Implementing a new multidisciplinary, remote, dementia staff training program for Veterans affairs nursing homes.

BACKGROUND: Preventing Loss of Independence through Exercise (PLIÉ) is a group program for people living with dementia that combines movements to support daily function with present moment body awareness and social engagement that has been found to have physical, emotional, social, and cognitive benefits. The goal of this study was to develop and refine a PLIÉ remote training program for interdisciplinary Veterans Affairs (VA) nursing home staff members also known as community living center (CLC) staff. METHODS: This pre-implementation study used iterative Plan-Do-Study-Act (PDSA) cycles. The 10-week PDSA cycles occurred from June to September 2021 at 2 VA nursing home sites. Remote training was delivered via Microsoft Teams and included 1-hour live-streamed weekly didactic sessions (nursing staff with PLIÉ instructor) focused on PLIÉ principles and 1-hour weekly live-streamed experiential sessions for staff to apply PLIÉ principles with residents. We administered weekly feedback surveys to iteratively refine the training process. RESULTS: 14 staff members participated (5 recreation therapists, 3 social workers, 2 registered nurses, 2 chaplains, 1 psychologist, and 1 speech pathologist). The experiential sessions were rated as most helpful overall. Key PDSA refinements included: (1) creating 10-minute video recording summaries to support learning, particularly for those unable to attend live training sessions due to clinical schedules; and (2) incorporating self-reflection and goal setting to support staff incorporation of PLIÉ principles into routine care and personal life. These refinements resulted in increased use of PLIÉ principles with the residents from 67 to 89% of the staff participants. 100% of regular attendees (11/11) rated their overall satisfaction with remote training as "very good" or "excellent." CONCLUSIONS: It was feasible to train interdisciplinary CLC staff participants to deliver an integrative group movement program for residents with dementia remotely. PDSA cycles supported refinement of the training process and improved uptake. A larger study of PLIÉ remote CLC staff training is needed to assess outcomes on residents and quality of care.

Quality improvement approach to reduce patient cycle time at a student-run free healthcare clinical network.

BACKGROUND: The University of Florida (UF) Equal Access Clinic Network (EACN) is the largest student-run free healthcare clinic network in Florida. The UF EACN serves those who are underinsured or uninsured in Alachua County and its surrounding area. Nationally, average total clinic time per medical visit has been established to be 84 min. PROBLEM: Before this project, average patient cycle time at the UF EACN was 125.3 min, and there was no established quality improvement (QI) team to implement changes to address inefficiencies. METHODS: This was a prospective QI study that recorded patient cycle times for patients who received healthcare at any of the four primary care free clinics across the UF EACN from 5 July 2022 to 6 April 2023. INTERVENTIONS: Eighteen Plan-Do-Study-Act cycles were tailored to each of the four primary care clinic's needs with a focus on reducing patient cycle time by addressing the following identified problems: prolonged intake process, translation services, limited numbers of volunteers, and other inefficiencies and bottlenecks in workflow. RESULTS: The median patient cycle time at the EACN shifted from 125.3 min to 112.7 min over a nine month period. This drop of 12.6 min meant patients saw a 10.1% reduction in patient cycle time across the EACN. CONCLUSION: Underserved patients at EACN are experiencing increased value by having shorter patient cycle times.

Continuous quality improvement in a community-wide TB screening and prevention programme in Papua New Guinea.

SETTING: Daru Island in Papua New Guinea (PNG) has a high prevalence of TB and multidrug-resistant TB (MDR-TB). OBJECTIVE: To evaluate the early implementation of a community-wide project to detect and treat TB disease and infection, outline the decision-making processes, and change the model of care. DESIGN: A continuous quality improvement (CQI) initiative used a plan-do-study-act (PDSA) framework for prospective implementation. Care cascades were analysed for case detection, treatment, and TB preventive treatment (TPT) initiation. RESULTS: Of 3,263 people screened for TB between June and December 2023, 13.7% (447/3,263) screened positive (CAD4TB or symptoms), 77.9% (348/447) had Xpert Ultra testing, 6.9% (24/348) were diagnosed with TB and all initiated treatment. For 5-34-year-olds without active TB (n = 1,928), 82.0% (1,581/1,928) had tuberculin skin testing (TST), 96.1% (1,519/1,581) had TST read, 23.0% (350/1,519) were TST-positive, 95.4% (334/350) were TPT eligible, and 78.7% (263/334) initiated TPT. Three PDSA review cycles informed adjustments to the model of care, including CAD4TB threshold and TPT criteria. Key challenges identified were meeting screening targets, sputum unavailability from asymptomatic individuals with high CAD4TB scores, and consumable stock-outs. CONCLUSION: CQI improved project implementation by increasing the detection of TB disease and infection and accelerating the pace of screening needed to achieve timely community-wide coverage.

