Quality Improvement Intervention

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Evaluation of a quality improvement intervention for labour and birth care in Brazilian private hospitals: a protocol

Evaluation of a quality improvement intervention for labour and birth care in Brazilian private hospitals: a protocol

There is a global concern about the excess of caesarean section (CS) worldwide. In Brazil, a quality improvement intervention called “Adequate Birth” (PPA) has been im- plemented to support 23 private hospitals that seek to reduce their CS rates. This study aims to evaluate PPA strategies and their effectiveness at reducing the inci- dence of CS as a primary outcome of birth care. It will also analyse factors that contributed to the success or failure of PPA implementation. We selected a conveni- ent sample of twelve hospitals. In each hospital, we interviewed and extracted data from hospital records of 400 puerperal women selected at random, in order to detect a 2.5% reduction in CS rate. We also conducted systematic observation and qualitative interviews in a subsample of eight hospitals. The effectiveness of quality improvement interventions at reducing CS rates requires further examination. This study will identify strategies that could promote healthier births.
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Effectiveness of a quality improvement intervention targeting cardiovascular risk factors: are patients responsive to information and encouragement by mail or post?

Effectiveness of a quality improvement intervention targeting cardiovascular risk factors: are patients responsive to information and encouragement by mail or post?

Introduction: There is important evidence on the beneficial effects of treatment of cardiovascular risk factors in terms of morbidity and mortality, but important challenges remain in motivating patients to adhere to their treatment regimen. This study aimed to describe the effectiveness of a quality improvement intervention that included information and regular encouragement by email or letter on cardiovascular risk factors for patients at high risk for cardiovascular disease. Methods: This randomized single-blind study included patients of both sexes aged between 45 and 80 years old who had increased cardiovascular risk. Patients were randomly allocated to either a usual care group (UCG) or advanced care group (ACG). Patients in the UCG received regular care while patients in the ACG received usual care plus regular information and encouragement on cardiovascular risk factors by email or letter. Visits for both groups were planned at 0, 3, and 6 months. The outcome measures were blood pressure, weight, body mass index (BMI), waist circumference (WC), and smoking status.
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Changing Use of Surgical Antibiotic Prophylaxis in Thika Hospital, Kenya: A Quality Improvement Intervention with an Interrupted Time Series Design

Changing Use of Surgical Antibiotic Prophylaxis in Thika Hospital, Kenya: A Quality Improvement Intervention with an Interrupted Time Series Design

time and resources. Many factors contributed to achieving successful implementation of policy – most importantly, local engagement with clinicians and support of the process of change. Our report demonstrates that changing from the outdated practice of post-operative prophylaxis is an achievable quality improvement intervention for hospitals in low-income settings. The looming threat of widespread antibiotic resistance means that there is a pressing need to improve antimicrobial use in low- resource settings [20]. Better use of antibiotics for surgical prophylaxis is a ‘‘low-hanging fruit’’ [21] that is worth picking for antibiotic stewardship programmes in hospitals in sub-Saharan Africa.
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A cluster randomized trial of a multifaceted quality improvement intervention in Brazilian intensive care units: study protocol

A cluster randomized trial of a multifaceted quality improvement intervention in Brazilian intensive care units: study protocol

Methods/design: This is a cluster randomized trial involving 118 ICUs in Brazil conducted in two phases. In the observational preparatory phase, we collect baseline data on processes of care and clinical outcomes from 60 consecutive patients with lengths of ICU stay longer than 48 h and apply the Safety Attitudes Questionnaire (SAQ) to 75% or more of the health care staff in each ICU. In the randomized phase, we assign ICUs to the experimental or control arm and repeat data collection. Experimental arm ICUs receive the multifaceted quality improvement intervention, including a checklist and definition of daily care goals during daily multidisciplinary rounds, clinician prompting, and feedback on rates of adherence to selected care processes. Control arm ICUs maintain usual care. The primary outcome is in-hospital mortality, truncated at 60 days. Secondary outcomes include the rates of adherence to appropriate care processes, rates of other clinical outcomes, and scores on the SAQ domains. Analysis follows the intention-to-treat principle, and the primary outcome is analyzed using mixed effects logistic regression.
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Evaluation of a quality improvement intervention for obstetric and neonatal care in selected public health facilities across six states of India

Evaluation of a quality improvement intervention for obstetric and neonatal care in selected public health facilities across six states of India

