Improving Barriers to Timely Colonoscopies: A New Approach to Overcoming Gaps in Medical Care.

This study investigates delays in transitioning from positive noninvasive multitarget stool DNA test results to scheduled diagnostic colonoscopies and identifies strategies aimed at improving patient care. A retrospective review revealed a 53% reduction in the average time from positive multitarget stool DNA test results to ordering colonoscopies postintervention. The findings demonstrate the significance of implementing a new communication system to expedite transitions in health care processes, showcasing its potential to significantly improve efficiency in patient care and health care provider workflows across various clinical testing scenarios. The findings emphasize the transformative impact of this communication system, shedding light on its ability to streamline processes and enhance patient care and staff experience.

The CLABSI Playbook: Design and Implementation of a Multipronged Approach to Decrease CLABSIs.

ABSTRACT: Central line-associated blood stream infections (CLABSIs) are a quality marker for the critical care environment. They have become an area of particular interest because they cost the healthcare system close to a billion dollars per year and have a significant impact on patient safety. Through a preliminary analysis of our system's CLABSI rates, we found significantly higher rates than the national average, prompting further investigation. We decreased our CLABSI rate by over 40% from 2021 (1.6 per 1,000 line days) to the fourth quarter of 2022 (0.91) and kept the rate below or around the national rate (0.86) for the last three quarters of 2022. Through looking at current outcome data, identifying key stakeholders, developing dedicated committees, conducting root cause analyses, monitoring progress, adjusting procedures, scaling to the system, and continuously monitoring and reporting results, we have shown the efficacy of this kind of quality improvement structure and strive to reduce our hospital system's impact on avoidable healthcare-associated patient harm.

Improving Maternal Health Care Quality and Outcomes: Evaluation of a Pregnancy Medical Home.

Current maternal care recommendations in the United States focus on monitoring fetal development, management of pregnancy complications, and screening for behavioral health concerns. Often missing from these recommendations is support for patients experiencing socioeconomic or behavioral health challenges during pregnancy. A Pregnancy Medical Home (PMH) is a multidisciplinary maternal health care team with nurse navigators serving as patient advocates to improve the quality of care a patient receives and health outcomes for both mother and infant. Using bivariate comparisons between PMH patients and reference groups, as well as interviews with project team members and PMH graduates, this evaluation assessed the impact of a PMH at an academic medical university on patient care and birth outcomes. This PMH increased depression screenings during pregnancy and increased referrals to behavioral health care. This evaluation did not find improvements in maternal or infant birth outcomes. Interviews found notable successes and areas for program enhancement.

Why the Indian Health Care Improvement Act Has Failed to Effectively Fund Workforce Development for the Indian Health Service.

The Indian Health Service (IHS) faces severe workforce shortages due to underfunding and underdevelopment of clinical training programs. Unlike other direct federal health care systems that have implemented clinical training paradigms as central parts of their success, the IHS has no formalized process for developing such programs internally or in partnership with academic institutions. While the Indian Health Care Improvement Act (IHCIA) authorizes mechanisms by which the IHS can support overall workforce development, a critical portion of the act (U.S. Code 1616p) intended for developing clinical training programs within the agency remains unfunded. Here, we review the funding challenges of the IHCIA, as well as its authorized and funded workforce development programs that have only partially addressed workforce shortages. We propose that through additional funding to 1616p, the IHS could implement clinical training programs needed to prepare a larger workforce more capable of meeting the needs of American Indian/Alaska Native communities.

Barriers and enablers for externally and internally driven implementation processes in healthcare: a qualitative cross-case study.

