Evidence-based quality improvement: the state of the science

Improving the quality of radiological examinations: effectiveness of an internal participatory approach

Quality problem or issue

To assess the quality of radiological examinations (REs) and to evaluate the effectiveness of a participatory continuous improvement approach to ensure best practices in a Portuguese hospital imaging department.

Initial assessment

At baseline, we found 232 (10.2%) non-compliances, mostly related to the criteria image centering and framing in chest radiography (CXR), proper use of radiological protection equipment in other conventional RE (CR) and X-ray beam collimation (CXR/CR).

Choice of solution

A baseline and three consecutive evaluations of the RE quality were conducted. Each assessment was followed by participatory focused interventions for improvement.

Implementation

For each evaluation, we selected a random sample (n = 60) of cases for four types of examination (total n = 240 for each assessment, and 960 for the whole project). Both the building of quality criteria and the design of interventions for improvement were participatory, involving the radiology technicians. Estimates of criteria compliance were calculated with 95% confidence intervals. The statistical significance of absolute and relative improvements was tested using one-tail z-tests.

Evaluation

After the intervention, non-compliances decreased to 48 (2.1%). Compliance estimates improved in 25 of 38 criteria assessed, with statistical significance for 5 criteria in CXR and 3 in CR and digestive examination.

Lessons learned

The internal participatory approach enabled the identification of existing quality problems and, by focusing on the more frequent quality defects, was effective in improving the quality of RE.

Learning from high risk industries may not be straightforward: a qualitative study of the hierarchy of risk controls approach in healthcare

OBJECTIVE

Though healthcare is often exhorted to learn from 'high-reliability' industries, adopting tools and techniques from those sectors may not be straightforward. We sought to examine the hierarchies of risk controls approach, used in high-risk industries to rank interventions according to supposed effectiveness in reducing risk, and widely advocated as appropriate for healthcare.

DESIGN

Classification of risk controls proposed by clinical teams following proactive detection of hazards in their clinical systems. Classification was based on a widely used hierarchy of controls developed by the US National Institute for Occupational Safety and Health (NIOSH).

SETTING AND PARTICIPANTS

A range of clinical settings in four English NHS hospitals.

RESULTS

The four clinical teams in our study planned a total of 42 risk controls aimed at addressing safety hazards. Most (n = 35) could be classed as administrative controls, thus qualifying among the weakest type of interventions according to the HoC approach. Six risk controls qualified as 'engineering' controls, i.e. the intermediate level of the hierarchy. Only risk control qualified as 'substitution', classified as the strongest type of intervention by the HoC.

CONCLUSIONS

Many risk controls introduced by clinical teams may cluster towards the apparently weaker end of an established hierarchy of controls. Less clear is whether the HoC approach as currently formulated is useful for the specifics of healthcare. Valuable opportunities for safety improvement may be lost if inappropriate hierarchical models are used to guide the selection of patient safety improvement interventions. Though learning from other industries may be useful, caution is needed.

Commentary on "Regulatory Support Improves Subsequent IRB/REC Approval Rates in Studies Initially Deemed Not Ready for Review: A CTSA Institution's Experience"

In response to researcher concerns a number of initiatives have been developed to support individual researchers seeking ethics review and approval. In this issue, Sonne et al. (2017) outline an example of an intervention to support researchers, which they refer to as a Regulatory Knowledge Support (RKS) service. While the study points to potential benefits, other studies have not had the desired impact on key performance measures. There is a need to develop a community of practice and expand the burgeoning evidence base regarding what interventions work, for whom, and under what circumstances. Advancing the research agenda requires: the development of theoretical models for intervention design and evaluation; developing consensus on key data for collection and measures of effectiveness; conducting evaluations using the strongest possible study designs, and; publishing the findings of evaluations.

Application of Lean Healthcare methodology in a urology department of a tertiary hospital as a tool for improving efficiency

OBJECTIVE

To describe the application of the Lean methodology as a method for continuously improving the efficiency of a urology department in a tertiary hospital.

MATERIAL AND METHODS

The implementation of the Lean Healthcare methodology in a urology department was conducted in 3 phases: 1) team training and improvement of feedback among the practitioners, 2) management by process and superspecialisation and 3) improvement of indicators (continuous improvement). The indicators were obtained from the Hospital's information systems. The main source of information was the Balanced Scorecard for health systems management (CUIDISS). The comparison with other autonomous and national urology departments was performed through the same platform with the help of the Hospital's records department (IASIST). A baseline was established with the indicators obtained in 2011 for the comparative analysis of the results after implementing the Lean Healthcare methodology.

RESULTS

The implementation of this methodology translated into high practitioner satisfaction, improved quality indicators reaching a risk-adjusted complication index (RACI) of 0.59 and a risk-adjusted mortality rate (RAMR) of 0.24 in 4 years. A value of 0.61 was reached with the efficiency indicator (risk-adjusted length of stay [RALOS] index), with a savings of 2869 stays compared with national Benchmarking (IASIST). The risk-adjusted readmissions index (RARI) was the only indicator above the standard, with a value of 1.36 but with progressive annual improvement of the same.

CONCLUSIONS

The Lean methodology can be effectively applied to a urology department of a tertiary hospital to improve efficiency, obtaining significant and continuous improvements in all its indicators, as well as practitioner satisfaction. Team training, management by process, continuous improvement and delegation of responsibilities has been shown to be the fundamental pillars of this methodology.

