Quality improvement studies: the need is there but so are the challenges

Improving newborn preventive services at the birth hospitalization: a collaborative, hospital-based quality-improvement project

OBJECTIVE

The goal was to test the effectiveness of a statewide, collaborative, hospital-based quality-improvement project targeting preventive services delivered to healthy newborns during the birth hospitalization.

METHODS

All Vermont hospitals with obstetric services participated. The quality-improvement collaborative (intervention) was based on the Breakthrough Series Collaborative model. Targeted preventive services included hepatitis B immunization; assessment of breastfeeding; assessment of risk of hyperbilirubinemia; performance of metabolic and hearing screens; assessment of and counseling on tobacco smoke exposure, infant sleep position, car safety seat fit, and exposure to domestic violence; and planning for outpatient follow-up care. The effect of the intervention was assessed at the end of an 18-month period. Preintervention and postintervention chart audits were conducted by using a random sample of 30 newborn medical charts per audit for each participating hospital.

RESULTS

Documented rates of assessment improved for breastfeeding adequacy (49% vs 81%), risk for hyperbilirubinemia (14% vs 23%), infant sleep position (13% vs 56%), and car safety seat fit (42% vs 71%). Documented rates of counseling improved for tobacco smoke exposure (23% vs 53%) and car safety seat fit (38% vs 75%). Performance of hearing screens also improved (74% vs 97%). No significant changes were noted in performance of hepatitis B immunization (45% vs 30%) or metabolic screens (98% vs 98%), assessment of tobacco smoke exposure (53% vs 67%), counseling on sleep position (46% vs 68%), assessment of exposure to domestic violence (27% vs 36%), or planning for outpatient follow-up care (80% vs 71%). All hospitals demonstrated preintervention versus postintervention improvement of > or = 20% in > or = 1 newborn preventive service.

CONCLUSIONS

A statewide, hospital-based quality-improvement project targeting hospital staff members and community physicians was effective in improving documented newborn preventive services during the birth hospitalization.

The U.S. health care system is in crisis: implications for academic medical centers and their missions

The medical care system in the United States is in crisis. Health care costs are escalating and threatening coverage for millions of people. Concerns about the quality of care and patient safety are heightening; patients and payers now publicly share these concerns and want to make providers more accountable. Traditionally, the response to rising health care costs has been to modify reimbursement models and incentives. Currently there is a movement to shift the responsibility of cost containment to the patients. The authors express doubts about the overall effectiveness of this strategy and propose reengineering the health care system to improve quality and efficiency. Leaders of academic medical centers must understand the forces and dynamics of change, and the potential institutional response to improve the quality and efficiency of their delivery systems and to preserve their missions: clinical care, education, research, and community service. As they suggest the operational changes needed to respond to this evolving health care environment, the authors discuss the implications for the various missions. The graduates of training programs must be prepared to function within multidisciplinary teams and constantly seek ways to improve quality and efficiency to ensure that care is accessible, affordable, and safe. Academic medical centers need to expand their research agenda to develop more expertise in quality and process improvement research. Additionally, they must provide the leadership to foster the transition from an era of "managed care" to an era of "organized systems of care."

Evaluation of a learning collaborative to improve the delivery of preventive services by pediatric practices

OBJECTIVE

Effective delivery of preventive services is an essential component of high-quality pediatric health care. However, both variation in and deviation from accepted guidelines have been reported. Learning collaboratives (LCs) have been shown to result in improvement in several aspects of pediatric care. The objective of this study was to determine whether pediatric practices that participated in a preventive services LC would improve their delivery of preventive services.

METHODS

After conducting an initial audit of the medical records of twenty 2-year-olds and twenty 4-year-olds for documentation of preventive services on the basis of national standards, practice teams attended a quality improvement workshop. They were presented with evidence to support the value of preventive services and the results of their audits and taught quality improvement methods, eg, rapid cycles of change. Each team developed plans to improve 1 or more services. Brief audits with feedback and monthly conference calls were used to support practices to conduct rapid cycles of change, to discuss barriers and solutions, and to monitor progress. The results of final chart audits of twenty 2-year-olds and 4-year-olds were compared with the initial chart audits. A Preventive Service Score (PSS) was assigned to each practice on the basis of the number of services provided, and initial to final comparisons were made.

RESULTS

Fourteen practices participated. PSSs improved for all practices after the LC. Mean PSS for 2-year-olds increased from 4.0 +/- 1.1 to 4.9 +/- 1.2 and for 4-year-olds increased from 3.8 +/- 1.8 to 5.6 +/- 1.9. The proportions of children who received 9 of the 10 individual preventive services also improved significantly.

CONCLUSION

LCs are a potentially effective method of improving the quality of care that is delivered by pediatric practices.

What can a pilot congestive heart failure disease management program tell us about likely return on investment?: A case study from a program offered to federal employees

In 1999, the Blue Cross and Blue Shield Federal Employee Program (FEP) implemented a pilot disease management program to manage congestive heart failure (CHF) among members. The purpose of this project was to estimate the financial return on investment in the pilot CHF program, prior to a full program rollout. A cohort of 457 participants from the state of Maryland was matched to a cohort of 803 nonparticipants from a neighboring state where the CHF program was not offered. Each cohort was followed for 12 months before the program began and 12 months afterward. The outcome measures of primary interest were the differences over time in medical care expenditures paid by FEP and by all payers. Independent variables included indicators of program participation, type of heart disease, comorbidity measures, and demographics. From the perspective of the funding organization (FEP), the estimated return on investment for the pilot CHF disease management program was a savings of $1.08 in medical expenditure for every dollar spent on the program. Adding savings to other payers as well, the return on investment was a savings of $1.15 in medical expenditures per dollar spent on the program. The amount of savings depended upon CHF risk levels. The value of a pilot initiative and evaluation is that lessons for larger-scale efforts can be learned prior to full-scale rollout.

