Traditional Quality Improvement Research Articles

Trustworthiness of Artificial Intelligence Applications for Quality Optimisation in Metal Additive Manufacturing

Market demand is driving the trend towards more individualised products, a phenomenon known as mass customisation. This has spurred the development of innovative technologies, collectively referred to as Industry 4.0. Within this framework, Metal Additive Manufacturing and Artificial Intelligence serve as cornerstone technologies. In manufacturing, Metal Additive Manufacturing promises the ability to efficiently produce low-volume products with reduced lead times. At the same time, it promises greater sustainability, reduced production complexity and improved supply chain resilience. However, the complex physical processes involved are beyond the capabilities of traditional quality improvement techniques such as Statistical Quality Control, necessitating the incorporation of Artificial Intelligence. Although the AI Act seeks to establish a robust regulatory framework to improve the trustworthiness of AI applications, empirical studies substantiating this trust in the context of quality optimisation remain scarce. To address this gap, this study explores the implementation of trustworthy AI in quality optimisation for Metal Additive Manufacturing, evaluating established frameworks and employing state-of-the-art methods to validate the trustworthiness of AI-based quality optimisation techniques. In addition, the physical plausibility and reliability of the AI models are qualitatively checked by process experts.

Balancing a seesaw – leaders perspectives on design and traditional quality improvement in healthcare

PurposeThe purpose of this paper is to explore and describe the perspectives and reasoning of senior development leaders in healthcare organizations, when reflecting on design as theory and practice in relation to more traditional methods and tools for improving quality and support innovation.Design/methodology/approachThe paper is based on a qualitative interview design with five development and innovation leaders from separate healthcare regions in Sweden. They have, to varying degrees, applied design theory and practice for quality improvement and innovation in their organizations. The interview transcript was analysed using a content analysis together with an interpretive approach.FindingsThe major findings are to be found in the balancing act for leadership and organizations in healthcare when it comes to introducing and combining different theories and practices for improving quality and support innovation. The balance is between the change in power dynamics and pushing traditional boundaries in a complex healthcare world.Practical implicationsThe narratives from the leaders' experience of applying design theory and practice for improving healthcare quality can help us create readiness and knowledge about how we prevent and/or facilitate planning and implementing design theories, practices, methods and tools in a healthcare context.Originality/valueThe study provides a unique insight when it captures and illustrates five different organizations' experiences when applying design for developing healthcare quality.

COVID-19 vaccine uptake among healthcare workers: an achievable quality improvement target.

There is a need to optimize SARS-CoV-2 vaccination rates amongst healthcare workers (HCWs) to protect staff and patients from healthcare-associated COVID-19 infection. During the COVID-19 pandemic, many organizations implemented vaccine mandates for HCWs. Whether or not a traditional quality improvement approach can achieve high-rates of COVID-19 vaccination is not known. Our organization undertook iterative changes that focused on the barriers to vaccine uptake. These barriers were identified through huddles, and addressed through extensive peer outreach, with a focus on access and issues related to equity, diversity and inclusion. The outreach interventions were informed by real-time data on COVID-19 vaccine uptake in our organization. The vaccine rate reached 92.3% by 6 December 2021 with minimal differences in vaccine uptake by professional role, clinical department, facility or whether the staff had a patient facing role. Improving vaccine uptake should be a quality improvement target in healthcare organizations and our experience shows that high vaccine rates are achievable through concerted efforts targeting specific barriers to vaccine confidence.

‘The way that we are collecting and using data has evolved’ evaluating the Australian National Stroke Audit programme to inform strategic direction

BackgroundThe National Stroke Audit has been used to audit and provide feedback to health professionals and stroke care services in Australia since 2007. The Australian Stroke Clinical Registry was piloted...

Improve-mentation for Faster Testing and Spread of Health Service Delivery Innovations.

Can we speed the testing, implementation and spread of management innovations in a systematic way to also contribute to scientific knowledge? Researchers and implementers have developed an approach to test and revise a local version of an innovation during its implementation. The chapter starts with a case example of an application of this combination of implementation and quality improvement sciences and practices (improve-mentation). It then summarizes four examples of this approach so as to help understand what improve-mentation is and how it is different from traditional quality improvement and traditional implementation of evidence-based practices. It considers gaps in knowledge that are hindering both more use of improve-mentation to generate scientific knowledge about spread and implementation, as well as more use of improve-mentation by health care service organizations and researchers. It closes by proposing fruitful research and development that can address these knowledge gaps to speed the implementation, sustainment and spread of care and management innovations.