Data-driven quality improvement in low-and middle-income country health systems: lessons from seven years of implementation experience across Mozambique, Rwanda, and Zambia

BACKGROUND

Well-functioning health systems need to utilize data at all levels, from the provider, to local and national-level decision makers, in order to make evidence-based and needed adjustments to improve the quality of care provided. Over the last 7 years, the Doris Duke Charitable Foundation's African Health Initiative funded health systems strengthening projects at the facility, district, and/or provincial level to improve population health. Increasing data-driven decision making was a common strategy in Mozambique, Rwanda and Zambia. This paper describes the similar and divergent approaches to increase data-driven quality of care improvements (QI) and implementation challenge and opportunities encountered in these three countries.

METHODS

Eight semi-structured in-depth interviews (IDIs) were administered to program staff working in each country. IDIs for this paper included principal investigators of each project, key program implementers (medically-trained support staff, data managers and statisticians, and country directors), as well as Ministry of Health counterparts. IDI data were collected through field notes; interviews were not audio recorded. Data were analyzed using thematic analysis but no systematic coding was conducted. IDIs were supplemented through donor report abstractions, a structured questionnaire, one-on-one phone calls, and email exchanges with country program leaders to clarify and expand on key themes emerging from IDIs.

RESULTS

Project successes ranged from over 450 collaborative action-plans developed, implemented, and evaluated in Mozambique, to an increase from <10% to >80% of basic clinical protocols followed in intervention facilities in rural Zambia, and a shift from a lack of awareness of health data among health system staff to collaborative ownership of data and using data to drive change in Rwanda.

CONCLUSION

Based on common successes across the country experiences, we recommend future data-driven QI interventions begin with data quality assessments to promote that rapid health system improvement is possible, ensure confidence in available data, serve as the first step in data-driven targeted improvements, and improve staff data analysis and visualization skills. Explicit Ministry of Health collaborative engagement can ensure performance review is collaborative and internally-driven rather than viewed as an external "audit."

Stakeholder-Driven Quality Improvement: A Compelling Force for Clinical Practice Guidelines

Clinical practice guideline development should be driven by rigorous methodology, but what is less clear is where quality improvement enters the process: should it be a priority-guiding force, or should it enter only after recommendations are formulated? We argue for a stakeholder-driven approach to guideline development, with an overriding goal of quality improvement based on stakeholder perceptions of needs, uncertainties, and knowledge gaps. In contrast, the widely used topic-driven approach, which often makes recommendations based only on randomized controlled trials, is driven by epidemiologic purity and evidence rigor, with quality improvement a downstream consideration. The advantages of a stakeholder-driven versus a topic-driven approach are highlighted by comparisons of guidelines for otitis media with effusion, thyroid nodules, sepsis, and acute bacterial rhinosinusitis. These comparisons show that stakeholder-driven guidelines are more likely to address the quality improvement needs and pressing concerns of clinicians and patients, including understudied populations and patients with multiple chronic conditions. Conversely, a topic-driven approach often addresses “typical” patients, based on research that may not reflect the needs of high-risk groups excluded from studies because of ethical issues or a desire for purity of research design.

Are emergency department clinical pathway interventions adequately described, and are they delivered as intended? A systematic review

Introduction

The accurate reproduction of clinical interventions and the evaluation of provider adherence in research publications improve the evaluation and implementation of research findings into clinical practice. We sought to examine the proportion of clinical pathway publications in an emergency department setting that adequately reported the following: (1) the exact reproduction of the clinical pathway that was implemented in the study, (2) the adherence to and correct execution of the clinical pathway intervention, and (3) the presence of a pre-implementation education phase.

Methods

We performed a descriptive systematic review of the literature from 2006 to 2015 using MEDLINE, EMBASE, CENTRAL, and CINAHL. All types of prospective trial designs were eligible. Validated clinical pathway criteria were used to identify relevant publications. Two reviewers independently collected data using a piloted data abstraction tool. Risk of bias was assessed using the Cochrane Effective Practice and Organization of Care Group Risk of Bias Tool and the Newcastle-Ottawa Scale.

Results

We identified 5947 publications, 44 of which met our inclusion criteria. The formal clinical pathway was fully reproduced in 27 (61%) publications, partially reproduced in 9 (21%), and not reproduced in 8 (18%). Only 14 (32%) studies reported whether at least one decision step was executed correctly. The presence of a pre-implementation education phase was reported in 33 (75%) studies.

Conclusion

The underreporting of intervention elements may present a barrier to both the evaluation and accurate replication of clinical pathway interventions. These finding may be useful for the elaboration of complex intervention reporting guidelines, improved reporting in future clinical pathway publications, and improved knowledge translation and exchange of clinical pathway interventions.

Improvement Science in Anaesthesia

PURPOSE OF REVIEW

This article offers an overview of the history and features of Improvement Science in general and some of its applications to Anaesthesia in particular.

RECENT FINDINGS

Improvement Science is an evolving discipline aiming to generate learning from quality improvement interventions. An increasingly common approach to improving Anaesthesia services is to employ large-scale perioperative data measurement and feedback programmes. Improvement Science offers important insights on questions such as which indicators to collect data for; how to capture that data; how it can be presented in engaging visual formats; how it could/should be fed back to frontline staff and how they can be supported in their use of data to generate improvement.

