Utilizing Quality Improvement Research Articles

Utilizing Quality Improvement Science to Improve Resident Neonatal Resuscitation Skills in the Delivery Room

Background: With the development of duty hour restrictions and increased demands on resident education, pediatric residents spend less time in the neonatal ICU (NICU) and, specifically, the delivery room (DR). Despite decreased training, many community pediatricians continue to cover well-baby nurseries and DRs. It is, therefore, crucial during residency to develop strong Neonatal Resuscitation Program (NRP) skills and become comfortable with resuscitating neonates. AIMs: This project set out with a global aim of improving neonatal outcomes by producing physicians competent and confident in …

A quality improvement initiative to reduce necrotizing enterocolitis across hospital systems

Necrotizing enterocolitis (NEC) is a devastating intestinal disease in premature infants. Local rates of NEC were unacceptably high. We hypothesized that utilizing quality improvement methodology to standardize care and apply evidence-based practices would reduce our rate of NEC. A multidisciplinary team used the model for improvement to prioritize interventions. Three neonatal intensive care units (NICUs) developed a standardized feeding protocol for very low birth weight (VLBW) infants, and employed strategies to increase the use of human milk, maximize intestinal perfusion, and promote a healthy microbiome. The primary outcome measure, NEC in VLBW infants, decreased from 0.17 cases/100 VLBW patient days to 0.029, an 83% reduction, while the compliance with a standardized feeding protocol improved. Through reliable implementation of evidence-based practices, this project reduced the regional rate of NEC by 83%. A key outcome and primary driver of success was standardization across multiple NICUs, resulting in consistent application of best practices and reduction in variation.

Utilizing Quality Improvement Strategies to Increase Continuous EEG Monitoring in Critically Ill Pediatric Patients with Persistent Encephalopathy Following Status Epilepticus (P2.303)

Utilizing Quality Improvement Strategies to Increase Continuous EEG Monitoring in Critically Ill Pediatric Patients with Persistent Encephalopathy Following Status Epilepticus (P2.303)

Development and Implementation of a Standardized Heparin Protocol for Left-Sided Pediatric Electrophysiology Procedures.

Heparin is used to decrease the risk of thromboembolic complications during electrophysiology studies (EPS); however, there is wide practice variation and minimal evidence to guide heparin dosing, particularly in pediatric patients. This study retrospectively analyzed heparin dosing and response, measured via activated clotting time (ACT), in patients undergoing EPS and used these data (pre-protocol cohort, n = 40), as well as guidance from available literature to implement a standardized heparin protocol (phase 1, n = 43). We utilized quality improvement methodology to refine this protocol (phase 2, n = 40) to improve therapeutic heparin response. Prior to the protocol, patients achieved therapeutic ACT levels (250-350s) only 35% of the time which improved to 60% during phase 1 (p < 0.05) and to 73% during phase 2 (p < 0.001 compared to pre-protocol). There were no thromboses or significant adverse events in any group. These results demonstrate the effectiveness of a standardized heparin protocol in achieving effective antithrombotic therapy during left-sided pediatric EPS.

Reducing Interdisciplinary Communication Failures Through Secure Text Messaging: A Quality Improvement Project.

Interdisciplinary communication failures contribute to medical mistakes and adverse events. At our institution, provider communication previously occurred through unidirectional pager systems. We utilized quality improvement methodology to (1) implement a secure text messaging system for providers on a pediatric ward and (2) evaluate its impact on communication failures. We aimed to reduce potential communication failures between providers by > 25% within 1 month. Implementation of secure text messaging occurred via Plan-Do-Study-Act cycles focused on education, feedback, and electronic health record interventions. We collected pager data before implementation and both pager and secure text messaging data after intervention. Potential communication failures were identified a priori through manual review of the messaging data to capture lack of closed-loop communication. A run chart was used to track daily potential communication failures and total communication volumes. Before implementation of secure text messaging, the median daily potential communication failure rate was 5.5%. Usage of secure text messaging increased after implementation, representing 3.5 of 7.2 communications per patient-day. Paging communications decreased from 4.2 to 3.7 per patient-day. Potential communication failures decreased to a median daily rate of 2.2%, representing a 59% reduction in communication failures. Implementation of secure text messaging using quality improvement methods resulted in a significant reduction in potential communication failures between residents and nurses. Future interventions will be aimed at maintaining and augmenting providers' use of secure text messaging to ensure the potential for communication failure remains low.

