Validated Quality Improvement Research Articles

Preventing and Treating Pain and Anxiety during Needle-Based Procedures in Children with Cancer in Low- and Middle-Income Countries.

Introduction: Children with cancer experience significant pain and anxiety during needle-based procedures. Undertreated pain in children has long-lasting consequences and reduces the efficacy of subsequent analgesic efforts. A validated quality improvement (QI) intervention, known as the "Children's Comfort Promise", includes (1) topical anesthetics, (2) sucrose or breastfeeding for infants, (3) comfort positioning, and (4) distraction techniques, and has been shown to be highly effective in decreasing procedural pain and anxiety in children. However, there is limited data about the adoption, adaptation, and implementation of these interventions in low- and middle-income countries (LMICs). Methods: A QI pilot project utilizing the Model for Improvement of the "Global Comfort Promise" was implemented in four global pediatric cancer hospitals (Lima, Peru; Barretos, Brazil; Pietermaritzburg, South Africa; and Manila, Philippines). Between August 2021 and January 2023, the pilot sites identified a specific aim, co-designed the measurement strategy with St. Jude Children's Research Hospital, and adopted, adapted, and implemented the project at their individual sites. Results: A total of 2,185 different procedures were recorded in the first year of implementation. Most patients were less than 10 years old (60.5%) and solid tumors (37.9%) were the most common diagnosis. Overall, healthcare professionals (98.3%) were satisfied with the procedures. Parents and patients reported that only 33.7% of patients experienced pain during the procedure. All (100%) parents and patients felt the healthcare teams adequately addressed their child's pain. Median self-reported adherence to ≥2 interventions was 98.0%. Challenges to the implementation of the QI initiative included lack of training, turnover of the medical staff, maintaining staff enthusiasm, and access to topical anesthetics. Each site had unique change ideas to implement the initiative. Conclusions: This multi-site, multi-country QI initiative was feasible and was successfully adopted, adapted, and implemented in the LMIC context to improve procedural pain in children (Global Comfort Promise). Additionally, this intervention resulted in high satisfaction of both healthcare professionals and patients/families. Further work is needed to overcome the challenges of topical anesthetic access and education of the workforce. Additional plans include modifying the Global Comfort Promise to include high-quality communication and expanding to additional sites with further refinement of the implementation strategy.

S1722 Improved Timely Documentation and Chart Encounter Closure Rates With the Implementation of a Validated Quality Improvement Process in the Division of Gastroenterology and Hepatology

S1722 Improved Timely Documentation and Chart Encounter Closure Rates With the Implementation of a Validated Quality Improvement Process in the Division of Gastroenterology and Hepatology

Building Resident Quality Improvement Knowledge and Engagement Through a Longitudinal, Mentored, and Experiential Learning-Based Quality Improvement Curriculum.

Quality improvement (QI) training is an essential component of resident medical education and a part of the ACGME core competencies. We present our residency's evidence-based QI curriculum, which outlines key components identified in the literature for successful QI education. Our curriculum included a mandatory five-part longitudinal educational series during ambulatory education sessions for second-year residents. Modeled after the Institute for Healthcare Improvement model for improvement and taught by a chief resident, our curriculum introduced residents to key QI concepts through case-based, just-in-time didactics and applied experiential learning via concurrent resident-led longitudinal QI projects. Residents received structured, multilayer mentorship from a faculty mentor in their field of interest and the chief resident of quality and patient safety. Their work-in-progress projects were presented to faculty QI experts and institutional leadership for additional feedback and mentorship. Since 2016, a total of 234 internal medicine residents have completed our QI curriculum and developed 67 QI projects, which have been presented at various local, regional, and national conferences. In the 2 most recent academic years, Quality Improvement Knowledge Application Tool Revised (QIKAT-R) scores significantly increased from 4.6 precurriculum to 6.3 postcurriculum (p < .001). A longitudinal, experiential, and mentored QI curriculum teaches residents QI skill sets through incorporating mechanisms associated with successful educational initiatives and adult learning theory. Our QIKAT-R results and project output show that our curriculum is associated with improved trainee QI knowledge and systems-level improvements.

Improving documentation of anticoagulation and antiplatelet recommendations after outpatient endoscopy

Clear documentation of instructions for resuming anticoagulant and antiplatelet (AC/AP) medications after gastrointestinal endoscopy is essential for high-quality postprocedure care. Yet, these recommendations are frequently absent, which may impact patient...