SUMMARY

Data measurement and feedback systems represent opportunities for anaesthetists to work with multidisciplinary colleagues to help improve services and outcomes for surgical patients. Improvement Science can help evaluate which approaches work, and in which contexts, and is therefore of value to healthcare commissioners, providers and patients.

Implementation and results of an integrated data quality assurance protocol in a randomized controlled trial in Uttar Pradesh, India

BACKGROUND

There are few published standards or methodological guidelines for integrating Data Quality Assurance (DQA) protocols into large-scale health systems research trials, especially in resource-limited settings. The BetterBirth Trial is a matched-pair, cluster-randomized controlled trial (RCT) of the BetterBirth Program, which seeks to improve quality of facility-based deliveries and reduce 7-day maternal and neonatal mortality and maternal morbidity in Uttar Pradesh, India. In the trial, over 6300 deliveries were observed and over 153,000 mother-baby pairs across 120 study sites were followed to assess health outcomes. We designed and implemented a robust and integrated DQA system to sustain high-quality data throughout the trial.

METHODS

We designed the Data Quality Monitoring and Improvement System (DQMIS) to reinforce six dimensions of data quality: accuracy, reliability, timeliness, completeness, precision, and integrity. The DQMIS was comprised of five functional components: 1) a monitoring and evaluation team to support the system; 2) a DQA protocol, including data collection audits and targets, rapid data feedback, and supportive supervision; 3) training; 4) standard operating procedures for data collection; and 5) an electronic data collection and reporting system. Routine audits by supervisors included double data entry, simultaneous delivery observations, and review of recorded calls to patients. Data feedback reports identified errors automatically, facilitating supportive supervision through a continuous quality improvement model.

RESULTS

The five functional components of the DQMIS successfully reinforced data reliability, timeliness, completeness, precision, and integrity. The DQMIS also resulted in 98.33% accuracy across all data collection activities in the trial. All data collection activities demonstrated improvement in accuracy throughout implementation. Data collectors demonstrated a statistically significant (p = 0.0004) increase in accuracy throughout consecutive audits. The DQMIS was successful, despite an increase from 20 to 130 data collectors.

CONCLUSIONS

In the absence of widely disseminated data quality methods and standards for large RCT interventions in limited-resource settings, we developed an integrated DQA system, combining auditing, rapid data feedback, and supportive supervision, which ensured high-quality data and could serve as a model for future health systems research trials. Future efforts should focus on standardization of DQA processes for health systems research.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT02148952 . Registered on 13 February 2014.

A 'movement for improvement'? A qualitative study of the adoption of social movement strategies in the implementation of a quality improvement campaign

Given the difficulties of implementing 'top-down' quality improvements, health service leaders have turned to methods that empower clinicians to co-produce 'bottom-up' improvements. This has involved the adoption of strategies and activities associated with social movements, with clinicians encouraged to participate in collective action towards the shared goal of improvement. This paper examines the adoption of social movement methods by hospital managers as a strategy for implementing a quality improvement 'campaign'. Our case study suggests that, despite the claim of empowering clinicians to develop 'bottom-up' improvements, the use of social movement methods can be more narrowly concerned with engaging clinicians in pre-determined programmes of 'top-down' change. It finds a prominent role for 'hybrid' clinical leaders and other staff representatives in the mobilisation of the campaign, especially for enrolling clinicians in change activities. The work of these 'hybrids' suggests some degree of creative mediation between clinical and managerial interests, but more often alignment with the aspirations of management. The study raises questions about the translation of social movement's theories as a strategy for managing change and re-inventing professionalism.

REDucing Unnecessary Coagulation Testing in the Emergency Department (REDUCED)

The PT/INR (prothrombin time/international normalized ratio) and aPTT (activated partial thromboplastin time) were tests developed in the early 20th century for specific and unique indications. Despite this, they are often ordered together routinely. The objective of this study was to determine if a multimodal intervention could reduce PT/INR and aPTT testing in the emergency department (ED). This was a prospective multi-pronged quality improvement study at St. Michael's Hospital. The initiative involved stakeholder engagement, uncoupling of PT/INR and aPTT testing, teaching, and most importantly a revision to the ED order panels. After changes to order panels, weekly rates of PT/INR and aPTT testing per 100 ED patients decreased (17.2 vs 38.4, rate ratio=0.45 (95% CI 0.43-0.47), p<0.001; 16.6 vs 37.8, rate ratio=0.44 (95% CI 0.42-0.46), p<0.001, respectively). Rate of creatinine testing per 100 ED patients, our internal control, increased during the same period (54.0 vs 49.7, rate ratio=1.09 (95% CI 1.06-1.12); p<0.0001) while the weekly rate per 100 ED patients receiving blood transfusions slightly decreased (0.5 vs 0.7, rate ratio=0.66 (95% CI 0.49-0.87), p=0.0034). We found that a simple process change to order panels was associated with meaningful reductions in coagulation testing without obvious adverse effects.

A healthcare quality management system underpinning the 3-E model and its application in a new tertiary hospital in Australia

Objectives

Engaging, enhancing and embedding clinical audit improvement activities into everyday practice to develop capacity, capability and culture in continuous improvement.

