Evolution and outcomes of a quality improvement program

Multidimensional assessment of infant, parent and staff outcomes during a family centered care enhancement project in a tertiary neonatal intensive care unit: study protocol of a longitudinal cohort study

BACKGROUND

The therapeutic advances and progress in the care for preterm infants have enabled the regular survival of very immature infants. However, the high burden of lifelong sequelae following premature delivery constitutes an ongoing challenge. Regardless of premature delivery, parental mental health and a healthy parent-child relationship were identified as essential prerogatives for normal infant development. Family centered care (FCC) supports preterm infants and their families by respecting the particular developmental, social and emotional needs in the Neonatal Intensive Care Unit. Due to the large variations in concepts and goals of different FCC initiatives, scientific data on the benefits of FCC for the infant and family outcome are sparse and its effects on the clinical team need to be elaborated.

METHODS

This prospective single centre longitudinal cohort study enrols preterm infants ≤ 32 + 0 weeks of gestation and/or birthweight ≤ 1500 g and their parents at the neonatal department of the Giessen University Hospital, Giessen, Germany. Following a baseline period, the rollout of additional FCC elements is executed following a stepwise 6-months approach that covers the NICU environment, staff training, parental education and psychosocial support for parents. Recruitment is scheduled over a 5.5. year period from October 2020 to March 2026. The primary outcome is corrected gestational age at discharge. Secondary infant outcomes include neonatal morbidities, growth, and psychomotor development up to 24 months. Parental outcome measures are directed towards parental skills and satisfaction, parent-infant-interaction and mental health. Staff issues are elaborated with particular focus on the item workplace satisfaction. Quality improvement steps are monitored using the Plan- Do- Study- Act cycle method and outcome measures cover the infant, the parents and the medical team. The parallel data collection enables to study the interrelation between these three important areas of research. Sample size calculation was based on the primary outcome.

DISCUSSION

It is scientifically impossible to allocate improvements in outcome measures to individual enhancement steps of FCC that constitutes a continuous change in NICU culture and attitudes covering diverse areas of change. Therefore, our trial is designed to allocate childhood, parental and staff outcome measures during the stepwise changes introduced by a FCC intervention program.

TRIAL REGISTRATION

Clinicaltrials.gov, trial registration number NCT05286983, date of registration 03/18/2022, retrospectively registered, http://clinicaltrials.gov .

Identifying contextually relevant improvement measures, illustrated by a case of executive walkrounds

PURPOSE

A method to engage salient organisational stakeholders in identifying and ranking measures of healthcare improvement programs is described. The method is illustrated using Executive WalkRounds (EWRs) in a multi-site Australian Health District.

DESIGN/METHODOLOGY/APPROACH

Subject matter experts (SMEs) conducted document analysis, identified potential EWRs measures, created driver diagrams and then eliminated weak measures. Next, a panel of executives skilled in EWRs ranked and ratified the potential measures using a modified Delphi technique.

FINDINGS

EWRs measurement selection demonstrated the feasibility of the method. Of the total time to complete the method 79% was contributed by SMEs, 14% by administration personnel and 7% by executives. Document analysis revealed three main EWRs aims. Ten of 28 potential measures were eliminated by the SME review. After repeated Delphi rounds the executive panel achieved consensus (75% cut-off) on seven measures. One outcome, one process and one implementation fidelity metric were selected to measure and monitor the impact of EWRs in the health district.

PRACTICAL IMPLICATIONS

Perceptions of weak relationships between measures and intended improvements can lead to practitioner scepticism. This work offers a structured method to combine the technical expertise of SMEs with the practical knowledge of healthcare staff in selecting improvement measures.

ORIGINALITY/VALUE

This research describes and demonstrates a novel method to systematically leverage formal and practical types of expertise to select measures that are strongly linked to local quality improvement goals. The method can be applied in diverse healthcare settings.

Staffs' and managers' perceptions of how and when discrete event simulation modelling can be used as a decision support in quality improvement: a focus group discussion study at two hospital settings in Sweden

OBJECTIVE

To explore healthcare staffs' and managers' perceptions of how and when discrete event simulation modelling can be used as a decision support in improvement efforts.