Standardizing postoperative handoffs using the evidence-based IPASS framework through a multidisciplinary initiative improves handoff communication for neurosurgical patients in the neuro-intensive care unit

Errors in communication are a major source of preventable medical errors. Neurosurgical patients frequently present to the neuro-intensive care unit (NICU) postoperatively, where handoffs occur to coordinate care within a large multidisciplinary team. A multidisciplinary working group at our institution started an initiative to improve postoperative neurosurgical handoffs using validated quality improvement methodology. Baseline handoff practices were evaluated through staff surveys and serial observations. A formalized handoff protocol was implemented using the evidence based IPASS format (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, Synthesis by receiver). Cycles of objective observations and surveys were employed to track practice improvements and guide iterative process changes over one year.Surveys demonstrated improved perceptions of handoffs as organized (17.1% vs 69.7%, p < 0.001), efficient (27.0% vs. 72.7%, p < 0.001), comprehensive (17.1% vs. 66.7%, p < 0.001), and safe (18.0% vs. 66.7%, p < 0.001), noting improved teamwork (31.5% vs. 69.7%, p < 0.001). Direct observations demonstrated improved communication of airway concerns (47.1% observed vs. 92.3% observed, p < 0.001), hemodynamic concerns (70.6% vs. 97.1%, p = 0.001), intraoperative events (52.9% vs. 100%, p < 0.001), neurological examination (76.5% vs. 100%, p < 0.001), vital sign goals (70.6% vs. 100%, p < 0.001), and required postoperative studies (76.5% vs. 100%, p < 0.001). Receiving teams demonstrating improved rates of summarization (47.1% vs. 94.2%, p = 0.005) and asking questions (76.5% vs 98.1%, p = 0.004). The mean handoff time during long-term follow-up was 4.4 min (95% confidence interval = 3.9–5.0 min).Standardization of handoff practices yields improvements in communication practices for postoperative neurosurgical patients.

Learning by Doing: Design and Evaluation of a Quality Improvement Curriculum for Pediatric Hospitalists.

Introduction:Quality improvement (QI) is a core competency for Pediatric Hospital Medicine (PHM) and required for maintenance of certification, but many hospitalists lack QI training. This project set out to increase a PHM faculty’s QI knowledge and comfort participating in QI projects, while concurrently applying the skills learned to a QI project in the hospital.Methods:We designed a 4-session curriculum utilizing principles of adult learning. Faculty immediately applied learned concepts to a QI project to increase the percentage of patients who were seen by an attending and billed for on the same day as admission to the PHM service. Attitudinal data and scores on the validated Quality Improvement Knowledge Application Tool- Revised knowledge assessment were compared precurriculum and postcurriculum. A manifest content analysis was carried out for qualitative questions.Results:Twenty faculty (83%) completed the preassessment; 15 (63%) completed the postassessment. Respondents showed statistically significant improvements in their perceived ability to participate in QI projects and their Quality Improvement Knowledge Application Tool- Revised scores. The group completed a QI project that increased revenue for the division. Faculty appreciated that the curriculum was applied to a real QI project and felt they would use the new skills in their daily practice.Discussion:This curricular model based on adult learning theory, with immediate application to a real QI project, conclusively showed attitudinal, knowledge-based, and hospital system-level improvements, and was well received by faculty.

Improving the paediatric surgery patient experience: an 8-year analysis of narrative quality data

BackgroundNarrative data about the patient experience of surgery can help healthcare professionals and administrators better understand the needs of patients and their families as well as provide a foundation for...

PARTNERED EVALUATION OF LONGITUDINAL IMPACT OF STAR-VA: IMPLICATIONS FOR PROGRAM SUSTAINABILITY

Between 2013 and 2018, 86 Community Living Center (CLC) teams received STAR-VA training and consultation and implemented the intervention. Program evaluation has consistently demonstrated that STAR-VA Veteran training cases experience significantly decreased frequency and severity of target behaviors, symptoms of depression, anxiety, and agitation. VA Central Office leaders responsible for ongoing STAR-VA implementation and evaluation sought to understand the program’s systemic impact on important outcomes, if outcomes are maintained, and factors influencing variation in sustained adherence to STAR-VA. This presentation will describe the rationale for and methods used to develop a valid quality improvement metric to assess behavioral symptoms of dementia, to compare Veteran- and site-level outcomes at trained and untrained CLCs, and to identify factors associated with sustained STAR-VA implementation. This partnered evaluation, combining quantitative and qualitative methodologies, is critical for informing operational strategies for promoting STAR-VA and supporting its sustained implementation in VA CLCs.

