Control, compare and communicate: designing control charts to summarise efficiently data from multiple quality indicators

Quality criteria/key components for high quality of diabetes management to avoid diabetes-related complications

Aim

The aim of this review shoud be to map data and to identify quality indicators for good practices for diabetes management and secondary prevention, specifically of type 2 diabetes.

Methods

To achieve this aim we performed the following steps: (i) a literature review on evaluation criteria, (ii) selection of quality criteria and key components for high quality of care, (iii) creation of a checklist to identify the best practice of diabetes management based on the detected criteria.

Results

The literature search about the quality indicators for diabetes care resulted in the following: identifying of key components and quality indicators for structure, process and outcome quality.

Conclusions

The set of quality criteria will be discussed and used to identify the best practice diabetes management programs for secondary prevention of type 2 diabetes.

The impact of disease severity adjustment on hospital standardised mortality ratios: Results from a service-wide analysis of ischaemic stroke admissions using linked pre-hospital, admissions and mortality data

Background

Administrative data are used to examine variation in thirty-day mortality across health services in several jurisdictions. Hospital performance measurement may be error-prone as information about disease severity is not typically available in routinely collected data to incorporate into case-mix adjusted analyses. Using ischaemic stroke as a case study, we tested the extent to which accounting for disease severity impacts on hospital performance assessment.

Methods

We linked all recorded ischaemic stroke admissions between July, 2011 and June, 2014 to death registrations and a measure of stroke severity obtained at first point of patient contact with health services, across New South Wales, Australia’s largest health service jurisdiction. Thirty-day hospital standardised mortality ratios were adjusted for either comorbidities, as is typically done, or for both comorbidities and stroke severity. The impact of stroke severity adjustment on mortality ratios was determined using 95% and 99% control limits applied to funnel plots and by calculating the change in rank order of hospital risk adjusted mortality rates.

Results

The performance of the stroke severity adjusted model was superior to incorporating comorbidity burden alone (c-statistic = 0.82 versus 0.75; N = 17,700 patients, 176 hospitals). Concordance in outlier classification was 89% and 97% when applying 95% or 99% control limits to funnel plots, respectively. The sensitivity rates of outlier detection using comorbidity adjustment compared with gold-standard severity and comorbidity adjustment was 74% and 83% with 95% and 99% control limits, respectively. Corresponding positive predictive values were 74% and 91%. Hospital rank order of risk adjusted mortality rates shifted between 0 to 22 places with severity adjustment (Median = 4.0, Inter-quartile Range = 2–7).

Conclusions

Rankings of mortality rates varied widely depending on whether stroke severity was taken into account. Funnel plots yielded largely concordant results irrespective of severity adjustment and may be sufficiently accurate as a screening tool for assessing hospital performance.

Transforming Resident Assessment: An Analysis Using Deming's System of Profound Knowledge

W. Edwards Deming, in his System of Profound Knowledge, asserts that leaders who wish to transform a system should understand four essential elements: appreciation for a system, theory of knowledge, knowledge about variation, and psychology. The Accreditation Council for Graduate Medical Education (ACGME) introduced the milestones program as a part of the Next Accreditation System to create developmental language for the six core competencies and facilitate programmatic assessment within graduate medical education systems. Viewed through Deming's lens, the ACGME can be seen as the steward of a large system, with everyone who provides assessment data as workers in that system. The authors use Deming's framework to illustrate the working components of the assessment system of the University of Cincinnati College of Medicine's internal medicine residency program and draw parallels to the macrocosm of graduate medical education. Successes and failures in transforming resident assessment can be understood and predicted by identifying the system and its aims, turning information into knowledge, developing an understanding of variation, and appreciating the psychology of motivation of participants. The authors offer insights from their experience for educational leaders who wish to apply Deming's elements to their own assessment systems, with questions to explore, pitfalls to avoid, and practical approaches in doing this type of work.

A quality improvement project using statistical process control methods for type 2 diabetes control in a resource-limited setting

Quality issue

Quality improvement (QI) is a key strategy for improving diabetes care in low- and middle-income countries (LMICs). This study reports on a diabetes QI project in rural Guatemala whose primary aim was to improve glycemic control of a panel of adult diabetes patients.

Initial assessment

Formative research suggested multiple areas for programmatic improvement in ambulatory diabetes care.

Choice of solution

This project utilized the Model for Improvement and Agile Global Health, our organization's complementary healthcare implementation framework.

Implementation

A bundle of improvement activities were implemented at the home, clinic and institutional level.

Evaluation

Control charts of mean hemoglobin A1C (HbA1C) and proportion of patients meeting target HbA1C showed improvement as special cause variation was identified 3 months after the intervention began. Control charts for secondary process measures offered insights into the value of different components of the intervention. Intensity of home-based diabetes education emerged as an important driver of panel glycemic control.

Lessons learned

Diabetes QI work is feasible in resource-limited settings in LMICs and can improve glycemic control. Statistical process control charts are a promising methodology for use with panels or registries of diabetes patients.

