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PubMed1998

Methodology of quality improvement projects for the Texas Medicare population.

The Texas Medical Foundation, the quality improvement organization for the state of Texas, develops local quality improvement projects for the Medicare population. These projects are developed as part of the Health Care Quality Improvement Program undertaken by the Health Care Financing Administration. The goal of a local quality improvement project is to collaborate with providers to identify and reduce the incidence of unintentional variations in the delivery of care that negatively impact outcomes. Two factors are critical to the success of a quality improvement project. First, as opposed to peer review that is based on implicit criteria, quality improvement must be based on explicit criteria. These criteria represent key steps in the delivery of care that have been shown to improve outcomes for a specific disease. Second, quality improvement must be performed in partnership with the health care community. As such, the health care community must play an integral role in the design and evaluation of a quality improvement project and in the design and implementation of the resulting quality improvement plan. Specifically, this article provides a historical perspective for the transition from peer review to quality improvement. It discusses key steps used in developing and implementing local quality improvement projects including topic selection, quality indicator development, collaborator recruitment, and measurement of performance/improvement. Two Texas Medical Foundation projects are described to highlight the current methodology and to illustrate the impact of quality improvement projects.

Angina Pectoris↗
PubMed1999

Benchmarking and quality improvement: the Harvard Emergency Department Quality Study.

PURPOSE: To determine whether feedback of comparative information was associated with improvement in medical record and patient-based measures of quality in emergency departments. SUBJECTS AND METHODS: During 1-month study periods in 1993 and 1995, all medical records for patients who presented to five Harvard teaching hospital emergency departments with one of six selected chief complaints (abdominal pain, shortness of breath, chest pain, hand laceration, head trauma, or vaginal bleeding) were reviewed for the percent compliance with process-of-care guidelines. Patient-reported problems and patient ratings of satisfaction with emergency department care were collected from eligible patients using patient questionnaires. After reviewing benchmark information, emergency department directors designed quality improvement interventions to improve compliance with the process-of-care guidelines and improve patient-reported quality measures. RESULTS: In the preintervention period, 4,876 medical records were reviewed (99% of those eligible), 2,327 patients completed on-site questionnaires (84% of those eligible), and 1,386 patients completed 10-day follow-up questionnaires (80% of a random sample of eligible participants). In the postintervention period, 6,005 medical records were reviewed (99% of those eligible), 2,899 patients completed on-site questionnaires (84% of those eligible), and 2,326 patients completed 10-day follow-up questionnaires (80% of all baseline participants). In multivariate analyses, adjusting for age, urgency, chief complaint, and site, compliance with process-of-care guidelines increased from 55.9% (preintervention) to 60.4% (postintervention, P = 0.0001). We also found a 4% decrease (from 24% to 20%) in the rate of patient-reported problems with emergency department care (P = 0.0001). There were no significant improvements in patient ratings of satisfaction. CONCLUSION: Feedback of benchmark information and subsequent quality improvement efforts led to small, although significant, improvement in compliance with process-of-care guidelines and patient-reported measures of quality. The measures that relied on patient reports of problems with care, rather than patient ratings of satisfaction with care, seemed to be more responsive to change. These results support the value of benchmarking and collaboration.

Benchmarking↗
PubMed2000

Optimising care of acute myocardial infarction: results of a regional quality improvement project.

The effects of a quality improvement intervention were evaluated in a before-after time-series study of 649 consecutive patients suffering acute myocardial infarction (AMI) in the West Moreton Health District over 2.5 years from March 1996 through to August 1998. After a 6-month baseline period, clinical practice guidelines were issued followed by sequential feedback to providers of clinical indicator data over a 1-year period. Resultant changes in practice were then evaluated during a 12-month post-intervention period. The proportion of eligible patients receiving early thrombolysis, lipid-lowering drugs and cardiac rehabilitation increased, respectively, from 30.8 to 70.0% (P = 0.001), from 23.4 to 56.4% (P = 0.003), and from 23.6 to 54.3% (P = 0.003). The in-hospital death rate, incidence of postinfarct angina and mean length of stay decreased, respectively, from 15.8 to 8.6% (P = 0.02), from 30.1 to 14.3% (P < 0.001), and from 7.4 to 6.3 days (P = 0.001). Despite the absence of control groups, the present study suggested that clinical guidelines combined with feedback of clinical indicators were useful in improving quality of care.

Age Factors↗
PubMed2004

Creating the evidence base for quality improvement collaboratives.