Method

Through the implementation of an electronic quality management system called Governance, Evidence, Knowledge and Outcome (GEKO), the key aspects of governance, evidence knowledge and outcomes were able to be applied to quality initiatives. Implementation of the GEKO system incorporated the principles of total quality control and management to include strategic management control and marketing in parallel with leadership strategies.

The vision was to motivate staff to enable ownership of the quality cycle of continuous improvement of patient care to incorporate underlying systems and processes that impact on patient care.

Results

A continuous improvement pathway was successfully established 4 months post hospital commissioning. Over 890 (approximately 16% workforce) multidisciplinary and multi-professional staff received training and support for QIs in 12 months; over 535 quality proposals were received on GEKO. Submissions by profession: nursing and midwifery 46% (246), medical 33% (177), allied health 9% (48), pharmacy 5% (27), and non-clinical staff 7% (37). Average new submissions per month were 42. Reviews demonstrated the application of a rapid cycle approach to develop, test, modify and refine improvements and enhanced clinical care.

Conclusion

Appropriate governance structure, processes, extensive education and training together with collaborative relationships are the keys to embed clinical audit improvement into everyday practice. The availability of a quality management system like GEKO is very useful to make QI accessible to all staff.

Use of a Digital Modified Checklist for Autism in Toddlers - Revised with Follow-up to Improve Quality of Screening for Autism

OBJECTIVES

To assess changes in quality of care for children at risk for autism spectrum disorders (ASD) due to process improvement and implementation of a digital screening form.

STUDY DESIGN

The process of screening for ASD was studied in an academic primary care pediatrics clinic before and after implementation of a digital version of the Modified Checklist for Autism in Toddlers - Revised with Follow-up with automated risk assessment. Quality metrics included accuracy of documentation of screening results and appropriate action for positive screens (secondary screening or referral). Participating physicians completed pre- and postintervention surveys to measure changes in attitudes toward feasibility and value of screening for ASD. Evidence of change was evaluated with statistical process control charts and χ² tests.

RESULTS

Accurate documentation in the electronic health record of screening results increased from 54% to 92% (38% increase, 95% CI 14%-64%) and appropriate action for children screening positive increased from 25% to 85% (60% increase, 95% CI 35%-85%). A total of 90% of participating physicians agreed that the transition to a digital screening form improved their clinical assessment of autism risk.

CONCLUSIONS

Implementation of a tablet-based digital version of the Modified Checklist for Autism in Toddlers - Revised with Follow-up led to improved quality of care for children at risk for ASD and increased acceptability of screening for ASD. Continued efforts towards improving the process of screening for ASD could facilitate rapid, early diagnosis of ASD and advance the accuracy of studies of the impact of screening.

An Overview of Research and Evaluation Designs for Dissemination and Implementation

The wide variety of dissemination and implementation designs now being used to evaluate and improve health systems and outcomes warrants review of the scope, features, and limitations of these designs. This article is one product of a design workgroup that was formed in 2013 by the National Institutes of Health to address dissemination and implementation research, and whose members represented diverse methodologic backgrounds, content focus areas, and health sectors. These experts integrated their collective knowledge on dissemination and implementation designs with searches of published evaluations strategies. This article emphasizes randomized and nonrandomized designs for the traditional translational research continuum or pipeline, which builds on existing efficacy and effectiveness trials to examine how one or more evidence-based clinical/prevention interventions are adopted, scaled up, and sustained in community or service delivery systems. We also mention other designs, including hybrid designs that combine effectiveness and implementation research, quality improvement designs for local knowledge, and designs that use simulation modeling.

SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised Publication Guidelines From a Detailed Consensus Process

Since the publication of Standards for QUality Improvement Reporting Excellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this manuscript, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) semi-structured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) two face-to-face consensus meetings to develop interim drafts, and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasizes the reporting of three key components of systematic efforts to improve the quality, value, and safety of healthcare: the use of formal and informal theory in planning, implementing, and evaluating improvement work; the context in which the work is done; and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve healthcare, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (http://www.squire-statement.org).

SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process

In the past several years, the science of health care improvement has advanced considerably. In this article, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) face-to-face consensus meetings to develop interim drafts, and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasizes 3 key components of systematic efforts to improve the quality, value, and safety of health care: formal and informal theory in planning, implementing, and evaluating improvement work; the context in which the work is done; and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve health care, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (www.squire-statement.org).

Continuous quality improvement in nephrology: a systematic review

BACKGROUND

Continuous quality improvement (CQI) has been successfully applied in business and engineering for over 60 years. While using CQI techniques within nephrology has received increased attention, little is known about where, and with what measure of success, CQI can be attributed to improving outcomes within nephrology care. This is particularly important as payors' focus on value-based healthcare and reimbursement is tied to achieving quality improvement thresholds. We conducted a systematic review of CQI applications in nephrology.

METHODS

Studies were identified from PubMed, MEDLINE, Scopus, Web of Science, CINAHL, Google Scholar, ProQuest Dissertation Abstracts and sources of grey literature (i.e., available in print/electronic format but not controlled by commercial publishers) between January 1, 2004 and October 13, 2014. We developed a systematic evaluation protocol and pre-defined criteria for review. All citations were reviewed by two reviewers with disagreements resolved by consensus.

