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PubMed2006

Intensive care unit quality improvement: a "how-to" guide for the interdisciplinary team.

OBJECTIVE: Quality improvement is an important activity for all members of the interdisciplinary critical care team. Although an increasing number of resources are available to guide clinicians, quality improvement activities can be overwhelming. Therefore, the Society of Critical Care Medicine charged this Outcomes Task Force with creating a "how-to" guide that focuses on critical care, summarizes key concepts, and outlines a practical approach to the development, implementation, evaluation, and maintenance of an interdisciplinary quality improvement program in the intensive care unit. DATA SOURCES AND METHODS: The task force met in person twice and by conference call twice to write this document. We also conducted a literature search on "quality improvement" and "critical care or intensive care" and searched online for additional resources. DATA SYNTHESIS AND OVERVIEW: We present an overview of quality improvement in the intensive care unit setting and then describe the following steps for initiating or improving an interdisciplinary critical care quality improvement program: a) identify local motivation, support teamwork, and develop strong leadership; b) prioritize potential projects and choose the first target; c) operationalize the measures, build support for the project, and develop a business plan; d) perform an environmental scan to better understand the problem, potential barriers, opportunities, and resources for the project; e) create a data collection system that accurately measures baseline performance and future improvements; f) create a data reporting system that allows clinicians and others to understand the problem; g) introduce effective strategies to change clinician behavior. In addition, we identify four steps for evaluating and maintaining this program: a) determine whether the target is changing with periodic data collection; b) modify behavior change strategies to improve or sustain improvements; c) focus on interdisciplinary collaboration; and d) develop and sustain support from the hospital leadership. We also identify a number of online resources to complement this overview. CONCLUSIONS: This Society of Critical Care Medicine Task Force report provides an overview for clinicians interested in developing or improving a quality improvement program using a step-wise approach. Success depends not only on committed interdisciplinary work that is incremental and continuous but also on strong leadership. Further research is needed to refine the methods and identify the most cost-effective means of improving the quality of health care received by critically ill patients and their families.

Advisory Committees↗

PubMed1997

Improving patient follow-up through implementation of an ambulatory care quality improvement program.

Nurse practitioners in ambulatory care settings must begin using quality improvement strategies to enhance patient outcomes and to improve patient follow-up. The article highlights the development and beginning stages of implementation of one such quality improvement program and discusses the actions that were taken to increase timeliness of key patient processes. An example of a quality improvement educational program, outlines of the plan, and scope of services are also provided.

Ambulatory Care↗

PubMed1997

End-stage renal disease: a proving ground for quality improvement in health care.

This article chronicles the health care quality improvement efforts that relate to patients with end stage renal disease (ESRD). The emphasis is on quality improvement as a management system as opposed to the quality improvements that resulted from strictly technical dialysis-related issues. The government has exercised considerable oversight on the ESRD program because of its growth and cost. History has shown that quality assurance (QA) has had little effect on improving quality or decreasing cost. The philosophy, methods, and tools of continuous quality improvement (CQI) have been shown to work in health care. CQI is a management system that offers hope for higher quality affordable health care. Computer technology is at last sophisticated enough to permit the collection of large amounts of clinical data at the point of care. This will permit CQI methods and tools to be applied generally at reasonable costs. Physicians in general and nephrologists in particular are beginning to understand the managed care environment. They are beginning to understand the paradigm shift that is required to effect the changes necessary for physicians to assume their leadership role in health care. This article reviews the quality efforts of the past and present. It discusses the strengths and weaknesses of efforts to improve quality and lastly presents a vision for the future.

Delivery of Health Care↗

PubMed2006

Quality improvement implementation and hospital performance on quality indicators.

