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PubMed1999

A new learning environment: combining clinical research with quality improvement.

The emphasis provided by quality improvement strategies on performance measurement and evaluation often results in our understanding of processes of care and, perhaps, better outcomes. There are different references for process evaluation: external peers, regional profiles of performance or a trending of one's own performance patterns. This paper proposes a methodology that enables learning from the daily practice of medicine by comparing alternative care processes and outcomes. Since it is estimated that 15-20% of medical practices are based on rigorous scientific data establishing their effectiveness, we have much to learn. We propose to learn from our daily practice by combining clinical research methods with quality improvement tools. The products comprise modified clinical trial and case-control studies. In a modified clinical trial, we would use a practice guideline as a control group and modify the guideline to create an experimental group. This method would maintain the internal validity of efficacy research while maintaining the external validity of effectiveness research. In the case-control method, it is possible to quantitate risk for a given outcome and focus improvement effort on factors associated with that outcome. We believe physicians will accept this learning approach because it is a more valid learning method than traditional quality improvement and, unlike randomized clinical trials, learning will occur in the daily practice of medicine.

Case-Control Studies↗

PubMedDate not supplied

The role of quality improvement in disease management: a statewide tuberculosis control success story.

This study describes Mississippi's statewide latent tuberculosis infection (LTBI) control management efforts to improve treatment outcomes using scientific quality improvement tools. LTBI medication completion rates were observed by month and by nine administrative health districts for a 12-month period. Analysis of variance (ANOVA) was conducted to see if there was any significant change between preintervention and postintervention in medication completion rates. Regression analysis was performed to test the linearity of change across the monthly rates. A change from a rate of 79.7 percent to 90.5 percent completion of the LTBI medication regimen was observed after the quality improvement intervention was instituted. During the quality improvement intervention, the mean reached 96.5 percent completion, followed by a slight decline at the end of the intervention to 90.5 percent. The analysis revealed that the mean LTBI medication completion rate across the nine administrative health districts was significantly increased and variability was decreased across all administrative health districts, with minor exceptions. A quality improvement team approach was shown to be effective in disease management by increasing LTBI medication completion. New baseline expectations can be established when quality improvement initiatives are implemented. This success can be linked, in part, to the use of scientific methods, precise and valid data, persuasive and clear goal setting, appropriate feedback, and ongoing monitoring.

Analysis of Variance↗

PubMed2001

Role of external quality assurance schemes in assessing and improving quality in medical laboratories.

Medical laboratories have a long tradition of external quality assessment. Starting from pure quality control of laboratory performances, most external quality schemes in Europe evolved into a powerful tool for improving quality of clinical outcome of results. External quality assurance in medical laboratories not only includes laboratory performance evaluation, but also evaluation of method performance, post-market vigilance, training and help. In the future, the quality of programmes will further be improved by accreditation of schemes international collaboration and by using IT applications.

Accreditation↗

PubMedDate not supplied

Reporting tools for clinical quality improvement.

To support clinical quality improvement (QI), effective quality analysis tools are essential. New strategies that we have incorporated into our routine assessment activities include comparative screening, clinical process benchmarking tables, and run charts for key quality indicators. To target areas for improvement, we use comparative screening. We have access to clinical data for 11 comparable medical centers. Currently, these data are used to identify our ranking relative to the others for mortality, readmission, and length of stay. Diagnosis-related groups and ICD-9-CM clusters serve as clinical groupings with defined minimal case volume requirements to ensure meaningful comparisons. These comparative reports permit our clinical leaders and hospital administrators to focus QI activities. Clinical process benchmarking involves peer-to-peer interfacility communication to identify those factors that create outstanding clinical performance. We successfully have used this tool to support process improvement in cardiac-surgery, administration of patient controlled analgesia, and respiratory therapy. Interdisciplinary QI teams identify the key investigative questions. Team members then contact their counterparts at similar facilities, which differ from our hospital in quality, based on empirical evidence or through comparative screening. The information that is obtained is collated in a tabular format, along with our own information, to permit easy identification of key clinical processes associated with better outcomes. Key quality and utilization goals at our hospital include reducing unplanned readmissions by 10%, achieving a 5% lower average length of stay, and not exceeding Health Care Financing Administration expected mortality rates in any clinical area.(ABSTRACT TRUNCATED AT 250 WORDS)

Academic Medical Centers↗

PubMed2002

The use of ACE inhibitors in the treatment of heart failure in Kentucky Medicare beneficiaries: a quality improvement project.

