Inflammatory bowel disease integral care units: Evaluation of a nationwide quality certification programme. The GETECCU experience.

BACKGROUND: One of the most valued targets in inflammatory bowel disease (IBD) is for physicians to provide and patients to receive a high-level quality of care. This study aimed to evaluate the implementation of a nationwide quality certification programme for IBD units. METHODS: Identification of quality indicators (QI) for IBD Unit certification was based on Delphi methodology that selected 53 QI, which were subjected to a normalisation process. Selected QI were then used in the certification process. Coordinated by GETECCU, this process began with a consulting round and an audit drill followed by a formal audit carried out by an independent certifying agency. This audit involved the scrutiny of the selected QI in medical records. If 80%-90% compliance was achieved, the IBD unit audited received the qualification of "advanced", and if it exceeded 90% the rating was "excellence". Afterwards, an anonymous survey was conducted among certified units to assess satisfaction with the programme for IBD units. RESULTS: As of January 2021, 66 IBD units adhere to the nationwide certification programme. Among the 53 units already audited by January 2021, 31 achieved the certification of excellence, 20 the advanced certification, and two did not obtain the certification. The main survey results indicated high satisfaction with an average score of 8.5 out of 10. CONCLUSION: Certification of inflammatory bowel disease units by GETECCU is the largest nationwide certification programme for IBD units reported. More than 90% of IBD units adhered to the programme achieved the certification.

Reducing the knowledge to action gap in hospital nutrition care - Developing and implementing nutritionDay 2.0.

BACKGROUND & AIMS: In hospital nutrition care the difficulty of translating knowledge to action often leads to inadequate management of patients with malnutrition. nutritionDay, an annual cross-sectional survey has been assessing nutrition care in healthcare institutions in 66 countries since 2006. While initial efforts led to increased awareness of malnutrition, specific local remedial actions rarely followed. Thus, reducing the Knowledge-to-action (KTA) gap in nutrition care requires more robust and focused strategies. This study describes the strategy, methods, instruments and experience of developing and implementing nutritionDay 2.0, an audit and feedback intervention that uses quality and economic indicators, feedback, benchmarking and self-defined action strategies to reduce the KTA gap in hospital nutrition care. METHODS: We used an evidence based multi-professional mixed-methods approach to develop and implement nutritionDay 2.0 This audit and feedback intervention is driven by a Knowledge-to-Action framework complemented with robust stakeholder analysis. Further evidence was synthesized from the literature, online surveys, a pilot study, World Cafés and individual expert feedback involving international health care professionals, nutrition care scientists and patients. RESULTS: The process of developing and implementing nutritionDay 2.0 over three years resulted in a new audit questionnaire based on 36 nutrition care quality and economic indicators at hospital, unit and patient levels, a new action-oriented feedback and benchmarking report and a unit-level personalizable action plan template. The evaluation of nutritionDay 2.0 is ongoing and will include satisfaction and utility of nutritionDay 2.0 tools and short-, mid- and long-term effects on the KTA gap. CONCLUSION: In clinical practice, nutritionDay 2.0 has the potential to promote behavioural and practice changes and improve hospital nutrition care outcomes. In research, the data generated advances knowledge about institutional malnutrition and quality of hospital nutrition care. The ongoing evaluation of the initiative will reveal how far the KTA gap in hospital nutrition care was addressed and facilitate the understanding of the mechanisms needed for successful audit and feedback. TRIAL REGISTRATION: Registration in clinicaltrials.gov: Identifier: NCT02820246.

A Collaborative Multicenter QI Initiative to Improve Antibiotic Stewardship in Newborns.