OBJECTIVE: To examine the association between the scope of quality improvement (QI) implementation in hospitals and hospital performance on selected indicators of clinical quality. DATA SOURCES: Secondary data from 1997 mailed survey of hospital QI practices, Medicare Inpatient Database, American Hospital Association's Annual Survey of Hospitals, the Bureau of Health Professions' Area Resource File, and two proprietary data sets compiled by Solucient Inc. containing data on managed care penetration and hospital financial performance. STUDY DESIGN: Cross-sectional study of 1,784 community hospitals to assess relationship between QI implementation approach and six hospital-level quality indicators. DATA COLLECTION/ABSTRACTION METHODS: Two-stage instrumental variables estimation in which predicted values (instruments) of four QI scope variables and control (exogenous) variables used to estimate hospital-level quality indicators. PRINCIPAL FINDINGS: Involvement by multiple hospital units in QI effort is associated with worse values on hospital-level quality indicators. Percentage of hospital staff and percentage of senior managers participating in formally organized QI teams are associated with better values on quality indicators. Percentage of physicians participating in QI teams is not associated with better values on the hospital-level quality indicators studied. CONCLUSIONS: Results supported the proposition that the scope of QI implementation in hospitals is significantly associated with hospital-level quality indicators. However, the direction of the association varied across different measures of QI implementation scope.

Cross-Sectional Studies↗

PubMed2002

Effectiveness of quality improvement: learning from evaluations.

The effectiveness of many quality improvement interventions has been studied, and research suggests that most have highly variable effects which depend heavily on the context in which they are used and the way they are implemented. This has three important implications. Firstly, it means that the approach to quality improvement used in an organisation probably matters less than how and by whom it is used. Rather than taking up, trying, and then discarding a succession of different quality improvement techniques, organisations should probably choose one carefully and then persevere to make it work. Secondly, future research into quality improvement interventions should be directed more at understanding how and why they work--the determinants of effectiveness--rather than measuring whether they work. Thirdly, some element of evaluation should be incorporated into every quality improvement programme so that its effectiveness can be monitored and the information can be used to improve the systems for improvement.

Efficiency, Organizational↗

PubMed2002

The role of clinical governance as a strategy for quality improvement in primary care.

This power considers the process of implementing clinical governance in primary care and its impact on quality improvement. It discuss how clinical governance is being implemented both at the level of Primary Care Organisations and general practices, and the challenges to implementing clinical governance. It also suggests a model for promoting the factors that will help clinical governance improve quality of care. The experience of implementing clinical governance is broadly positive to date. However, the government needs to match its commitment to a ten-year programme of change with realistic timetables to secure the cultural and organisational changes needed to improve quality of care.

Efficiency, Organizational↗

PubMed2003

Approaches to quality improvement in nursing homes: lessons learned from the six-state pilot of CMS's Nursing Home Quality Initiative.

BACKGROUND: In November 2002, the Centers for Medicare & Medicaid Services (CMS) launched a Nursing Home Quality Initiative that included publicly reporting a set of Quality Measures for all nursing homes in the country, and providing quality improvement assistance to nursing homes nationwide. A pilot of this initiative occurred in six states for six months prior to the launch. METHODS: Review and analysis of the lessons learned from the six Quality Improvement Organizations (QIOs) that led quality improvement efforts in nursing homes from the six pilot states. RESULTS: QIOs in the six pilot states found several key outcomes of the Nursing Home Quality Initiative that help to maximize the potential of public reporting to leverage effective improvement in nursing home quality of care. First, public reporting focuses the attention of all stakeholders in the nursing home industry on achieving good quality outcomes on a defined set of measures, and creates an incentive for partnership formation. Second, publicly reported quality measures motivate nursing home providers to improve in certain key clinical areas, and in particular to seek out new ways of changing processes of care, such as engaging physicians and the medical director more directly. Third, the lessons learned by QIOs in the pilot of this Initiative indicate that certain approaches to providing quality improvement assistance are key to guiding nursing home providers' desire and enthusiasm to improve towards a using a systematic approach to quality improvement. CONCLUSION: The Nursing Home Quality Initiative has already demonstrated the potential of public reporting to foster collaboration and coordination among nursing home stakeholders and to heighten interest of nursing homes in quality improvement techniques. The lessons learned from this pilot project have implications for any organizations or individuals planning quality improvement projects in the nursing home setting.