Implementation of a Formal Debriefing Program After Pediatric Rapid Response Team Activations

BACKGROUND

Debriefing after pediatric rapid response team activations (RRT-As) in a tertiary care children's hospital was identified to occur only sporadically. The lack of routine debriefing after RRT-As was identified as a missed learning opportunity.

OBJECTIVE

We implemented a formal debriefing program and assessed staff attitudes toward and experiences with debriefing after pediatric RRT-As.

METHODS

Real-time feedback for pediatrics residents captured clinical and debriefing data for each RRT-A from July 2014 to June 2016. The debriefing on physiology, team communication, and anticipation of clinical deterioration was introduced in July 2015. To assess debriefing perceptions, residents, intensive care fellows, nurses, and respiratory therapists participated in anonymous preintervention and postintervention surveys. We also developed a workshop to teach residents how to lead debriefing.

RESULTS

Debriefing after RRT-As increased from 26% preintervention to 46% postintervention (P < .0001). A total of 43 of 76 pediatrics residents (57%) attended at least 1 of 4 debriefing workshops. Both preintervention and postintervention, more than 80% (70 of 78 preintervention and 54 of 65 postintervention) of health professionals surveyed strongly agreed or agreed that there was a benefit to debriefing after RRT-As. Postintervention, 65% (26 of 40) of respondents strongly agreed or agreed that debriefing improved their understanding of the RRT-A process. The rate of debriefing was sustained at 46% (6 months after the end of the study period).

CONCLUSIONS

Debriefing frequency after pediatric RRT-As significantly increased with the introduction of a formal debriefing program. A majority of health professionals and trainees reported this practice was a valuable experience.

Making quality registers supporting improvements: a systematic review of the data visualization in 5 quality registries

Traditionally, quality registries have been initiated, developed, and used by physicians essentially for research purposes. There is an unrealized opportunity to expand and strengthen the contribution of quality registries in health care quality improvement. This article aims to characterize quality registry annual reports regarding factors deemed important to process improvement. The 2012 annual reports of the 5 most highly developed Swedish quality registries were examined. Each of the 636 charts included was coded according to an abstraction form. Results show that league tables are highly prevalent, whereas funnel plots and control charts are rare. Health care quality is monitored over time on the basis of few and highly aggregated measurements, and it is usually measured using percentages. In conclusion, quality registry annual reports lack both the level of detail and the consideration of random variation necessary to being able to be systematically used in process improvement. Users of annual reports are recommended caution when discussing differences in quality, both over time and across health care providers, as they can be due to chance and insufficient guidance is provided on the reports in this regard. To better support process improvement, annual reports should thus be more detailed and give more consideration to random variation.

High-risk prescribing and monitoring in primary care: how common is it, and how can it be improved?

The safety of medication use in primary care is an area of increasing concern for health systems internationally. Systematic reviews estimate that 3-4% of all unplanned hospital admissions are due to preventable drug-related morbidity, the majority of which have been attributed to shortcomings in the prescribing and monitoring stages of the medication use process. We define high-risk prescribing as medication prescription by professionals, for which there is evidence of significant risk of harm to patients, and which should therefore either be avoided or (if avoidance is not possible) closely monitored and regularly reviewed for continued appropriateness. Although prevalence estimates vary depending on the instrument used, cross-sectional studies conducted in primary care equivocally show that it is common and there is evidence that it can be reduced. Quality improvement strategies, such as clinical decision support, performance feedback and pharmacist-led interventions have been shown to be effective in reducing prescribing outcomes but evidence of improved patient outcomes remains limited. The increasing implementation of electronic medical records in primary care offer new opportunities to combine different strategies to improve medication safety in primary care and to integrate services provided by different stakeholders. In this review article, we describe the spectrum of high-risk medication use in primary care, review approaches to its measurement and summarize research into its prevalence. Based on previously developed interventions to change professional practice, we propose a systematic approach to improve the safety of medication use in primary care and highlight areas for future research.

Establishing a standardized quality management system for the European Health Network GA2LEN

BACKGROUND

Quality management is increasingly important in clinical practice. The Global Allergy and Asthma European Network (GA(2)LEN) is a network of clinical and scientific excellence with originally 25 allergy centres in 16 European countries, a scientific society (European Academy of Allergology and Clinical Immunology), and a patient organization (European Federation of Allergy and Airways Diseases Patients' Associations). Although some allergy centres adhere to internal quality criteria, the implementation of a standardized quality management system for allergy centres across Europe was lacking.

OBJECTIVES

To implement standardized quality criteria among allergy centres organized within GA(2)LEN and thus ensure equal standards of diagnosis and care as well as to establish a culture of continuous quality improvement.

METHODS

Quality criteria covering, e.g., diagnostic and therapeutic procedures, and emergency preparedness to assure patient safety were developed and agreed upon by all 25 participating centres. To assure implementation of quality criteria, centres were audited to check quality indicators and document deviations. A follow-up survey was used to assess the usefulness of the project.