Heart failure (HF) is a highly prevalent and frequently fatal condition. During 1998, 10,815 Medicare beneficiaries in Kentucky were diagnosed as having HF; 14,777 beneficiaries were hospitalized for the condition, and 696 Medicare beneficiaries died with HF as the primary diagnosis. Proper diagnosis and subsequent treatment with angiotensin converting enzyme (ACE) inhibitors improve functional status, quality of life, and survival among HF patients. Health Care Excel, Incorporated (HCE), the Medicare Quality Improvement Organization for Kentucky, collaborated with a select group of Kentucky hospitals to conduct an HF quality improvement project. The improved pharmacotherapy by these hospitals is presented and discussed. The use of ACE inhibitors improved from 54.1% to 66.0% and the use of either ACE inhibitors or angiotensin II receptor blockers (ARBs) to 72.1%.

Angiotensin-Converting Enzyme Inhibitors↗

PubMed1996

Quality improvement nearing the 21st century: prospects and perils.

Quality improvement is the key to providing universal access to affordable high quality health care to all Americans. By eliminating the major quality problems of overuse and misuse of health services, quality of care can be improved and costs reduced at the same time. Thus, resources can be made available to provide necessary and effective care to those currently left out of the system. Three strategies exist for improving quality: regulation, professionalism, and competition. Each has strengths and weaknesses. Achieving quality improvement for populations will require a blend of all three strategies. The New York State Department of Health uses such a blended strategy to improve quality of care for patients undergoing cardiac surgery. This program includes regulation that strictly limits the number of hospitals permitted to offer cardiac surgical services, a professionally driven effort to improve outcomes following coronary artery bypass surgery, and the competitive peer pressure generated by publishing hospital and surgeon-specific mortality data. During the first four years when all three components of the program were in effect (1989-1992), risk-adjusted operative mortality following CABG surgery fell by 41%.

Cardiac Surgical Procedures↗

PubMed1998

The role of regulation in quality improvement.

Many new methods for measuring the quality of health care have been devised since 1970. For the past ten years, the health care field has been struggling to integrate industrial models into its quality improvement systems. In order to judge whether regulation has evolved in tandem with these developments, three critical questions are examined: Is regulation improving the quality of health care? Are regulators integrating the tools of quality research into their oversight activities? Is there a way to combine continuous quality improvement (CQI) and modern methods of quality measurement into a new regulatory format? An exploration of these questions produces relatively little evidence that regulation has moved in the recommended direction, although there are some encouraging signs that regulators are becoming more responsive to the issues.

Delivery of Health Care↗

PubMed2004

[The role of clinical audit in the quality improvement of health care].

The aim of clinical audit is continuous improvement of the quality of care through systematic and critical review of current practice against explicit criteria and the implementation of change if necessary. The audit is a regular multidisciplinary activity by which all participants of care including doctors, nurses and other health professionals carry out a systematic review of their own practice. Data collected during the process of audit should be handled with care, and individual data concerning care-givers, patients or health professionals must be treated confidentially. Clinical audit needs realistic timeframe and necessary resources as well as tolerant culture of learning organisations. Furthermore the success of clinical audit depends on the commitment and support of the management of the organisations. Clinical audit could relatively easily be embodied into the current practice of peer-review processes and other quality improvement initiatives in Hungary. Widespread and systemic application of clinical audit may improve the quality of patient care and maintain the trust of the population. However, clinical audit should be effective and cost-effective. The recently published methodological guideline by the Ministry intends to promote good practice in clinical audit.

Humans↗

PubMed1999

Setting up improvement projects in small scale primary care practices: feasibility of a model for continuous quality improvement.

OBJECTIVES: To evaluate the feasibility of a model for continuous quality improvement in small scale general practice and the improvement projects that practices ran after the introduction of continuous quality improvement. DESIGN: A descriptive study. SETTING: Twenty general practices in the Netherlands tested the model in an intervention period of 18 months. INTERVENTION: A model for continuous quality improvement adapted for general practice was introduced into the practices using a structured strategy. Practices were supported by trained facilitators. MAIN OUTCOME MEASURES: Acceptance at introduction and continued application of the model; the topics of improvement projects that were set up in the practices; whether the improvement projects had been completed; whether they had met the criteria (the use of the "quality cycle" and the Oxford audit score); and whether the self set objectives had been met. RESULTS: The model was introduced and accepted in all participating practices. Practices started 51 improvement projects. At the end of the study period 33 improvement projects had been completed. Practices chose a wide variety of objectives for these projects; most of them concerned medical or organisational topics. Practices started projects mainly because the topic was felt to be a problem or was causing a bottleneck in the organisation. The quality cycle was used in all projects, but practices did not always collect data and evaluate the outcomes. Fourteen projects could be discerned as "full audit". No differences existed in the quality of improvement projects among the various types of practice or between the topics addressed. At the end of the study period half of the practices continued applying the model. CONCLUSION: This study showed that the model was feasible for small scale general practice. However, application of the model tended to disintegrate after the facilitator had left the practice. Practices succeeded reasonably well in running improvement projects. Introduction of continuous quality improvement should particularly focus on this. It is suggested that intensive support is necessary to implement and maintain continuous quality improvement in small scale practices.

