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PubMedDate not supplied

Quality improvement's new focus yields quantitative results.

Health care quality improvement methods are now undergoing fundamental change. The emphasis is shifting from inspection of physician practices to continuous improvement of clinical processes validated by quantitative results. This change is long overdue. Traditional quality assurance methods that operate retrospectively and alienate physicians are not useful in a marketplace where quality and cost control are a matter of survival. Physician practices are only as good as the institutional processes they rely upon, and any quality improvement method that alienates physicians is doomed. Quality improvement is impossible without the support of physicians, because true improvement is driven and quantified by clinical data. Physicians are needed to interpret that data.

Clinical Protocols↗

PubMedDate not supplied

West Virginia Medical Institute: the Quality Improvement Organization for West Virginia.

The Federal Quality Improvement program, (QIO), charged with quality improvement and some case review activities is conducted under a contract with the Centers for Medicare and Medicaid Services (formerly HCFA), now CMS. Every state has one organization which handles this program and in West Virginia, the West Virginia Medical Institute has been responsible for this work for over 30 years. When case review is involved, the conclusions are communicated to individual physicians and hospitals. Occasionally, serious quality of care concerns are encountered. This article explains the case review process and why cases are selected, and also makes suggestions about how individual physicians may appeal or respond. It is designed to help enhance understanding of the program and its goals.

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

PubMed2001

Implementing continuous quality improvement at the facility level.

Continuous Quality Improvement (CQI) is a disciplined approach to problem solving. The 4 basic building blocks of the program include; leadership, planning, quality control, and quality improvement. It is customer focused, data driven, and empowers the employees to meet the needs of their patients. Management teams that successfully adopt the underlying philosophic tenets of the program and provide adequate resources for training and implementation may realize such benefits as improved clinical outcomes, increased patient and staff satisfaction, increased staff productivity, fewer adverse events, enhanced cost effectiveness, and an improvement in overall organizational performance.

Humans↗

PubMed2006

Quality improvement initiative for chronic pain assessment and management in the nursing home: a pilot study.

OBJECTIVES: To improve assessment and management of chronic pain in the nursing home through a method of continuous quality improvement. DESIGN: Quality improvement. SETTING: One nursing home in North Carolina as the primary site and 3 related facilities as secondary sites. INTERVENTION: Formation of a quality improvement team that reviewed current clinical practice guidelines, updated the policies and procedures, developed tools for pain assessment, and educated the staff in pain assessment and management principles. The "Plan-Do-Study-Act" (PDSA) paradigm was employed. MEASUREMENT: The staff's pain-related knowledge was measured with multiple-choice tests before and after an educational program. The completeness of the documentation and satisfaction of patients and families with pain assessment and management were also measured before and after the intervention. RESULTS: Before the intervention, the mean number of questions correct on the staff test was highest among the registered nurses (RN) (13.7 out of 16), intermediate among the licensed practical nurses (LPN) (12.4), and lowest among the certified nursing assistants (CNA) (9.4). After the intervention the scores were 16 for the RNs, 12.9 for the LPNs, and 12.0 for the CNAs. In addition, 8 of 9 elements of a complete pain assessment showed improvement in documentation. The level of satisfaction for both the patients and families measured by interviews also increased. CONCLUSION: Education and use of the PDSA paradigm improved staff knowledge and patient and family satisfaction with chronic pain assessment and management.

Clinical Competence↗

PubMed1997

The design of evaluations for continuous quality improvement.

Many health care organizations are modeling continuous quality improvement activities after designs used in business and industry. This has resulted in a somewhat standardized and possibly limited approach to conducting quality improvement activities. In contrast, the evaluation paradigm provides a broader approach because the design of an evaluation may be based on the questions to be examined, or the design may emerge during the process of conducting the evaluation. This article examines the design of evaluations used for continuous quality improvement activities in health care and human service organizations. Through a case example, the benefits of using alternative evaluation designs are explored. In particular, use of alternative approaches to gather and evaluate information about restrictive treatment interventions in a mental health setting are presented.

Evaluation Studies as Topic↗

PubMedDate not supplied

The role of the principal clinical coordinator in the Health Care Financing Administration's Health Care Quality Improvement Initiative.

