Using the Plan, Do, Study, Act Model to Implement a Quality Improvement Program in Your Practice.

BackgroundEmergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients.ObjectivesThe objectives were to assess whether or not the QI programme improves 90-day survival after emergency abdominal surgery; to assess effects on 180-day survival, hospital stay and hospital readmission; and to better understand these findings through an integrated process evaluation, ethnographic study and cost-effectiveness analysis.DesignThis was a stepped-wedge cluster randomised trial. Hospitals were organised into 15 geographical clusters, and commenced the QI programme in random order over 85 weeks. Analyses were performed on an intention-to-treat basis. The primary outcome was analysed using a mixed-effects parametric survival model, adjusting for time-related effects. Ethnographic and economics data were collected in six hospitals. The process evaluation included all hospitals.SettingThe trial was set in acute surgical services of 93 NHS hospitals.ParticipantsPatients aged ≥ 40 years who were undergoing emergency abdominal surgery were eligible.InterventionThe intervention was a QI programme to implement an evidence-based care pathway.Main outcome measuresThe primary outcome measure was mortality within 90 days of surgery. Secondary outcomes were mortality within 180 days, length of hospital stay and hospital readmission within 180 days. The main economic measure was the quality-adjusted life-years.Data sourcesData were obtained from the National Emergency Laparotomy Audit database; qualitative interviews and ethnographic observations; quality-of-life and NHS resource use data were collected via questionnaires.ResultsOf 15,873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 participants in the usual care group and 7374 in the QI group. The primary outcome occurred in 1393 participants in the usual care group (16%), compared with 1210 patients in the QI group (16%) [QI vs. usual care hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.96 to 1.28]. No differences were found in mortality at 180 days or hospital readmission; there was a small increase in hospital stay in the QI group (HR for discharge 0.90, 95% CI 0.83 to 0.97). There were only modest improvements in care processes following QI implementation. The ethnographic study revealed good QI engagement, but limited time and resources to implement change, affecting which processes teams addressed, the rate of change and eventual success. In some sites, there were challenges around prioritising the intervention in busy environments and in obtaining senior engagement. The intervention is unlikely to be cost-effective at standard cost-effectiveness thresholds, but may be cost-effective over the lifetime horizon.LimitationsSubstantial delays were encountered in securing data access to national registries. Fewer patients than expected underwent surgery and the mortality rate was lower than anticipated.ConclusionsThere was no survival benefit from a QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. The modest impact of the intervention on process measures, despite good clinician engagement, may have been limited by the time and resources needed to improve patient care.Future workFuture QI programmes must balance intervention complexity with the practical realities of NHS services to ensure that such programmes can be delivered with the resources available.Trial registrationCurrent Controlled Trials ISRCTN80682973 andThe Lancetprotocol 13PRT/7655.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 7, No. 32. See the NIHR Journals Library website for further project information.

Objective <p>We successfully implemented the ADA’s Diabetes INSIDE<sup>®</sup> quality improvement program at a University hospital and safety-net health system (Tulane and Parkland), focused on system-wide improvement in poorly controlled type 2 diabetes (HbA1c>8.0% [64 mmol/mol]). In this study, we estimated the 5-year risk reduction in complications and mortality associated with the QI program.</p> <p>Research Design and Methods</p> <p>The QI implementation period was one year, followed by the post-intervention period of six months to evaluate the impact of QI on clinical measures. We measured the differences between the baseline and post-intervention clinical outcomes in 2,429 individuals with HbA1c >8% (64 mmol/mol) at baseline and used the Building, Relating, Assessing, Validating Outcomes (BRAVO™) of diabetes model to project the 5-year risk reduction of diabetes-related complications under the assumption that intervention benefits persist over time. An alternative assumption that intervention benefits diminish by 30% every year was also tested.</p> <p>Results</p> <p>The QI program was associated with reductions in HbA1c (-0.84%) and LDL-C (-5.94 mg/dl) among individuals with HbA1c level >8.0% (64 mmol/mol), with greater reduction in HbA1c (-1.67%) and LDL-C (-6.81 mg/dl) among those with HbA1c level > 9.5% at baseline (all p<0.05). The implementation of the Diabetes INSIDE<sup>® </sup>QI program was associated with 5-year risk reductions in major adverse cardiovascular events (MACE, Relative Risk (RR): 0.78, 95% confidence interval (CI):0.75-0.81) and all-cause mortality (RR:0.83, 95% CI: 0.82-0.85) among individuals with baseline HbA1c level >8.0% (64 mmol/mol), and MACE (RR: 0.60, 95% CI:0.56-0.65) and all-cause mortality (RR: 0.61, 95% CI: 0.59-0.64) among individuals with baseline HbA1c level > 9.5% (80 mmol/mol). Sensitivity analysis also identified a substantially lower risk of diabetes-related complications and mortality associated with the QI program.</p> <p>Conclusions</p> <p>Our modeling results suggest that the ADA’s Diabetes INSIDE<sup>®</sup> QI program would benefit the patients and population by substantially reducing the 5-year risk of complications and mortality in individuals with diabetes. </p>