RESULTS

We initially identified 468 publications; 40 were excluded as duplicates or not available/not in English. An additional 352 did not meet criteria for full review due to: 1. Not meeting criteria for inclusion = 196 (e.g., reviews, news articles, editorials) 2. Not nephrology-specific = 153, 3. Only available as abstracts = 3. Of 76 publications meeting criteria for full review, the majority [45 (61%)] focused on ESRD care. 74% explicitly stated use of specific CQI tools in their methods. The highest number of publications in a given year occurred in 2011 with 12 (16%) articles. 89% of studies were found in biomedical and allied health journals and most studies were performed in North America (52%). Only one was randomized and controlled although not blinded.

CONCLUSIONS

Despite calls for healthcare reform and funding to inspire innovative research, we found few high quality studies either rigorously evaluating the use of CQI in nephrology or reporting best practices. More rigorous research is needed to assess the mechanisms and attributes by which CQI impacts outcomes before there is further promotion of its use for improvement and reimbursement purposes.

Delivery Room Quality Improvement Project Improved Compliance with Best Practices for a Community NICU

A Quality Improvement bundle was implemented with the goal of standardizing the multidisciplinary approach to delivery room management. We used a Pre-Post Quality Improvement initiative with the following aims: (1) Placement of a functioning pulse oximeter by two minutes after birth, (2) Delayed intubation, (3) Normothermia on Neonatal Intensive Care Unit Admission, (4) Use of a pre-brief, debrief, and delivery room checklist. Data was collected for 548 infants, which represents every admission to the Palomar Rady Children’s Hospital Neonatal Intensive Care Unit during the 35 month study period from January 1, 2010 to November 30, 2012. The intervention began on May 1, 2011. The objective of increasing the frequency of each goal was met. A significant decrease in rates of retinopathy of prematurity in our post-intervention group was found. Odds ratio 0.00 (0.000, 0.696) p = 0.008. However, this was not confirmed in the multivariable analysis so should be interpreted with caution. This quality improvement project had a positive effect on newborn resuscitation at Palomar Medical Center.

The Role of Disease Management in Pay-for-Performance Programs for Improving the Care of Chronically Ill Patients

To date, pay-for-performance programs targeting the care of persons with chronic conditions have primarily been directed at physicians and provide an alternative to health plan-sponsored chronic disease management (DM) programs. Both approaches require similar infrastructure, and each has its own advantages and disadvantages for program implementation. Pay-for-performance programs use incentives based on patient outcomes; however, an alternative system might incorporate measures of structure and process. Using a conceptual framework, the authors explore the variation in 50 diabetes DM programs using data from the 2002 National Business Coalition on Health’s eValue8 Request for Information (RFI). The authors raise issues relevant to the assignment of accountability for patient outcomes to either health plans or physicians. They analyze the association betweenRFI scores measuring structures and processes, and HEDIS diabetes intermediate outcome measures. Finally, the strengths and weaknesses of using the RFI scores as an alternative metric for pay-for-performance programs are discussed.

SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised Publication Guidelines From a Detailed Consensus Process

Supplemental Digital Content is Available in the Text.

Improvement Science: conceptual and theoretical foundations for its application to healthcare quality improvement

The development and study of healthcare quality improvement interventions have been reshaped, moving from more intuitive approaches, dominated by biomedical vision and premised on easy transferability, to gradually acknowledge the need for more planning and systematization, with greater incorporation of the social sciences and enhancement of the role of context. Improvement Science has been established, with a conceptual and methodological framework for such studies. Considering the incipient of the debate and scientific production on Improvement Science in Brazil, this article aims to expound its principal conceptual and theoretical fundamentals, focusing on three central themes: the linkage of different disciplines; recognition of the role of context; and the theoretical basis for the design, implementation, and evaluation of interventions. Resumo: O desenvolvimento e estudo de intervenções para a melhoria do cuidado de saúde tem ganhado novo contorno, movendo-se das abordagens mais intuitivas, com domínio da visão biomédica e assentadas no pressuposto de fácil transferibilidade, para gradativamente reconhecer a necessidade de mais planejamento e sistematização, com maior incorporação das ciências sociais e valorização do papel do contexto. A Ciência da Melhoria do Cuidado de Saúde vem se estabelecendo, propiciando referencial conceitual e metodológico para tais estudos. Considerando a incipiência do debate e produção sobre Ciência da Melhoria do Cuidado de Saúde no Brasil, este artigo objetiva discorrer sobre as principais bases conceituais e teóricas que a sustentam, com foco em três temas centrais: a articulação de diferentes disciplinas; o reconhecimento do papel do contexto; e o embasamento teórico para o desenho, implementação e avaliação das intervenções.

Changing Labor and Delivery Practice: Focus on Achieving Practice and Documentation Standardization with the Goal of Improving Neonatal Outcomes

OBJECTIVE

To establish multifactorial shoulder dystocia response and management protocol to promote sustainable practice change.

DATA SOURCES/STUDY SETTING

Primary data collection was conducted over 3 years. Implementation of the protocol spanned 13 months. Data collection occurred at five sites, which were chosen for their diversity in both patient mix and geographical location.

STUDY DESIGN

Case study evaluation methodology was used to examine clinician engagement and protocol adoption.