CONTEXTE: L'île de Daru en Papouasie-Nouvelle-Guinée (PNG) présente une forte prévalence de la TB et de la TB multirésistante (MDR-TB). OBJECTIF: Évaluer la mise en œuvre précoce d'un projet à l'échelle de la communauté pour détecter et traiter la TB et l'infection, décrire les processus de prise de décision et changer le modèle de soins. CONCEPTION: Une initiative d'amélioration continue de la qualité (CQI, pour l'anglais « continuous quality improvement ¼) a utilisé un cadre de planification, d'action, d'étude, d'action (PDSA, pour l'anglais «plan-do-study-act ¼) pour la mise en œuvre prospective. Les cascades de soins ont été analysées pour la détection des cas, le traitement et l'initiation du traitement préventif de la TB. RÉSULTATS: Sur 3 263 personnes dépistées pour la TB entre juin et décembre 2023, 13,7% (447/3 263) ont été dépistées positives (CAD4TB ou symptômes), 77,9% (348/447) ont subi un test Xpert Ultra, 6,9% (24/348) ont reçu un diagnostic de TB et toutes ont commencé un traitement. Chez les 5 à 34 ans sans TB active (n = 1 928), 82,0% (1 581/1 928) ont subi un test cutané à la tuberculine (TCT), 96,1% (1 519/1 581) ont eu un test de dépistage du TCT, 23,0% (350/1 519) étaient positifs au TCT, 95,4% (334/350) étaient éligibles au TPT et 78,7% (263/334) ont initié le TPT. Trois cycles d'examen PDSA ont permis d'ajuster le modèle de soins, y compris le seuil CAD4TB et les critères TPT. Les principaux défis identifiés étaient l'atteinte des objectifs de dépistage, l'indisponibilité des expectorations chez les personnes asymptomatiques avec des scores CAD4TB élevés et les ruptures de stock de consommables. CONCLUSION: L'ACQ a amélioré la mise en œuvre du projet en augmentant la détection de la TB et de l'infection et en accélérant le rythme de dépistage nécessaire pour atteindre une couverture à l'échelle de la communauté en temps opportun.

Decreasing Patient Visit Length at a Student-Run Free Clinic via a Continuous Quality Improvement Project.

INTRODUCTION: The University of Florida Equal Access Clinic Network (EACN) is the largest student-run free clinic (SRFC) network in Florida. This student-driven, continuous quality improvement (CQI) project is intended to decrease total patient visit length at Eastside clinic, one of EACN's primary care sites. The original median visit length of 126.25 minutes represented a significant time burden for patients, especially those with limited transportation or inflexible schedules. METHODS: Over six months, four Plan-Do-Study-Act (PDSA) cycles were implemented. PDSA cycle 1 increased personnel and space for taking vitals. PDSA cycle 2 reduced redundancy in the intake process. PDSA cycle 3 triaged patients to match patient complexity with student experience level. PDSA cycle 4 introduced "nudge" interventions to reinforce clinic flow. Total patient visit length and time spent at each step of clinic flow were recorded anonymously for each patient visit. The median visit length per week was tracked on a run chart. RESULTS: From PDSA cycle 1 through PDSA cycle 4, the median visit length decreased from 126 minutes to 114 minutes. This shift was primarily driven by a decrease in the length of patient intake from a median of 19 minutes to 9 minutes. The run chart did not show clear trends until PDSA cycle 4, which demonstrated a strong downward trend. CONCLUSION: This study demonstrated the ability of a student-driven CQI model to decrease patient visit length in an SRFC setting. Similar models could be used to address this and other contributors to patient experience across SRFCs nationwide.

Nurse performed bladder ultrasound: a clinical quality improvement initiative.