Keywords: percutaneous coronary intervention; structural heart disease intervention; congential heart disease; adults; congenital heart disease; pediatrics

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

Human papillomavirus (HPV) vaccination could prevent most of the ~34,000 HPV-attributable cancers diagnosed annually in the US, but uptake remains suboptimal. Healthcare systems are key partners in implementing HPV vaccination quality improvement (QI) programs. To inform future system-level HPV vaccine initiatives, we sought to understand HPV vaccine QI from the perspective of QI program leaders in healthcare systems. We conducted telephone interviews with a multi-state sample of 17 QI leaders in 15 systems. We analyzed data qualitatively via thematic analysis to describe QI leaders’ perspectives on prioritizing and implementing HPV vaccine QI. All QI leaders endorsed HPV vaccination as beneficial, and some had already prioritized increasing uptake to improve adolescent health and meet payor reimbursement standards. Those not prioritizing HPV vaccination cited concerns including the relatively small size of adolescent patient populations, lack of buy-in among providers, and the need to focus on health services perceived as more profitable or urgent. When implementing HPV vaccine QI programs, QI leaders reported key barriers to be the lack of robust data systems and acceptable QI metrics, limited time, and pressures of a fee-for-service clinical environment. Facilitators included automation and standardization in QI efforts and passionate vaccine champions. Almost all QI leaders reported future plans to implement HPV vaccine QI projects. Findings suggest that many healthcare systems are motivated to improve HPV vaccination. However, resistance to guideline-consistent quality metrics, the narrow target of one vaccine in the adolescent patient population, payment structures, and constrained time of providers are key barriers to practice improvements.

Dermatologists must develop an office quality improvement (QI) program to document the quality of care. This activity is being monitored by health maintenance organizations, insurance companies, and accreditation organizations, such as the Accreditation Association for Ambulatory Health Care,¹the Joint Commission on Accreditation of Healthcare Organizations, and the National Committee for Quality Assurance.²The Accreditation Association for Ambulatory Health Care considers quality management and improvement to be an essential standard for accreditation. This article will present a QI program that links QI activities, peer review, and risk management in an organized, systematic manner. Through the use of a QI program, patient outcomes can be documented in an office setting.

The Status of Quality Improvement Programs for Pediatric Traumatic Brain Injury Care in Argentina

Patients undergoing emergency abdominal surgery are exposed to a high risk of death. A quality improvement (QI) programme to improve the survival for these patients was evaluated in the Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial. This study aims to assess its cost-effectiveness versus usual care from a UK health service perspective. Data collected in a subsample of trial participants were employed to estimate costs and quality-adjusted life years (QALYs) for the QI programme and usual care within the 180-day trial period, with results also extrapolated to estimate lifetime costs and QALYs. Cost-effectiveness was estimated using incremental cost-effectiveness ratios (ICERs). The probability of being cost-effective was determined for different cost-effectiveness thresholds (£13,000 to £30,000 per QALY). Analyses were performed for lower-risk and higher-risk subgroups based on the number of surgical indications (single vs multiple). Within the trial period, QI was more costly (£467) but less effective (-0.002 QALYs). Over a lifetime, it was more costly (£1395) and more effective (0.018 QALYs), but did not appear to be cost-effective (ICER: £77,792 per QALY, higher than all cost-effectiveness thresholds; probability of being cost-effective: 28.7%-43.8% across the thresholds). For lower-risk patients, QI was more costly and less effective both within trial period and over a lifetime and it did not appear to be cost-effective. For higher-risk patients, it was more costly and more effective, and did not appear cost-effective within the trial period (ICER: £158,253 per QALY) but may be cost-effective over a lifetime (ICER: £14,293 per QALY). The QI programme does not appear cost-effective at standard cost-effectiveness thresholds. For patients with multiple surgical indications, this programme is potentially cost-effective over a lifetime, but this is highly uncertain.

Nearly 70 million adults in the United States have hypertension, and only about 50% of those adults have a blood pressure reading below 140/90 mm Hg. Target: BP is a national initiative co-led by the American Heart Association and American Medical Association aimed at improving blood pressure control nationally to reduce the number of Americans who suffer the consequences of high blood pressure including myocardial infarctions, heart failure, strokes, and chronic kidney disease. Target: BP will equip physician practices and health care systems with the resources and technical assistance to achieve a minimum 70% blood pressure control rate with a target of reaching 80% or higher. Target: BP is a multi-faceted, evidence-based, data-driven quality improvement initiative that leverages the AMAs membership and strategic focus on improving health outcomes and the AHAs success in disseminating large scale improvement initiatives like Get With the Guidelines - Stroke, an effective cerebrovascular quality improvement and recognition program. This initiative offers participating healthcare systems, ambulatory clinical practices and individual clinicians the following: A mass communication campaign to raise public awareness about the importance of controlling high blood pressure A quality improvement program and relevant tools to help clinicians and care teams implement the latest hypertension guidelines and improve management and treatment of patients with hypertension, including check lists, treatment algorithms, protocols and fact sheets Opportunities to contribute data for tracking blood pressure control rates and benchmarking against other participants regionally and nationally Opportunities to be recognized formally for achieving a 70% blood pressure control rate, improving blood pressure control, reducing therapeutic inertia and using self-measured blood pressure monitoring Access to a national advisory group of experts in improving blood pressure control Since its initiation in November 2015, over 250 healthcare systems and clinics have committed to participate in Target: BP.