OBJECTIVES: To determine if NICU teams participating in a multicenter quality improvement (QI) collaborative achieve increased compliance with the Centers for Disease Control and Prevention (CDC) core elements for antibiotic stewardship and demonstrate reductions in antibiotic use (AU) among newborns. METHODS: From January 2016 to December 2017, multidisciplinary teams from 146 NICUs participated in Choosing Antibiotics Wisely, an Internet-based national QI collaborative conducted by the Vermont Oxford Network consisting of interactive Web sessions, a series of 4 point-prevalence audits, and expert coaching designed to help teams test and implement the CDC core elements of antibiotic stewardship. The audits assessed unit-level adherence to the CDC core elements and collected patient-level data about AU. The AU rate was defined as the percentage of infants in the NICU receiving 1 or more antibiotics on the day of the audit. RESULTS: The percentage of NICUs implementing the CDC core elements increased in each of the 7 domains (leadership: 15.4%-68.8%; accountability: 54.5%-95%; drug expertise: 61.5%-85.1%; actions: 21.7%-72.3%; tracking: 14.7%-78%; reporting: 6.3%-17.7%; education: 32.9%-87.2%; P < .005 for all measures). The median AU rate decreased from 16.7% to 12.1% (P for trend < .0013), a 34% relative risk reduction. CONCLUSIONS: NICU teams participating in this QI collaborative increased adherence to the CDC core elements of antibiotic stewardship and achieved significant reductions in AU.

Intervention fidelity monitoring of Urban Zen Integrative Therapy (UZIT) for persons with pulmonary hypertension.

BACKGROUND: Systematic and consistent dose delivery is critical in intervention research. Few studies testing complementary health approach (CHA) interventions describe intervention fidelity monitoring (IFM) and measurement. OBJECTIVE: To describe methodological processes in establishing and measuring consistent dose, delivery, and duration of a multi-component CHA intervention. METHODS: Adults with pulmonary hypertension received six weekly, 1-hour Urban Zen Integrative Therapy (UZIT) sessions. A total of 78 sessions were delivered and 33% of these sessions were audited. Intervention dose (time allocated to each component), intervention consistency (protocol adherence audits), and intervention delivery (performance and sequence of components) were captured using remote video observation and review of the recorded video. IFM audits were performed at the beginning (n = 16), middle (n = 5), and end (n = 5) of the study. RESULTS: UZIT interventionists adhered to the intervention protocol (99.3%) throughout the study period. Interventionists delivered UZIT components within the prescribed timeframe: 1) Beginning: gentle body movement (18.9 ± 5.8 min.), restorative pose with guided body awareness meditation (21.3 ± 2.7 min.), and Reiki (22.8 ± 3.1 min.); 2) Middle: gentle body movement (15.9 ± 1.5 min.), pose/body awareness meditation (30.1 ± 6.5 min.), and Reiki (30.1 ± 7.0 min.); 3) End: gentle body movement (18.1 ± 3.6 min.), pose/body awareness meditation (35.3 ± 6.4 min.), and Reiki (34.5 ± 7.0 min.). Essential oil inhalation was delivered during UZIT sessions 100% of the time. Interventionists adhered to treatment delivery behaviors throughout the study period: beginning (98.86%), middle (100%), and end (100%). DISCUSSION: In this pilot study, we demonstrated that the dose, consistency, and delivery of multi-component CHA therapy can be standardized and monitored to ensure intervention fidelity.

Stroke mortality audit using the Structured Judgement Review method.

Mortality data provided by the Sentinel Stroke National Audit Programme demonstrated the Royal Cornwall Hospitals Trust (RCHT) to have a higher than national average mortality ratio.1 In response to this, the RCHT stroke department undertook a mortality review of patients admitted with stroke making use of the Structured Judgement Review (SJR) process.2The review found all patients were deemed as receiving adequate, good or excellent care. There were no cases where death was deemed as definitely avoidable. The team found the SJR to be a useful, validated tool for mortality review though recognised specific limitations to its use and wider limitations within our review process. Focused areas for improvement derived from the review included improving compliance with local palliative care guides, improved documentation, links with primary care via Care Quality Commission atrial fibrillation group and consideration of improved scanning facilities. We also acknowledged wider unaccounted factors which may impact stroke mortality and thus influence perceived mortality ratios.