Safer transitioning Optimising Frail Elderly Patients Care From Hospital to Home

Safer transitioning Optimising Frail Elderly Patients Care From Hospital to Home

Implementation of a systematic method for the identification, tracking, and treatment of malnutrition in pediatric patients with acute lymphoblastic leukemia.

184 Background: It is estimated that the prevalence of malnutrition in children with cancer may be as high as 50%. Optimization of nutritional status is known to be associated with improved tolerance of cancer therapy, decreased infection risk, increased quality of life and increased survival. There are established methods for improving nutrition, but we have observed barriers to the identification of at risk patients, adherence to recommended interventions and continued surveillance. Methods: We identified patients in the intensive phases of therapy for acute lymphoblastic leukemia/lymphoblastic lymphoma. Using improvement science methods, we developed a standardized approach to the identification, treatment and tracking of patients at risk for malnutrition. We utilized quality improvement techniques to identify the problems with the current system and implement change. These changes included standardization of an algorithm for nutritional treatment and follow up, creation of a daily electronic report for identification of at risk patients, and improved communication with providers in regard to patient nutrition. Results: At baseline, nearly 10% of our target patients were impacted by significant weight loss. Utilizing quality improvement techniques, we were able to establish the most common causes of failure in our system (awareness of the problem, identification of at-risk patients, tracking and monitoring at-risk patients and provider/patient adherence to recommended nutritional interventions). Interventions were employed using plan-do-study-act quality improvement methods, including the development of an electronic identification and tracking system designed for these patients. We were able to significantly decrease the number of patients with weight loss using these methods. Conclusions: Malnutrition is associated with poor outcomes in patients with cancer. Use of quality improvement methods allowed us to identify key drivers and test/implement specific interventions to combat this problem. In this proof of principle cohort, this has resulted in a significant improvement in the nutritional status of our patients.

Developing an outcomes framework for the dietetic service.

Demonstrating our value as individual practitioners and services is a key priority. Developing robust process and outcome measures supports us to achieve this. Outcomes also enable us to provide the highest level of patient-centred care by helping us to re-model the relationship between user and provider through capturing and using patient-related experience and outcome measures to inform service development. This article discusses our journey as a dietetic service in developing and implementing an outcomes framework utilising quality improvement methodology. This work was undertaken as part of a Silver 'Improving Quality Together' (IQT) project, a 1000 Lives initiative ( NHS Wales, 2013 ). Find out more about improving quality together at www.IQT.wales.nhs.uk .

The Golden Hour: Providing Very Premature Infants a Favorable Beginning

The first hour of life in a very premature neonate is a critical period of transition requiring extra-uterine adaptation of multiple organ systems for which the vulnerable neonate is ill prepared. Medical interventions provided to the neonate during this golden first hour of life can have significant implications on immediate survival and long term morbidities. Delayed cord clamping, delivery room temperature stabilization, strategies to establish functional residual capacity and gentle ventilation, early administration of dextrose and amino acid infusions, antibiotics when indicated and timely successful placement of peripheral or umbilical venous catheters are areas of focus during golden hour care. Premature infants born and resuscitated at tertiary and quaternary care centers have improved survival chances and outcomes when compared to similar “out-born” infants which highlight the role of experienced and skilled resuscitation teams in the golden hour. Strategies to standardize the various elements used in the resuscitation and stabilization of the very premature neonate that utilize quality improvement measures such as a golden hour protocol may help improve timeliness and efficacy of care provided in the first hour of life.