Intensive efforts are under way to improve health care quality and safety throughout the United States and abroad. Many of these efforts use the quality improvement collaborative method, an approach emphasizing collaborative learning and exchange of insights and support among a set of health care organizations. Unfortunately, the widespread acceptance and reliance on this approach are based not on solid evidence but on shared beliefs and anecdotal affirmations that may overstate the actual effectiveness of the method. More effective use of the collaborative method will require a commitment by users, researchers, and other stakeholders to rigorous, objective evaluation and the creation of a valid, useful knowledge and evidence base. Development of this evidence base will require improved conceptions of the nature of quality problems, quality improvement processes, and the types of research needed to elucidate these processes. Researchers, journal editors, and funding agencies must also cooperate to ensure that published evaluations are relevant, comprehensive, and cumulative.

Cooperative Behavior↗
PubMed2003

Performance evaluation of quality improvement team in an anesthesiology department.

BACKGROUND: In health care community, quality improvement pathway has always been treated as critical index to control cost, improve efficiency and promote service quality, particularly in the last decade. From theoretical standpoint, clinical practice as well as research data, quality improvement team has been demonstrated to play an important role in the adaptation to the changing health environment and enhancement of the competition through the improvement process. The purpose of this study was to explore members' job satisfaction, morale, organizational commitment and inventory management through quality improvement team intervention in a department of anesthesiology. METHODS: This study was of a quasi-experimental and longitudinal design. The subjects involved 45 nurse anesthetists (the experiment group, intervention of quality improvement team) and 50 operation room nurses (control group) in a general hospital. The quality improvement team had been initiated and implemented pursuant to the quality improvement process for 8 months. GEEs (Generalized Estimating Equations) model was used to examine the differences in job satisfaction, morale, organizational commitment, and the inventory management was also examined between two groups. RESULTS: After control of all variables, except education background, such as age, marital status, education, position and nursing experience, a natural growth effect was observed on quality improvement team. The results revealed that the experimental group showed significant positive effects on both job satisfaction and organizational commitment after the intervention. The morale scale did not differ significantly between two groups. In the inventory management, the experimental group successfully decreased the monthly consumable materials stock with a descending rate of 24.8%, while in the control group, the inventory was increased 16.9% in the basal stock instead. CONCLUSIONS: As other previous reports did, the present study also demonstrated that intervention of the quality improvement team improves the nurse anesthetists' job satisfaction, such as promotion of autonomy, organizational policy and positive member interaction. Moreover, it improves work efficiency, service quality as well as control of the stock inventory.

Adult↗
PubMed1991

New JCAHO standards emphasize continuous quality improvement.

Traditional clinical quality assurance may be an endangered species. In a new effort, the Joint Commission on Accreditation of Healthcare Organizations is issuing new standards requiring all hospital CEOs to become educated in continuous quality improvement methods.

Data Collection↗
PubMed2001

PathworX: an informatics tool for quality improvement.

To optimize quality of care while conserving resources requires the right information and the right organizational processes. PathworX, a care management and documentation system developed at Vanderbilt, coordinates interdisciplinary care based on evidence-based best practices and provides information about the achievement of patient care goals as an indicator of quality. Using data about goal achievement and resource consumption in a process of continual quality improvement enables hospital units to reduce waste while improving patient outcomes.

Decision Support Systems, Clinical↗
PubMed2003

Impact of quality improvement efforts on race and sex disparities in hemodialysis.

CONTEXT: By improving the process of care, quality improvement efforts have the potential to reduce race and sex disparities. However, little is known about whether reductions actually occur. National quality improvement activities targeting hemodialysis patients provide an opportunity to examine this issue. OBJECTIVE: To determine the effect of quality improvement efforts on race and sex disparities among hemodialysis patients. DESIGN, SETTING, AND SUBJECTS: Longitudinal study of 58 700 randomly selected hemodialysis patients from throughout the United States in 1993 through 2000. INTERVENTION: Medicare-funded quality improvement project involving monitoring of patient outcomes, feedback of performance data, and education of clinicians at dialysis centers. MAIN OUTCOME MEASURES: Changes in hemodialysis dose (Kt/V), anemia management (hemoglobin level), and nutritional status (albumin level). RESULTS: The proportion of all patients with an adequate hemodialysis dose increased 2-fold. In 1993, 46% of white patients and 36% of black patients received an adequate hemodialysis dose compared with 2000 when the proportions were 87% and 84%, respectively. Thus, the gap between white and black patients decreased from 10% to 3% (P<.001). The gap between female and male patients decreased from 23% to 9% over the same period (P =.008). The proportion of all patients with adequate hemoglobin levels increased 3-fold. The proportion of all patients with adequate albumin levels remained unchanged. Race and sex disparities in anemia management and nutritional status did not change significantly. CONCLUSIONS: Quality improvement efforts have a variable impact on race and sex disparities in health outcomes. Further work is needed to determine how quality improvement methods can be targeted to reduce health disparities.

