success is measured. A CPR system can be used to provide fast, organized access to large amounts of patient information to support structured quality improvement activities.

Effect of Managed Care on Cardiovascular Specialists: Involvement, Attitudes and Practice Adaptations

This study was undertaken to determine the extent to which cardiovascular specialists are involved with and affected by managed care and to ascertain their attitudes toward it. This survey also served as the follow-up to an initial study on the subject performed by the American College of Cardiology in 1993. The initial 1993 study was performed to address the lack of any comprehensive examination of the impact of managed care on cardiovascular specialists. In 1995, to reexplore this question and follow up the 1993 findings, the College conducted a survey of its membership in the following areas: 1) physician relationship with managed care plans; 2) number of managed care contracts; 3) breakdown of revenue by payment source; 4) changes in practice in response to managed care; and 5) physician attitudes toward managed care. To the extent feasible, the 1995 questionnaire paralleled the 1993 instrument to facilitate comparisons. A questionnaire was mailed to 5,147 practicing College members in the United States, who were categorized by specialty as pediatric cardiologists, adult cardiologists or cardiovascular surgeons. Mailings were sent to 1) all pediatric cardiologists and cardiovascular surgeons; 2) randomly selected adult cardiologists practicing in 10 states with high managed care penetration; and 3) randomly selected adult cardiologists in the nine U.S. census areas who were not practicing in the 10 states with high managed care penetration. Usable surveys were returned by 1,236 respondents, for an overall response rate of 24%. Involvement with at least one type of managed care organization was reported by 89% of respondents, up from 76% in 1993. Although managed care relationships had increased across physician age, region, practice and specialty, respondents indicated that, on average, well below 50% of their practice revenues stem from managed care contracts. To adapt to the managed care environment, strategic practice changes, such as joining a cardiovascular network, implementing continuous quality improvement systems and adopting clinical pathways, were being instituted by most respondent practices of nine or more physicians. Smaller groups were less active. Most respondents involved with managed care disliked its effects, particularly in clinical matters. Their attitudes toward the assumption of risk, managed fee-for-service arrangements and a private versus single-payer system show that there is no uniformity of opinion regarding the best means to contain costs and promote efficiency. Managed care has become an established part of cardiovascular specialist practice in the United States. Although this trend is viewed with some disfavor, most respondents are making practice changes to adapt to this new environment.

CQI: Improving the time to thrombolytic therapy for patients with acute myocardial infarction in the emergency department

The objective of this study was to implement a system of continuous quality improvement to reduce delays in the administration of thrombolytic therapy for patients with acute myocardial infarction in the emergency department (ED). The setting was a community hospital ED with an annual census of approximately 40,000 patients. The participants included all patients presenting to the ED with a diagnosis of acute myocardial infarction eligible for thrombolytic therapy. A cross-functional team analyzed the process of events that occurred from the arrival of a patient in the ED to treatment with thrombolytic therapy. The entire process was documented in a process flow diagram. Measurements of key time intervals were made, and remedies were designed and implemented based on these results. In the postintervention period, the performance level of the new process was evaluated and the results were compared with those in the preintervention period. In the postinter-vention period, the median elapsed time from ED admission to thrombolysis was 40 min, which was significantly shorter that the median preintervention time of 62 min. This study successfully applied the theory of continuous quality improvement to reduce the delays to thrombolytic therapy for patients with acute myocardial infarction in the ED.

1422 Quality—to assure or improve? Achieving the goals in cancer nursing care

Nursing initiatives at the European level to explore issues relating to quality will be identified and reviewed. Particular attention will be paid to the establishment and subsequent activities of EUROQUAN–the European Association for Quality Assurance in Nursing—and its impact in raising awareness about quality issues in nursing across national frontiers. Methods for evaluating quality and developing standards in nursing will be briefly outlined and their application to cancer nursing discussed. Examples of recent developments in France will be used to demonstrate how these processes have been applied in practice. It will be shown that traditional quality assurance methods have not been entirely successful in their application in France and the reasons for this will be explained. It will be argued further that for France a system of continuous quality improvement has been shown to offer the greatest potential for success. The principal elements of continuous quality improvement will be described and examples of its successful implementation in the Francophone countries of Western Europe will be given. Nursing initiatives at the European level to explore issues relating to quality will be identified and reviewed. Particular attention will be paid to the establishment and subsequent activities of EUROQUAN–the European Association for Quality Assurance in Nursing—and its impact in raising awareness about quality issues in nursing across national frontiers. Methods for evaluating quality and developing standards in nursing will be briefly outlined and their application to cancer nursing discussed. Examples of recent developments in France will be used to demonstrate how these processes have been applied in practice. It will be shown that traditional quality assurance methods have not been entirely successful in their application in France and the reasons for this will be explained. It will be argued further that for France a system of continuous quality improvement has been shown to offer the greatest potential for success. The principal elements of continuous quality improvement will be described and examples of its successful implementation in the Francophone countries of Western Europe will be given.

Continuous Quality Improvement in a Community Teaching Hospital

The purpose of this report is to describe the workings of continuous quality improvement (CQI) in a nonprofit community teaching hospital. An earlier report reviewed the adoption by a hospital system of CQI and discussed the implications and opportunities for the discipline of hospital epidemiology.1 This article will further develop the theme of CQI, discussed in recent months in Infection Control and Hospital Epidemiology2-4 and other journals,58 by offering a case history of one hospital's journey down the CQI management pathway-the origins, the aids, and the barriers to adoption, the development of the first CQI teams, and future prospects.