Background: Bladder ultrasound (BUS) provides an accurate measurement of post-void residual (PVR) volume and bladder assessment. Access to BUS is dependent on practitioner availability with delays resulting in poor symptom management, delayed discharge and dissatisfaction. Developing nursing practice to perform BUS can address these patient's needs.Aims: Through a quality improvement initiative the aims were (1) to develop theoretical knowledge and practical competence of nurses to perform BUS, (2) to evaluate nursing activity in relation to BUS, (3) to evaluate stakeholders perceptions of the initiative.Methods: Based on the Deming Plan-Do-Study-Act (PDSA) cycle, an interprofessional team was created and a theoretical/practical based education program was devised. Activity in relation to the nurse-performed BUS was collected and analysed descriptively. Stakeholder perceptions were evaluated via patient and physician questionnaires subject to descriptive analysis and a focus group with nurses analysed descriptively.Results: The team developed a training program to perform BUS, certifying 11 nurses. Investigation of nursing activity related to BUS (n = 202) showed its use for PVR evaluation, and symptom and catheter assessment. It aided decision-making and nurse-physician communication. Stakeholders were satisfied with the initiative. Patients (n = 30) felt nurses were competent, clearly explaining the procedure, results and inspiring confidence. Physicians (n = 2) saw BUS as enhancing efficiency and care quality, while nurses (n = 7) felt this new skill enhanced nursing care providing a more holistic approach. Team reflection on the results of the evaluation confirmed BUS utility and activity, while nurses requested continuing education and a post-certification refresher course.Conclusion: Through reflection on clinical practice areas for improvement to enhance patient care were identified by the nursing team. Application of the PDSA cycle provided a structured approach to guide the quality improvement initiative. Improvements in nursing care and patient care processes have been observed and this has been a positive experience for stakeholders.

Using a quality improvement tool, Plan-Do-Study-Act cycle, to boost TB notification in India post-Covid-19 pandemic.

Quality improvement tools such as the Plan-Do-Study-Act (PDSA) cycle hold tremendous potential to improve the quality of healthcare in India. The electronic-PDSA tool was previously developed by CETI (Collaboration to Eliminate TB among Indians) and successfully piloted in small groups. In this study the e-PDSA was scaled up across the nation over a brief 10 week period to boost TB notification by training District Tuberculosis Officers (DTOs) virtually post-Covid-19 pandemic. Quality improvement counselors, who were interns from Masters in Public Health Institutions, were liaisons to "hand-hold" and assist the DTOs through the PDSA cycle. The course was voluntary and offered to all DTOs through Central TB Division and State TB Officers from May 2022 to July 2022. Of the 779 Districts in India and nearly equal number of DTOs, 546 (70%) DTOs enrolled in the course and of these 437 (80%) conducted a PDSA while 342 (43%) districts/DTOs did not enroll or did not complete a PDSA. With a baseline notification in February-March-April 2022 and intervention in May-June-July 2022; 55% of the districts in the PDSA group showed improvement in TB Notification compared to 45% in the non-PDSA group. When data was analyzed by population (not district) there was a trend in increase in notification post-pandemic in both PDSA and non-PDSA groups, and the PDSA group had a slightly higher 5.6 per 100,000 population improvement compared to 5.0 per 100,000 in the non-PDSA group. The cost of intervention was $40,000 or $92 per DTO for three months. The course was highly acceptable with DTOs rating 4.3 out of 5 in recommending the course to other DTOs. Our data shows that a large scale-up of the PDSA cycle is feasible, economical and effective with little additional resources. The focus was on increasing the efficiency of the existing processes well within the authority of the DTO. Repeat cycle of PDSA with notification and other measures such as presumptive sputum examination could significantly impact the program and help to achieve TB Free India.

The Plan-Do-Study-Act (PDSA): An Iterative Approach to Optimize Residents Performance in the American Board of Surgery in-Training Exam (ABSITE).