BACKGROUND: Quality in healthcare is a subject in need of continuous attention. Quality improvement (QI) programmes with the purpose of increasing service quality are therefore of priority for healthcare leaders and governments. This study explores the implementation process of two different QI programmes, one externally driven implementation and one internally driven, in Norwegian nursing homes and home care services. The aim for the study was to identify enablers and barriers for externally and internally driven implementation processes in nursing homes and homecare services, and furthermore to explore if identified enablers and barriers are different or similar across the different implementation processes. METHODS: This study is based on an exploratory qualitative methodology. The empirical data was collected through the 'Improving Quality and Safety in Primary Care - Implementing a Leadership Intervention in Nursing Homes and Homecare' (SAFE-LEAD) project. The SAFE-LEAD project is a multiple case study of two different QI programmes in primary care in Norway. A large externally driven implementation process was supplemented with a tracer project involving an internally driven implementation process to identify differences and similarities. The empirical data was inductively analysed in accordance with grounded theory. RESULTS: Enablers for both external and internal implementation processes were found to be technology and tools, dedication, and ownership. Other more implementation process specific enablers entailed continuous learning, simulation training, knowledge sharing, perceived relevance, dedication, ownership, technology and tools, a systematic approach and coordination. Only workload was identified as coincident barriers across both externally and internally implementation processes. Implementation process specific barriers included turnover, coping with given responsibilities, staff variety, challenges in coordination, technology and tools, standardizations not aligned with work, extensive documentation, lack of knowledge sharing. CONCLUSION: This study provides understanding that some enablers and barriers are present in both externally and internally driven implementation processes, while other are more implementation process specific. Dedication, engagement, technology and tools are coinciding enablers which can be drawn upon in different implementation processes, while workload acted as the main barrier in both externally and internally driven implementation processes. This means that some enablers and barriers can be expected in implementation of QI programmes in nursing homes and home care services, while others require contextual understanding of their setting and work.

Integrating a Community-Based Health Information System with a Patient-Centered Medical Home to improve care of patients with hypertension: a longitudinal observational study protocol.

BACKGROUND: The primary healthcare system in Pakistan focuses on providing episodic, disease-based care. Health care for low-middle income communities is largely through a fee-for-service model that ignores preventive and health-promotive services. The growing burden of cardiovascular illnesses requires restructuring of the primary health care system allowing a community-to-clinic model of care to improve patient- and community-level health indicators. METHODS: We propose a model that integrates a Patient-Centered Medical Home (PCMH) with a Community-Based Health Information System (CBHIS) using hypertension (HTN) as an example. This protocol describes the integration and evaluation of the PCMH-CBHIS infrastructure through a population-based, observational, longitudinal study in a low-middle income, urban community in Pakistan. Participants are being enrolled in CBHIS and will be followed longitudinally over two years for HTN outcomes. A mixed-methods approach is adopted to evaluate the process of integrating PCMH with CBHIS. This involves building partnerships with the community through formal and informal meetings, focus group discussions, and a household health assessment survey (HAS). Community members identified with HTN are linked to PCMH for disease management. A customized electronic medical record system links community-level data with patient-level data to track changes in disease burden. The RE-AIM evaluation framework will be used to monitor community and individual-level metrics to guide implementation assessment, the potential for generalization, and the effectiveness of the PCMH in improving HTN-related health outcomes. Ethical clearance has been obtained from the Ethics Review Committee at Aga Khan University (2022-6723-20985). DISCUSSION: This study will evaluate the value of restructuring the primary care health system by ensuring systematic community engagement and measurement of health indicators at the patient- and community-level. While HTN is being used as a prototype to generate evidence for the effectiveness of this model, findings from this initiative will be leveraged towards strengthening the management of other acute and chronic conditions in primary care settings. If effective, the model can be used in Pakistan and other LMICs and resource-limited settings.

Development of a Web-Based Oxygenation Dashboard for Preterm Neonates: A Quality Improvement Initiative.