Evaluation Studies as Topic↗

PubMed1995

Improving quality through cost recovery in Niger.

New evidence on the quality of health care from public services in Niger is discussed in terms of the relationships between quality, costs, cost-effectiveness and financing. Although structural attributes of quality appeared to improve with the pilot project in Niger, significant gaps in the implementation of diagnostic and treatment protocols were observed, particularly in monitoring vital signs, diagnostic examination and provider-patient communications. Quality improvements required significant investments in both fixed and variable costs; however, many of these costs were basic input requirements for operation. It is likely that optimal cost-effectiveness of services was not achieved because of the noted deficiencies in quality. In the test district of Boboye, the revenues from the copayments alone covered about 34% of the costs of medicines or about 20% of costs of drugs and administration. In Say, user fees covered about 50-55% of the costs of medicines or 35-40% of the amount spent on medicines and cost-recovery administration. In Boboye, taxes plus the additional copayments covered 120-180% of the cost of medicines, or 75-105% of the cost of medicines plus administration of cost recovery. Decentralized management and legal conditions in the pilot districts appeared to provide the necessary structure to ensure that the revenues and taxes collected would be channelled to pay for quality improvements.

Clinical Protocols↗

PubMed2001

Improving serum albumin levels in hemodialysis patients by a continuous quality improvement project.

Protein nutrition and serum albumins predict present and future mortality and morbidity. The North East Albuquerque Dialysis Center undertook a quality improvement project to improve serum albumin levels in hemodialysis patients. The dialysis facility's quality assurance team evolved into a continuous quality improvement team just before this project. The timeline and steps in this evolution are presented. The continuous quality improvement project process analysis, interventions, and outcome rates are also described. The project has resulted in a rate of less than or equal to 10% of hemodialysis patients with serum albumins less than 3.4 for the past 3 years.

Humans↗

PubMed1995

Continuous quality improvement and the education of the generalist physician.

The new health care environment--centered on patients, focused on health, and managed by generalists--requires new competencies for the generalist physician. Among these are knowledge and skills for the continuous improvement of health care. In many areas, generalist physicians already use quality improvement methods and principles to improve the health and health care of their communities. Efforts to teach medical students and residents to improve quality continuously in health care are beginning. Early lessons are: (1) quality improvement is most effectively learned in the context of real work; (2) initial emphasis must be on the basics; (3) the focus is on the needs of those we serve; (4) interdisciplinary skills are essential and best learned during clinical training; and (5) the best learning environment for future generalist physicians, one which results in optimism about the future and the ability to make things better, is an environment that is continuously improving.

Arizona↗

PubMed1995

Continuous quality improvement in inpatient clinical nutrition services.

Defining quality patient care is a complex and often confusing issue. This article describes one hospital's experience in applying quality improvement theories to inpatient clinical nutrition practice. The key to measuring quality was the use of standardized practice guidelines. In this article, terms such as continuous quality improvement are clarified and fundamental assumptions such as "quality is defined as conformance to requirements" are discussed. We review a working model for the 10-step plan of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and its application in practice, including the indicators and measurement tools used. Actual results from ongoing quality improvement efforts are addressed and compared to the JCAHO nine components of quality patient care. Because of preexisting nutrition practice guidelines at the Yale-New Haven Hospital, improvements in the delivery of patient nutrition care could be demonstrated; these included enhanced efficiencies in screening and intervention. Continuous quality improvement initiatives do work, and practitioners can use the practice experience presented here as a conceptual framework to justify or validate the quality of patient nutrition care in their own institutions.

Connecticut↗

PubMed2004

Informatics resources to support health care quality improvement in the veterans health administration.