INTRODUCTION: American Board of Surgery (ABS) In-Training Examination (ITE), or ABSITE, preparation requires an effective study approach. In 2014, the ABS announced the alignment of ABSITE to the SCORE® Curriculum. We hypothesized that implementing a Plan-Do-Study-Act (PDSA) approach would help surgery residents improve their performance on the ABSITE. METHOD: Over 20 years, in a single institution, residents' ABSITE performance was evaluated over 3 timeframes: Time A (2004-2013), no specific curriculum; Time B (2014-2019), an annual comprehensive ABSITE-simulated SCORE®-based multiple-choice exam (MCQ) was administered; and Time C (2020-2023), like Time B with the addition of the PDSA approach for those with less than 60% correct on the ABSITE-simulated SCORE®-based exam. At the beginning of the academic year, in July, all residents are encouraged to (1) initiate a study plan for the upcoming ABSITE using SCORE® guided by the published ABSITE outlines content topics (Plan), (2) take an ABSITE-simulated SCORE®-based exam in October (Do), (3) assess the results/scores (Study), and (4) identify appropriate next steps (Act). Correlational analysis was performed to evaluate the association between ABSITE scores and ABSITE-simulated SCORE®-based exam scores in Time B and Time C. The primary outcome was the change in the proportions of ABSITE scores <30th percentile. RESULTS: A total of 294 ABSITE scores of 94 residents (34 females and 60 males) were analyzed. We found stronger correlation between the correct percentage on ABSITE and ABSITE-simulated SCORE®-based exam scores in Time C (r = 0.73, p < 0.0001) compared to Time B (0.62, p < 0.0001). The percentage of residents with ABSITE scores lower than 30th percentile dropped significantly from 14.0% to 3.7% (p = 0.016). CONCLUSION: Implementing the Plan-Do-Study-Act (PDSA) approach using the SCORE® curriculum significantly enhances residents' performance on the ABSITE exam. Surgery residents are encouraged to use this approach and to utilize the SCORE-contents outlined by the ABS in their study plan.

Using quality improvement frameworks to develop, implement, and evaluate a novel ambulatory oncology pharmacy practice model: A descriptive example.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: To describe the application of the Plan-Do-Study-Act quality improvement framework in the development, implementation, and evaluation of a novel pharmacy practice model in ambulatory oncology. SUMMARY: Four iterations of the Plan-Do-Study-Act framework were completed to develop a patient-facing, pharmacist-led ambulatory oncology clinic program. The clinic provided care to patients with prostate cancer on oral anticancer therapy. Metrics were collected throughout all stages of development to inform target processes for improvement. The pharmacist saw 136 patients between July 2019 and January 2023, resulting in 464 total encounters. The pharmacist provided clinical interventions and counseling to patients newly starting on oral anticancer therapy and those established on therapy using a longitudinal model of care. CONCLUSION: Application of the Plan-Do-Study-Act quality improvement framework to a novel pharmacy practice model supported the development, evaluation, and sustainability of a pharmacist-led ambulatory oncology clinic providing care to patients with prostate cancer on oral anticancer therapy.

Reducing Delays in MRIs Under Sedation and General Anesthesia Using Quality Improvement Tools.

OBJECTIVE: Develop structured, quality improvement interventions to achieve a 15%-point reduction in MRIs performed under sedation or general anesthesia (GA) delayed more than 15 min within a 6-month period. METHODS: A prospective audit of MRIs under sedation or GA from January 2022 to June 2023 was conducted. A multidisciplinary team performed process mapping and root cause analysis for delays. Interventions were developed and implemented over four Plan, Do, Study, Act (PDSA) cycles, targeting workflow standardization, preadmission patient counseling, reinforcing adherence to scheduled scan times and written consent respectively. Delay times (compared with Kruskal-Wallis and Dunn's tests), delays more than 15 min and delays of 60 min or more at baseline and after each PDSA cycle were recorded. RESULTS: In all, 627 MRIs under sedation or GA were analyzed, comprising 443 at baseline and 184 postimplementation. Of the 627, 556 (88.7%) scans were performed under sedation, 22 (3.5%) under monitored anesthesia care, and 49 (7.8%) under GA. At baseline, 71.6% (317 of 443) scans were delayed over 15 min and 28.2% (125 of 443) scans by 60 min or more, with a median delay of 30 min. Postimplementation, there was a 34.7%-point reduction in scans delayed more than 15 min, a 17.5%-point reduction in scans delayed by 60 min or more, and a reduction in median delay time by 15 min (P < .001). DISCUSSION: Structured interventions significantly reduced delays in MRIs under sedation and GA, potentially improving outcomes for both patients and providers. Key factors included a diversity of perspectives in the study team, continued stakeholder engagement and structured quality improvement tools including PDSA cycles.

Bridging technology and care: integrating web-based PROMs in mental health services for refugees: a study on clinician training and technology adoption.

