Tools and methods for quality improvement and patient safety in perinatal care

Climate change and health care facilities: A risk analysis framework through a mapping review

INTRODUCTION

Climate change (CC) has been identified as the biggest global health threat of the 21st century. Although health care facilities (HCF) play a central role in the care of populations, there has been no comprehensive assessment of the impact of CC on HCF. The objective of our study was to highlight the components of HCFs affected by CC through a mapping review of the literature.

METHODS

To meet our objective, we first assessed the place of HCFs in relation to CC in the scientific literature and in the Intergovernmental Panel on Climate Change (IPCC) reports. Bibliometric data from the PubMed database were analyzed between 1979 and 2021 to assess the penetration of keywords on CC alone, and in relation to health and HCF in particular. Second, we analyzed the changes in HCF keywords in the IPCC reports. Finally, we conducted a mapping review in five databases, of the international scientific literature published between 1979 and 2019, and identified the components of HCF affected by CC using the Ishikawa diagram.

RESULTS

From the 2000s, the number of publications on CC and HCF increased gradually with 137 articles in 2005, and even more sharply since 2008 with 358 articles published and 813 in 2021. Even though CC is only recently present in the biomedical literature, all climatic events (warming and heatwaves, droughts, wildfires, storms, hurricanes and cyclones, floods and sea-level rise, and other indirect effects) have had an impact on at least one component of HCF.

CONCLUSION

HCFs are already impacted, in all their components, by CC. By enhancing our understanding of the impacts of CC on HCF, this work could contribute to the engagement of health professionals in the implementation of mitigation and adaptation actions, thereby limiting the consequences of CC on patient care.

Integrating women’s voices in quality improvement for maternity care: A qualitative study

INTRODUCTION

Improving the quality of maternity care is high on the national agenda in the Netherlands. One aspect gaining significant attention is integrating women’s experiences – as users of maternity care – in this quality improvement. The aim of this study was to gain deeper insights into how maternity care professionals in Dutch Maternity Care Collaborations integrate women’s voices into quality improvement as part of integrated maternity care and what role midwives can have in this.

METHODS

This was a descriptive qualitative study, using semi-structured individual interviews and content analysis for an in-depth exploration of maternity care professionals’ experiences and opinions on integrating women’s voices in quality improvement. Participants were twelve maternity care professionals involved in quality improvement activities from eight Dutch Maternity Care Collaborations.

RESULTS

Four themes emerged: ‘Quality improvement based on women's voices is still in its infancy’ and was experienced as an important but challenging topic; ‘Collecting women's voices’ was conducted, but needed more facilitation; Using women's voices’ was hindered by a lack of expertise and a structured feedback and feedforward system; and ‘Ensuring listening to women's voices’ and integrating them in quality improvement required further facilitation.

CONCLUSIONS

Care professionals emphasized that listening to women’s voices for quality improvement is important but challenging due to the lack of expertise, organizational structure, time, and financial resources. A feasible implementation strategy including concrete support is recommended by maternity care professionals to boost action.

Visual process maps to support implementation efforts: a case example

BACKGROUND

Process mapping is often used in quality improvement work to examine current processes and workflow and to identify areas to intervene to improve quality. Our objective in this paper is to describe process maps as a visual means of understanding modifiable behaviors and activities, in this case example to ensure that goals of care conversations are part of admitting a veteran in long-term care settings.

METHODS

We completed site visits to 6 VA nursing homes and reviewed their current admission processes. We conducted interviews to document behaviors and activities that occur when a veteran is referred to a long-term care setting, during admission, and during mandatory VA reassessments. We created visualizations of the data using process mapping approaches. Process maps for each site were created to document the admission activities for each VA nursing home and were reviewed by the research team to identify consistencies across sites and to identify potential opportunities for implementing goals of care conversations.

RESULTS

We identified five consistent behaviors that take place when a veteran is referred and admitted in long-term care. These behaviors are assessing, discussing, decision-making, documenting, and re-assessing.

CONCLUSIONS

Based on the process maps, it seems feasible that the LST note and order template could be completed along with other routine assessment processes. However, this will require more robust multi-disciplinary collaboration among both prescribing and non-prescribing health care providers. Completing the LST template during the current admission process would increase the likelihood that the template is completed in a timely manner, potentially alleviate the perceived time burden, and help with the provision of veteran-centered care.

Roles of Registered Nurses in Pediatric Preventive Care Delivery: A Pilot Study on Between-office Variation and Within-office Role Overlap

PURPOSE

Registered nurses (RN) participate in delivery of routine pediatric preventive care. This pilot study characterized variation in RN roles and overlap with other team roles.