Sustaining Improvements of Surgical Site Infections by Six Sigma DMAIC Approach.

SSIs (surgical site infections) are associated with increased rates of morbidity and mortality. The traditional quality improvement strategies focusing on individual performance did not achieve sustainable improvement. This study aimed to implement the Six Sigma DMAIC method to reduce SSIs and to sustain improvements in surgical quality. The surgical procedures, clinical data, and surgical site infections were collected among 42,233 hospitalized surgical patients from 1 January 2019 to 31 December 2020. Following strengthening leadership and empowering a multidisciplinary SSI prevention team, DMAIC (Define, Measure, Analyze, Improve, and Control) was used as the performance improvement model. An evidence-based prevention bundle for reduction of SSI was adopted as performance measures. Environmental monitoring and antimicrobial stewardship programs were strengthened to prevent the transmission of multi-drug resistant microorganisms. Process change was integrated into a clinical pathway information system. Improvement cycles by corrective actions for the risk events of SSIs were implemented to ensure sustaining improvements. We have reached the targets of the prevention bundle elements in the post-intervention period in 2020. The carbapenem resistance rates of Enterobacteriaceae and P. aeruginosa were lower than 10%. A significant 22.2% decline in SSI rates has been achieved, from 0.9% for the pre-intervention period in 2019 to 0.7% for the post-intervention period in 2020 (p = 0.004). Application of the Six Sigma DMAIC approach could significantly reduce the SSI rates. It also could help hospital administrators and quality management personnel to create a culture of patient safety.

The 5D Cycle for Health Equity: Combining Black Feminism, Radical Imagination, and Appreciative Inquiry to Transform Perinatal Quality Improvement.

Too often, quality improvement initiatives are rooted in the health care system's oppressive structures and hierarchies. Transformative quality improvement models that embody the wisdom and liberatory potential of oppressed groups areneeded to address the alarming inequities within perinatal health. Inspired by experiences with Appreciative Inquiry, a possibility-focused change model, and frustrated by the limits of traditional quality improvement, the author sought new approaches to perinatal quality improvement. Inquiry into Black feminist recommendations for perinatal quality improvement and the principles of radical imagination led to the creation of the 5D Cycle for Health Equity, which grounds Appreciative Inquiry's 5D cycle (define, discover, dream, design, deliver/destiny) in Black feminism and radical imagination. The 5D Cycle for Health Equity is an innovative approach to addresshealth inequities by challenging oppressive quality improvement methods and health care structures. The cycle guides quality improvement collectives through a process that redefines harm and health equity; discovers new understandings of wellness across the past, present, and future; dreams of equitable care with the principles of antioppression and collectivity; designs solutions that embody the liberatory practices of oppressed groups; delivers solutions that strive to free everyone by freeing the most oppressed; and forges a new destiny. Midwives are well poised to use the 5D Cycle for Health Equity to disrupt structures of inequity and foster a health care system that supports the health and wellness of oppressed groups.

80 Identifying Positive Deviant Nurses in the Speed of Administering Antibiotics for Sepsis and Discovering Their Tactics

Positive deviance (PD) is an application of complexity leadership theory that fosters organizational learning of difficult tasks. PD may also be able to avoid the increased burnout associated with the top-down management tactics of traditional quality improvement (QI). We assessed whether PD may be an appropriate strategy to improve sepsis care by testing for the presence of heterogeneity in nursing antibiotic administration time (AAT) for severe sepsis or septic shock patients and identifying the positive deviant nurses.