This study explores the integration of a web-based electronic database technology containing patient-reported outcome measures (PROMs) with electronic health records for refugees with PTSD, emphasizing the systematic inclusion of patient perspectives in clinical decision-making. Our research addresses the notable gap in literature regarding training clinicians for the competent integration of health information technology in healthcare. The training program developed aimed at equipping clinicians, particularly inexperienced with technology, to effectively utilize an electronic PROM system for collecting systematic patient information. Our study is set in the context of the Mental Health Services (MHS) in Denmark, focusing on a specialized clinic for treating trauma-affected refugees. The multidisciplinary team involved in this project reflects a wide range of healthcare professionals. The training program employed a variety of activities over nearly 2 years, adapting to feedback and aiming to engage clinicians in continuous improvement processes. Analyzing qualitative data with thematic analysis we interpreted that the training's extended focus on discussion of the implementation process, with limited hands-on experience, potentially reinforced clinicians' hesitations toward new technology, rather than reducing them. Clinicians prioritized immediate concerns over potential long-term benefits. Despite this, their approach reflects a strong commitment to patient welfare and careful evaluation of new practices. Notably, there were also positive engagements with the technology, highlighting its potential in patient care. This study concludes that the successful integration of technology in clinical settings hinges on its alignment with clinicians' workflows, respect for their professional judgment, and clear benefits to patient care.

Quality improvement initiative to standardise the anthropometric assessment for children under the age of 5 years at an urban primary health centre in New Delhi.

BACKGROUND: Anthropometric assessment in the paediatric population is particularly important to assess the child's general health status, nutritional adequacy, and growth and developmental pattern. However, there are often shortcomings in the quality of anthropometric assessment done in primary healthcare settings despite the presence of established guidelines. In this study, we plan to use the quality improvement (QI) principles to improve the anthropometric assessment of under-5 children attending an urban primary health centre in Delhi, India. METHODS: The study was conducted from December 2022 to February 2023. A baseline assessment was conducted to identify the gaps in the anthropometric measurement of under-5 children visiting the outpatient department. A QI team consisting of doctors and key health staff of urban health centre as its members was formed. A root cause analysis of the identified problems was done and changes were planned and implemented in a Plan-Do-Study-Act cycle. RESULTS: There was a marked improvement in the quality of anthropometric measurements, particularly in length measurement for children <24 months of age (0% at baseline vs 81.0% at end-line). However, the improvement in weight measurement of children less than 5 years was lesser (16.2% at baseline vs 44.6% at end-line). CONCLUSION: Anthropometric assessment of under-5 children can be standardised through the involvement of all stakeholders and capacity building of the concerned healthcare providers, using the QI approach. Repeated assessments are required to ensure the sustainability of the change.

Health Information System Strengthening During Antenatal Care in Haiti: Continuous Quality Improvement Study.

BACKGROUND: Journey to 9 Plus (J9) is an integrated reproductive, maternal, neonatal, and child health approach to care that has at its core the goal of decreasing the rate of maternal and neonatal morbidity and mortality in rural Haiti. For the maximum effectiveness of this program, it is necessary that the data system be of the highest quality. OpenMRS, an electronic medical record (EMR) system, has been in place since 2013 throughout a tertiary referral hospital, the Hôpital Universitaire de Mirebalais, in Haiti and has been expanded for J9 data collection and reporting. The J9 program monthly reports showed that staff had limited time and capacity to perform double charting, which contributed to incomplete and inconsistent reports. Initial evaluation of the quality of EMR data entry showed that only 18% (58/325) of the J9 antenatal visits were being documented electronically at the start of this quality improvement project. OBJECTIVE: This study aimed to improve the electronic documentation of outpatient antenatal care from 18% (58/325) to 85% in the EMR by J9 staff from November 2020 to September 2021. The experiences that this quality improvement project team encountered could help others improve electronic data collection as well as the transition from paper to electronic documentation within a burgeoning health care system. METHODS: A continuous quality improvement strategy was undertaken as the best approach to improve the EMR data collection at Hôpital Universitaire de Mirebalais. The team used several continuous quality improvement tools to conduct this project: (1) a root cause analysis using Ishikawa and Pareto diagrams, (2) baseline evaluation measurements, and (3) Plan-Do-Study-Act improvement cycles to document incremental changes and the results of each change. RESULTS: At the beginning of the quality improvement project in November 2020, the baseline data entry for antenatal visits was 18% (58/325). Ten months of improvement strategies resulted in an average of 89% (272/304) of antenatal visits documented in the EMR at point of care every month. CONCLUSIONS: The experiences that this quality improvement project team encountered can contribute to the transition from paper to electronic documentation within burgeoning health care systems. Essential to success was having a strong and dedicated nursing leadership to transition from paper to electronic data and motivated nursing staff to perform data collection to improve the quality of data and thus, the reports on patient outcomes. Engaging the nursing team closely in the design and implementation of EMR and quality improvement processes ensures long-term success while centering nurses as key change agents in patient care systems.

