ED Provider-Based Palliative Care Electronic Notification: A Quality Improvement Initiative (QI650)

Data Management for Quality Improvement: How to Collect and Manage Data.

BackgroundThe identification and articulation of programme theory can support effective design, execution and evaluation of quality improvement (QI) initiatives. Programme theory includes an agreed aim, potential interventions to achieve this...

The American Academy of Pediatrics recommends annual influenza vaccination for all children 6 months and older, yet only 59% of children nationally received the vaccine during the 2014-2016 influenza seasons. Of these, only 4% received the vaccine in a hospital setting. The goal of this quality improvement (QI) initiative was to increase influenza vaccination status at discharge at least twofold in children admitted to our hospital during the 2017-2018 influenza season compared with the 2016-2017 season. The QI initiative was conducted in the inpatient units at a tertiary care children's hospital. Interventions included electronic medical record triggers, provider education, and peer comparison. The primary outcome measure was the percentage of children discharged from the hospital with at least 1 dose of the influenza vaccine received either at the hospital or before admission. Queries about the influenza vaccination status of children were used as a process measure. Length of stay was used as a balancing measure. The percentage of hospitalized children discharged with at least 1 dose of the vaccine increased 4.7-fold during the QI initiative (46%) compared with baseline (10%). There was a fourfold increase in parental query about the influenza vaccination status of their children (68%) during the QI initiative compared with the baseline period (16%). No significant difference occurred in the median length of stay among patients admitted during the QI initiative versus the baseline period. We increased influenza vaccination status among children admitted to our hospital using electronic medical record triggers, provider education, and peer comparison.

Identifying children ready for transfer out of the pediatric intensive care unit (PICU) is an area that may benefit from clinical decision support (CDS). We previously implemented a quality improvement (QI) initiative to accelerate the transfer evaluation of non-medically complex PICU patients with viral bronchiolitis receiving floor-appropriate respiratory support. Design a CDS tool adaptation of this QI initiative to further accelerate transfer evaluation of appropriate patients. The original initiative focused on identifying for transfer evaluation otherwise healthy children admitted to the PICU with bronchiolitis who had been receiving floor-appropriate levels of respiratory support for at least 6 hours. However, this initiative required that clinicians manually track the respiratory support of qualifying patients. We designed an electronic health record (EHR)-based CDS tool to automate identification of transfer-ready candidates. The tool parses EHR data to identify children meeting prior QI initiative criteria and alerts clinicians to assess transfer readiness once a child has been receiving floor-appropriate respiratory support for 6 hours. We compared time from reaching floor-appropriate support to placement of the transfer order ("time-to-transfer"), PICU length of stay (LOS), and hospital LOS between patients admitted prior to our QI initiative (December 1, 2018-October 19, 2019, "pre-QI phase"), during the initiative but before CDS tool implementation (October 20, 2019-February 7, 2022, "QI phase"), and after CDS implementation (February 8-November 11, 2022, "CDS phase"). CDS-phase patients (n = 131) had a shorter median time-to-transfer of 5.23 (interquartile range [IQR], 3.38-10.0) hours compared with QI-phase patients (n = 304) at 5.93 (IQR, 4.23-12.2) hours (p = 0.04). PICU and hospital LOS values decreased from the pre-QI (n = 150) to QI phase. Though LOS reductions were sustained during the CDS phase, further reductions from QI to CDS phase were not statistically significant. An EHR-based CDS adaptation of a prior QI initiative facilitated timely identification of PICU patients with bronchiolitis ready for transfer evaluation. Such tools might allow PICU clinicians to focus on other high-acuity tasks while accelerating transfer evaluation of appropriate patients.

Quality Improvement is a Professional Responsibility in Diabetes Care

With a lack of standard processes in first parenteral dose medication administration in the home and community setting, a quality improvement initiative was undertaken by provincial home and community care service provider organizations (SPOs) in Ontario to support an evidence-based practice approach for administering the first dose of an intravenous (IV) medication. The project group, consisting of clinical leaders and business competitors, united to collaborate and support evidence-based, safe patient care. The group developed an evidence-based approach to screening patients for safe administration of the first dose of a parenteral medication within the home and community setting. Aligning the practice of administering the first dose of a parenteral medication is critical to providing safe, consistent, equitable, and timely care for all patients requiring a first dose in the home and community setting. From the SPO perspective, this improvement initiative has achieved the primary goal of aligning on a consistent patient safety screening tool used to support determining if first dose administration of a parenteral medication in the community is safe for the patient. Outputs of this work include collaborating with the provincial government funder and with SPOs who are competing for the same contracts within this sector, and the development of evidence-based resources to support patient screening. An exciting outcome was the opportunity to align with the Canadian Vascular Access Association (CVAA) and their mission statement of advocating for safe, quality patient care across the healthcare system (CVAA, n.d.). By developing an evidence-based approach to administering the first dose of a parenteral medication, this group has advocated for CVAA to include elements of the quality improvement (QI) initiative within the newly updated 2024 CVAA guidelines. This manuscript outlines the continued and thorough process undertaken by SPOs and the provincial government funder for home and community care to standardize best practices for administering a first dose of a parenteral medication in this unique sector. The successes and challenges encountered in aligning all those with a vested interest are highlighted.