METHODS

We conducted a pilot cross-sectional survey of RNs from an urban/suburban pediatric primary care network. RNs described tasks during preventive visits and other staff completing similar tasks. Health system data characterized office staffing, volume, and patient population. We assessed whether role overlap and time on key tasks was associated with office characteristics or staffing ratios.

RESULTS

Twenty-three offices reported a mean ratio of RNs to physicians and nurse practitioners of 0.99 (range 0.62-1.33). Of tasks RNs completed during preventive care, health education overlapped most with physician/nurse practitioner roles (17 sites with overlap) and rooming patients overlapped most with medical assistant roles (20 sites with overlap). Across sites, RNs spent 9% of time on health education and 26% on rooming. Offices with more role overlap between RNs and physicians/nurse practitioners had higher RN to physician/nurse practitioner ratios (1.13 versus 0.86, t-test p-value 0.002). There was no association between role overlap and other office characteristics, or between RN time on key tasks and staffing ratios.

CONCLUSIONS

RN staffing ratios varied twofold across offices. RNs spent more time on tasks that overlapped with medical assistant roles than tasks that overlapped with physician/nurse practitioner roles.

PRACTICE IMPLICATIONS

Opportunities exist to optimize RN pediatric primary care roles, for example by delegating certain tasks. Optimization may reduce costs, while improving quality, patient experience, and staff satisfaction.

The relationship between patient safety and quality improvement in neonatology

Patient safety and healthcare quality have become foundational components of neonatal care, and hospitals and neonatal intensive care units have developed robust programs and structures committed to improving outcomes through rigorous quality improvement methods. Despite increasingly more sophisticated frameworks for defining and understanding quality, the relationship between patient safety and health care quality is not clearly defined. Safety is often defined as the avoidance of injury and harm, while quality is typically defined as achieving the best possible health care outcomes. Safety can be considered one of multiple domains of quality, and safety can also be considered synonymous with quality. Regardless, both safety and quality are driven by systems of care, and improvement methods should focus on understanding and improving these systems. While many improvement methods will apply to safety goals or quality goals, there are unique aspects of patient safety that require specific tools and approaches. Achieving the safest and highest quality healthcare for our patients and families requires an understanding of the tools needed to improve both safety and quality.

Building the Driver Diagram: A Mixed-Methods Approach to Identify Causes of Unplanned Extubations in a Large Neonatal ICU

BACKGROUND

The key driver diagram (KDD) is an important tool used by improvement teams to guide and frame their work. Methods to build a KDD when little relevant literature or reliable local data exist are poorly described. This article describes the process used in our neonatal ICU (NICU) to build a KDD to decrease unplanned extubations (UE) in chronically ventilated infants.

METHODS

Twenty-seven factors hypothesized to be associated with UE in our NICU were identified. An expert panel of 33 staff members completed three rounds of a modified Delphi process administered through an online interface. After the third round, panel members provided suggestions for interventions to target all factors meeting criteria for consensus. These qualitative data were analyzed by inductive thematic analysis. A follow-up survey to all panel members was used to assess the feasibility of this process for future use.

RESULTS

After three Delphi rounds, 14 factors met consensus and eight main interventions were identified through thematic analysis. These data were used to build a KDD for testing. All participants who completed the follow-up survey (20/20) stated willingness to participate in this process in the future and 18/20 (90%) stated they would be "more willing" or "much more willing" to support interventions developed using this process.

CONCLUSION

A novel mixed-methods approach was used to generate a KDD combining a Delphi process with thematic analysis. This approach provides improvement teams a rigorous and reproducible method to understand local context, generate consensus KDDs, and improve local buy-in for improvement interventions.

Modeling Causal Relationships in Quality Improvement

Taking the time to plan a quality improvement project before starting the project improves the likelihood of success. Understanding the tools that can be utilized for identification of a problem, the causes behind it, and the development of the theoretical framework of the planned improvement are crucial. Fishbone diagrams or cause and effect diagrams are often utilized to identify the root causes leading to an identified problem. Keydriver diagrams can provide the structure for a quality improvement project, establishing the aim and identifying the drivers and interventions that lead to change. This paper reviews these two quality improvement tools. When beginning a quality improvement project, several tools can be used to begin identifying where to target efforts. Utilizing process maps and failure modes and effects analysis (FMEA) can help define a process, identify failures, and develop interventions to be considered. Process maps identify potential gaps or excess steps and reveal sequential relationships. FMEAs aid in the development of causal relationships between a failure mode and its effects, priming the quality improver to create interventions. An additional way to model causal relationships is with fishbone diagrams and key driver diagrams. The fishbone diagram enables teams to consider why a problem has occurred and search for the root causes. The key driver diagram provides the ultimate aim of the project, identifies the drivers which will affect accomplishing the aim, and the interventions that affect the identified drivers. This paper will carefully examine both fishbone diagrams and key driver diagrams.