The role of formative evaluation in implementation research and the QUERI experience

This article describes the importance and role of 4 stages of formative evaluation in our growing understanding of how to implement research findings into practice in order to improve the quality of clinical care. It reviews limitations of traditional approaches to implementation research and presents a rationale for new thinking and use of new methods. Developmental, implementation-focused, progress-focused, and interpretive evaluations are then defined and illustrated with examples from Veterans Health Administration Quality Enhancement Research Initiative projects. This article also provides methodologic details and highlights challenges encountered in actualizing formative evaluation within implementation research.

Implementation and refinement of a research utilization course for oncology nurses

PURPOSE/OBJECTIVES

To describe the implementation and refinement of a yearly research utilization (RU) course for oncology nurses.

DESIGN

Formative program evaluation.

SAMPLE

22 oncology nurses selected based on competitively reviewed project proposals.

METHODS

The one-day RU course was held five times prior to the annual fall Oncology Nursing Society conference. The course consisted of brief didactic sessions on RU, project presentations by participants, faculty reviews, and discussions of practical issues related to project implementation.

MAIN RESEARCH VARIABLES

Course content, usefulness of course components.

FINDINGS

Based on immediate postcourse, 6-month, and 12-month feedback, refinements were made to the course. A major change (in year three) was the addition of a "preparation packet," which contained resources about RU and directed students to accomplish specific precourse goals, and access to a faculty mentor. Evaluation scores were good to outstanding for the content and usefulness of the course presentations, critiques by faculty, and discussion sessions. Interviews with participants indicated that a majority completed or were working on their projects within four years of completing the course.

CONCLUSIONS

RU and some of its components (pursuing a literature search, making a practice change) are not processes that most nurses are familiar with, but these processes can be taught to nurses with focused clinical concerns.

IMPLICATIONS FOR NURSING

An RU course with a low faculty-to-student ratio, adequate course materials, and systematic instruction can lead to research-based changes in practice.

Perceptions of health care providers' communication: relationships between patient-centered communication and satisfaction

Specific communication practices of multiple professionals in health care settings can impact patient outcomes. This study, conducted at a large Children's Hospital, sought to determine the extent to which patient-centered communication (PCC) affected satisfaction with communication and with care itself. Parents of child patients (N = 195) reported on the communication practices of physicians, nurses, and hospital staff members during their most recent stay in the hospital. Surveys were completed on site. Health care providers' use of PCC behaviors, especially immediacy and perceived listening, was positively associated with satisfaction with care and with communication. In addition, PCC behaviors were perceived to be used more frequently with children in better health than with children with poorer health status.

Changing the model of care for patients with acute coronary syndromes

Acute coronary syndromes (ACS) represent a major cause of morbidity and mortality for patients with cardiovascular disease, but evidence-based therapies shown to improve outcomes for ACS are often underused in clinically eligible patients. Although clinical practice guidelines have been developed to provide standards for the diagnosis and treatment of patients with ACS and to provide physicians with a framework for clinical decision-making, multiple obstacles have hindered their implementation and questions remain about the applicability of guidelines for diverse clinical situations. Systematic reviews of quality-improvement studies have shown that multifaceted approaches using targeted educational interventions, creation of quality standards, and regular performance feedback are needed to ensure sustained improvements in care. Approaches to quality improvement thus are being redirected to focus on multidisciplinary collaborations designed to improve the entire process of care for patients with ACS. Multiple large observational registries and quality-improvement initiatives now are capturing data regarding adherence to practice guidelines and contemporary patterns of care for ACS. This comprehensive evaluation of ACS treatment will help guide efforts designed to promote evidence-based care and ultimately determine the effect of widespread implementation of practice guidelines on clinical outcomes. The shifting model of care for ACS therefore suggests that quality improvement and monitoring of adherence to practice guidelines should be considered components of optimal clinical practice.

Quality of care of patients hospitalized with congestive heart failure

BACKGROUND

Congestive heart failure (CHF) is an increasingly prevalent poor-prognosis condition for which effective interventions are available. It is -therefore important to determine the extent to which patients with CHF receive appropriate care in Australian hospitals and identify ways for improving suboptimal care, if it exists.

AIM

To evaluate the quality of in-hospital acute care of patients with CHF using explicit quality indicators based on published guidelines.

METHODS

A retrospective case note review was -performed, involving 216 patients admitted to three teaching hospitals in Brisbane, Queensland, Australia, between October 2000 and April 2001. Outcome measures were process-of-care quality -indicators calculated as proportions of all, or strongly -eligible (ideal), patients who received -specific interventions.

RESULTS

Assessment of underlying causes and acute precipitating factors was undertaken in 86% and 76% of patients, respectively, and objective evaluation of left ventricular function was performed in 62% of patients. Prophylaxis for deep venous thrombosis (DVT) was used in only 29% of ideal patients. Proportions of ideal patients receiving pharmacological treatments at discharge were: (i) angiotensin--converting enzyme inhibitors (ACEi) (82%), (ii) target doses of ACEi (61%), (iii) alternative vasodilators in patients ineligible for ACEi (20%), (iv) beta-blockers (40%) and (v) warfarin (46%).

CONCLUSIONS

Opportunities exist for improving quality of in-hospital care of patients with CHF, -particularly for optimal prescribing of: (i) DVT prophylaxis, (ii) ACEi, (iii) second-line vasodilators, (iv) beta-blockers and (v) warfarin. More research is needed to identify methods for improving quality of in-hospital care.