Understanding the barriers to quality care in ovarian cancer: results from a needs assessment and quality improvement initiative

Criteria for evaluating programme theory diagrams in quality improvement initiatives: a structured method for appraisal

BackgroundAccess to safe surgical care represents a critical gap in healthcare delivery and development in many low- and middle-income countries, including Ethiopia. Quality improvement (QI) initiatives at hospital level may contribute to closing this gap. Many such quality improvement initiatives are carried out through international health partnerships. Better understanding of how to optimise quality improvement in low-income settings is needed, including through partnership-based approaches. Drawing on a process evaluation of an intervention to improve surgical services in an Ethiopian hospital, this paper offers lessons to help meet this need.MethodsWe conducted a qualitative process evaluation of a quality improvement project which aimed to improve access to surgical services in an Ethiopian referral hospital through better management. Data was collected longitudinally and included: 66 in-depth interviews with surgical staff and project team members; observation (135 h) in the surgery department and of project meetings; project-related documentation. Thematic analysis, guided by theoretical constructs, focused on identifying obstacles to implementation.ResultsThe project largely failed to achieve its goals. Key barriers related to project design, partnership working and the implementation context, and included: confusion over project objectives and project and partner roles and responsibilities; logistical challenges concerning overseas visits; difficulties in communication; gaps between the time and authority team members had and that needed to implement and engage other staff; limited strategies for addressing adaptive—as opposed to technical—challenges; effects of hierarchy and resource scarcity on QI efforts. While many of the obstacles identified are common to diverse settings, our findings highlight ways in which some features of low-income country contexts amplify these common challenges.ConclusionWe identify lessons for optimising the design and planning of quality improvement interventions within such challenging healthcare contexts, with specific reference to international partnership-based approaches. These include: the need for a funded lead-in phase to clarify and agree goals, roles, mutual expectations and communication strategies; explicitly incorporating adaptive, as well as technical, solutions; transparent management of resources and opportunities; leadership which takes account of both formal and informal power structures; and articulating links between project goals and wider organisational interests.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1639-4) contains supplementary material, which is available to authorized users.

Introduction: Nasal injury is an important concern with the use of non-invasive ventilation delivered by masks or prongs. Despite regular skin integrity assessment and close monitoring, we found a high incidence rate of nasal skin injuries in nearly 70% of neonates receiving non-invasive ventilation admitted into our neonatal intensive care unit (NICU). Methods: A quality improvement (QI) initiative to reduce the incidence of nasal injuries secondary to nasal mask application in inborn neonates admitted to our NICU by 50% from baseline over 8 weeks. We performed fishbone analysis and multiple Plan-Do-Study-Act (PDSA) cycles targeted to reduce nasal injury following nasal mask application for non-invasive ventilation. A QI team comprising resident doctors, nurses and staff neonatologists was formed to drive change. Key interventions were strengthening the protocol-based application of nasal masks and consistent monitoring and documenting injuries. Data were collected weekly and plotted on run charts. Results: The successive implementation of interventions led to the reduction of injury by 46% (71%–25%) at the end of 5 weeks of intervention. The interventions have been incorporated into our unit policy and have sustained at 45% for 3 months following the QI initiative. Conclusion: QI methods involving training and educating healthcare workers about the step-by-step application of nasal masks and frequent assessment for nasal injury helped reduce the nasal injury rate in our unit. Incorporation into the NICU policies was crucial for the sustenance of culture change.

Congenital hypothyroidism (CH) is a prevalent endocrine disorder that can lead to intellectual disability, psychomotor dysfunction, and impaired growth if not treated promptly. Early diagnosis and consistent monitoring are critical, especially during the first three years of life. We developed a PowerBI dashboard integrated with the electronic medical record (EMR) to track thyroid-stimulating hormone (TSH) levels, clinic visits, and upcoming appointments for patients aged 3 months to 3 years. It enables real-time identification of patients not meeting clinical targets, facilitating timely interventions. Prior to dashboard implementation, 75% of patients achieved two or more normal TSH values annually. One year post-implementation, this figure rose to 91%, and further refinements increased it to 93% the following year. The dashboard also improved clinic efficiency by streamlining communication and reducing manual data tracking. This quality improvement (QI) initiative shows the effectiveness of EMR-integrated dashboards in improving clinical outcomes and operational efficiency. The model is scalable and adaptable for other chronic pediatric conditions requiring regular follow-up and laboratory monitoring. Our findings support broader adoption of similar PowerBI dashboards in Endocrinology and other specialties focused on chronic disease management. Highlights Electronic dashboard implementation significantly improved clinical outcomes for pediatric patients with congenital hypothyroidism (CH) at Phoenix Children’s Hospital. TSH monitoring compliance increased from 75% to 93% over two years following dashboard deployment. The dashboard enabled real-time tracking of lab results, appointments, and patient demographics, streamlining care coordination. Quality improvement methodology using Plan-Do-Study-Act (PDSA) cycles facilitated iterative enhancements to the dashboard and clinical workflow. The project demonstrates a scalable model for other institutions to improve care for chronic pediatric conditions requiring frequent follow-up and lab monitoring.