BACKGROUND: Preterm neonates are extensively monitored to require strict oxygen target attainment for optimal outcomes. In daily practice, detailed oxygenation data are hardly used and crucial patterns may be missed due to the snapshot presentations and subjective observations. This study aimed to develop a web-based dashboard with both detailed and summarized oxygenation data in real-time and to test its feasibility to support clinical decision making. METHODS: Data from pulse oximeters and ventilators were synchronized and stored to enable real-time and retrospective trend visualizations in a web-based viewer. The dashboard was designed based on interviews with clinicians. A preliminary version was evaluated during daily clinical rounds. The routine evaluation of the respiratory condition of neonates (gestational age < 32 weeks) with respiratory support at the NICU was compared to an assessment with the assistance of the dashboard. RESULTS: The web-based dashboard included data on the oxygen saturation (SpO2), fraction of inspired oxygen (FiO2), SpO2/FiO2 ratio, and area < 80% and > 95% SpO2 curve during time intervals that could be varied. The distribution of SpO2 values was visualized as histograms. In 65% of the patient evaluations (n = 86) the level of hypoxia was assessed differently with the use of the dashboard. In 75% of the patients the dashboard was judged to provide added value for the clinicians in supporting clinical decisions. CONCLUSIONS: A web-based customized oxygenation dashboard for preterm neonates at the NICU was developed and found feasible during evaluation. More clear and objective information was found supportive for clinicians during the daily rounds in tailoring treatment strategies.

A multiphase, multicentre development and validation of two maturity tools assessing the implementation of the FlaQuM co-creation roadmap.

As part of the new Flanders Quality Model (FlaQuM) towards sustainable quality management systems, a co-creation roadmap with 6 primary drivers and 19 building blocks that guides healthcare organizations has been developed. Currently, no assessment tool is available to monitor hospitals' quality management systems implementation according to this co-creation roadmap. Therefore, we aimed to measure the maturity of the implementation of the FlaQuM co-creation roadmap in hospitals. A three-phase approach in co-design with 19 hospitals started with defining the scope, followed by establishing content validity through a literature review, involvement of content experts (n = 47), 20 focus groups with content experts (n = 79), and a Delphi round with healthcare quality managers (n = 19) to test the content validity index. Construct validity was assessed by confirmatory factor analyses and convergent validity by Spearman's ρ correlation coefficients. Based on 17 included existing maturity instruments and subcomponents of content experts, two maturity tools were developed according to the implementation of the FlaQuM co-creation roadmap: (i) a maturity matrix with 52 subcomponents and (ii) a co-creation scan with 19 statements. The overall scale-content validity index varied between 93.3% and 90.0% in terms of relevance and clarity, respectively. In a sample of 119 healthcare professionals, factor analyses revealed a six-factor structure and 16 (84.2%) of the 19 hypothesis for testing convergent validity between both maturity tools were statistically significant. Measuring the implementation of the FlaQuM co-creation roadmap and monitoring its maturity over time should be feasible by using these comprehensive maturity tools in hospitals. Results of both tools should be able to describe the current state of hospitals' implementation of the co-creation roadmap as basis for strategic improvement plans and next steps.

Process management program to prevent falls in hospitalized patients with neuropsychiatric disorders: a quality improvement program.

BACKGROUND: Falls were among the most common adverse nursing events. The incidence of falls in patients with neuropsychiatric disorders was high, and the occurrence of falls not only caused physical and psychological harm to patients but also led to medical disputes. Therefore, interventions for falls prevention were essential, but evaluations of the intervention process were lacking. METHODS: In this study, a process management program to prevent falls based on the "structure-process-outcome" quality evaluation model was designed and applied to the clinical practice of falls prevention in hospitalized patients with neuropsychiatric disorders. The process quality evaluation checklist to prevent falls was used to supervise the implementation effect of intervention measures to prevent falls, identify the problems in the intervention measures, and make continuous improvements, to reduce the incidence of falls in such hospitalized patients as the final index. RESULTS: The incidence of inpatient falls decreased from 0.199‰ (0.199 per 1000 patient-days) to 0.101‰ (0.101 per 1000 patient-days) before and after the implementation of the process management program for 12 months, 24 months, and 36 months, respectively, and the difference was statistically significant (P < .05). The probability of falls was reduced by 49% after 36 months of monitoring. Furthermore, the proportion of patients at high risk of falls exhibited a downward trend. CONCLUSION: This quality improvement program was feasible and effective at reducing falls in hospitalized patients with neuropsychiatric disorders. Therefore, attention should be given to monitoring process quality in the management of falls.

Bypassing the Brick-and-Mortar Hospital: Increasing Direct Admissions from the Emergency Department to Inpatient Hospital-at-Home.