Information systems are increasingly important for measuring and improving health care quality. A number of integrated health care delivery systems use advanced information systems and integrated decision support to carry out quality assurance activities, but none as large as the Veterans Health Administration (VHA). The VHA's Quality Enhancement Research Initiative (QUERI) is a large-scale, multidisciplinary quality improvement initiative designed to ensure excellence in all areas where VHA provides health care services, including inpatient, outpatient, and long-term care settings. In this paper, we describe the role of information systems in the VHA QUERI process, highlight the major information systems critical to this quality improvement process, and discuss issues associated with the use of these systems.

Benchmarking↗

PubMed1990

Quality improvement in pharmacy: a prescription for change.

Quality improvement activities offer pharmacists opportunities for establishing their roles as clinical practitioners, documenting their contributions to quality-of-care improvement, and bringing recognition to pharmacy as a clinical profession. Unfortunately, pharmacists haven't yet recognized the importance of or need for these programs. Drug usage evaluations and quality improvement still are not considered a benefit or an opportunity but continue to be perceived as boring, tedious tasks that must be performed for the Joint Commission rather than the patient. The time has come to refocus our emphasis on what really matters. We need to build quality improvement programs not merely to placate the Joint Commission but to improve the quality of care for patients. We need to build quality improvement programs that extend to the grass roots level of every organization so that everyone is involved, participating, and committed to correcting patient-care problems. This commitment must become a routine habit, a daily acknowledgment, and an ongoing process. Clinical practitioners must become actively involved in quality improvement programs by developing valid, reliable indicators to help ensure safe, appropriate use of drugs. We need to develop a computer model to assist in data collection for drug usage evaluations and quality improvement projects. And we must create a multidisciplinary team of practitioners, including physicians, nurses, and pharmacists, to thoroughly evaluate and respond to this information. A successful team effort means everybody wins, and the biggest winner of all is--and must be--the patient.

Joint Commission on Accreditation of Healthcare Or↗

PubMed1996

Academic quality improvement: new medicine in old bottles.

Academic medical centers and clinicians have been slow to embrace continuous quality improvement. The Mount Sinai Medical Center in New York has created a new Department of Health Policy that combines an academic research mission with an administrative mission to demonstrate improving quality of care. This article discusses the conceptual framework that undergirds this new effort, its organizational structure and initial agenda of activities, and why we believe it will succeed in engaging academic physicians in quality improvement.

Academic Medical Centers↗

PubMed1994

Deming meets Braverman: toward a progressive analysis of the continuous quality improvement paradigm.

The continuous quality improvement (CQI) model has rapidly become the dominant management paradigm in U.S. industrial and health care leadership circles. Despite its widespread corporate acceptance and its relevance to public sector policy issues, there has been a paucity of progressive analysis of CQI. The authors begin by noting remarkable similarities between CQI critiques of Taylorism (so-called scientific management of work) with those made by Braverman, a leading Marxist analyst of the work process. Each of the 14 principles of CQI pioneer W. E. Deming are explained and analyzed for their progressive content. These pluses are then contrasted with 18 problematic issues in an attempt to challenge and go beyond the constraints of CQI as it is currently being applied in health care and other sectors. These issues include (1) mismatch between rhetoric and reality, (2) public sector issues, and (3) broader contradictions. The authors emphasize the genuine need for improving health care quality and the relevance of CQI for addressing this need. They challenge progressives to grapple with the profound contradictions by the CQI paradigm inviting a broader dialogue on CQI's meaning for improving the public's health.

Delivery of Health Care↗

PubMedDate not supplied

Improving diabetes care through a multicomponent quality improvement model in a practice-based research network.

This article reports the impact of a multicomponent quality improvement intervention on adherence with 13 measures of diabetes care and a summary measure, the Diabetes Summary Quality Index (Diabetes-SQUID). The intervention was conducted between January 1, 2004, and July 1, 2005, within 66 primary care practices in 33 states, including 372 providers and 24 250 adult patients with diabetes. Across all practices, the average Diabetes-SQUID was 50.6% (10th percentile 36.5%, 90th percentile 63.0%) on January 1, 2004, and 58.4% (10th percentile 47.6%, 90th percentile 69.7%) on July 1, 2005, with an average absolute improvement of 7.8% (95% confidence interval, 5.9%-9.7%). Significant improvements occurred for 12 of the 13 individual measures: blood pressure and urine microalbumin monitoring; HDL cholesterol, LDL cholesterol, triglyceride, and glycosylated hemoglobin measurements; prescription of antiplatelet therapy; and blood pressure, HDL-cholesterol, LDL-cholesterol, triglyceride, and glycosylated hemoglobin control. The findings suggest that a multicomponent intervention can have a robust impact on quality of care for diabetes.

Diabetes Mellitus↗