DATA COLLECTION METHODS

The training completion for all practice engagement team activities was collected by the site project manager and entered into a flat file. Data from the labor and delivery notes, medical records, and interviews with labor and delivery teams were gathered and analyzed by the senior investigator.

PRINCIPAL FINDINGS

In the first year, there was a threefold increase in shoulder dystocia reporting, which continued in years 2 and 3. In the first year, 96 percent of clinicians completed all training elements and in subsequent years, 98 percent completed the follow-up training. Overall teams reached a 99 percent adoption rate of the shoulder dystocia protocol.

CONCLUSIONS

System and site management teams implemented a standardized shoulder dystocia protocol that fostered effective teamwork and obstetric team readiness for managing shoulder dystocia emergencies.

SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised Publication Guidelines from a Detailed Consensus Process

Since the publication of Standards for Quality Improvement Reporting Excellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this manuscript we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015, using 1) semistructured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group; 2) two face-to-face consensus meetings to develop interim drafts; and 3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasizes the reporting of three key components of systematic efforts to improve the quality, value, and safety of health care: the use of formal and informal theory in planning, implementing, and evaluating improvement work; the context in which the work is done; and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve health care, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (www.squire-statement.org).

Using the Theoretical Domains Framework (TDF) to understand adherence to multiple evidence-based indicators in primary care: a qualitative study

Background

There are recognised gaps between evidence and practice in general practice, a setting posing particular implementation challenges. We earlier screened clinical guideline recommendations to derive a set of ‘high-impact’ indicators based upon criteria including potential for significant patient benefit, scope for improved practice and amenability to measurement using routinely collected data. Here, we explore health professionals’ perceived determinants of adherence to these indicators, examining the degree to which determinants were indicator-specific or potentially generalisable across indicators.

Methods

We interviewed 60 general practitioners, practice nurses and practice managers in West Yorkshire, the UK, about adherence to four indicators: avoidance of risky prescribing; treatment targets in type 2 diabetes; blood pressure targets in treated hypertension; and anticoagulation in atrial fibrillation. Interview questions drew upon the Theoretical Domains Framework (TDF). Data were analysed using framework analysis.

Results

Professional role and identity and environmental context and resources featured prominently across all indicators whilst the importance of other domains, for example, beliefs about consequences, social influences and knowledge varied across indicators. We identified five meta-themes representing more general organisational and contextual factors common to all indicators.

Conclusions

The TDF helped elicit a wide range of reported determinants of adherence to ‘high-impact’ indicators in primary care. It was more difficult to pinpoint which determinants, if targeted by an implementation strategy, would maximise change. The meta-themes broadly underline the need to align the design of interventions targeting general practices with higher level supports and broader contextual considerations. However, our findings suggest that it is feasible to develop interventions to promote the uptake of different evidence-based indicators which share common features whilst also including content-specific adaptations.

SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process

Since the publication of Standards for Quality Improvement Reporting Excellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this manuscript, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using 1) semistructured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group; 2) 2 face-to-face consensus meetings to develop interim drafts and 3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasizes the reporting of 3 key components of systematic efforts to improve the quality, value and safety of healthcare: the use of formal and informal theory in planning, implementing and evaluating improvement work; the context in which the work is done and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve healthcare, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (www.squire-statement.org).

Testing the use of practice facilitation in a cluster randomized stepped-wedge design trial to improve adherence to cardiovascular disease prevention guidelines: HealthyHearts NYC

BACKGROUND

HealthyHearts NYC (HHNYC) will evaluate the effectiveness of practice facilitation as a quality improvement strategy for implementing the Million Hearts' ABCS treatment guidelines for reducing cardiovascular disease (CVD) among high-risk patients who receive care in primary care practices in New York City. ABCS refers to (A) aspirin in high-risk individuals; (B) blood pressure control; (C) cholesterol management; and (S) smoking cessation. The long-term goal is to create a robust infrastructure for implementing and disseminating evidence-based practice guidelines (EBPG) in primary care practices.

METHODS/DESIGN

We are using a stepped-wedge cluster randomized controlled trial design to evaluate the implementation process and the impact of practice facilitation (PF) versus usual care on ABCS outcomes in 250 small primary care practices. Randomization is at the practice site level, all of which begin as part of the control condition. The intervention consists of one year of PF that includes a combination of one-on-one onsite visits and shared learning across practice sites. PFs will focus on helping sites implement evidence-based components of patient-centered medical home (PCMH) and the chronic care model (CCM), which include decision support, provider feedback, self-management tools and resources, and linkages to community-based services.

DISCUSSION

We hypothesize that practice facilitation will result in superior clinical outcomes compared to usual care; that the effects of practice facilitation will be mediated by greater adoption of system changes in accord with PCMH and CCM; and that there will be increased adaptive reserve and change capacity.

TRIAL REGISTRATION

NCT02646488.

Patient safety: this is public health

Avoidable patient harm is a major public health concern, and may already have surpassed heart disease as the leading cause of death in the United States. While the public health community has contributed much to one aspect of patient harm prevention, infection control, the tools and techniques of public health have far more to offer to the emerging field of patient safety science. Patient safety practice has become increasingly professionalized in recent years, but specialist degree programs in the field remain scarce. Healthcare organizations should consider graduate training in public health as an avenue for investing in the professional development of patient safety practitioners, and schools and programs of public health should support further research and teaching to support patient safety improvement.