The Health Care Quality Improvement Initiative (HCQII) is the Health Care Financing Administration's latest approach to quality management by peer review organizations (PROs) of the health care delivered to Medicare beneficiaries. The principal clinical coordinator (PCC) of each PRO, a physician with both clinical and methodological expertise, has the overall responsibility for all HCQII-related activities. The PCC works with a clinical coordinating team to analyze patterns of care and provide feedback about these patterns to the medical community for the purpose of improving the quality of care. Each PRO provides its PCC with the necessary infrastructure and expertise to conduct pattern analyses and implement the dissemination process. However, the effectiveness of the HCQII will depend largely on the PCC's ability to maintain the full support and cooperation of the local medical community. The success of the PCC role under the HCQII may enable it to serve as a useful model of physician leadership in the quality oversight organizations that will accompany national health care reform.

Cardiology Service, Hospital↗

PubMed2004

Educating health professionals to improve quality of care for asthma.

Recent studies have shown significant progress in improving the quality of care for asthma. The most successful interventions have combined multiple elements: educational sessions that engage learners in discussing cases and practicing new skills; use of new resources, tools and practice patterns to enable quality improvement; and reinforcement of improvements through peer support, incentives or administrative review. Future research should include more randomised controlled trials to test the effectiveness of quality improvement interventions, more detailed descriptions of strategies to change health professional behaviour and studies to determine whether effective interventions can be translated to other settings, disseminated widely and sustained over time.

Asthma↗

PubMed1991

Quality improvement: an imperative for medical care.

For continuous process improvement to be successful at the site of care, an organizational structure for quality improvement should be in place. Quality improvement requires (1) an environment for quality improvement and (2) tools for improvement, including statistical and meeting tools. Physicians and all other care givers and support personnel must cooperate for process knowledge to be complete and usable. Perhaps there is no such thing as a purely "clinical" system, because the contiguous systems influence clinical behavior so completely they are almost inseparable. Process improvement specifications are not the same thing as standards as we now understand them. Process improvement specification are process based. They expect, are designed for, and handle divergent pathophysiologic conditions by focusing on processes. Individual institutions define and measure their outputs, but these outputs are judged against their customers' needs and expectations (thereby becoming outcomes) for performance, features, reliability, conformance, durability, serviceability, aesthetics, and perceived quality. Outcomes research as known today can help us understand the needs and expectations of our customers. Moreover, any team can improve the framework of quality improvement.

Contract Services↗

PubMed2001

A decade's experience with quality improvement in cardiac surgery using the Veterans Affairs and Society of Thoracic Surgeons national databases.

OBJECTIVE: To review the Department of Veteran Affairs (VA) and the Society of Thoracic Surgeons (STS) national databases over the past 10 years to evaluate their relative similarities and differences, to appraise their use as quality improvement tools, and to assess their potential to facilitate improvements in quality of cardiac surgical care. SUMMARY BACKGROUND DATA: The VA developed a mandatory risk-adjusted database in 1987 to monitor outcomes of cardiac surgery at all VA medical centers. In 1989 the STS developed a voluntary risk-adjusted database to help members assess quality and outcomes in their individual programs and to facilitate improvements in quality of care. METHODS: A short data form on every veteran operated on at each VA medical center is completed and transmitted electronically for analysis of unadjusted and risk-adjusted death and complications, as well as length of stay. Masked, confidential semiannual reports are then distributed to each program's clinical team and the associated administrator. These reports are also reviewed by a national quality oversight committee. Thus, VA data are used both locally for quality improvement and at the national level with quality surveillance. The STS dataset (217 core fields and 255 extended fields) is transmitted for each patient semiannually to the Duke Clinical Research Institute (DCRI) for warehousing, analysis, and distribution. Site-specific reports are produced with regional and national aggregate comparisons for unadjusted and adjusted surgical deaths and complications, as well as length of stay for coronary artery bypass grafting (CABG), valvular procedures, and valvular/CABG procedures. Both databases use the logistic regression modeling approach. Data for key processes of care are also captured in both databases. Research projects are frequently carried out using each database. RESULTS: More than 74,000 and 1.6 million cardiac surgical patients have been entered into the VA and STS databases, respectively. Risk factors that predict surgical death for CABG are very similar in the two databases, as are the odds ratios for most of the risk factors. One major difference is that the VA is 99% male, the STS 71% male. Both databases have shown a significant reduction in the risk-adjusted surgical death rate during the past decade despite the fact that patients have presented with an increased risk factor profile. The ratio of observed to expected deaths decreased from 1.05 to 0.9 for the VA and from 1.5 to 0.9 for the STS. CONCLUSION: It appears that the routine feedback of risk-adjusted data on local performance provided by these programs heightens awareness and leads to self-examination and self-assessment, which in turn improves quality and outcomes. This general quality improvement template should be considered for application in other settings beyond cardiac surgery.