DESIGN

Two focus group discussions were performed.

SETTING

Two settings were included: a rheumatology department and an orthopaedic section both situated in Sweden.

PARTICIPANTS

Healthcare staff and managers (n=13) from the two settings.

INTERVENTIONS

Two workshops were performed, one at each setting. Workshops were initiated by a short introduction to simulation modelling. Results from the respective simulation model were then presented and discussed in the following focus group discussion.

RESULTS

Categories from the content analysis are presented according to the following research questions: how and when simulation modelling can assist healthcare improvement? Regarding how, the participants mentioned that simulation modelling could act as a tool for support and a way to visualise problems, potential solutions and their effects. Regarding when, simulation modelling could be used both locally and by management, as well as a pedagogical tool to develop and test innovative ideas and to involve everyone in the improvement work.

CONCLUSIONS

Its potential as an information and communication tool and as an instrument for pedagogic work within healthcare improvement render a broader application and value of simulation modelling than previously reported.

Reduced time from diagnosis to stone-free status in patients with ureteral calculi

Purpose - The purpose of this paper is to describe an improvement project and its effects on decreasing the time from diagnosis to treatment for patients with kidney stones and to reduce the negative effects related to untreated stones at one hospital in western Sweden. Design/methodology/approach - A quantitative descriptive study based on Nolan's improvement model was used. The quality improvement effects were evaluated using statistical process control. Findings - Extracorporeal shock wave lithotripsy treatment's positive effects within 48 hours were described as efficiency (decreased waiting time) from diagnosis to treatment, even if a re-treatment was necessary. The results also showed a reduction in the usage of percutaneous nephropyelostomies as a treatment option. Research limitations/implications - This study includes data from one department at one hospital in one country. Comparative data include the time from acute radiological examination to final treatment but not total re-treatments, complications or time to up following radiological examination. However, the study was performed over one year and analyzed data from medical records in a systematic way. Practical implications - This study may inspire measuring and developing routines from diagnosis to treatment for patients who are transferred within different departments at one hospital. Social implications - By measuring the working process, resource use within a healthcare organization could be visualized. Planning and co-operation at different managerial levels are key factors for success when improvement projects are performed. Originality/value - Studies in improvement projects considering ureteral or kidney stones are generally lacking; thus, this study is important for improving the care of patients with this diagnose.

An improvement project within urological care

Purpose

– The purpose of this paper is to describe staff experiences in an on-going improvement project regarding patients with ureteral stones.

Design/methodology/approach

– A qualitative descriptive study based on eight group interviews and 48 narratives, was performed. Data were analysed using qualitative content analysis. Trustworthiness was ensured by using a well-documented improvement process method during six months.

Findings

– The results formed three categories: an absent comprehensive view; complexity; and vulnerability within the organisation. A holistic perspective regarding urological care at the micro-, meso- and macro-levels is needed to improve planning and caring processes.

Research limitations/implications

– This study includes one team (six members, different health professionals) within the same urology department.

Practical implications

– Results show that staff need information, such as guidelines and support throughout the improvement work to deliver high-quality care. Moreover, there is a need for evidence-based guidelines at national level to support improvement work.

Social implications

– Healthcare staff need to pay attention to all team member needs to improve urological care. Organisational and managerial aspect are needed to support clear and common goals regarding healthcare improvement work.

Originality/value

– Urological improvement projects, generally, are lacking, which is why this study is important to improve nephrolithiasis patient care.

Insights into physician scheduling: a case study of public hospital departments in Sweden

PURPOSE

The purpose of this paper is to describe current physician scheduling and concomitant opportunities for improvement in public hospital departments in Sweden.

DESIGN/METHODOLOGY/APPROACH

A total of 13 departments spread geographically across Sweden covering seven different specialties participated in the study. Data were collected through interviews with individuals involved in creating physician schedules. All departments investigated provided copies of the documents necessary for physician scheduling.