Adult↗
PubMed1990

Developing employee ownership of the quality improvement process.

Developing true employee ownership of quality improvement is a process in itself. It begins with sending clear signals to employees that management fully supports the process and is committed to making it successful. It is reinforced when managers provide for the progressive education of all employees to ensure that job requirements are known and are achievable. Employee ownership of quality improvement continues to develop with ongoing management action that makes it clear that doing things right the first time is a part of the organizational culture. Encouraging the use of prevention--including quality improvement responsibilities in job descriptions and performance appraisals; the use of problem identification systems; and employee involvement in corrective action teams, quality improvement teams, and the management of the process--sends the message to employees that employee ownership of the process is a way of life in the organization. When success of the quality improvement effort is related to and understood as the key to the organization's success, as well as that of individual employees, and when each employee personally accepts the importance of his or her own role in making quality happen, the organization is well on its way to achieving its quality improvement objectives.

Consumer Behavior↗
PubMed2001

Divisions, general practice and continuous quality improvement. What is the connection?

BACKGROUND: Quality improvement in general practice needs to take into account not only the clinical behaviour of individual general practitioners but also the system within which they work. DISCUSSION: Continuous quality improvement (CQI) is an approach to helping clinicians work toward 'best practice' through system wide support. Its emphasis is on the improvement of processes through leadership, a team approach, the use of data, and small scale quality improvement projects. CONCLUSION: CQI may be useful for divisions of general practice to develop and improve their infrastructure and also to support quality improvement in individual general practices.

Benchmarking↗
PubMed2006

Inter-disciplinary focus groups on telephone medicine: a quality improvement initiative.

OBJECTIVE: To identify opportunities for quality improvement in long-term care telephone medicine using a model of interdisciplinary focus groups. DESIGN: Descriptive pilot project. SETTING: Extended Care and Rehabilitation Center (ECRC), Durham VA Medical Center, Durham, North Carolina. PARTICIPANTS: Eight of 20 registered or licensed practical nurses and 4 of 6 geriatric medicine fellows voluntarily participated in this quality improvement project. MEASUREMENTS: In two 45-minute focus groups, participants were asked to discuss 3 open-ended questions related to telephone medicine. Comments were recorded during the discussions; topical themes were identified by the authors. RESULTS: Participant comments could be categorized into 4 domains describing the characteristics of nurses and physicians who practice the best telephone medicine: (1) provides the appropriate medical component of patient care; (2) appreciates contextual issues; (3) respects the other party's time and resources; and (4) possesses a collaborative attitude. The focus groups identified 5 quality improvement goals: (1) better nursing assessment and provision of patient information; (2) minimization of non-urgent calls after hours; (3) more decisive physician action (or explanation of inaction); (4) better physician familiarity with facility policies/logistics; and (5) better communication/paging system. The discussion format allowed nurses and physicians to identify and respond to potential barriers to improving quality in each area. CONCLUSION: Nurses and physicians appreciate unique aspects of long-term care telephone medicine and identify distinct barriers to improving practice. Interdisciplinary focus groups were a productive step toward understanding the telephone medicine experience in our facility and developing quality improvement interventions for both nurses and physicians.

After-Hours Care↗
PubMed1989

Implementing a quality improvement program.

Implementing a Quality Improvement Program (QIP) is a high priority matter for most health care organizations. Implementation requires the commitment of top management, measurement tools, statistical tools, problem-solving tools, and training for all levels of employees. This article describes the need for managing costs and quality, quality improvement concepts, examples of problem-solving tools, and the role of the facilitator in the QIP process.

Cost Control↗
PubMed1995

A comprehensive system for quality improvement in ambulatory care: assessing the quality of diabetes care.

A comprehensive state-of-the-art system for quality improvement in ambulatory care has been designed to test (1) whether patients at 8 intervention sites demonstrate improved health status and satisfaction with their care as compared to patients at 8 control sites and (2) the extent to which timely patient self-reported data influences provider practice patterns. During the study pilot period, several investigators developed, tested and analyzed disease-specific questionnaires for 7 common chronic conditions. An advanced automated information system was designed to link hospital computer information and patient questionnaire data in order to provide timely communication between patients and providers about important health problems. This report briefly describes the 3-year quality of ambulatory care clinical trial and details the development and pilot testing of the disease specific questionnaire for diabetes. Reliability testing showed correlations were higher for fixed events such as foot ulcers than for subjective judgments such as satisfaction with providers. Responsiveness testing indicated that this questionnaire could measure behavior and care modifications in patients 6 months following an outpatient education course, compared to the baseline pre-education values. Diabetes severity information has been collected from self-administered questionnaires and laboratory data to assist providers in assessing the patients' likelihood of 4-year mortality. It is anticipated that the rapid identification of important patient issues will assist patients and clinicians in mutually addressing and resolving health care problems, thereby improving the quality of outpatient care.