Patient-perceived barriers to early initiation of prenatal care at a large, urban federally qualified health center: a mixed-methods study.

BACKGROUND: Early initiation of prenatal care is widely accepted to improve the health outcomes of pregnancy for both mothers and their infants. Identification of the various barriers to entry into care that patients experience may inform and improve health care provision and, in turn, improve the patient's ability to receive necessary care. AIM: This study implements a mixed-methods approach to establish methods and procedures for identifying barriers to early entry to prenatal care in a medically-vulnerable patient population and areas for future quality improvement initiatives. METHODS: An initial chart review was conducted on obstetrics patients that initiated prenatal care after their first trimester at a large federally qualified health center in Brooklyn, NY, to determine patient-specified reasons for delay. A thematic analysis of these data was implemented in combination with both parametric and non-parametric analyses to characterize the population of interest, and to identify the primary determinants of delayed entry. RESULTS: The age of patients in the population of interest (n = 169) was bimodal, with a range of 15 - 43 years and a mean of 28 years. The mean gestational age of entry into prenatal care was 19 weeks. The chart review revealed that 8% recently moved to Brooklyn from outside of NYC or the USA. Nine percent had difficulty scheduling an initial prenatal visit within their first trimester. Teenage pregnancy accounted for 7%. Provider challenges with documentation (21%) were noted. The most common themes identified (n = 155) were the patient being in transition (21%), the pregnancy being unplanned (17%), and issues with linkage to care (15%), including no shows or patient cancellations. Patients who were late to prenatal care also differed from their peers dramatically, as they were more likely to be Spanish-speaking, to be young, and to experience a relatively long delay between pregnancy confirmation and entry into care. Moreover, the greatest determinant of delayed entry into care was patient age. CONCLUSION: Our study provides a process for other like clinics to identify patients who are at risk for delayed entry to prenatal care and highlight common barriers to entry. Future initiatives include the introduction of a smart data element to document reasons for delay and use of community health workers for dedicated outreach after no show appointments or patient cancellations.

Quality improvement initiative: improving obstetric triaging practices in a rural maternal hospital in central India.

Triaging of obstetric patients by emergency care providers is paramount. It helps provide appropriate and timely management to prevent further injury and complications. Standardised trauma acuity scales have limited applicability in obstetric triage. Specific obstetric triage index tools improve maternal and neonatal outcomes but remain underused. The aim was to introduce a validity-tested obstetric triage tool to improve the percentage of correctly triaged patients (correctly colour-coded in accordance with triage index tool and attended to within the stipulated time interval mandated by the tool) from the baseline of 49% to more than 90% through a quality improvement (QI) process.A team of nurses, obstetricians and postgraduates did a root cause analysis to identify the possible reasons for incorrect triaging of obstetric patients using process flow mapping and fish bone analysis. Various change ideas were tested through sequential Plan-Do-Study-Act (PDSA) cycles to address issues identified.The interventions included introduction and application of an obstetric triage index tool, training of triage nurses and residents. We implemented these interventions in eight PDSA cycles and observed outcomes by using run charts. A set of process, output and outcome indicators were used to track if changes made were leading to improvement.Proportion of correctly triaged women increased from the baseline of 49% to more than 95% over a period of 8 months from February to September 2020, and the results have been sustained in the last PDSA cycle, and the triage system is still sustained with similar results. The median triage waiting time reduced from the baseline of 40 min to less than 10 min. There was reduction in complications attributable to improper triaging such as preterm delivery, prolonged intensive care unit stay and overall morbidity. It can be thus concluded that a QI approach improved obstetric triaging in a rural maternity hospital in India.

Resident-led improvement project to screen for primary hyperaldosteronism in patients with resistant hypertension in an outpatient clinic.