What makes an effective Quality Improvement Manager? A qualitative study in the New Zealand Health System

PurposeQuality improvement is an international priority, and health organisations invest heavily in this endeavour. Little, however, is known of the role and perspectives of Quality Improvement Managers who are responsible for quality improvement implementation. We explored the quality improvement managers’ accounts of what competencies and qualities they require to achieve day-to-day and long-term quality improvement objectives.DesignQualitative exploratory design using an interpretivist approach with semi-structured interviews analysed thematically.Setting and participants.Interviews were conducted with 56 quality improvement managers from 15 (out of 20) New Zealand District Health Boards. Participants were divided into two groups: traditional and clinical quality improvement managers. The former group consisted of those with formal quality improvement education—typically operations managers or process engineers. The latter group was represented by clinical staff—physicians and nurses—who received on-the-job training.ResultsThree themes were identified: quality improvement expertise, leadership competencies and interpersonal competencies. Effective quality improvement managers require quality improvement experience and expertise in healthcare environments. They require leadership competencies including sense-giving, taking a long-term view and systems thinking. They also require interpersonal competencies including approachability, trustworthiness and supportiveness. Traditional and clinical quality improvement managers attributed different value to these characteristics with traditional quality improvement managers emphasising leadership competencies and interpersonal skills more than clinical quality improvement managers.ConclusionsWe differentiate between traditional and clinical quality improvement managers, and suggest how both groups can be better prepared to be effective in their roles. Both groups require a comprehensive socialisation and training process designed to meet specific learning needs.

Zero-defect manufacturing the approach for higher manufacturing sustainability in the era of industry 4.0: a position paper

For manufacturing companies, quality management is a key feature for increasing the competitiveness, productivity, profitability, and sustainability of their systems. Quality improvement (QI) methods aim to achieve high-quality parts without reducing performance. The Industry 4.0 framework brought technological developments that cannot be used by traditional QI methods, such as Six Sigma, Lean, Lean Six, the Theory of Constraints, and Total Quality Management, which are widely used in manufacturing companies. The need for higher manufacturing sustainability and market requirements has led to the search for alternative QI methods with superior performance to traditional QI methods such as Zero-Defect Manufacturing (ZDM). The current paper is a position paper with a goal to present the ZDM approach and providing a clear definition about ZDM to align everyone in one common understanding of ZDM. Many researchers and manufactures are skeptical about ZDM, therefore, numerous argumentative questions have been created and answered, to convince them why they should migrate from traditional QI methods to ZDM. The migration to ZDM has already started, to support this statement numerous facts from the literature have been presented. Finally, several directions were identified, demonstrating that there is still plenty of room for research in several domains.

9 Are There Positive Deviant Providers in the Speed of Ordering Antibiotics for Sepsis?

Positive deviance (PD) is an application of complexity leadership theory that fosters organizational learning of difficult tasks. PD may also be able to avoid the increased burnout associated the top-down management tactics of traditional quality improvement (QI). We assessed whether PD may be an appropriate strategy to improve sepsis care by testing for the presence of heterogeneity in provider antibiotic ordering time (AOT) for severe sepsis or septic shock patients and identifying the positive deviant providers. We included all patients with severe sepsis or septic shock who presented to the University of Kansas Emergency Department over a 7-month period (September 2020 to March 2021), were cared for by categorical emergency medicine residents, and each member of the care team (resident physician, attending physician, and nurse) cared for at least three patients during the study period. First, we measured the percent heterogeneity (I2) of AOTs with separate random effects analyses for each personnel type (resident physician, attending physician, and nurse) on the patients’ health care teams. Then, the positive deviant personnel were identified as the individuals whose mean AOT and confidence interval were faster than the mean AOT for their personnel type. The results of the first analysis were displayed in forest plots. Second, to assess the contributions of each personnel type to the AOT, we performed regression analyses to measure the percent of variance (R2) of the AOTs attributable to each personnel type. The regression analyses were weighted by the inverse of the variance of the AOTs for each member of the patients’ care teams. The incremental contribution of each personnel type was measured by regression of their AOTs with the residual times of the regression of the dominant personnel. 371 patients were included. Random effects analyses showed statistically significant heterogeneity with “moderate” I2 values of 42%, 58%, and 32% for the residents, nurses, and attendings, respectively. There were 3, 6, and 2 positive deviants, respectively. Regression found that the residents, nurses, and attendings all made statistically significant contributions to the variation in AOT with percent R2s of 0.9%, 0.3%, and 0.3%, respectively. Regression of residuals showed significant, independent effects of the residents and nurses. The contributions to the variations are much higher when all ordering providers are studied (60.2% for ordering provider and 42.5% for nurse) We noted heterogeneity in mean AOT across both resident and attending physicians. In addition, the AOT for a given patient was associated with AOTs of other cases managed by the same care team. Within each personnel type, some providers on average demonstrated quicker AOTs compared to peers. Considering the practice environment is constant, the heterogeneity in mean AOT suggests differences in practice patterns. These results support the role of a positive deviance approach to QI with focus on the residents and nurses in identifying and disseminating best tactics within our emergency department.