Relationship between residency placement and clerkship site enrollment: a retrospective analysis.

CONTEXT: Osteopathic medical students frequently engage in clinical clerkships away from their home teaching institution, which can help them decide on a residency program, gain additional experience in a new environment, and further their professional contacts. Conventional wisdom states that these audition clerkships are an important factor in residency placement, but the educational literature concerning the topic is lacking. OBJECTIVE: To determine the relationship between clerkship site enrollment and residency placement so that empirical guidelines can be established for osteopathic medical students in the process of making informed decisions about their clerkships, particularly during the fourth year. METHODS: A retrospective analysis was conducted. Data on clerkship and residency placement were compiled for the classes of 2008, 2009, and 2010 at the New York Institute of Technology College of Osteopathic Medicine, and χ2 goodness-of-fit analysis and χ2 tests of independence were used to explore relationships between clerkship and residency placement. RESULTS: Of 862 graduates, data were available for 812 (94.2%). Statistically significant relationships were noted between residency program status (osteopathic, allopathic, and military) and audition clerkship, with fewer graduates completing audition clerkships in allopathic programs and with more graduates completing audition clerkships in osteopathic and military residency programs than expected from an independent relationship. A total of 416 graduates (51.2%) did not enroll in the residency program where they completed their audition clerkship. A total of 352 graduates (43.3%) enrolled in the residency program where they completed their audition clerkship. An additional 44 graduates (5.4%) did not complete an audition clerkship in the discipline of their residency program but rotated at a hospital. A total of 364 graduates (44.8%) enrolled in osteopathic residency programs, 425 (52.3%) enrolled in allopathic programs, and 23 (2.8%) enrolled in military programs. CONCLUSION: Although the results of this study are specific to 1 medical school, they provide evidence to counter long-held beliefs that audition clerkships determine residency placement.

Learning from preventable deaths: exploring case record reviewers' narratives using change analysis.

OBJECTIVE: To determine if applying change analysis to the narrative reports made by reviewers of hospital deaths increases the utility of this information in the systematic analysis of patient harm. DESIGN: Qualitative analysis of causes and contributory factors underlying patient harm in 52 case narratives linked to preventable deaths derived from a retrospective case record review of 1000 deaths in acute National Health Service Trusts in 2009. PARTICIPANTS: 52 preventable hospital deaths. SETTING: England. MAIN OUTCOME MEASURES: The nature of problems in care and contributory factors underlying avoidable deaths in hospital. RESULTS: The change analysis approach enabled explicit characterisation of multiple problems in care, both across the admission and also at the boundary between primary and secondary care, and illuminated how these problems accumulate to cause harm. It demonstrated links between problems and underlying contributory factors and highlighted other threats to quality of care such as standards of end of life management. The method was straightforward to apply to multiple records and achieved good inter-rater reliability. CONCLUSION: Analysis of case narratives using change analysis provided a richer picture of healthcare-related harm than the traditional approach, unpacking the nature of the problems, particularly by delineating omissions from acts of commission, thus facilitating more tailored responses to patient harm.

An audit of pharyngeal gonorrhoea treatment in a public sexual health clinic in Adelaide, South Australia.

In recent times there have been changes to guidelines regarding the management of gonorrhoea, from both the Centers for Disease Control and Prevention in 2010 and the British Association for Sexual Health and HIV (BASHH) in 2011. Coinciding with their release we conducted a clinical audit of our treatment protocol for gonorrhoea. In 2010, local data on the minimum inhibitory concentrations for Neisseria gonorrhoeae indicated an increase in local isolates that were less sensitive to ceftriaxone (11.6% c.f. 5.3% in 2009). We have a long history of using 250 mg of ceftriaxone to treat all standard sites of gonorrhoea infection followed with tests of cure in all cases. In a retrospective clinical audit of an 11-year period from 2000 up to and including 2010 we identified six test-of-cure failures over 11 years after treating a total of 215 patients with pharyngeal gonorrhoea.