Clinical practice guidelines recommend screening for primary hyperaldosteronism (PH) in patients with resistant hypertension. However, screening rates are low in the outpatient setting. We sought to increase screening rates for PH in patients with resistant hypertension in our Veterans Affairs (VA) outpatient resident physician clinic, with the goal of improving blood pressure control. Patients with possible resistant hypertension were identified through a VA Primary Care Almanac Metric query, with subsequent chart review for resistant hypertension criteria. Three sequential patient-directed cycles were implemented using rapid cycle improvement methodology during a weekly dedicated resident quality improvement half-day. In the first cycle, patients with resistant hypertension had preclinic PH screening labs ordered and were scheduled in the clinic for hypertension follow-up. In the second cycle, patients without screening labs completed were called to confirm medication adherence and counselled to screen for PH. In the third cycle, patients with positive screening labs were called to discuss mineralocorticoid receptor antagonist (MRA) initiation and possible endocrinology referral. Of 97 patients initially identified, 58 (60%) were found to have resistant hypertension while 39 had pseudoresistant hypertension from medication non-adherence. Of the 58 with resistant hypertension, 44 had not previously been screened for PH while 14 (24%) had already been screened or were already taking an MRA. Our screening rate for PH in resistant hypertension patients increased from 24% at the start of the project to 84% (37/44) after two cycles. Of the 37 tested, 24% (9/37) screened positive for PH, and 5 patients were started on MRAs. This resident-led quality improvement project demonstrated that a focused intervention process can improve PH identification and treatment.

Breaking barriers: assessing the impact of clinical quality improvements on reducing health disparities in hypertension care among Mumbai's urban slums.

The clinical quality improvement initiatives, led by the organisation's Health Equity Working Group (HEWG), aim to support healthcare providers to provide equitable, quality hypertension care worldwide. After coordinating with the India team, we started monitoring the deidentified patient data collected through electronic health records between January and May 2021. After stratifying data by age, sex and residence location, the team found an average of 55.94% of our hypertensive patients control their blood pressure, with an inequity of 11.91% between male and female patients.The objective of this study was to assess the effectiveness of using clinical quality improvement to improve hypertension care in the limited-resourced, mobile healthcare setting in Mumbai slums. We used the model for improvement, developed by Associates in Process Improvement. After 9-month Plan-Do-Study-Act (PDSA) cycles, the average hypertensive patients with controlled blood pressure improved from 55.94% to 89.86% at the endpoint of the initiative. The gender gap reduced significantly from 11.91% to 2.19%. We continued to monitor the blood pressure and found that the average hypertensive patients with controlled blood pressure remained stable at 89.23% and the gender gap slightly increased to 3.14%. Hypertensive patients have 6.43 times higher chance of having controlled blood pressure compared with the preintervention after the 9-month intervention (p<0.001).This paper discusses the efforts to improve hypertension care and reduce health inequities in Mumbai's urban slums. We highlighted the methods used to identify and bridge health inequity gaps and the testing of PDSA cycles to improve care quality and reduce disparities. Our findings have shown that clinical quality improvement initiatives and the PDSA cycle can successfully improve health outcomes and decrease gender disparity in the limited-resource setting.

Mock court: a valuable tool to teach legal procedures to undergraduate medical students.

BACKGROUND: Teaching through role-plays is a preferred modality when certain behaviours or skills need to be taught. They provide a risk-free environment that simulates a real-life scenario. For a clinician, appearance in a Court of Law as an expert witness is a part of his/her legal obligation. OBJECTIVE: To explore the utility of Mock Court as an additional teaching tool for undergraduate medical students, in understanding and familiarizing with legal procedures, specifically the courtroom procedures. METHODOLOGY: We conducted Mock Court sessions with the students playing various roles, following which feedback was collected from the students, teachers and guest assessors. The data was statistically analysed by comparison of frequencies and paired t-test (pre- and post-session comparison). RESULTS: The study revealed a positive effect of the Mock Court sessions on the students, based on their increased confidence, motivation and a better grasp of legal procedures. There was a statistically significant (p < 0.001) improvement in the understanding of specific aspects of courtroom procedures after the session. CONCLUSION: The authors recommend the active implementation of Mock Court as a teaching aid for undergraduate medical students, and the use of PDSA (Deming) cycle as a tool for quality-checks and self-improvement in subsequent sessions.

Implementing the practice of early skin-to-skin contact among infants ≥35 weeks gestation born vaginally: a quality improvement study.