Home hospital programs continue to grow across the United States. There are limited studies around the process of patient selection and successful acquisition from the emergency department. The article describes how an interdisciplinary team used quality improvement methodology to significantly increase the number of admissions directly from the emergency department to the Advanced Care at Home program.

Improving Parental Knowledge of Medically Complex Neonates Through Scheduled Conferences.

Reports of parental dissatisfaction from incomplete or inconsistent information led to a quality improvement (QI) project to establish planned family conferences at 10 days and 1 month of life, for 50% of the medically complex neonates admitted to a neonatal intensive care unit within 1 year. A QI team instituted a system in which social workers scheduled family conferences and a neonatologist conducted the conferences. Team members tracked measures using statistical process control charts over 21 months. The QI team scheduled conferences for greater than 80% of eligible families, with an 86% completion rate on days 10 and 30, exceeding project goals of 50%. The majority of the families surveyed were satisfied with the meetings. Only 2% of parents surveyed found meetings burdensome, compared to 14% of physicians. A sustainable method for scheduling meetings and preparation for conferences, including the use of a template led to success.

Involving the Patient and Family in the Transfer of Information at Shift Change in a Pediatric Emergency Department.

BACKGROUND: The transfer of information at the change of shift is a critical point for patient experience during the care process. The aim of this study was to evaluate caregivers' perceptions before and after the implementation of a multidisciplinary bedside handoff in a pediatric emergency department (PED). METHODS: This was a quality improvement pre-post intervention, single-center study. The authors included caregivers of patients allocated in the observation unit of a PED during health care provider shift change. The study was made up of the following phases: (1) preintervention survey distribution, (2) implementation of the bedside handoff, involving all health care professionals (including nurses, nursing assistants, and pediatricians) and caregivers, and (3) postintervention survey distribution. The survey explored the three dimensions of patient experience defined as main study outcomes: information received and communication with professionals, participation, and continuity of care. RESULTS: A total of 102 surveys were collected (51 each in the preintervention and postintervention phases). In the preintervention phase, 94.1% of caregivers would have wished to be actively involved in the change of shift. In the postintervention phase, more caregivers felt that professionals had proper introductions (49.0% vs. 84.3%; p < 0.01), had kept them informed of the plan to be followed (58.8% vs. 84.3%; p = 0.02), and encouraged questions (45.1% vs. 82.4%; p < 0.01). Caregivers of the postintervention phase perceived less disorganization during the change of shift (25.5% vs. 5.9%; p = 0.01) and a greater sense of continuity (64.7% vs. 86.3%; p = 0.02). CONCLUSION: The bedside handoff is a useful strategy to improve patient and family perceptions of communication with professionals, information received, and continuity of care at health care providers shift change. Future lines of research and improvement include ensuring equity in participation in the bedside handoff for all caregivers, monitoring the handoffs to determine how often patients/caregivers participate and correct mistakes in information transfer. and exploring professionals' perceptions.

Improving Outcomes in Patients Sent to the Emergency Department from Outpatient Providers: A Receiver-Driven Handoff Process Improvement.

BACKGROUND: Outpatient providers refer to emergency departments (EDs) due to findings requiring assessment beyond existing capabilities. However, poor communication surrounding these transitions may hinder safety and timeliness of emergency care. Receiver-driven handoff (RDH) is a process that helps ensure that all pertinent information is shared. This quality improvement project aimed to (1) improve knowledge of RDH, (2) increase satisfaction and perceptions surrounding RDH, (3) modify behaviors in relation to RDH, and (4) decrease referred patients leaving without being seen (LWBS). METHODS: The Iowa Model and Implementation Framework guided this evidence-based quality improvement project. A multidisciplinary team developed and implemented a standardized RDH process consisting of screening to determine whether a patient was referred to the ED, review of electronic health record (EHR), and use of EHR documentation. Process measures were collected via questionnaire pre- and postimplementation and were analyzed quantitatively. Outcome measures were trended by a statistical process control p-chart, which was developed to demonstrate changes in the percentage of patients who were referred to the ED from the outpatient setting and LWBS. RESULTS: The average response for the question "How satisfied are you with the handoff of patient information from referring clinic providers to the ED?" increased from 1.51 preintervention to 2.04 postintervention (p = 0.005). Respondents rated the information received during handoff higher postintervention (2.12 vs. 2.52, p = 0.04). Compliance with screening for referral to the ED was 84.0%. The proportion of patients LWBS after referral decreased by 6.2 percentage points (p < 0.001). CONCLUSION: Using RDH in conjunction with a standardized triage screening may improve quality of information shared during this vulnerable transition and may assist in reduction of referred patients LWBS. The RDH process should be adapted into everyday workflow to ensure sustainability and effectiveness.