The data pertain to an intervention project and are taken from hospital records that are routinely collected and hence no ethical clearance was required. This was a basic program evaluation that was a routine part of implementation with no additional data col- lected than would be normally expected in such a program. Anonymity and patients ’ /clinicians ’ rights were respected and we had permission from facilities plus MOH to implement the intervention. Further- more, as per the national guidelines for biomedical research, “ research on publicly available information, documents, records, works, performances, reviews, quality assurance studies, archival materials or third- party interviews, service programs for benefit of public having a bearing on public health programs, and consumer acceptance studies ” are waived from voluntary informed consent process [15]. The use of data for a quality improvement intervention falls in the above mentioned category.
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Reduced neonatal mortality in a regional hospital in Mozambique linked to a Quality Improvement intervention

Reduced neonatal mortality in a regional hospital in Mozambique linked to a Quality Improvement intervention

Background: Neonatal mortality remains a serious health issue especially in low resource countries, where 99% of neonatal deaths occur. Doctors with Africa CUAMM is an Italian non-governmental organization in the field of healthcare that has been working in Africa since 1955. In Mozambique, at the Central Beira Hospital (CBH), it has a project with the aim of supporting the neonatal intensive care unit (NICU) and the Obstetrical Department of the CBH through a multi-level intervention. Our aim was to evaluate the effectiveness of CUAMM continuous Quality Improvement intervention in terms of reduction of the overall neonatal mortality rate in the NICU of CBH.
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Development of the Quality Improvement Minimum Quality Criteria Set (QI-MQCS): A Tool for Critical Appraisal of Quality Improvement Intervention Publications

Development of the Quality Improvement Minimum Quality Criteria Set (QI-MQCS): A Tool for Critical Appraisal of Quality Improvement Intervention Publications

We designed the QI-MQCS to determine the minimum quality threshold of core QI domains. QI experts selected and prioritised domains in order to establish a feasible critical appraisal instrument. Furthermore, we developed detailed scoring criteria in an iterative process to ensure reliability. The assessment must rely on the information presented in the publica- tion, and reliable scoring requires clear guidance that cannot be based on guessing or inside knowledge of individual reviewers. Nevertheless, reporting short- comings may not necessarily indicate the absence of the process in the conduct of the study (eg, the publica- tion ’ s word limits may have precluded a full descrip- tion of the methods) and the psychometric evaluation distinguished only whether the domain criteria were met or not. Using the QI-MQCS and its assessment domains as a framework may allow reviewers to further differentiate study quality by creating response
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Unregulated provider perceptions of audit and feedback reports in long-term care: cross-sectional survey findings from a quality improvement intervention

Unregulated provider perceptions of audit and feedback reports in long-term care: cross-sectional survey findings from a quality improvement intervention

This analysis supports recommendations for clinical edu- cators who teach unregulated providers in LTC settings. While quality of care may be covered in orientation pro- grams or other in-services, it is not given much time or weight in the current curriculum or continuing education programs for unregulated providers. Additional emphasis on education around quality of care is warranted, given the evidence that these providers can understand the informa- tion and find it useful in their practice. However, as we dis- cuss above, simply giving an understandable feedback report to unregulated care providers may not be enough to guarantee practice change in LTC environments. This may be because these environments are characterized by hier- archical decision-making and management structures. In- novative approaches to supporting active engagement of the unregulated provider in quality improvement interven- tions should be considered.
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Assessment of paediatric inpatient care during a multifaceted quality improvement intervention in Kenyan District Hospitals – use of prospectively collected case record data

Assessment of paediatric inpatient care during a multifaceted quality improvement intervention in Kenyan District Hospitals – use of prospectively collected case record data

We evaluated a multi-faceted approach to implemen- tation of clinical guidelines aimed at treatment of illnesses that cause most deaths in Kenyan district hos- pitals. We used data collected by personnel present in the hospital for two week survey periods prior to inter- vention and 6 and 18 months after intervention. The data showed that prior use of guideline recommended practices for treatment of children with severe illness was poor at baseline. Data further showed marked im- provement in adoption of guideline recommended prac- tices in both partial and full intervention groups but improvements were more marked in the full intervention group. It is worth noting that improvements were sus- tained between 6 to 18 months after initial training despite very high staff turn-over amongst the junior clinicians re- sponsible for much care. Indeed, of 109 clinical staff re- sponsible for attending to the patients sampled as part of the retrospective data analysis in survey 4 in the interven- tion hospitals, only nine (8.3%) had received any specific formal or ad hoc guideline-related training [6].
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Identifying Quality Improvement intervention publications - A comparison of electronic search strategies.