Journal Article↗

PubMed2002

[Cost-effectiveness of quality improvement measures in health care].

GOAL: To discuss the costs and cost-effectiveness of quality improvement programs in health care. COST SAVINGS THROUGH QUALITY IMPROVEMENT: A quality improvement program saves costs if its investment costs are lower than savings from avoiding medical services. Cost savings are most likely realized if a) an overuse or misuse problem is targeted, b) many patients are affected, and c) striving for optimal quality is avoided. The overall prospect of cost savings is small, however. COST-EFFECTIVENESS OF QUALITY IMPROVEMENT PROGRAMS: From a societal perspective a quality improvement is economically attractive if an improvement in health status justifies its expenses including induced costs--even if total costs increase. In the USA a cost-effectiveness ratio of $50,000 per quality-adjusted life year is often applied as a maximum acceptable threshold value. From an institutional perspective the impact of a quality program on revenues is also important. An improvement of the image may increase the number of cases and thus revenues. For services reimbursed on a per-diem basis revenues behave according to changes in the length of stay. From an institutional perspective it is therefore reasonable to consider economic criteria when targeting problem areas.

Cost-Benefit Analysis↗

PubMed2005

Quality improvement for depression in primary care: do patients with subthreshold depression benefit in the long run?

OBJECTIVE: Quality improvement programs for depression can improve outcomes, but the utility of including patients with subthreshold depression in quality improvement programs is unclear. The authors examined 57-month effects of quality improvement on clinical outcomes and mental health care utilization of primary care patients with depressive disorder and subthreshold depression. METHOD: In a group-level, randomized, controlled trial, 46 primary care clinics were randomly assigned to provide usual care or care with a quality improvement intervention that included provider training and other resources for either medication management (medications quality improvement) or evidence-based psychotherapy (therapy quality improvement). Among 1,356 enrolled depressed patients, 991 completed the 57-month follow-up interview (604 patients with depressive disorder and 387 with subthreshold depression). Outcomes measured at 57 months were presence of probable depressive disorder, unmet need for appropriate care (untreated probable disorder), and mental health care utilization in the prior 6 months. RESULTS: Among patients with subthreshold depression at baseline, those seen in clinics with quality improvement programs with special resources for therapy were less likely to have probable depressive disorder and unmet need for care at follow-up, compared with those seen in clinics that provided usual care. Among patients with depressive disorder at baseline, those seen in clinics with quality improvement programs with special resources for medication management were less likely to have unmet need for care at follow-up, compared with those seen in clinics that provided usual care. Patients with subthreshold depression at baseline seen in clinics with a quality improvement intervention were less likely at follow-up to have had a mental health visit (in primary care or specialty care, depending on the intervention) in the prior 6 months. CONCLUSIONS: Relative to usual care, quality improvement interventions improved 57-month outcomes (probable depression, unmet need, or both) for primary care patients with depressive disorder and subthreshold depression and lowered use of mental health visits for those with subthreshold depression. The results highlight the feasibility and utility of including patients with subthreshold depression in such programs.

Adult↗

PubMed2005

Quality improvement programme on the frontline: an International Committee of the Red Cross experience in the Democratic Republic of Congo.

BACKGROUND: Majority of research in Quality Improvement, focuses on developed countries or development programs. Humanitarian organisations frequently work in developing countries, often in emergency situations with rapid staff turnover. Objectives of this study are twofold: first to develop a methodology of motivation and restoration of collapsed health structures through the creation of community based QI indicators; second, to implement these indicators to improve quality of care. METHODOLOGY: Using a community-based approach, the International Committee of the Red Cross (ICRC) team together with local health committee and nurses developed quality indicators divided into six different categories. Of 16 community primary health centers and four hospitals supported by ICRC, six health centers and one hospital were chosen to follow quality indicators for three of six indicator categories. Initial data were collected in January 2003 and compared with data serially gathered throughout the year. RESULTS: In the category rational prescription, all health facilities except for one showed improvement in every category. In the hygiene category, four of seven health structures showed 100% improvement in their score. Three of seven facilities showed impressive improvement in the category pharmacy management. CONCLUSION: Involving the community to design population based indicators helped communities take ownership of the indicators. Our findings that poor performance on indicators prompted communities to seek training and assistance to improve quality of care emphasized this. Continued adherence and improvement in each category confirmed the long term effects of teaching sessions in the areas of rational prescription, hygiene and pharmacy maintenance.