Online audit and feedback improve fetal second-trimester four-chamber view images: a randomised controlled trial.

OBJECTIVES: We aimed to study the impact of online audit and feedback on fetal four-chamber view image quality. METHODS: Ultrasonographers uploaded a set of four-chamber views from 10 consecutive screening examinations and a second set 3 months later. They were randomised to receive (group A) or not (group B) a feedback for their first set. The primary outcome was the difference in image mean score and in percentage of inadequate images between the first set and the second set, comparing the groups with and without feedback. RESULTS: There were 258 ultrasonographers who completed the trial (group A: 122; group B: 136), and 5160 images were audited. In both groups, the mean score increased. In group A, it rose from 17.0 to 18.5 (p < 0.0001), and in group, B from 17.6 to 18.3 (p < 0.0001). The improvement was greater in group A than in group B (1.5 vs. 0.7, p = 0.0007). The mean percentage of inadequate images decreased in both groups. In group A, it dropped from 32% to 19% (p < 0.0001), and in group B, from 26% to 21% (p = 0.012). The decrease was greater in group A than in group B (13% vs. 5%, p = 0.007). CONCLUSIONS: Image quality improved following online audit, the improvement being slightly greater with feedback.

COCPIT: a tool for integrated care pathway variance analysis.

Electronic Health Record (EHR) data has the potential to track patients' journeys through healthcare systems. Many of those journeys are supposed to follow Integrated Care Pathways (ICPs) built on evidence based guidelines. An ICP for a particular condition sets out "what should happen", whereas the EHR records "what did happen". Variance analysis is the process by which the difference between expected and actual care is identified. By performing variance analysis over multiple patients, patterns of deviation from idealised care are revealed. The use of ICP variance analysis, however, is not as widespread as it could be in healthcare quality improvement processes - we argue that this is due to the difficulty of combining the required specialist knowledge and skills from different disciplines. COCPIT (Collaborative Online Care Pathway Investigation Tool) was developed to overcome this difficulty and provides clinicians and health service managers with a web-based tool for Care Pathway Variance Analysis.

Can the APO method be used for measuring soft data?: a pilot study.

OBJECTIVES: The aims were to develop auditing according to the APO (Audit Project Odense) method for measuring soft data, exemplified by a holistic view, and to test the instrument. DESIGN: A descriptive study of the development of an APO chart and a test registration. SETTING: Primary health care, Blekinge County, Sweden. SUBJECTS: Ten general practitioners (GPs) were invited to transform categories of the concept of a holistic view obtained in an earlier study, into 30 variables on an APO registration chart. The participants chose to study different kinds of knowledge as aspects of holistic care. MAIN OUTCOME MEASURE: An APO registration chart and test of the instrument. RESULTS: After three meetings the group had drawn up an APO registration chart supplemented with Likert scales. A pilot audit was performed. Eight doctors registered 255 consultations. In assessment of the patients' problems, factual medical knowledge was important in 83% of the cases, familiarity in 53%, and a capacity for judgement in 36%. In decision-making factual medical knowledge was used in 88% and capacity for judgement in 58%. A holistic view was necessary for the outcome in 43% and valuable in 25%. The GPs used the Likert scales in a majority of the cases. CONCLUSIONS: In this first step in developing an instrument, the results indicate that the APO method could be an alternative for studying what happens in the consultation, and the occurrence of an abstract phenomenon such as the use of different kinds of knowledge as part of a holistic view.

Drug allergy documentation--time for a change?