Improving Care Delivery: Location Timestamps to Enhance Process Measurement of a Clinical Workflow.

We applied the FOCUS-Plan-Do-Check-Act framework to reduce the time from arrival to sedation for long-bone fractures. First, we added supplementary framework-defining steps to repeat the Clarifying and Understanding steps. We then extracted objective time-based data from an electronic health record (EHR) system and a real-time locating system (RTLS). We then compared and contrasted the findings of traditional surveys with analyses of timed steps within the sedation workflow. When identifying the source of delays, traditional survey techniques yielded ambiguous and even conflicting results based on clinical roles. The timestamps supported 5 measurable clinical role of subworkflows. By measuring the time to completion for 54 sedation cases, workflow patterns and significant bottlenecks were identified. Analyzing the time to complete individual tasks provided a more nuanced description of workflow delays and clarity when traditional survey results conflicted. Augmenting traditional QI process maps with EHR and RTLS timestamps better explained workflow bottlenecks, informing the QI team when selecting targets for subsequent Plan-Do-Check-Act work.

Improving efficiency and reducing costs of MRI-Guided prostate brachytherapy using Time-Driven Activity-Based costing

INTRODUCTIONIntegrated quality improvement (QI) and cost reduction strategies can help increase value in cancer care. Time-driven activity-based costing (TDABC) is a bottom-up costing tool that measures resource use over the full care cycle. We applied standard QI and TDABC methods to improve workflow efficiency and reduce costs for MRI-guided prostate brachytherapy. METHODS AND MATERIALSWe constructed process maps of the baseline prostate brachytherapy workflow from initial consultation through one year after treatment. Process maps reflected resources and time required at each step. TDABC costs were calculated by multiplying each process time by the cost per min of the resource(s) used at that step. We then used plan-do-study-act methodology to identify workflow inefficiencies and implement solutions to reduce resource consumption. RESULTSThe highest cost components at baseline were the operating room (OR) (40%), imaging (8.7%), and consultation (7.6%). Higher-than-expected costs (3%) were incurred during surgery scheduling. After targeted QI initiatives, OR time was reduced from 90 to 70 min, which reduced overall cost by 5%. Personnel task downshifting reduced costs by 10% at consultation and 77% at surgery scheduling. Re-engineering of follow-up protocols reduced costs by 8.4%. Costs under the new workflow decreased by 18.2%. CONCLUSIONSTDABC complements traditional QI initiatives by quantifying the highest cost steps and focusing QI initiatives to reduce costs and improve efficiency. As payment reform evolves toward bundled payments, TDABC and QI initiatives will help providers understand, communicate, and improve the value of cancer care.

Improving drug prescription in general practice using a novel quality improvement model

Introduction Quality improvement (QI) clusters have been established in many countries to improve healthcare using the Breakthrough Series’ collaboration model. We investigated the effect of a novel QI approach based on this model of performed medication reviews and drug prescription in a Norwegian municipality. Methods All 27 General Practitioners (GPs) in a mid-size Norwegian municipality were invited to join the intervention, consisting of three peer group meetings during a period of 7–8 months. Participants learned practical QI skills by planning and following up QI projects within drug prescription practice. Evaluation forms were used to assess participants’ self-rated improvement, reported medication review reimbursement codes (MRRCs) were used as a process measure, and defined daily doses (DDDs) of potentially inappropriate drugs (PIDs) dispensed to patients aged 65 years or older were used as outcome measures. Results Of the invited GPs, 25 completed the intervention. Of these, 76% self-reported improved QI skills and 67% reported improved drug prescription practices. Statistical process control revealed a non-random increase in the number of MRRCs lasting at least 7 months after intervention end. Compared with national average data, we found a significant reduction in dispensed DDDs in the intervention municipality for benzodiazepine derivates, benzodiazepine-related drugs, drugs for urinary frequency and incontinence and non-steroid anti-inflammatory and antirheumatic medications. Conclusion Intervention increased the frequency of medication reviews, resulting in fewer potentially inappropriate prescriptions. Moreover, there was self-reported improvement in QI skills in general, which may affect other practice areas as well. Intervention required relatively little absence from clinical practice compared with more traditional QI interventions and could, therefore, be easier to implement. KEY POINT The current study investigated to what extent a novel model based on the Breakthrough Series’ collaborative model affects GP improvement skills in general practice and changes their drug prescription. KEY FINDINGS Most participants reported better improvement skills and improved prescription practice. The number of dispensed potentially inappropriate drugs decreased significantly in the intervention municipality compared with the national average. The model seemed to lead to sustained changes after the end of the intervention.