Utilizing Quality Improvement Processes to Reverse the Rising Trends of Cesarean-Section Births [30J

INTRODUCTION: To report on quality processes aimed at decreasing primary C/S rates and Perinatal Core Measure 2 (PCO2): C/S in term singleton vertex nulliparous pregnancies. METHODS: From May 2014, processes included: 1) review of local risk factors; 2) Provider education; 3) Kaizen to implement minimum duration of labor calculations; 4) C/S Committee reviews utilizing ACOG/SMFM guidelines with feedback to obstetricians; 5) Daily benchmarked C/S rates for awareness; 6) providers' surveys on attitudes & potential opportunities; 7) serial C/S rates score cards distribution; 8) monitoring safety committees; 9) C/S checklist; 10) Patient education including safe labor brochures; 11) nursing focus on natural labor, bedside care, and positional changes; 12) residents as a focus of change. Primary outcomes were primary C/S and PCO2 rates; secondary outcomes included operative vaginal deliveries, postpartum hemorrhage (PPH), chorioamnionitis, perineal trauma and perinatal mortality rates. United Health Consortium upper quartile average was the benchmark. RESULTS: U-chart analysis of individual physician primary C-S rates was within control limits demonstrating that the C/S rate was due to culture and not “outliers.” From April 2014 to July 2015, primary C/S decreased significantly from 22.5% to 13.9%, and PCO2 from 38.98% to 17.29% There were no significant trends in forceps deliveries: 2.4% to 1.4%; vacuum deliveries: 3.7% to 1.1%; chorioamnionitis 0.7% to 0.2%, PPH: 3.4% to 2.4%, non-instrumental perineal trauma: 1.7% to 1.75%, or instrumental perineal trauma: 20% to 35.7%. CONCLUSION: Quality processes can result in safe reduction of the primary C/S rate by a focus on “natural labor” with patience without increasing co-morbidity.

Don’t just screen intervene; a quality improvement initiative to improve physical health screening of young people experiencing severe mental illness

Purpose – The purpose of this paper is to improve the quality of monitoring of risk factors that predict the likelihood of people with severe mental illness (SMI) developing cardiovascular disease (CVD), diabetes and obesity, major contributors to poor physical health and risk of premature mortality. Design/methodology/approach – The first phase of the AQuA “Don’t just screen-intervene” initiative supported five specialised community-based Early Intervention for Psychosis services in North West England to assess the effectiveness of monitoring of cardiometabolic risk in their patients using standards derived from the Lester Positive Cardiometabolic Health Resource, a nationally acknowledged framework for people with psychosis receiving antipsychotic medication. The initial findings formed the basis for a quality improvement programme which ran from November 2012 until May 2013. Findings – By the end of a six month quality improvement programme the likelihood of a patient receiving a comprehensive cardiometabolic risk screening (evidenced by recorded measurement of body mass index or waist circumference, blood pressure, blood glucose and lipid profile, assessment of smoking status and enquiry of relevant family history) had increased from 10 to between 63 and 80 per cent. Research limitations/implications – Cardiometabolic risk monitoring from the onset of psychosis and its treatment can be improved utilising quality improvement methodology in real-world specialist mental health services. Earlier identification and treatment of risk factors that predict higher rates of obesity, diabetes and SMI may help people with SMI avoid life-restricting and life-shortening physical disorders. Practical implications – Given the National Audit of Schizophrenia findings of inadequate screening in those with established SMI alongside evidence that CVD risk can emerge early in the course of psychosis, a group of early intervention in psychosis services in North West England decided to examine this aspect of their routine clinical practice. This service evaluation describes the effectiveness of a quality improvement programme based on the Lester Positive Cardiometabolic Health Resource (referred to as Lester resource henceforth) to improve the effectiveness of monitoring of risk factors that predict the likelihood of people experiencing psychosis and schizophrenia developing CVD diabetes and obesity. Social implications – A combination of social disadvantage and unhealthy lifestyles, adverse cardiometabolic impacts of antipsychotic medication and inequitable access to physical healthcare combine to put people with SMI at particular risk from CVD, the single biggest cause of premature death, and much more common than suicide (Brown et al., 2010). Despite higher rates of potentially modifiable CVD risk factors (De Hert et al., 2009) people with SMI appear to be missing out on opportunities to actively prevent conditions like CVD and diabetes compared to the general population. Originality/value – People with SMI such as schizophrenia die 15-20 years earlier on average than the general population. Around 20 per cent of premature deaths can be explained by suicide and injury, but the remainder arise from a variety of natural causes such as CVD, chronic obstructive pulmonary disorder and certain cancers and infections (Nordentoft et al., 2013). The authors worked with five mental health trusts in the North West of England covering a sample of over 500 cases within early intervention services.