OBJECTIVE OF THE STUDY: To audit patients' allergy documentation in a large rural hospital an to make recommendations about accurate drug allergies in hospital settings. SETTING: A 257 bed large hospital and fully integrated health service in Australia, providing a range of services including; medicine, surgery, aged care, cancer care, mental health, maternity and rehabilitation. METHOD: A retrospective design was used to fulfil the aims of this study. Patient medical records were randomly selected and checked for allergy documentation over a 6 month period. RESULTS: A total of 521 patients' medical records were reviewed. Of all the medical records examined in total, 269 (52%) had no allergy, while 252 (48%) reported some kind of allergy. Overall, only three patients (0.6%) had their allergy details fully and accurately recorded in the three places audited and they are the front cover of the patients' notes, the admission notes and the drug chart. CONCLUSION: Many preventable medical errors are caused by poor documentation which is often due to lack of drug allergy information. All health professional should be more pro-active in determining the manner of any drug allergy or adverse drug reactions (ADR) along with the extent of the reaction.

An audit of the prevalence of recorded nicotine dependence treatment in an Australian psychiatric hospital.

OBJECTIVES: To investigate the prevalence of recorded smoking status, nicotine dependence assessment, and nicotine dependence treatment provision; and to examine the patient characteristics associated with the recording of smoking status. METHOD: A retrospective systematic medical record audit was conducted of all psychiatric inpatient discharges over a six-month period (1 September 2005 to 28 February 2006), at a large Australian psychiatric hospital, with approximately 2,000 patient discharges per year. A one-page audit tool identifying patient characteristics and prevalence of recorded nicotine dependence treatment, and requiring ICD-10-AM diagnoses coding was used. RESULTS: From 1,012 identified discharges, 1,000 medical records were available for audit (99%). Documentation of smoking status most frequently occurred on the admission form (28.8%) and diagnoses summary (41.6%). Documentation of nicotine dependence was not found in any record, and recording of any nicotine dependence treatment was negligible (0-0.5%). The rate of recorded smoking status on discharge summaries was 6%. Patients with a diagnosis of alcohol, cannabis, sedative use disorders or asthma were twice as likely to have their smoking status recorded compared to those who did not have these diagnoses. CONCLUSIONS: Mental health services, by failing to diagnose and document treatment for nicotine dependence, do not conform to current clinical practice guidelines, despite nicotine dependence being the most commonly diagnosed psychiatric disorder. IMPLICATIONS: Considerable system change and staff support is required to provide an environment where a primary prevention approach such as smoking care can be sustained.

Improved quality monitoring of multi-center acupuncture clinical trials in China.

BACKGROUND: In 2007, the Chinese Science Division of the State Administration of Traditional Chinese Medicine(TCM) convened a special conference to discuss quality control for TCM clinical research. Control and assurance standards were established to guarantee the quality of clinical research. This paper provides practical guidelines for implementing strict and reproducible quality control for acupuncture randomized controlled trials (RCTs). METHODS: A standard quality control program (QCP) was established to monitor the quality of acupuncture trials. Case report forms were designed; qualified investigators, study personnel and data management personnel were trained. Monitors, who were directly appointed by the project leader, completed the quality control programs. They guaranteed data accuracy and prevented or detected protocol violations. Clinical centers and clinicians were audited, the randomization system of the centers was inspected, and the treatment processes were audited as well. In addition, the case report forms were reviewed for completeness and internal consistency, the eligibility and validity of the patients in the study was verified, and data was monitored for compliance and accuracy. RESULTS AND DISCUSSION: The monitors complete their reports and submit it to quality assurance and the sponsors. Recommendations and suggestions are made for improving performance. By holding regular meetings to discuss improvements in monitoring standards, the monitors can improve quality and efficiency. CONCLUSIONS: Supplementing and improving the existed guidelines for quality monitoring will ensure that large multi-centre acupuncture clinical trials will be considered as valid and scientifically stringent as pharmaceutical clinical trials. It will also develop academic excellence and further promote the international recognition of acupuncture.

The difficulty of questioning clinical practice: experience of facility-based case reviews in Ouagadougou, Burkina Faso.