Identifying Quality Improvement intervention publications - A comparison of electronic search strategies.

We selected a random sample of 30 publications from all 297 studies registered in November 2007 in a data- base maintained by the Cochrane Effective Practice and Organization of Care Group (EPOC). EPOC articles are hand searched for this specialized register of evaluations of interventions designed to improve professional prac- tice and the delivery of effective health services, includ- ing various forms of continuing education, quality assurance, informatics, financial, organisational, and reg- ulatory interventions that can affect the ability of health- care professionals to deliver services more effectively and efficiently [14]. Four publications (all conference abstracts) were excluded because they were not indexed in MEDLINE, leaving 26 publications. One publication [15] was also part of the SQUIRE group article selection (set #2).
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Increasing Tdap Coverage Among Postpartum Women: A Quality Improvement Intervention

Increasing Tdap Coverage Among Postpartum Women: A Quality Improvement Intervention

Our results are subject to some limitations. The initiative was conducted in a single suburban women’s hospital in an affluent area and near a major metropolitan hub. Although this setting provided for a highly active postpartum service, the singularity of the setting may limit the generalizability of our intervention. Nonetheless, the insights gained from our experience can guide the application and study of future similar initiatives in health care settings of various sizes. Our study design also had the potential for bias. Observer bias (Hawthorne effect) among the nursing staff on postpartum units may have played a role with the initial rollout of our intervention. The efforts to minimize this bias, however, would have diminished the commitment of the implementation staff. Modifying workflow pattern is an intensive process in the early stages, as floor staff members adjust daily practice to accommodate changes. We suggest that a measure of observer bias was necessary to create the momentum necessary to efficiently implement the interventions into the daily workflow.
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Increasing Tdap Coverage Among Postpartum Women: A Quality Improvement Intervention

Increasing Tdap Coverage Among Postpartum Women: A Quality Improvement Intervention

Open communication, broad involvement by multiple project members, securing leadership buy-in, and flexible interventions were key lessons learned in the present study. By valuing the input of all project personnel, a successful 5-step intervention was devised, integrated, and adapted in the field. Although the intervention is appropriate for a large hospital with high patient turnover, we anticipate adjustments are possible when addressing barriers in smaller community hospitals with a different peripartum and postpartum floor dynamic. The accomplishment of our interdisciplinary advisory committee is applicable to all facilities with QI ambitions. Educating and extending outreach to hospital leadership is a strategy that can be applied to any QI project that relies on the cooperation of several divisions within a system. A larger hospital setting requires this approach, as a greater number of entities are involved in the planning and implementation of interventions. After demonstrating the effectiveness of the 5-step intervention in our women’s hospital, we expect to expand to labor and delivery. Although vaccinating women after delivery is a positive step, ACIP
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A Quality Improvement Intervention to Increase Access to Pediatric Subspecialty Practice

A Quality Improvement Intervention to Increase Access to Pediatric Subspecialty Practice

OBJECTIVE: To improve access to new pediatric endocrinology ap- pointments in an urban academic hospital faculty-based practice. METHODS: Three strategies were implemented to increase the number of appointment slots: new patient appointments were protected from conversion to follow-up appointments; all physicians, including senior faculty, were scheduled to see 3 to 4 new patients per session; and sessions devoted exclusively to follow-up appointments were added based on demand. The main outcomes for this quality improvement activity were waiting times for new and follow-up appointments, monthly visit volume, the per-provider visit volume, differences in the proportion of new visits, and clinic arrival rates pre- and postintervention.
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Evaluation of a Quality Improvement Intervention to Increase Use of Telephonic Interpretation

Evaluation of a Quality Improvement Intervention to Increase Use of Telephonic Interpretation

This QI intervention and evaluation were conducted at SCH, a large children ’ s hospital in the Paci fi c Northwest. In 2012, 16% of hospitalized children were from families with LEP. Fifty-six percent of those spoke Spanish; the next most common languages were Somali, Vietnamese, and Russian. Language need was assessed at hospital registration by asking what language the parents or caregivers prefer for medical communication. This registration question replaced the previous question, regarding primary language spoken at home, in July 2011, shortly before the QI intervention. All clinic schedulers and hospital registration staff were trained to ask the new question of all families at every encounter. The preferred language for care was recorded in the patient electronic medical record (EMR). Given that most individuals who prefer a non- English language for medical care have LEP, 29 we refer to these families
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Effectiveness of a multi-component quality improvement intervention on rates of hyperglycaemia