Cardiac Surgical Procedures↗

PubMed2002

Quality improvement in cardiac care.

Quality improvement in cardiac care has made considerable progress over the past 30 years. During that period, there has been the development of multi-institutional databases to monitor outcomes following cardiothoracic surgery. These databases initially began using only volume and unadjusted operative (30-day) mortality as outcome criteria. There has been a progressive increase in their sophistication, with the building of risk models based on preoperative variables, which accurately predict the risk of adverse outcomes. Other outcomes have been added including risk-adjusted mortality and morbidity; efficiency outcomes such as length of stay, quality of life, functional health status, neuropsychological outcomes; and long-term outcomes.

Cardiac Surgical Procedures↗

PubMedDate not supplied

Moving toward continuous quality improvement.

Consumers are looking for better quality health care for their dollar. Nursing is challenged with providing excellent care in an age of shrinking resources. After years of chart audits and quality assurance, a new and broader focus is emerging. Continuous quality improvement is the latest theme in the ever-changing area of quality. It seeks to improve care through improving the processes used in delivering the care. A smooth transition from quality assurance to continuous quality improvement is possible through a complete understanding of both concepts, a willingness to work with others in the organization, and the ability to focus on process rather than on people.

Clinical Protocols↗

PubMedDate not supplied

Quality improvement: a race with no finish.

Quality improvement has been used in other industries for its ability to help achieve objectives in price sensitive markets and against tough competition, according to authors Kevin Sullivan and Ellen Meier, RN, M.B.A. Quality improvement also has strategic implications for every group practice concerned about maintaining profit margins, satisfying patients and payers and lifting the morale of its employees.

Cost Control↗

PubMed2006

Benchmarking as a tool of continuous quality improvement in postoperative pain management.

BACKGROUND AND OBJECTIVE: Quality of acute pain management is far from being satisfactory. These deficits are not caused by the complexity of the medical problem but by difficulties in organization and hospital structures, sand procedures. Continuous quality improvement is a recommended tool to overcome such difficulties and to increase quality in the long run. This study reports the implementation of benchmarking-based continuous quality improvement to improve postoperative pain management at a university hospital. METHODS: A specialised pain nurse interviewed patients of three surgical departments on the first day after surgery, and continuously assessed process and outcome quality parameters. A multidisciplinary team of anaesthetists, surgeons, nurses and pharmacists implemented a regular procedure of data analysing and internal benchmarking. Results and suggested improvements were fed back to the healthcare teams. RESULTS: From 1998 to 2002, 6,756 patients were assessed. Average pain on ambulation and maximal pain were 3.7 +/- 2.4 and 5.0 +/- 2.5 (mean +/- SD) on a 11-point numeric rating scale. Pain intensity at rest was 1.9 +/- 1.8. Over time, pain intensity on ambulation decreased (P = 0.022) whereas maximal pain and pain at rest remained unchanged. There was an increase in the number of patients who received non-opioid analgesia (P < 0.001). CONCLUSIONS: A continuous quality improvement process could be established and is now successfully used in clinical routine. Cornerstones of this project were frequent assessments of process and outcome parameters, regular benchmarking and implementation of feedback mechanisms. Changes in organization of medical management and multidisciplinary teamwork seem to be more important than medical or technical aspects.

Abdomen↗

PubMed2004

The Prevention Index: using technology to improve quality assessment.

OBJECTIVE: To improve quality of care assessment for preventive medical services and reduce assessment costs through development of a comprehensive prevention quality assessment methodology based on electronic medical records (EMRs). DATA SOURCES: Random sample of 775 adult and 201 child members of a large nonprofit managed care system. STUDY DESIGN: Problems with current, labor-intensive quality measures were identified and remedied using EMR capabilities. The Prevention Index (PI) was modeled by assessing five-year patterns of delivery of 24 prevention services to adult and child health maintenance organization (HMO) members and comparing those services to consensus recommendations and to selected Health Plan Employer Data and Information Set (HEDIS) scores for the HMO. DATA COLLECTION: Comprehensive chart reviews of 976 randomly selected members of a large managed care system were used to model the Prevention Index. PRINCIPAL FINDINGS: Current approaches to prevention quality assessment have serious limitations. The PI eliminates these limitations and can summarize care in a single comprehensive index that can be readily updated. The PI prioritizes services based on benefit, using a person-time approach, and separates preventive from diagnostic and therapeutic services. CONCLUSIONS: Current methods for assessing quality are expensive, cannot be applied at all system levels, and have several methodological limitations. The PI, derived from EMRs, allows comprehensive assessment of prevention quality at every level of the system and at lower cost. Standardization of quality assessment capacities of EMRs will permit accurate cross-institutional comparisons.