Ambulatory Care↗
PubMed1997

Quality improvement in the ambulatory surgical setting.

Quality improvement is considered part of "business as usual" in the health care field. Some institutions have progressed further into their quality improvement efforts than others. Nonetheless, there is always the opportunity to learn from the efforts of others and to adopt their methods for use in one's own setting when possible. Included in this article is a case study outlining the use of the FOCUS PDCA methodology for quality improvement. The information identifies ways of introducing and beginning quality improvement efforts in a way that can be translated into other ambulatory health care settings.

Ambulatory Surgical Procedures↗
PubMed1998

Overview of issues in improving quality of care for children.

OBJECTIVE: To provide a framework for a research agenda-setting conference on quality of care for children. DATA SOURCES/STUDY SETTING: Literature review. CONCLUSIONS: Research on quality of care for children has lagged behind its counterpart for adults. Defining key issues and questions in seven topic areas-the health of children; the efficacy and effectiveness of health services for children; assessing quality of care; improving quality of care within health services delivery systems; assessing and improving quality at the community level; getting financial incentives right; and disseminating information about the results of research investigations-will facilitate the development of an effective research strategy. Ultimately, enhanced information in these areas will lead to improvements in the processes and outcomes of care for children.

Child↗
PubMed2006

The holy Grail of surgical quality Improvement: process measures or risk-adjusted outcomes?

Quality of care in surgery has garnered increased attention. Focus on the structure, processes of care, and use of risk-adjusted outcomes has offered different possible solutions. Volume-outcome studies have consistently demonstrated relationships between higher surgeon and hospital volume and favorable outcomes. The policy implications for quality improvement remain unclear. Recent efforts have focused on the use of risk-adjusted outcomes, such as the American College of Surgeons National Surgical Quality Improvement Program, to drive quality improvement. Conversely, large efforts, mandated by the Center for Medicare and Medicaid Services, have focused on process measures, such as perioperative complication prevention. For the future of surgical quality improvement, the combination of process measures and risk-adjusted outcomes are essential. It is only through the combined use of improved understanding of the relationship of processes of care and outcomes that we will make surgical care safer and improve quality.

General Surgery↗
PubMed1994

Achieving sustained quantifiable results in an interdepartmental quality improvement project.

BACKGROUND: In the mid-1980s Beth Israel Hospital Boston began a participatory management approach that encourages all members of the organization to improve productivity, efficiency, and quality through interdepartmental and intradepartmental project teams. The CT [computerized tomography]-Nursing-Transport Team, the hospital's first quality improvement project Team, grew out of an organizational challenge to solve an interdepartmental problem. The goal of the project was to have inpatients arrive on time for their scheduled CT-Scan appointment. Prior to the project's inception, over 50% of all inpatients scheduled for CT-Scans arrived more than 20 minutes late. METHODS: The team learned the Juran quality improvement methodology, using just-in-time training. The methodology consists of four major steps: problem definition and organization, the diagnostic journey, the remedial journey, and holding the gains. The team used many quality improvement tools including flow-charting, checksheets, histograms, Pareto charts, run charts, and brainstorming to find the root causes of the problem and achieve results. RESULTS: The team members collected data and flowcharted the complexity of the CT appointment and patient pick-up process to pinpoint the root causes of delays. They found that three floors accounted for a majority of the delays and that four reasons for delays explained two-thirds of the problem. Additionally, as nurses and CT technologists flowcharted the process, they found that they used a different definition of "on-call" and that misconceptions existed about the scan and the preparation for it. When transporters were included on the team, the team discovered that delays occurred in a pattern and that communication with central transport was poor and inconsistent. After the team made changes in break times, equipment, communication, planning, and timing, the late patient arrivals dropped dramatically--more than 80% of patients arrived within five minutes of a scheduled appointment. One year after the project team stopped meeting, close to 70% of patients continue to arrive within five minutes of their scheduled appointment time, despite increased volume and no additional scanners. CONCLUSION: The success of the project reinforced many well-known quality improvement conditions for success. These include (1) choosing a project that is "high pain, high drain," (2) having a committed project leader who can keep the team effort going, (3) using data to lead the team to the root cause of a problem by pointing out where, when, and why the problems occur, (4) utilizing flow-charting and shadowing to understand the process from a fresh perspective, and (5) holding well-facilitated meetings with a defined purpose, ground rules, and meaningful agenda.

Boston↗