Development and Evaluation of I-PASS-to-PICU: A Standard Electronic Template to Improve Referral Communication for Interfacility Transfers to the Pediatric ICU.

BACKGROUND: Miscommunication during interfacility handoffs to a higher level of care can harm critically ill children. Adapting evidence-based handoff interventions to interfacility referral communication may prevent adverse events. The objective of this project was to develop and evaluate a standard electronic referral template (I-PASS-to-PICU) to improve communication for interfacility pediatric ICU (PICU) transfers. METHODS: I-PASS-to-PICU was iteratively developed in a single PICU. A core PICU stakeholder group collaboratively designed an electronic health record (EHR)-supported clinical note template by adapting elements from I-PASS, an evidence-based handoff program, to support information exchange between referring clinicians and receiving PICU physicians. I-PASS-to-PICU is a receiver-driven tool used by PICU physicians to guide verbal communication and electronic documentation during PICU transfer calls. The template underwent three cycles of iterative evaluation and redesign informed by individual and group interviews of multidisciplinary PICU staff, usability testing using simulated and actual referral calls, and debriefing with PICU physicians. RESULTS: Individual and group interviews with 21 PICU staff members revealed that relevant, accurate, and concise information was needed for adequate admission preparedness. Time constraints and secondhand information transmission were identified as barriers. Usability testing with six receiving PICU physicians using simulated and actual calls revealed good usability on the validated System Usability Scale (SUS), with a mean score of 77.5 (standard deviation 10.9). Fellows indicated that most fields were relevant and that the template was feasible to use. CONCLUSION: I-PASS-to-PICU was technically feasible, usable, and relevant. The authors plan to further evaluate its effectiveness in improving information exchange during real-time PICU practice.

Navigating Transitions in Oncology Care: From Emergency Department to Outpatient Clinic.

OBJECTIVE: This quality improvement project was a collaborative effort with Penn Medicine's emergency department (ED) and oncology nurse navigators (ONNs). The goal of the project was to streamline patient transitions from the ED to the outpatient oncology clinic by developing a standardized referral process. The main objectives were to simplify and automate the referral process using the electronic medical record, improve multidisciplinary communication across the care continuum, ensure timely follow-up, and address barriers to oncology care. METHODS: The ED providers placed a consult to ONNs. The ONNs reached out to the patient within 48 hours of the consult. They maintained a database of patient referrals and collected information such as patient demographics, reason for referral, insurance, and patient outcomes. RESULTS: The ED providers referred 204 patients to the ONNs from April 2022 to September 2023. The development of a standardized referral process from the ED to the outpatient oncology clinic proved successful. Of the patients referred, the ONNs facilitated 98 cancer diagnoses and 80 of those patients are receiving oncology care at Penn Medicine. The median time to the patient's first appointments was seven days, diagnosis was 15 days, and treatment initiation occurred within 32 days. CONCLUSION: The project team achieved their goal of facilitating timely access to oncology care, ensuring continuity, and addressing patient-specific barriers. IMPLICATIONS FOR NURSING PRACTICE: This quality improvement initiative highlights the ONNs' role in enhancing access and equity in cancer care delivery. The success of the project underscores the ONN's expertise and leadership in addressing healthcare disparities in oncology care. Collaboratively, the teams created a new referral workflow improving care transitions from the ED to the outpatient oncology clinic. The project sets a precedent for optimizing patient care transitions, demonstrating the positive impact of ONNs as key members of the multidisciplinary healthcare team.