Community Participation↗

PubMed2000

Determining when quality improvement initiatives should be considered research: proposed criteria and potential implications.

Quality improvement initiatives have become a major force in shaping health care. These initiatives are diverse but share a common goal of generating knowledge that will guide improvements in health care. Although quality improvement occupies an uncertain territory between clinical care and research, this difference is extremely important. If a quality improvement initiative is research, federal regulations require a variety of procedures that must be followed to protect the human subjects involved. Conversely, if the same initiative is not research, the regulations outlining these procedures are not applicable. This article proposes 2 criteria to determine whether a quality improvement initiative should be reviewed as research. Such an initiative should be reviewed and regulated as research if (1) the majority of patients involved are not expected to benefit directly from the knowledge to be gained or (2) if additional risks or burdens are imposed to make the results generalizable. Implementation of these criteria offers the possibility that the rights and interests of those who participate in quality improvement initiatives will be protected.

Ethical Review↗

PubMed2004

Quality improvement activities and expanded school mental health services.

Quality improvement (QI) activities, designed to enhance program evaluation efforts and to improve quality of care, have become increasingly important in children's services research. QI activities examine outcomes and provide accountability data that can be very useful for telling the story of the development, implementation, and effectiveness of expanded school mental health (ESMH) programs. This article discusses the implementation and results of QI activities for two ESMH programs, one relatively new program, and one with 10 years of experience. When presenting each case example, the authors review key QI activities such as developing new measures and interventions, evaluating costs of care, and disseminating results to clinicians, program administrators, and funders. The article concludes with a discussion of the importance of QI in school-based mental health and reviews directions for future research and program development.

Adolescent↗

PubMed1999

Measuring patient satisfaction for quality improvement.

BACKGROUND: Surveys used for health plan quality reporting are generally administered annually to health plan enrollees to assess satisfaction with both the health plan and health care services. Therefore, surveys may lack sensitivity to measure the effects of patient-focused, quality improvement initiatives that could demonstrate results in a shorter time period. OBJECTIVES: We describe the development and testing of a multidimensional, visit-specific measure of satisfaction with primary care that may be used in quality improvement. METHODS: Conducted in five adult and pediatric primary care sites serving a commercial, largely managed-care population, the survey includes the Medical Outcomes Study Visit-Specific Questionnaire, the American Board of Internal Medicine Patient Satisfaction Questionnaire, and locally developed items. We assessed the instrument's reliability, validity, and utility for quality improvement. RESULTS: For both adult and pediatric samples, three factors emerged: satisfaction with the provider, satisfaction with access, and satisfaction with the office. Satisfaction with the provider and with the office were independently correlated with overall satisfaction in both samples; satisfaction with access was significantly correlated with overall satisfaction only for adults. For adults, patients who disenrolled from the health plan were less satisfied with the office compared with patients who remained with the health plan. Finally, for adults, we detected significant differences across practice sites in terms of satisfaction with office and access; for children, there were intersite differences in terms of satisfaction with provider, office, and access. CONCLUSIONS: We have support for the reliability and validity of this instrument that has identified differences in satisfaction between practice sites that may be used for quality improvement.

Adult↗

PubMed2004

Quality assessment program in primary care clinics: a tool for quality improvement.