The Logic Behind a Multimethod Intervention to Improve Adherence to Clinical Practice Guidelines in a Nationwide Network of Primary Care Practices

The gap between evidence-based guidelines for clinical care and their application in medical settings is well established and widely discussed. Effective interventions are needed to help health care providers reduce this gap. Whereas the development of clinical practice guidelines from biomedical and clinical research is an example of Type 1 translation, Type 2 translation involves successful implementation of guidelines in clinical practice. This article describes a multimethod intervention that is part of a Type 2 translation project aimed at increasing adherence to clinical practice guidelines in a nationwide network of primary care practices that use a common electronic medical record (EMR). Practice performance reports, site visits, and network meetings are intervention methods designed to stimulate improvement in practices by addressing personal and organizational factors. Theories and evidence supporting these interventions are described and could prove useful to others trying to translate medical research into practice. Additional theory development is needed to support translation in medical offices.

An evaluation of three methods of in-hospital cardiac arrest educational debriefing: The cardiopulmonary resuscitation debriefing study

BACKGROUND

The use of cardiac arrest educational debriefing has been associated with improvements in cardiopulmonary resuscitation (CPR) quality and patient outcome. The practical challenges associated with delivering some debriefing approaches may not be generalisable to the UK health setting. The aim of this study was to evaluate the deliverability and effectiveness of three cardiac arrest debriefing approaches that were tailored to UK working practice.

METHODS

We undertook a before/after study at three hospital sites. During the post-intervention period of the study, three cardiac arrest educational debriefing models were implemented at study hospitals (one model per hospital). To evaluate the effectiveness of the interventions, CPR quality and patient outcome data were collected from consecutive adult cardiac arrest events attended by the hospital cardiac arrest team. The primary outcome was chest compression depth.

RESULTS

Between November 2011 and July 2014, 1198 cardiac arrest events were eligible for study inclusion (782 pre-intervention; 416 post-intervention). The quality of CPR was high at baseline. During the post-intervention period, cardiac arrest debriefing interventions were delivered to 191 clinicians on 344 occasions. Debriefing interventions were deliverable in practice, but were not associated with a clinically important improvement in CPR quality. The interventions had no effect on patient outcome.

CONCLUSION

The delivery of these cardiac arrest educational debriefing strategies was feasible, but did not have a large effect on CPR quality. This may be attributable to the high-quality of CPR being delivered in study hospitals at baseline.

TRIAL REGISTRATION

ISRCTN39758339.

Strategies for Improving Vaccine Delivery: A Cluster-Randomized Trial

OBJECTIVE

New emphasis on and requirements for demonstrating health care quality have increased the need for evidence-based methods to disseminate practice guidelines. With regard to impact on pediatric immunization coverage, we aimed to compare a financial incentive program (pay-for-performance [P4P]) and a virtual quality improvement technical support (QITS) learning collaborative.

METHODS

This single-blinded (to outcomes assessor), cluster-randomized trial was conducted among unaffiliated pediatric practices across the United States from June 2013 to June 2014. Practices received either the P4P or QITS intervention. All practices received a Vaccinator Toolkit. P4P practices participated in a tiered financial incentives program for immunization coverage improvement. QITS practices participated in a virtual learning collaborative. Primary outcome was percentage of all needed vaccines received (PANVR). We also assessed immunization up-to-date (UTD) status.

RESULTS

Data were analyzed from 3,147 patient records from 32 practices. Practices in the study arms reported similar QI activities (∼6 to 7 activities). We found no difference in PANVR between P4P and QITS (mean ± SE, 90.7% ± 1.1% vs 86.1% ± 1.3%, P = 0.46). Likewise, there was no difference in odds of being UTD between study arms (adjusted odds ratio 1.02, 95% confidence interval 0.68 to 1.52, P = .93). In within-group analysis, patients in both arms experienced nonsignificant increases in PANVR. Similarly, the change in adjusted odds of UTD over time was modest and nonsignificant for P4P but reached significance in the QITS arm (adjusted odds ratio 1.28, 95% confidence interval 1.02 to 1.60, P = .03).

CONCLUSIONS

Participation in either a financial incentives program or a virtual learning collaborative led to self-reported improvements in immunization practices but minimal change in objectively measured immunization coverage.

Improving the Context Supporting Quality Improvement in a Neonatal Intensive Care Unit Quality Collaborative: An Exploratory Field Study

Successful quality improvement (QI) requires a supportive context. The goal was to determine whether a structured curriculum could help QI teams improve the context supporting their QI work. An exploratory field study was conducted of 43 teams participating in a neonatal intensive care unit QI collaborative. Using a curriculum based on the Model for Understanding Success in Quality, teams identified gaps in their context and tested interventions to modify context. Surveys and self-reflective journals were analyzed to understand how teams developed changes to modify context. More than half (55%) targeted contextual improvements within the microsystem, focusing on motivation and culture. “Information sharing” interventions to communicate information about the project as a strategy to engage more staff were the most common interventions tested. Further study is needed to determine if efforts to modify context consistently lead to greater outcome improvements.