Effectiveness of a multi-component quality improvement intervention on rates of hyperglycaemia

There are limitations to our study that warrant consider- ation. First, our project was a series of interventions, and we cannot determine which components were most effec- tive. Second, we are unable to parse out confounding factors, including the Hawthorne effect, although this may be minimised due to the long time frame. We were able to control for temporal trend through time series analysis, increasing strength of causal inference. Although our interventions did provide real-time feedback and clinical decision support, our analysis is retrospective. We attempted to use objective measures, but were not able to blind the investigators. Third, generalisability outside our institution may be limited. Although the SHM-GCMI is open to any institution, our institution has distinguishing features that contributed to successful implementation of these improvement efforts. Our institution is a single hospital with employee physicians and strong central governance, which may facilitate institutional buy-in. We also have a long history with Lean methods, so this method of process improvement is well established. We were also early adopters of the EHR, and so have extensive experience in customising order sets and collecting data. Many aspects of our interventions were highly technical in nature and may be difficult for institutions with less experience using an EHR, or using a less customisable EHR. Nonetheless, we believe our interventions could be equally successful at other institutions with appropriate executive leadership and technical resources. Finally, we were not able to directly measure the cost of the inter- ventions, as they were integrated into our standard care processes. Thus, we cannot provide an estimate of any cost savings.
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Prescribing Data in General Practice Demonstration (PDGPD) project   a cluster randomised controlled trial of a quality improvement intervention to achieve better prescribing for chronic heart failure and hypertension

Prescribing Data in General Practice Demonstration (PDGPD) project a cluster randomised controlled trial of a quality improvement intervention to achieve better prescribing for chronic heart failure and hypertension

Australian [5,6] and overseas studies report that treat- ment of HT [7-15] and heart failure [16-19] are not well aligned with evidence-based guidelines. For example, in Australia, fewer than 50 percent of heart failure patients admitted to any of three hospitals in Tasmania were being treated with target doses of the recommended drugs [18]. Among Australian patients attending general practice, under-prescribing for heart failure was found both in terms of the number receiving the recom- mended drugs and the dosage levels [20,21]. A national Australian survey reported the prevalence of untreated HT at 15.2% [13] and four consecutive GP audits of self- reported prescribing practices concluded that there was room for improvement in the management of hyperten- sive patients with co-morbidities [14].
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Implementing a Guideline to Improve Management of Syncope in the Emergency Department

Implementing a Guideline to Improve Management of Syncope in the Emergency Department

Because of the wide variation in man- agement of pediatric syncope in our ED and across the country, we designed a quality improvement intervention, starting with the development of an evidence-based guideline. The ED-based syncope guideline was based on best available evidence gleaned from a com- prehensive literature search and was developed through consensus via a mul- tidisciplinary collaboration between experts from emergency medicine, car- diology, neurology, and nursing. A pedi- atric emergency physician and nurse led

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Decreasing Glycosylated Hemoglobin with Nutrition, Exercise and Bi Monthly Telephone Calls in Patients with Type 2 Diabetes Mellitus

Decreasing Glycosylated Hemoglobin with Nutrition, Exercise and Bi Monthly Telephone Calls in Patients with Type 2 Diabetes Mellitus

Background: Decreasing glycosylated hemoglobin (HbgA1c) is a primary diabetes treatment goal. Despite the simplicity of the HbgA1c goal, failure to achieve this goal is a major healthcare concern. Healthcare providers fail to adequately educate patients on how to implement behavioral modifi- cations needed for successful goal achievement. Narrowed focused patient encounters, reliance on patient self-education, denial, and delayed follow-up appointments limit a patient’s ability to im- plement required behavioral changes. Aim: This study was a quality improvement intervention designed to determine whether a personalized nutrition and exercise plan in conjunction with bi- monthly telephone reinforcement calls improved the HbgA1c of patients with type 2 diabetes mel- litus. Setting: The study was conducted at a community clinic located in the southeastern U.S. that provides care predominantly to the working poor and uninsured patients. Sample: Type 2 diabetic patients (n = 40) with a baseline HbgA1c > 7%. Intervention: A nurse practitioner; certified di- abetic educator and an exercise physiologist developed an individualized action plan with each participant. Baseline HbgA1c values were documented and participants were scheduled for three education sessions as well as telephone calls twice monthly for three months followed by a repeat HbgA1c. Results: Pretest and posttest HbgA1c data were analyzed using the Wilcoxon T-test statis- tic to determine if a personalized nutrition and exercise action plan in addition to bi-monthly tel- ephone calls to the participants contributed to a decrease in the HbgA1c. Level of significance was set at an alpha value of less 0.05. The observed value of the test statistics t = 2.2714, with df = 62, p-value = 0.01292 rejects the null hypothesis. The p-value (0.012) demonstrated a significant im- provement. Conclusion: Individualized attention and frequent reinforcement facilitated patients’ need to develop and integrate self-management behaviors, thereby, reducing the HbgA1c level and helping them to reach the desired goal.
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Using a quality improvement model to enhance providers’ performance in maternal and newborn health care: a post only intervention and comparison design