A Multi-Interventional Nutrition Program for Newborns with Congenital Heart Disease

To evaluate how outcomes changed in newborns undergoing surgery for congenital heart disease after implementation of a standardized preoperative and postoperative nutrition program. We performed a single-center cohort study of newborns who underwent cardiac surgery between September 2008 and July 2015. We evaluated growth and feeding outcomes in the 2years of preprogram time (phase 0), in the 2years after initiation of a postoperative feeding algorithm (phase 1), and in the 2years following introduction of a preoperative feeding program (phase 2) using traditional statistics and quality improvement methods. The study included 570 newborns with congenital heart disease. Weight-for-age z-score change from birth to hospital discharge significantly improved from phase 0 (-1.02 [IQR, -1.45 to -0.63]) to phase 1 (-0.83 [IQR, -1.25 to -0.54]; P=.006), with this improvement maintained in phase 2 (-0.89 [IQR, -1.30 to -0.56]; P=.017 across phases). Gastrostomy tube use decreased significantly (25% in phase 0 vs 12% and 14% in phases 1 and 2; P<.001) and preoperative enteral feeding increased significantly (47% and 46% in phases 0 and 1 vs 76% in phase 2; P<.001) without increases in necrotizing enterocolitis, hospital stay, or mortality. Introduction of a multi-interventional nutrition program was associated with improved weight gain, fewer gastrostomy tubes at hospital discharge, and increased preoperative enteral feeding without increases in necrotizing enterocolitis, hospital stay, or mortality.

Intersection of Bias, Structural Racism, and Social Determinants With Health Care Inequities.

* Abbreviation: SDoH — : social determinant of health Race, and more specifically, racism, is recognized as an important social determinant of health (SDoH) and a key driver of health inequities.1–3 The study “Race, Postoperative Complications, and Death in Apparently Healthy Children” in this issue of Pediatrics provides new evidence of race as a critical social determinant of surgical outcomes.4 The investigators demonstrate that apparently healthy Black children had a higher risk of postoperative mortality, complications, and serious adverse events than their white counterparts. Identifying these disparities using the National Surgical Quality Improvement Program pediatric database highlights the importance of health care practices to more deliberately consider equity in their quality improvement portfolios. The analyses were done among children with American Society of Anesthesiologists physical status 1 (normal healthy patients) or 2 (patients with mild systemic disease, such as mild asthma). By excluding children with significant comorbidities, this study helps advance knowledge beyond most previous pediatric disparities research focused on identifying disparities by exploring potential root causes. The findings suggest that, although preoperative comorbidities have previously been proposed as a factor contributing to postoperative disparities, they do not explain the results in the current study. Implicit racial bias has been proposed as another potential source of health care … Address correspondence to Tiffani J. Johnson, MD, MSc, Department of Emergency Medicine, University of California, Davis, 4150 V St, Suite 2100, Sacramento, CA 95817. E-mail: tjo{at}ucdavis.edu

Improving quality in a complex primary care system-An example of refugee care and literature review.