RESULTS

Deviations were documented mainly in the areas of emergency care/patient safety (27.3% lacked regular emergency training of doctors and nurses; 22.7% inadequate emergency intervention equipment; 22.7% lacked critical incidence reporting/root cause analyses) and handling of extracts/pharmaceuticals (31.8% lacked temperature logs of fridges; 4.5% inadequate check of expiration dates). Quality improvement was initiated as shown by findings of re-audits. Usefulness of the project was rated high.

CONCLUSION

The establishment of a quality management system with joint standards of care and harmonized procedures can be achieved in an international health network and ensures quality of care.

[Analysis of complaints in primary care using statistical process control]

OBJECTIVE

To analyze patient complaints in a Primary Health Care District (PHCD) using statistical process control methods compared to multivariate methods, as regards their results and feasibility of application in this context.

MATERIAL AND METHOD

Descriptive study based on an aggregate analysis of administrative complaints.

SETTING

Complaints received between January 2005 and August 2008 in the Customer Management Department in the 3rd PHCD Management Office, Madrid Health Services. Complaints are registered through Itrack, a computer software tool used throughout the whole Community of Madrid.

MAIN VARIABLES

Total number of complaints, complaints sorted by Reason and Primary Health Care Team (PHCT), total number of patient visits (including visits on demand, appointment visits and home visits) and visits by PHCT and per month and year.

STATISTICAL ANALYSIS

Multivariate analysis and control charts were used.

RESULTS

44-month time series with a mean of 76 complaints per month, an increasing trend in the first three years and decreasing during summer months. Poisson regression detected an excess of complaints in 8 out of the 44 months in the series. The control chart detected the same 8 months plus two additional ones.

CONCLUSIONS

Statistical process control can be useful for detecting an excess of complaints in a PHCD and enables comparisons to be made between different PHC teams. As it is a simple technique, it can be used for ongoing monitoring of customer perceived quality.

The use of statistical control charts to monitor and improve the management of education department resources

Educators are responsible for the management of resources. Statistical control charts (SCCs) may be used by educators to improve resource utilization. In this article, the author describes the use of SCCs and presents a case study that demonstrates the power of SCCs to monitor processes and outcomes, to prompt change, and to be used as an effective presentation tool.

Effect of Lean method implementation in the histopathology section of an anatomical pathology laboratory

Background:

In the USA, the lack of processes standardisation in histopathology laboratories leads to less than optimal quality, errors, inefficiency and increased costs. The effectiveness of large-scale quality improvement initiatives has been evaluated rarely.

Aim:

To measure the effect of implementation of a Lean quality improvement process on the efficiency and quality of a histopathology laboratory section.

Methods:

A non-concurrent interventional cohort study from 1 January 2003 to 31 December 2006 was performed, and the Lean process was implemented on 1 January 2004. Also compared was the productivity of the Lean histopathology section to a sister histopathology section that did not implement Lean processes. Pre- and post-Lean specimen turnaround time and productivity ratios (work units/full time equivalents) were measured. For 200 Lean interventions, a 5-part Likert scale was used to assess the impact on error, success and complexity.

Results:

In the Lean laboratory, the mean monthly productivity ratio increased from 3439 to 4074 work units/full time equivalents (p<0.001) as the mean daily histopathology section specimen turnaround time decreased from 9.7 to 9.0 h (p = 0.01). The Lean histopathology section had a higher productivity ratio compared with a sister histopathology section (1598 work units/full time equivalents, p<0.001) that did not implement Lean processes. The mean impact, success and complexity of interventions were 2.4, 2.7 and 2.5, respectively. The mean number of specific error causes affected by individual interventions was 2.6.

Conclusion:

It is concluded that Lean process implementation improved efficiency and quality in the histopathology section.

Combining multiple indicators of clinical quality: an evaluation of different analytic approaches

OBJECTIVE

To compare different methods of combining quality indicators scores to produce composite scores that summarize the overall performance of health care providers.

METHODS

Five methods for computing a composite quality score were compared: the "All-or-None," the "70% Standard," the "Overall Percentage," the "Indicator Average," and the "Patient Average." The first 2 "criterion-referenced" methods assess the degree to which a provider has reached a threshold for quality of care for each patient (100% or 70%). The remaining "absolute score" methods produce scores representing the proportion of required care successfully provided. Each method was applied to 2 quality indicator datasets, derived from audits of UK family practitioner records. Dataset A included quality indicator data for 1178 patients from 16 family practices covering 23 acute, chronic, and preventative conditions. Dataset B included data on 3285 patients from 60 family practices, covering 3 chronic conditions.

RESULTS

The results varied considerably depending on the method of aggregation used, resulting in substantial differences in how providers scored. The results also varied considerably for the 2 datasets. There was more agreement between methods for dataset B, but for dataset A 6 of the 16 practices moved between the top and bottom quartiles depending upon the method used.

CONCLUSIONS

Different methods of computing composite quality scores can lead to different conclusions being drawn about both relative and absolute quality among health care providers. Different methods are suited to different types of application. The main advantages and disadvantages of each method are described and discussed.