FINDINGS

Physician scheduling required the temporal coordination of patients, physicians, non-physician staff, rooms and equipment. A six-step process for creating physician schedules could be distinguished: capacity and demand overview, demand goal and schedule setting, vacation and leave requests, schedule creation, schedule revision, and schedule execution. Several opportunities for improvement could be outlined; e.g. overreliance on memory, lacking coordination of resources, and redundant data entering.

RESEARCH LIMITATIONS/IMPLICATIONS

The paucity of previous studies on physician scheduling lends an exploratory character to this study and calls for a more thorough evaluation of the feasibility and effects of the approaches proposed. The study excluded the scheduling of non-physician staff.

PRACTICAL IMPLICATIONS

To improve physician scheduling and enable timeliness, three approaches are proposed: reinforcing centralisation, creating learning opportunities, and improving integration.

ORIGINALITY/VALUE

This paper is among the few to investigate physician scheduling, which is essential for delivering high quality care, particularly concerning timeliness. Several opportunities for improvement identified in this study are not exclusive to physician scheduling but are pervasive in healthcare processes in general.

An exploratory analysis of the model for understanding success in quality

BACKGROUND

Experience suggests that differences in context produce variability in the effectiveness of quality improvement (QI) interventions. However, little is known about which contextual factors affect success or how they exert influence.

PURPOSE

Using the Model for Understanding Success in Quality (MUSIQ), we perform exploratory quantitative tests of the role of context in QI success.

METHODOLOGY

We used a cross-sectional design to survey individuals participating in QI projects in three settings: a pediatric hospital, hospitals affiliated with a state QI collaborative, and organizations sponsoring participants in an improvement advisor training program. Individuals participating in QI projects completed a questionnaire assessing contextual factors included in MUSIQ and measures of perceived success. Path analysis was used to test the direct, indirect, and total effects of context variables on QI success as hypothesized in MUSIQ.

FINDINGS

In the 74 projects studied, most contextual factors in MUSIQ were found to be significantly related to at least one QI project performance outcome. Contextual factors exhibiting significant effects on two measures of perceived QI success included resource availability, QI team leadership, team QI skills, microsystem motivation, microsystem QI culture, and microsystem QI capability. There was weaker evidence for effects of senior leader project sponsors, organizational QI culture, QI team decision-making, and microsystem QI leadership. These initial tests add to the validity of MUSIQ as a tool for identifying which contextual factors affect improvement success and understanding how they exert influence.

PRACTICE IMPLICATIONS

Using MUSIQ, managers and QI practitioners can begin to identify aspects of context that must be addressed before or during the execution of QI projects and plan strategies to modify context for increased success. Additional work by QI researchers to improve the theory, refine measurement approaches, and validate MUSIQ as a predictive tool in a wider range of QI efforts is necessary.

A measurement instrument for spread of quality improvement in healthcare

OBJECTIVE

The aim of this study was to develop and test a measurement instrument for spread of quality improvement in healthcare. The instrument distinguishes: (i) spread of work practices and their results and (ii) spread practices and effectiveness. Relations between spread and sustainability of changed work practices were also explored to assess convergent validity.

DESIGN

We developed and tested a measurement instrument for spread in a follow-up study. The instrument consisted of 18-items with four subscales.

SETTING AND PARTICIPANTS

The sample consisted of former improvement teams in a quality improvement program for long-term care (nteams = 73, nrespondents = 127). Data were collected in a questionnaire about 1 year post-pilot site improvement implementation.

INTERVENTIONS

Quality improvements in long-term care practices.

MAIN OUTCOME MEASURES

Four variables were construed: (i) actions for spread of work practices, (ii) actions for spread of results, (iii) effectiveness of spread of work practices and (iv) effectiveness of spread of results.

RESULTS

Psychometric analysis yielded positive results on the item level. The intended four-factor model yielded satisfactory fit. The internal consistency of each scale was fine (Cronbach's α 0.70-0.93). Bivariate correlations revealed that the spread variables were strongly related but distinct, and positively related to the sustainability variables.

CONCLUSIONS

The psychometric properties are in line with methodological standards. Convergent validity was confirmed with sustainability. The measurement instrument offers a good starting point for the analysis of spread.