All positive screening of newborns for cystic fibrosis using the dried blood spot 2-tiered immunoreactive trypsinogen/DNA method requires subsequent sweat chloride testing for confirmation. Obtaining an adequate volume of sweat to measure chloride is a challenge for many cystic fibrosis centers across the nation. The standard for patients older than 3 months is less than 5% quantity not sufficient (QNS) and for patients 3 months or younger is less than 10% QNS. To set up a quality improvement (QI) program for sweat testing to improve QNS rates using the Wescor Macroduct (Wescor, Inc, Logan, Utah) method at Texas Children's Hospital's laboratory, Houston, Texas. Single-center study. Quantity not sufficient rates were evaluated for 4 months before and 8 months after implementation of the QI program for patients aged 3 months or younger and those older than 3 months. The QI program included changes in technician training, service, site of collection, mode of collection, weekly review, and forms to screen patients for medications that may alter sweat production. A marked improvement was observed in the rates of QNS, which declined considerably from 16.7% to 8.5% (≤3 months old) and from 9.3% to 2.2% (>3 months old) after implementation of the QI initiative in both age categories. This report demonstrates the effectiveness of the QI program in significantly improving QNS rates in sweat chloride testing in a pediatric hospital.

A survey of residents’ experience with patient safety and quality improvement concepts in radiation oncology

Variations in emergency care quality for alcohol-related liver disease (ARLD) have been highlighted. To determine whether introduction of a regional quality improvement (QI) programme was associated with a reduction in potentially avoidable inpatient mortality. Retrospective observational cohort study using hospital administrative data spanning a 1-year period before (2014/2015) and 3years after a QI initiative at seven acute hospitals in North West England. The intervention included serial audit of a bundle of process metrics. An algorithm was developed to identify index ("first") emergency admissions for ARLD (n=3887). We created a standardised mortality ratio (SMR) to compare relative mortality and regression models to examine risk-adjusted odds of death. In 2014/2015, three of seven hospitals had an SMR above the upper control limit ("outliers"). Adjusted odds of death for patients admitted to outlier hospitals was higher than non-outliers (OR 2.13, 95% CI 1.32-3.44, P=0.002). Following the QI programme there was a step-wise reduction in outliers (none in 2017/2018). Odds of death was 67% lower in 2017/2018 compared to 2014/2015 at original outlier hospitals, but unchanged at other hospitals. Process audit performance of outliers was worse than non-outliers at baseline, but improved after intervention. There was a reduction in unexplained variation in hospital mortality following the QI intervention. This challenges the pessimism that is prevalent for achieving better outcomes for patients with ARLD. Notwithstanding the limitations of an uncontrolled observational study, these data provide hope that co-ordinated efforts to drive adoption of evidence-based practice can save lives.

Status of trauma quality improvement programs in the Andean region: What foundation do we have to build on

Healthcare systems are attempting to reduce hospital readmissions due to chronic obstructive pulmonary disease (COPD). A retrospective study of a quality improvement (QI) program performed at a single center whose multifaceted intervention included nocturnal administration of advanced positive airway pressure (PAP) modality (or noninvasive positive pressure ventilation [NIPPV]) called averaged volume assured pressure support (AVAPS-AE) initiation by a respiratory therapist (RT), medication reconciliation by a pharmacist, adequate provision of oxygen, and ongoing RT-led care. In this QI program, consecutive patients who had been hospitalized twice in a single year with an acute COPD exacerbation underwent such interventions after they met specific selection criteria. Three-hundred ninety-seven consecutive patients were eligible for the program because they had two or more hospitalizations in the previous year. The proportion of patients who were readmitted on two or more occasions decreased from 100% (397 of 397) in the year prior to initiation of intervention to 2.2% (9 of 397) in the following year (χ(2) = 758, p < 0.0001). Seventy patients died over the one year following initiation of the multifaceted intervention. A composite outcome of rehospitalization and death was associated with inhaled steroids (adjusted odds ratio [adjOR] of 2.13; 95% confidence interval [CI] 1.09, 4.17; p = 0.02), whereas inhaled antimuscarinics tended to be associated with less risk for rehospitalization or death (adjOR 0.56; 95% CI 0.34, 1.03; p = 0.06). In a retrospective cohort study of a QI initiative undertaken at a single center, we have observed that a multifaceted intervention that involved initiation of nocturnal advanced PAP (NIPPV) modality, RT-led respiratory care, medication reconciliation, appropriate oxygen therapy initiation, and patient education led to significant reduction in rehospitalization.

Impact of electronic data interchange technology on quality improvement and inventory reduction programs: A field study