Improving outcomes in emergency general surgery: Construct of a collaborative quality initiative.

BACKGROUND: Emergency general surgery conditions are common, costly, and highly morbid. The proportion of excess morbidity due to variation in health systems and processes of care is poorly understood. We constructed a collaborative quality initiative for emergency general surgery to investigate the emergency general surgery care provided and guide process improvements. METHODS: We collected data at 10 hospitals from July 2019 to December 2022. Five cohorts were defined: acute appendicitis, acute gallbladder disease, small bowel obstruction, emergency laparotomy, and overall aggregate. Processes and inpatient outcomes investigated included operative versus nonoperative management, mortality, morbidity (mortality and/or complication), readmissions, and length of stay. Multivariable risk adjustment accounted for variations in demographic, comorbid, anatomic, and disease traits. RESULTS: Of the 19,956 emergency general surgery patients, 56.8% were female and 82.8% were White, and the mean (SD) age was 53.3 (20.8) years. After accounting for patient and disease factors, the adjusted aggregate mortality rate was 3.5% (95% confidence interval [CI], 3.2-3.7), morbidity rate was 27.6% (95% CI, 27.0-28.3), and the readmission rate was 15.1% (95% CI, 14.6-15.6). Operative management varied between hospitals from 70.9% to 96.9% for acute appendicitis and 19.8% to 79.4% for small bowel obstruction. Significant differences in outcomes between hospitals were observed with high- and low-outlier performers identified after risk adjustment in the overall cohort for mortality, morbidity, and readmissions. The use of a Gastrografin challenge in patients with a small bowel obstruction ranged from 10.7% to 61.4% of patients. In patients who underwent initial nonoperative management of acute cholecystitis, 51.5% had a cholecystostomy tube placed. The cholecystostomy tube placement rate ranged from 23.5% to 62.1% across hospitals. CONCLUSION: A multihospital emergency general surgery collaborative reveals high morbidity with substantial variability in processes and outcomes among hospitals. A targeted collaborative quality improvement effort can identify outliers in emergency general surgery care and may provide a mechanism to optimize outcomes. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

A Quality Improvement Project to Support Post-Intensive Care Unit Patients with COVID-19: Structured Telephone Support.

BACKGROUND: More than 50% of intensive care unit (ICU) survivors suffer from long-lasting physical, psychosocial, and cognitive health impairments, also called "post-intensive care syndrome" (PICS). Intensive care admission during the COVID-19 pandemic was especially uncertain and stressful, both for patients and for their family. An additional risk of developing symptoms of PICS was feared in the absence of structural aftercare for the patient and family shortly after discharge from the hospital. The purpose of this quality improvement study was to identify PICS symptoms and to support post-intensive care patients and families in the transition from the hospital to the home. Therefore, we offered post-ICU patients and families structured telephone support (STS). METHODS: This was a quality improvement study during the 2019 COVID-19 pandemic. A project team developed and implemented a tool to structure telephone calls to identify and order symptoms according to the PICS framework and to give individual support based on this information. We supported post-ICU patients diagnosed with COVID-19 pneumonia and their family caregivers within four weeks after hospital discharge. The reported findings were both quantitative and qualitative. RESULTS: Forty-six post-ICU patients received structured telephone support and reported symptoms in at least one of the three domains of the PICS framework. More than half of the patients experienced a loss of strength or condition and fatigue. Cognitive and psychological impairments were reported less frequently. Family caregivers reported fewer impairments concerning fatigue and sleeping problems and expressed a need for a continuity of care. Based on the obtained information, the ICU nurse practitioners were able to check if individual care plans were optimal and clear and, if indicated, initiated disciplines to optimize further follow-up. CONCLUSIONS: The implementation of the STS tool gave insight in the impairments of post-ICU patients. Surprisingly, family caregivers expressed fewer impairments. Giving support early after hospital discharge in a structured way may contribute to providing guidance in the individual care plans and treatment of the early symptoms of PICS (-F).