Adult↗

PubMed1994

[Structured documentation in gastroscopy: a method for improved quality assurance?].

To further improve quality assurance of gastrointestinal endoscopy, a computer assisted documentation system for gastroscopic data was assessed. In this context, for the structured written recording system, parameters "expenditure of time" and "acceptance by doctors" was evaluated. Contrary to free, unstructured data recording, the structured system employing predefined terms was able to promote doctors' acceptance of endoscopic terminology standards.

Attitude of Health Personnel↗

PubMed2006

An empirical investigation of quality improvement initiatives in for-profit and not-for-profit hospitals: environmental, competitive and outcome concerns.

PURPOSE: The objective of this study is to shed some light on quality improvement practices of for-profit and not-for-profit hospitals DESIGN/METHODOLOGY/APPROACH: The scope and effectiveness of several quality improvement efforts are studied for a sample of 110 hospitals. Factor analysis was utilized to analyze the data collected. FINDINGS: The results of this study tended to suggest that for-profit and not-for-profit hospitals were more similar than different with the regard to the effective utilization of quality improvement initiatives, thus underscoring the utility of quality improvement efforts despite differences in operating characteristics, strategies and operating constraints. RESEARCH LIMITATIONS/IMPLICATIONS: The sample used in this study is limited. Thus, the results should be interpreted accordingly. PRACTICAL IMPLICATIONS: This study offers decision-makers in healthcare operational settings empirical evidence of the operational and strategic effectiveness of different quality improvement efforts, thus justifying investments related to the initiation and implementation of such quality improvement efforts. ORIGINALITY/VALUE: This study represents an important step toward understanding the effective implementation of quality improvement initiatives in different operational settings.

Adult↗

PubMed2006

Promoting physicians' self-assessment and quality improvement: the ABIM diabetes practice improvement module.

INTRODUCTION: The American Board of Internal Medicine (ABIM) recognized that certification and recertification must be based on an assessment of performance in practice as well as an examination of medical knowledge. Physician self-assessment of practice performance is proposed as one method that certification boards may use to evaluate competence in practice-based learning and improvement and systems-based practice. METHODS: Sixteen practicing general internists and endocrinologists with 10-year time-limited certification participated in a beta test of the ABIM's diabetes practice improvement module (PIM) as part of their recertification program. A PIM consists of a self-directed medical record audit, practice system survey, and patient survey. A quality improvement education specialist from the Connecticut Quality Improvement Organization provided on-site and distance consultation on quality improvement methods and tools. An independent audit assessed the reliability of physician self-audit. Qualitative interviews were conducted at 2 time points to assess for physician satisfaction and behavioral change in quality improvement. RESULTS: Fourteen physicians completed the diabetes PIM. All but 1 physician found the medical record audit to provide important information about the practice. Of the 11 physicians who completed a follow-up interview, 10 stated that the quality improvement education specialist helped improve their practice. DISCUSSION: Self-assessment using the ABIM diabetes PIM as part of recertification provides valuable practice information and can lead to meaningful behavioral change by physicians. Collaboration with an educator in quality improvement appears to facilitate the effects of the practice improvement module. Future work should investigate the effect on patient outcomes.

Adult↗

PubMedDate not supplied

Quality assurance and continuous quality improvement within air transport programs.

INTRODUCTION: In June of 1993, the Association of Air Medical Services (AAMS) Quality Management Committee surveyed 240 air medical programs regarding their Quality Assurance and Continuous Quality Improvement activities. METHODS: The survey tool consisted of questions related to Quality Assurance/Continuous Quality Improvement program structure and specific Quality Assurance indicators contained in the AAMS/NFNA Quality Assurance Resource Document. Comparisons were made among fixed-wing, rotor-wing, and combined programs, for use of the Quality Assurance Resource Document, for availability of computers and for hospital-based versus profit or public service programs. RESULTS: Returned surveys totaled 148 for a 62% return rate, with most of the respondents being single hospital based programs. Ninety-three percent of those surveyed have a Quality Assurance program in place to monitor indicators, whereas 63% have also begun to include the Continuous Quality Improvement team process. Only 50% of respondents use computers in their Quality Assurance/Continuous Quality Improvement activities. CONCLUSION: Significant differences among groups were found for several Quality Assurance indicators.

Air Ambulances↗