Applying traditional industrial quality improvement (QI) methodologies to primary care is often inappropriate because primary care and its relationship to the healthcare macrosystem has many features of a complex adaptive system (CAS) that is particularly responsive to bottom-up rather than top-down management approaches. We report on a demonstration case study of improvements made in the Family Health Center (FHC) of the JPS Health Network in a refugee patient population that illustrate features of QI in a CAS framework as opposed to a traditional QI approach. We report on changes in health system utilization by new refugee patients of the FHC from 2016 to 2017. We review the literature and summarize relevant theoretical understandings of quality management in complex adaptive systems as it applies to this case example. Applying CAS principles in the FHC, utilization of the Emergency Department and Urgent Care Center by newly arrived refugee patients before their first clinic visit was reduced by more than half (total visits decreased from 31%-14% of the refugee patients). Our review of the literature demonstrates that traditional algorithmic top-down QI processes are most often unsuccessful in improving even a few single-disease metrics, and increases clinician burnout and penalizes clinicians who care for vulnerable patients. Improvement in a CAS occurs when front-line clinicians identify care gaps and are given the flexibility to learn and self-organize to enable new care processes to emerge, which are created from bottom-up leadership that utilize existing interdependencies and interact with the top levels of the organization through intelligent top-down causation. We give examples of early adapters who are better applying the principles of CAS change to their QI efforts. Meaningful improvement in primary care is more likely achieved when the impetus to implement change shifts from top-down to bottom-up.

Leveraging Advanced Practice Nursing in Complex Health Care Systems.

The US health care system has seen unprecedented growth in health care cost with only a mediocre return on investment. Achieving sustained quality improvement will require innovation that is effectively integrated into complex systems of care. Complexity leadership has the ability to place value on traditional quality improvement processes, with less focus on rigid structure and more attention on the potential for flexibility and creativity at the point of care. Clinical team leaders, such as nurse practitioners, must nurture adaptability to the constantly changing clinical environment while balancing structured thinking of team members. Nurse practitioners operating in interdisciplinary teams are well positioned to foster adaptive change through rapid cycle improvements at the point of care. As a learning approach to quality improvement, the PDSA (plan-do-study-act) method should be seen as a useful tool for organizations to create an emergent quality improvement process. This article discusses the significance of nurse practitioner leadership using the PDSA method informed by complexity leadership theory and the impact for clinical practice.

Beyond ‘find and fix’: improving quality and safety through resilient healthcare systems

The aim was to develop a method based on resilient healthcare principles to proactively identify system vulnerabilities and quality improvement interventions. Ethnographic methods to understand work as it is done in practice using concepts from resilient healthcare, the Concepts for Applying Resilience Engineering model and the four key activities that are proposed to underpin resilient performance-anticipating, monitoring, responding and learning. Accident and Emergency Department (ED) and the Older People's Unit (OPU) of a large teaching hospital in central London. ED-observations 104h, and 14 staff interviews. OPU-observations 60h, and 15 staff interviews. Data were analysed to identify targets for quality improvement. In the OPU, discharge was a complex and variable process that was difficult to monitor. A system to integrate information and clearly show progress towards discharge was needed. In the ED, patient flow was identified as a complex high-intensity activity that was not supported by the existing data systems. The need for a system to integrate and display information about both patient and organizational factors was identified. In both settings, adaptive capacity was limited by the absence of systems to monitor the work environment. The study showed that using resilient healthcare principles to inform quality improvement was feasible and focused attention on challenges that had not been addressed by traditional quality improvement practices. Monitoring patient and workflow in both the ED and the OPU was identified as a priority for supporting staff to manage the complexity of the work.

Using Safety Barrier Analysis to Facilitate Quality Improvement in Health Care: Improving Venous Thromboembolism Prophylaxis as a Proof of Concept.

Effective quality improvement is a key factor in optimizing the care of hospitalized patients. Unfortunately, the US health care system has a poor safety record when compared to other major industries. For example, at 250 000 per year, medical errors are the third leading cause of death in the United States. Safety barrier management, a widely used methodology in high-risk industries such as commercial airline transportation and oil drilling, has not been widely used in traditional quality improvement efforts in health care, which rely more on standard lean Six Sigma quality approaches. The authors describe a quality improvement project that uses safety barrier analysis to help inform solutions to improve venous thromboembolism prophylaxis in hospitalized patients. This study found that safety barrier analysis helped inform solutions to improve venous thromboembolism prophylaxis at the study institution and can be a useful adjunct to standard lean Six Sigma methodologies for quality improvement in health care.