BACKGROUND: Early skin-to-skin contact (SSC) at birth has been shown to improve neonatal outcomes due to enhanced cardiorespiratory stability, thermoregulation and breastfeeding success. LOCAL PROBLEM: The practice of early SSC was virtually non-existent in our delivery room (DR). METHODS AND INTERVENTIONS: The study was conducted in a newly established tertiary care teaching hospital in Western Rajasthan, India. We aimed to improve the median duration of early SSC from 0 min to at least 60 min over 24 weeks in our DR. A quality improvement (QI) team was formed, and all inborn infants ≥35 weeks born vaginally from 9 March 2017 were included. Using the tools of point-of-care QI, we found the lack of standard operating procedure, lack of knowledge among nursing staff regarding early SSC, routine shifting of all infants to radiant warmer, the practice of prioritising birthweight documentation and vitamin K administration as the major hindrances to early SSC. Various change ideas were implemented and tested sequentially through multiple plan-do-study-act (PDSA) cycles to improve the duration of early SSC. Interventions included framing a written policy for SSC, sensitising the nursing staff and resident doctors, actively delaying the alternate priorities, making early SSC a shared responsibility among paediatricians, obstetricians, nursing staff and family members, and continuing SSC in the recovery area of the DR complex. RESULTS: The duration of early SSC increased from 0 to 67 min without any additional resources. The practice of SSC got well established in the system as reflected by a sustained improvement of 63 min and 72 min, respectively, at the end of 2 months and 4 years after study completion. CONCLUSION: Using the QI approach, we established and sustained the practice of early SSC for more than 60 min in our unit by using system analysis and testing change ideas in sequential PDSA cycles.

Implementation of a quality improvement initiative for standardising essential newborn care in a teaching public hospital in rural central India.

OBJECTIVE: Our aim was to refine the essential newborn care practices by employing the multidisciplinary peer team-led quality improvement (QI) projects. DESIGN: In 2017, concerning the same, the department focused on early initiation of breast feeding, prevention of hypothermia within an hour of life and rational usage of antibiotics among babies admitted to neonatal intensive care unit (NICU). Baseline data reported the rate of initiation of breast feeding, hypothermia and antibiotic exposure rate as 35%, 78% and 75%, respectively. Root causes were analysed and a series of Plan-Do-Study-Act cycles were conducted to test the changes. The process of change was studied through run charts (whereas control charts were used for study purpose). RESULT: After the implementation of the QI projects, the rate of initiation of breast feeding was found to be improved from 35% to 90%, the incidence of hypothermia got reduced from 78% to 10% and the antibiotic exposure rate declined from 75% to 20%. Along with the improvement in indicators related to essential newborn care, down the stream we found a decrease in the percentage of culture-positive sepsis rate in the NICU. CONCLUSION: Peer team-led QI initiatives in a resource-limited setting proved beneficial in improving essential newborn care practices.

Reducing inpatient opioid consumption after caesarean delivery: effects of an opioid stewardship programme and racial impact in a community hospital.

Caesarean section is the most common inpatient surgery in the USA, with more than 1.1 million procedures in 2020. Similar to other surgical procedures, healthcare providers rely on opioids for postoperative pain management. However, current evidence shows that postpartum patients usually experience less pain due to pregnancy-related physiological changes. Owing to the current opioid crisis, public health agencies urge providers to provide rational opioid prescriptions. In addition, a personalised postoperative opioid prescription may benefit racial minorities since research shows that this population receives fewer opioids despite greater pain levels. Our project aimed to reduce inpatient opioid consumption after caesarean delivery within 6 months of the implementation of an opioid stewardship programme.A retrospective analysis of inpatient opioid consumption after caesarean delivery was conducted to determine the baseline, design the opioid stewardship programme and set goals. The plan-do-study-act method was used to implement the programme, and the results were analysed using a controlled interrupted time-series method.After implementing the opioid stewardship programme, we observed an average of 80% reduction (ratio of geometric means 0.2; 95% CI 0.2 to 0.3; p<0.001) in inpatient opioid consumption. The institution designated as control did not experience relevant changes in inpatient opioid prescriptions during the study period. In addition, the hospital where the programme was implemented was unable to reduce the difference in inpatient opioid demand between African Americans and Caucasians.Our project showed that an opioid stewardship programme for patients undergoing caesarean delivery can effectively reduce inpatient opioid use. PDSA, as a quality improvement method, is essential to address the problem, measure the results and adjust the programme to achieve goals.