Combining training in knowledge translation with quality improvement reduced 30-day heart failure readmissions in a community hospital: a case study

RATIONALE, AIMS AND OBJECTIVES

Training programmes in evidence-based practice (EBP) frequently fail to translate their content into practice change and care improvement. We linked multidisciplinary training in EBP to an initiative to decrease 30-day readmissions among patients admitted to a community teaching hospital for heart failure (HF).

METHODS

Hospital staff reflecting all services and disciplines relevant to care of patients with HF attended a 3-day innovative capacity building conference in evidence-based health care over a 3-year period beginning in 2009. The team, facilitated by a conference faculty member, applied a knowledge-to-action model taught at the conference. We reviewed published research, profiled our population and practice experience, developed a three-phase protocol and implemented it in late 2010. We tracked readmission rates, adverse clinical outcomes and programme cost.

RESULTS

The protocol emphasized patient education, medication reconciliation and transition to community-based care. Senior administration approved a full-time nurse HF coordinator. Thirty-day HF readmissions decreased from 23.1% to 16.4% (adjusted OR = 0.64, 95% CI = 0.42-0.97) during the year following implementation. Corresponding rates in another hospital serving the same population but not part of the programme were 22.3% and 20.2% (adjusted OR = 0.87, 95% CI = 0.71-1.08). Adherence to mandated HF quality measures improved. Following a start-up cost of $15 000 US, programme expenses balanced potential savings from decreased HF readmissions.

CONCLUSION

Training of a multidisciplinary hospital team in use of a knowledge translation model, combined with ongoing facilitation, led to implementation of a budget neutral programme that decreased HF readmissions.

Factors influencing change in clinical practice

Purpose

– The quality improvement in colonoscopy study was a region wide service improvement study to improve adenoma detection rate at colonoscopy by implementing evidence into routine colonoscopy practice. Implementing evidence into clinical practice can be challenging. The purpose of this paper is to perform a qualitative interview study to evaluate factors that influenced implementation within the study.

Design/methodology/approach

– Semi-structured interviews were conducted with staff in endoscopy units taking part in the quality improvement in colonoscopy study, after study completion. Units and interviewees were purposefully sampled to ensure a range of experiences was represented. Interviews were conducted with 11 participants.

Findings

– Key themes influencing uptake of the quality improvement in colonoscopy evidence bundle included time, study promotion, training, engagement, positive outcomes and modifications. Areas within themes were increased awareness of quality in colonoscopy (QIC), emphasis on withdrawal time and empowerment of endoscopy nurses to encourage the use of quality measures were positive outcomes of the study. The simple, visible study posters were reported as useful in aiding study promotion. Feedback sessions improved engagement. Challenges included difficulty arranging set-up meetings and engaging certain speciality groups.

Originality/value

– This evaluation suggests that methods to implement evidence into clinical practice should include identification and empowerment of team members who can positively influence engagement, simple, visible reminders and feedback. Emphasis on timing of meetings and strategies to engage speciality groups should also be given consideration. Qualitative evaluations can provide important insights into why quality improvement initiatives are successful or not, across different sites.

Bridging the gap between pragmatic intervention design and theory: using behavioural science tools to modify an existing quality improvement programme to implement "Sepsis Six"

BACKGROUND

Sepsis has a mortality rate of 40 %, which can be halved if the evidence-based "Sepsis Six" care bundle is implemented within 1 h. UK audit shows low implementation rates. Interventions to improve this have had minimal effects. Quality improvement programmes could be further developed by using theoretical frameworks (Theoretical Domains Framework (TDF)) to modify existing interventions by identifying influences on clinical behaviour and selecting appropriate content. The aim of this study was to illustrate using this process to modify an intervention designed using plan-do-study-act (P-D-S-A) cycles that had achieved partial success in improving Sepsis Six implementation in one hospital.

METHODS

Factors influencing implementation were investigated using the TDF to analyse interviews with 34 health professionals. The nursing team who developed and facilitated the intervention used the data to select modifications using the Behaviour Change Technique (BCT) Taxonomy (v1) and the APEASE criteria: affordability, practicability, effectiveness, acceptability, safety and equity.

RESULTS

Five themes were identified as influencing implementation and guided intervention modification. These were:(1) "knowing what to do and why" (TDF domains knowledge, social/professional role and identity); (2) "risks and benefits" (beliefs about consequences), e.g. fear of harming patients through fluid overload acting as a barrier to implementation versus belief in the bundle's effectiveness acting as a lever to implementation; (3) "working together" (social influences, social/professional role and identity), e.g. team collaboration acting as a lever versus doctor/nurse conflict acting as a barrier; (4) "empowerment and support" (beliefs about capabilities, social/professional role and identity, behavioural regulation, social influences), e.g. involving staff in intervention development acting as a lever versus lack of confidence to challenge colleagues' decisions not to implement acting as a barrier; (5) "staffing levels" (environmental context and resources), e.g. shortages of doctors at night preventing implementation. The modified intervention included six new BCTs and consisted of two additional components (Sepsis Six training for the Hospital at Night Co-ordinator; a partnership agreement endorsing engagement of all clinical staff and permitting collegial challenge) and modifications to two existing components (staff education sessions; documents and materials).

CONCLUSIONS

This work demonstrates the feasibility of the TDF and BCT Taxonomy (v1) for developing an existing quality improvement intervention. The tools are compatible with the pragmatic P-D-S-A cycle approach generally used in quality improvement work.