OBJECTIVE: To describe the implementation of facility-based case reviews (medical audits) in a maternity unit and their effect on the staff involved. DESIGN: Cross-sectional descriptive study. SETTING: A 26-bed obstetric unit in a district hospital in Ouagadougou, Burkina Faso. SAMPLE: Sixteen audit sessions conducted between February 2004 and June 2005. Thirty-five staff members were interviewed. METHODS: An analysis of all the tools used in the management of the audit was performed: attendance lists, case summary cards and register of recommendations. The perceptions of the staff about the audits were collected through a questionnaire administrated by an external investigator from 10 June 2005 to 16 June 2005. MAIN OUTCOME MEASURES: Session participation, types of problems identified, recommendations proposed and implemented and staff reaction to the audits. RESULTS: Only 7 midwives from a total of 15 regularly attended the sessions. Eighty-two percent of the recommendations made during the audits have been implemented, but sometimes after a delay of several months. Interviewed personnel had a good understanding of the audit goals and viewed audit as a factor in changing their practice. However, midwives highlighted problems of bad interpersonal communication and lack of anonymity during the audit sessions, and pointed out the difficulty of practising self-criticism. CONCLUSIONS: A lack of staff commitment and the resistance of maternity personnel to being evaluated by their peers or service users are reducing acceptance of routine audits. The World Health Organization must take all these factors into account when promoting the institutionalisation of medical audits in obstetrics.

Embedding quality improvement and patient safety at Liverpool Women's NHS Foundation Trust.

The provision of safe high-quality care in obstetrics and gynaecology is a key target in the UK National Health Service (NHS), in part because of the high cost of litigation in this area. Good risk management processes should improve safety and reduce the cost of litigation to the NHS. This chapter looks at structures and processes for improving quality and patient safety, using the stepwise approach described by the National Patient Safety Authority (NPSA). This encompasses building a safety culture, leading and supporting staff, integrating risk management activity, promoting reporting, involving and communicating with patients and the public, learning and sharing safety lessons, and implementing solutions to prevent harm. Examples from the Liverpool Women's NHS Foundation Trust are used to illustrate these steps, including how they were developed, what obstacles had to be overcome, ongoing challenges, and whether good risk management has translated into better, safer health care.

National audit of the sensitivity of double-contrast barium enema for colorectal carcinoma, using control charts For the Royal College of Radiologists Clinical Radiology Audit Sub-Committee.

AIM: To audit the sensitivity of double-contrast barium enema (DCBE) for colorectal carcinoma, as currently practised in UK departments of radiology. METHODS: As part of its programme of national audits, the Royal College of Radiologists Clinical Radiology Audit Sub-Committee undertook a retrospective audit of the sensitivity of DCBE for colorectal carcinoma during 2002. The following targets were set: demonstration of a lesion > or =95%; correct identification as a carcinoma > or =90%. RESULTS: Across the UK, 131 departments took part in the audit, involving 5454 examinations. The mean demonstration rate was 92.9% and the diagnosis rate was 85.9%, slightly below the targets set. The equivocal rate (lesion demonstrated, but not defined as malignant) was 6.9%, the perception failure rate was 2.8% and the technical failure rate was 4.4%. Control-chart methodology was used to analyze the data and to identify any departments whose performance was consistent with special-cause variation. CONCLUSION: When compared with the diagnosis rate (84.6%) and demonstration rate (92.7%) reported in the Wessex Audit 1995, [Thomas RD, Fairhurst JJ, Frost RA. Wessex regional audit: barium enema in colo-rectal carcinoma. Clin Radiol 1995;50:647-50.] a similar level of performance was observed in the NHS today, implying that the basic process for undertaking and reporting DCBE has remained relatively unchanged over the last few years. Improvement in the future will require fundamental changes to the process of reporting DCBE, in order to minimize the perception failure rate and accurately to describe lesions, so reducing the equivocal rate. Control-chart methodology has a useful role in identifying strategies to deliver continual improvement.