BACKGROUND: Assessment of quality of health care is a major ongoing project of the Israeli Defense Forces (IDF) medical corps. OBJECTIVE: (i) To describe mechanisms of quality assessment (QA) in IDF primary care clinics; (ii) to compare quality of care in different types of primary care clinics; and (iii) to test the hypothesis that implementation of the QA program results in improved quality of care. RESEARCH DESIGN: A prospective, single-blinded, uncontrolled, non-randomized study. MEASURES: Teams of two physicians carry out the QA process once or twice a year according to clinic size. Five areas were evaluated: (i) physician-patient interaction; (ii) medical chart evaluation; (iii) high-risk patients management; (iv) medical care provided by specialists; and (v) medical staff guidance. Clinics were classified in two groups: single-physician clinics (battalion troop clinics) and multi-physician clinics (home-front base clinics). General Linear Models were used for analysis. A P-value <0.05 was considered significant. RESULTS: In 2000 and 2001, 99 primary clinics and 162 primary care physicians were assessed. Seventy-four (45%) physicians were evaluated twice. Single-physician clinics scored higher than multi-physician clinics on most QA parameters. Physicians had significantly better QA results at the second encounter, regardless of the type of clinic. CONCLUSIONS: A primary care medicine QA system is feasible in the IDF. It allows for standardized, reliable, and comprehensive assessment of primary care across the military clinics. We postulate that the increase in QA assessment scores from one examination to the next one indicates an improvement in quality due to the QA program.

Ambulatory Care Facilities↗

PubMed1994

Incorporation of continuous quality improvement in a hospital dietary department's quality management program.

What techniques or steps are necessary to overcome obstacles and achieve the incorporation of continuous quality improvement (CQI) methods in existing quality management programs? Education of staff, identification of customers' expectations, and implementation of a plan to administer activities are critical to a positive outcome of CQI efforts. Our article outlines one approach to the transition from quality assurance to CQI using the FOCUS-PDCA technique. We use the example of improving the timeliness of late tray deliveries to demonstrate how to implement the conversion to CQI using the FOCUS-PDCA technique. The dietetics practitioners may apply the sequential steps described in the article to successfully incorporate the CQI concept in most hospital dietary departments' quality management activities.

Dietary Services↗

PubMed2002

Contracting for quality: Medicare's quality improvement organizations.

This paper examines the role of quality improvement organizations (QIOs, formerly known as PROs, or peer review organizations) in improving the quality of medical care delivered to Medicare beneficiaries in both fee-for-service and managed care environments. It looks at the expansion of the QIOs' portfolio in their new contract cycle to include quality improvement activities in nursing homes, home health services, and physicians' offices as well as responsibilities for public education. The paper explores the evolution of QIOs, changes in their priorities over time, and the projects in which they are currently engaged. It also considers their role in the formulation and execution of a national quality agenda.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed1997

Implementing continuous quality improvement in home care: a success story.

Continuous quality improvement (COI) is fast becoming the method of choice for home care organizations to assess and improve the quality of their services. This article illustrates care agency took the first step toward implementing COI. Interviews with the executive director, clinical director, continuous quality improvement coordinator, business office manager, and health information manager provide a glimpse into their initial concerns and their successes. Advice from each participant is offered to agencies attempting to implement COI for the first time.

Attitude of Health Personnel↗

PubMed2003

Use of patient satisfaction data in a continuous quality improvement program for endoscopic sinus surgery.

OBJECTIVE: Continuous quality improvement (CQI) is an effort by health care providers to improve the quality of service by continuously exceeding patients' expectations. Patient satisfaction is one of the measures of the quality of care. The aims of this study were to report the patients' evaluation of endoscopic sinus surgery (ESS) and to explore the feasibility in using patient satisfaction data in the CQI program for ESS. METHODS: Eighty-three patients completed a validated patient satisfaction survey (PSS) 1 month after undergoing ESS. Logistic regression models were applied to determine the confounders of patient satisfaction. RESULTS: In general, 72% of patients were very satisfied with the services. Education level and milder disease correlated with higher overall satisfaction levels (P </= 0.01). Anesthesia, the addition of nasal septal surgery, intranasal packing, and postoperative sinuscopy had significant impacts on patient satisfaction (P < 0.05). CONCLUSION: ESS is a good technique to evaluate for implementing efforts in quality improvement. Confounding factors need to be adjusted before patient satisfaction data can be used in a CQI program.

Adolescent↗