A quality improvement collaborative to build improvement capacity in regional primary care support organisations

Strong primary care is foundational for effective, efficient health systems but remains variable in health systems around the world. Increasing quality improvement capacity in primary care support organisations has potential...

Using Always Events to derive patient-centred quality improvement priorities in a specialist primary care service providing care to a homeless population

Background‘Always Events’ (AE) is a validated quality improvement (QI) method where patients, and/or carers, are asked what is so important that it should ‘always’ happen when they interact with healthcare...

In pursuit of quality and safety: an 8-year study of clinical peer review best practices in US hospitals.

Gather normative data on the goals of clinical peer review; refine a best-practice model and related self-assessment inventory; identify the interval progress towards best-practice adoption. Online survey (2015-16) of a cohort of 457 programs first studied by volunteer sampling in either 2007 or 2009 on 40 items assessing the degree of conformance to a validated quality improvement (QI) model and addressing program goals, structure, process, governance, and impact on quality and safety. Acute care hospitals of all sizes in the USA. Physicians and hospital leaders or hospital staff with intimate program knowledge. None. Subjectively-rated program impact on quality and safety; QI model score. Two hundred and seventy responses (59% response rate) showed that clinical peer review most commonly aims to improve quality and safety. From 2007 to 2015, the median [inter-quartile range, IQR] annual rate of major program change was 20% [11-24%]. Mean [confidence interval, CI] QI model scores increased 5.6 [2.9-8.3] points from 46.2 at study entry. Only 35% scored at least 60 of 80 possible points-'C' level progress in adopting the QI model. The analysis supports expansion of the QI model and an associated self-assessment inventory to include 20 items on a 100-point scale for which a 10-point increase predicts a one level improvement in quality impact with an odds ratio [CI] of 2.5 [2.2-3.0]. Hospital and physician leaders could potentially accelerate progress in quality and safety by revisiting their clinical peer review practices in light of the evidence-based QI model.

Risk-Adjusted Margin Positivity Rate as a Surgical Quality Metric for Non-Small Cell Lung Cancer

Incomplete lung cancer resection connotes poor prognosis; the incidence varies with patient demographic, clinical, and institutional factors. We sought to develop a valid, survival impactful, facility-based surgical quality metric that adjusts for related patient demographic and clinical characteristics. Facilities performing resections for patients diagnosed with stage I to IIIA non-small cell lung cancer in the National Cancer Data Base between 2004 and 2011 were identified. Multivariate logistic regression modeling was used to estimate the expected number of margin-positive cases by adjusting for patient risk mix and calculate the observed-to-expected ratio for each facility. Facilities were categorized as outperformers (observed-to-expected ratio less than 1, p < 0.05), nonoutliers (p > 0.05), and underperformers (observed-to-expected ratio greater than 1, p < 0.05); and their characteristics across performance categories were compared by χ2 tests. Multivariate Cox proportional hazard analyses were conducted, adjusting for patient demographic and clinical characteristics. A total of 96,324 patients underwent surgery at 809 facilities. The overall observed margin-positive rate was 4.4%. Sixty-one facilities (8%) were outperformers, 644 (80%) were nonoutliers, and 104 (13%) were underperformers. One third (36%) of National Cancer Institute-designated facilities, 13% of academic comprehensive cancer programs, 5% of comprehensive community cancer programs, and 13% of "other" facilities achieved outperforming status but no community cancer programs did. Interestingly, 9% of National Cancer Institute-designated facilities and 11% of academic comprehensive cancer program facilities were underperformers. Adjusting for patient demographic and clinical characteristics, outperformers had a 5-year all-cause hazard ratio of 0.88 (95% confidence interval: 0.85 to 0.91, p < 0.0001) compared with nonoutliers, and 0.80 (95% confidence interval: 0.77 to 0.84, p < 0.0001) compared with underperformers. Facility performance in lung cancer surgery can be captured by the risk-adjusted margin-positivity rate, potentially providing a valid quality improvement metric.