Using a quality improvement model to enhance providers’ performance in maternal and newborn health care: a post only intervention and comparison design

performance on ANC (236 provider-client interactions), uncomplicated labor and delivery (226 provider-client interactions), and immediate PNC services in the six hours after delivery (232 provider-client interactions); observations were divided equally between intervention and comparison groups. Main outcomes were provider performance scores, calculated as the percentage of essential tasks in each service area completed by providers. Multilevel analysis was used to calculate adjusted mean percentage performance scores and standard errors to compare intervention and comparison groups. Results: There was no statistically significant difference between intervention and comparison facilities in overall mean performance scores for ANC services (63.4% at intervention facilities versus 61.0% at comparison facilities, p = 0.650) or in any specific ANC skill area. MNH providers ’ overall mean performance score for uncomplicated labor and delivery care was 11.9 percentage points higher in the intervention than in the comparison group (77.5% versus 65.6%; p = 0.002). Overall mean performance scores for immediate PNC were 22.2 percentage points higher at intervention than at comparison facilities (72.8% versus 50.6%; p = 0.001); and there was a significant difference of 22 percentage points between intervention and comparison facilities for each PNC skill area: care for the newborn and health check for the mother. Conclusions: The SBM-R quality improvement intervention made a significant positive impact on MNH providers ’ performance during labor and delivery and immediate PNC services, but not during ANC services. Scaling up the intervention to other facilities and regions may increase the availability of good quality MNH services across Ethiopia. The findings will also guide implementation of the government ’ s five-year (2015 – 2020) health sector transformation plan and health care quality strategies needed to meet the country ’ s MNH goals.
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Development of a complex intervention to promote appropriate prescribing and medication intensification in poorly controlled type 2 diabetes mellitus in Irish general practice

Development of a complex intervention to promote appropriate prescribing and medication intensification in poorly controlled type 2 diabetes mellitus in Irish general practice

Our intervention addresses a core implementation prob- lem, in the delivery of care to patients with poor control of T2DM. By following the MRC framework, with a de- tailed literature review and utilising theory to develop and inform the intervention functions, our complex intervention is more likely to be successful. Only one of the 37 studies identified in the systematic review exam- ined a professionally targeted intervention, for patients with poor control of T2DM. The DECIDE intervention will add to the evidence base in this regard, addressing clinical inertia and medication intensification in the gen- eral practice. The DECIDE CDSS is currently a web- based tool, but could be integrated into electronic health records in different health systems if found to be effect- ive. Though the DECIDE intervention development process proved time consuming, it was comprehensive and involved a multidisciplinary approach with collabor- ation between clinicians, health psychologists, ICT spe- cialists and researchers. A potential issue is the use of the term ‘poorly controlled’ diabetes as this is the term commonly used in the studies we included. However, we recognise that negative linguistic phrases directed at pa- tients can create undesirable effects, especially if the fac- tors affecting a patient’s management are beyond their control [52]. As an example, using the phrase ‘poorly controlled ’ can lead to a moral judgement about an out- come on behalf of a physician. Whilst physicians will continue to utilise phrases such as ‘poor control’ , when glycaemic control is far above a target level, it is important that physicians do not use such terms to criticise or judge a patient, especially when the reasons behind ‘poor con- trol ’ are multifaceted, including clinical inertia [7, 8, 52]. The BCW framework, incorporating the COM-B model and BCT generation, is a comprehensive, conceptually coherent and practical method of addressing behaviour change in any setting. As there are significant overlaps be- tween frameworks, choosing another framework over the BCW would unlikely lead to a focus on alternative BCTs or alternative intervention functions.
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