Using Improvement Methodology to Optimize Echocardiographic Imaging of Coronary Arteries in Children

According to the American Society of Echocardiography, coronary artery (CA) imaging is recommended in pediatric examinations to identify CA anomalies. A review of the authors' center's echocardiographic studies revealed that CA images were often nondiagnostic. The aim of this study was to utilize quality improvement methodology to increase the percentage of first-time pediatric studies with definitive CA identification from a baseline of 45% to a goal of at least 75% in 9months. A scoring system was developed to characterize the completeness of CA imaging. One point was scored for demonstration of each of the following: right CA origin by two-dimensional imaging, right CA origin by color flow Doppler imaging, left CA origin by two-dimensional imaging, and left CA origin by color flow Doppler imaging. A score of 4 was considered to represent definitive imaging. A baseline was obtained on 100 first-time echocardiograms with normal findings. During the intervention, 10 randomly selected first-time studies with normal findings were scored weekly for assessment of CA imaging. Interventions were focused on the following domains: excellence in image quality, shared ownership, transparency, and effective communication. Key interventions included labeling CA images, requiring two-dimensional and color Doppler images, optimization of settings, and elimination of macros for CA reporting. The percentage of definitive CA identification increased from 45% to 82.5% over 4months and was sustained for 7months. Accurate reporting of incomplete CA imaging increased from 17% to 77.5%. Improved pediatric CA imaging and reporting were achieved through the implementation of key interventions.

Measurable results: Reducing staff injuries on a specialty psychiatric unit for patients with developmental disabilities.

Quality improvement initiative focused on staff injury reduction on a specialized inpatient psychiatric unit which offers acute stabilization for children and adolescents with complex high-risk behaviors. To utilize quality improvement principles and interventions to reduce staff injuries on a specialized inpatient child/adolescent psychiatric unit. Direct care clinical staff within an inpatient psychiatric unit for patients with co-occurring developmental disabilities and psychiatric illness were the focus of the initiative. Direct care clinical staff and clinical administrators were the active participants in the quality improvement initiative, focusing upon the interactions between staff and patients. OSHA-recordable injuries were documented to guide initiatives and measure outcomes on weekly run charts with raw data measures of all staff injuries and the number of days elapsed between injuries. Rapid Plan, Do, Study, Act (PDSA) cycles were utilized to test interventions and guide decision making. Three months of a structured and systematic intervention trial produced the first adopted interventions in August 2011. The following six months reflected a 65% reduction of staff injuries (from 2.2 injuries per week to 0.77 injuries per week). Between January and August 2011, there were eight OSHA-recordable injuries with an average of 26.5 days between injuries. The average number of days between OSHA-recordable injuries has increased from 26.5 days at baseline to 124 days. An initiative utilizing quality improvement principles reduced staff injuries on an inpatient specialized psychiatric unit. Reliability principles, system adaption, and engagement of the frontline nursing clinicians have proven to be foundational and vital to guide the initiative.

Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit

Ineffective communications among healthcare providers are common and increases the risk of medical errors. During the perioperative period, multiple handoffs occur within a short period of time, and failure to convey important patient information can compromise safety. We used quality improvement methodology to improve the reliability of our handoffs in the operating room and postanesthesia care unit (PACU). Two quality improvement teams were developed to focus on the intraoperative and postanesthesia handoff processes. Key driver diagrams and 'smart aims' were developed for each process based on feedback from anesthesia and nursing staff, and handoff checklists were developed and revised using multiple plan-do-study-act cycles. Data on the reliability of the handoff processes were obtained prior to initiation of the projects and throughout the 6-month project period. The reliability of intraoperative anesthesia handoffs improved from 20% to 100% with use of the intraoperative handoff checklist. Similarly, with the introduction of a standardized PACU checklist, the reliability of PACU handoffs improved from 59% to greater than 90%. We utilized quality improvement methodology to develop and implement standardized checklists for handoffs of care in the operating room and PACU. Acceptance of and adherence to the standardized handoff protocols dramatically increased the quality and reliability of our handoff process.

Abstract 333: Design and Implementation of a Pediatric Outpatient Cardiology Clinic Renovation Utilizing Quality Improvement Methodology

Background: With increasing pressure to manage medical resources prudently, quality improvement methodology can be utilized to increase efficiency and decrease cost in current outpatient cardiology clinic operations. However, there are few examples of quality improvement methodology applied to the design, implementation and management of a renovation project aimed at meeting a five year projected volume increase of 155% and multidisciplinary clinic expansion. We hypothesized that by using quality improvement methodology, the increasing volume demands could be met by improving clinic flow and thus maintain patient access while reducing medical resource expansion. Methods: Outpatient cardiology clinics and testing functions were assessed for clinic visit volumes and duration, testing volumes and durations, patient no show rates, the number of provider clinic hours, room utilization, scheduling template design and accuracy, and the scheduling process. Baseline assessments were made prior to process improvement efforts. A series of interventions were made as follows: modification of the patient follow up scheduling process, reduction in the number of scheduling templates, modification of templates to include pre visit nursing and electrocardiographic acquisition time, change from half day to all day clinic templates, pre visit registration, limiting of exam room assignment to a maximum of 3 per provider and spread of the clinic across 5 days per week. Results: Baseline data revealed a 43% no show rate, room utilization was 34%, patient access defined by lag days between first contact and appointment was 22 days. These metrics indicated that the number of exam rooms needed to meet our projected volume increase would result in an increase from 10 to 30 rooms. Two years into our interventions and our no show rate is 6%, room utilization is 68%, patient access has improved with lag days at 10. These improvements have occurred in the presence of an 18% annual volume increase, an increase of 5% in patient provider hours and an exam room increase from 10 to 23. Conclusions: Process improvement methodology applied to room utilization, patient scheduling, provider staffing patterns and clinic visit templates can be successfully utilized to design and implement an outpatient cardiology clinic renovation. If properly applied, process improvement can be a method to maximize the use of current and future medical resources while insuring patient access to services.

Do quality improvement systems improve health library services? A systematic review

A turbulent financial and political climate requires health libraries to be more accountable than ever. Quality improvement systems are widely considered a 'good thing to do', but do they produce useful outcomes that can demonstrate value? To undertake a systematic review to identify which aspects of health libraries are being measured for quality, what tools are being used and what outcomes are reported following utilisation of quality improvement systems. Many health libraries utilise quality improvement systems without translating the data into service improvements. Included studies demonstrate that quality improvement systems produce valuable outcomes including a positive impact on strategic planning, promotion, new and improved services and staff development. No impact of quality improvement systems on library users or patients is reported in the literature. The literature in this area is sparse and requires updating. We recommend further primary research is conducted in health libraries focusing upon the outcomes of utilising quality improvement systems. An exploration of quality improvement systems in other library sectors may also provide valuable insight for health libraries.