Validation of Case Finding Algorithms for Hepatocellular Cancer From Administrative Data and Electronic Health Records Using Natural Language Processing

Accurate identification of hepatocellular cancer (HCC) cases from automated data is needed for efficient and valid quality improvement initiatives and research. We validated HCC International Classification of Diseases, 9th Revision (ICD-9) codes, and evaluated whether natural language processing by the Automated Retrieval Console (ARC) for document classification improves HCC identification. We identified a cohort of patients with ICD-9 codes for HCC during 2005-2010 from Veterans Affairs administrative data. Pathology and radiology reports were reviewed to confirm HCC. The positive predictive value (PPV), sensitivity, and specificity of ICD-9 codes were calculated. A split validation study of pathology and radiology reports was performed to develop and validate ARC algorithms. Reports were manually classified as diagnostic of HCC or not. ARC generated document classification algorithms using the Clinical Text Analysis and Knowledge Extraction System. ARC performance was compared with manual classification. PPV, sensitivity, and specificity of ARC were calculated. A total of 1138 patients with HCC were identified by ICD-9 codes. On the basis of manual review, 773 had HCC. The HCC ICD-9 code algorithm had a PPV of 0.67, sensitivity of 0.95, and specificity of 0.93. For a random subset of 619 patients, we identified 471 pathology reports for 323 patients and 943 radiology reports for 557 patients. The pathology ARC algorithm had PPV of 0.96, sensitivity of 0.96, and specificity of 0.97. The radiology ARC algorithm had PPV of 0.75, sensitivity of 0.94, and specificity of 0.68. A combined approach of ICD-9 codes and natural language processing of pathology and radiology reports improves HCC case identification in automated data.

EDITORIAL

EDITORIAL

Is delayed laparotomy for blunt abdominal trauma a valid quality improvement measure in the era of nonoperative management of abdominal injuries?

Review of hemodynamically stable patients who undergo laparotomy for trauma greater than 4 hours after admission is an American College of Surgeons quality improvement filter. We reviewed our recent experience with patients who underwent laparotomy for trauma greater than 4 hours after admission to evaluate the reasons for delay, and to determine whether they were because of failure of nonoperative management or other causes. The registry at our Level I trauma center was searched from January 1998 through December 2000 for patients who required a laparotomy for trauma greater than 4 hours after admission. Of 3,369 admitted blunt trauma patients, 90 (2.7%) underwent laparotomy for trauma, of which 26 (29%) were identified as delayed laparotomies greater than 4 hours after admission. The most common mechanism of injury was motor vehicle crash, the mean Injury Severity Score was 18, and 65% of the patients had significant distracting injuries. Five patients had laparotomy greater than 24 hours after admission. The average time to the operating room in the remaining patients was 8.6 hours. Clinical examination (61%) findings were the most common indication for operation. Gastrointestinal (GI) tract injury was the most common injury associated with delay in laparotomy (58%). GI tract injuries are the predominant injury leading to delayed laparotomy for blunt trauma (58%). Failed nonoperative management of solid organ injuries occurred less frequently (15%). Future efforts should concentrate on earlier identification of GI tract injury. Delayed laparotomy for blunt abdominal trauma is a valid quality improvement measure.

Modeling case mix adjustment of stroke rehabilitation outcomes.

Case mix adjustment models for long-term stroke rehabilitation outcomes should be developed (1) to facilitate equitable comparisons of outcomes across treatment settings, thereby reducing disincentives for treating complex cases, (2) to improve triage into the most appropriate level of rehabilitative care after discharge from acute care, and (3) to confirm that case mix factors are equated in treatment effectiveness studies and by random assignment across conditions in clinical trials. Case mix adjustment is necessary for valid quality improvement processes. A conceptual model of case mix adjustment of long-term rehabilitation outcomes is presented that (1) is diagnosis-specific, (2) includes demographic variables as important case mix factors, (3) encompasses triage into rehabilitation as well as treatment processes as aspects of quality of rehabilitative care, (4) contains outcomes measuring functional status as well as mortality and morbidity, and (5) keys timing of outcomes to onset of conditions requiring rehabilitation rather than discharge from rehabilitation. The number of potential interactions among case mix indicators requires a sophisticated analytic framework. Random factors in the model illustrate that case mix adjustment can never be perfect. Nevertheless, it is essential. A brief review of the stroke literature on prediction of long-term outcomes suggests that additional work is needed to specify relevant case mix indicators.