Introduction The Rural Surgical Obstetrical Networks (RSON) initiative in BC was developed to stabilize and grow low volume rural surgical and obstetrical services. One of the wrap-around supportive interventions was funding for Continuous Quality Improvement (CQI) initiatives, done through a local provider-driven lens. This paper reviews mixed-methods findings on providers’ experiences with CQI and the implications for service stability. Background Small, rural hospitals face barriers in implementing quality improvement initiatives due primarily to lack of resource capacity and the need to prioritize clinical care when allocating limited health human resources. Given this, funding and resources for CQI were key enablers of the RSON initiative and seen as an essential part of a response to assuaging concerns of specialists at higher volume sites regarding quality in lower volume settings. Methods Data were derived from two datasets: in-depth, qualitative interviews with rural health care providers and administrators over the course of the RSON initiative and through a survey administered at RSON sites in 2023. Findings Qualitative findings revealed participants’ perceptions of the value of CQI (including developing expanded skillsets and improved team function and culture), enablers (the organizational infrastructure for CQI projects), challenges in implementation (complications in protecting/prioritizing CQI time and difficulty with staff engagement) and the importance of local leadership. Survey findings showed high ratings for elements of team function that relate directly to CQI (team process and relationships). Conclusion Attention to effective mechanisms of CQI through a rural lens is essential to ensure that initiatives meet the contextual realities of low-volume sites. Instituting pathways for locally-driven quality improvement initiatives enhances team function at rural hospitals through creating opportunities for trust building and goal setting, improving communication and increasing individual and team-wide motivation to improve patient care.

Implementing guidelines for risk-stratified thromboprophylaxis among gynecologic oncology patients: A quality improvement initiative

Diabetes Self-Management Education and Support is the foundation of any diabetes program. Providing consistent and up-to-date educational materials (EM) can be challenging for any diabetes program. In 2017, a Quality Improvement (QI) Initiative was started to ensure that all clinicians (> 35 Certified Diabetes Care and Education Specialist and 60 diabetes care providers) across our network, had a standardized approach to development and maintaining patient EM. The QI plan had three aims: person with diabetes (PWD) should receive the most current information, providers should have access to current EM for all diabetes related topics and PWD should receive a consistent message across the education disciplines. The need for a web based application to host EM was identified. An inventory of all EM showed a total of 351; a centralized process overseen by a multidisciplinary committee was developed, core EM aligned with the AADE7 Self-Care BehaviorsTM were identified. New standards included: Reviewing and updating EM every 2-3 years (or sooner reflecting the most current practice), format should be conducive to learning, and templates should be consistent within categories. Results: Share Point was chosen as the web based application and the Education Document Repository (EDR) was built and launched in 2018. The percentage of EM that met the newly developed standards increased from 20% at baseline to 80%, and the work load of maintaining the EM decreased by 30%. The EDR hosts 250 EM, has 13 categories and the highest percentage of EM belong to: nutrition 30%, technology 19% (pumps and CGMs), pediatrics 12% and medications 10%. In addition to the AADE7, other categories were created; such as: pediatrics, young adults, pregnancy to address the need of our patient population and user experience. Through this initiative all diabetes programs within our network of 10 locations across 6 states, have access to high quality patient EM. As our network grows we will be able to provide EM without delay. Disclosure A. Millan-Ferro: None. L.A. Higgins: Consultant; Self; Eli Lilly and Company. J.M. Rizzotto: None.

Asymptomatic elevated blood pressure (BP) is common in the hospital. There is no evidence supporting the use of intravenous (IV) antihypertensives in this setting. To determine the prevalence and effects of treating asymptomatic elevated BP with IV antihypertensives and to investigate the efficacy of a quality improvement (QI) initiative aimed at reducing utilization of these medications. Retrospective cohort study. Urban academic hospital. Patients admitted to the general medicine service, including the intensive care unit (ICU), with ≥1 episode of asymptomatic elevated BP (>160/90 mm Hg) during hospitalization. A two-tiered, QI initiative. The primary outcome was the monthly proportion of patients with asymptomatic elevated BP treated with IV labetalol or hydralazine. We also analyzed median BP and rates of balancing outcomes (ICU transfers, rapid responses, cardiopulmonary arrests). We identified 2,306 patients with ≥1 episode of asymptomatic elevated BP during the 10-month preintervention period, of which 251 (11%) received IV antihypertensives. In the four-month postintervention period, 70 of 934 (7%) were treated. The odds of being treated were 38% lower in the postintervention period after adjustment for baseline characteristics, including length of stay and illness severity (OR = 0.62; 95% CI 0.47-0.83; P = .001). Median SBP was similar between pre- and postintervention (167 vs 168 mm Hg; P = .78), as were the adjusted proportions of balancing outcomes. Hospitalized patients with asymptomatic elevated BP are commonly treated with IV antihypertensives, despite the lack of evidence. A QI initiative was successful at reducing utilization of these medications.