Early Evaluation Results From a Statewide Quality Improvement Training Program for Local Public Health Departments in North Carolina

Many state and local public health agencies have developed accreditation systems and are utilizing quality improvement (QI) methods and tools to improve the public health infrastructure. Development of strategies to support and build the capacity of the public health workforce to apply QI can help advance these efforts. This article describes the adaptation and creation of a standardized QI training program for local health departments (LHDs), explores the effectiveness of the program in increasing the confidence of the LHD staff to apply QI methods and tools, and discusses lessons learned from the first cohort of the program. An existing program designed for health care professionals was pilot tested, adapted, and used in 8 LHDs. A formative evaluation of the new public health QI training program was conducted through a hybrid internal and external evaluation model. Pre/postsurveys were used to measure participant satisfaction and the capacity of LHD staff to conduct QI. Staff from 8 LHDs successfully completed the program and 94% of participants reported that they were satisfied with the overall training program. Seventy percent of participants reported a higher perceived confidence in conducting a QI project, and all participants reported sharing QI tools and methods with their coworkers. These findings suggest that QI training programs using methods and tools previously applied in health care and other industries can be successfully adapted to public health. Although additional studies are needed to validate the results, this training model can be used to inform future work in developing a standardized QI training program in public health.

Utilizing quality improvement methods to prevent falls and injury from falls: Enhancing resident safety in long-term care

Introduction Internationally, the growing evidence related to preventable adverse events within healthcare settings has resulted in the creation of numerous patient safety and quality improvement initiatives. In Canada, Safer Healthcare Now!, a national patient safety initiative of the Canadian Patient Safety Institute, and the Registered Nurses’ Association of Ontario, the professional association representing registered nurses in Ontario, have partnered to combine quality improvement expertise with evidence-based practice expertise to accelerate improvement in the area of falls prevention and injury reduction. The synergistic relationship between Safer Healthcare Now! and the Registered Nurses’ Association of Ontario has resulted in the evolution of the Safer Healthcare Now! national Falls Prevention intervention. The ultimate goal of the Falls Prevention intervention is to improve care by translating “what we know” into “what we do,” by supporting quality improvement teams to make changes at the local level to enhance the patient experience. Method This article provides an overview of Safer Healthcare Now! as a national patient safety initiative, and highlights the results of a National Collaborative on Falls Prevention as a knowledge translation strategy utilized within the long-term care setting. A description of expanding supports for knowledge translation will also be provided.

The Power of Process Improvement Methodology on a Highly Complex Pediatric Bone Marrow Transplant Unit's Catheter Associated Blood Stream Infection Rates

Cincinnati Children's Hospital Medical Center (CCHMC) has instituted a major safety initiative to reduce central venous catheter (CVC) blood stream infections (BSI). A multidisciplinary approach utilizing quality improvement methodology was implemented initially in the PICU, leading to the development of a CVC maintenance bundle.

Utilizing Quality Improvement Methods to Improve Patient Care Outcomes in a Pediatric Residency Program

Although there is an expectation for outcomes-oriented training in residency programs, the reality is that few guidelines and examples exist as to how to provide this type of education and training. We aimed to improve patient care outcomes in our pediatric residency program by using quality improvement (QI) methods, tools, and approaches. A series of QI projects were implemented over a 3-year period in a pediatric residency program to improve patient care outcomes and teach the residents how to use QI methods, tools, and approaches. Residents experienced practice-based learning and systems-based assessment through group projects and review of their own patient outcomes. Resident QI experiences were reviewed quarterly by the program director and were a mandatory part of resident training portfolios. Using QI methodology, we were able to improve management of children with obesity, to achieve high compliance with the national patient safety goals, improve the pediatric hotline service, and implement better patient flow in resident continuity clinic. Based on our experiences, we conclude that to successfully implement QI projects in residency programs, QI techniques must be formally taught, the opportunities for resident participation must be multiple and diverse, and QI outcomes should be incorporated in resident training and assessment so that they experience the benefits of the QI intervention. The lessons learned from our experiences, as well as the projects we describe, can be easily deployed and implemented in other residency programs.