Basics of quality improvement in health care.

With the rapid expansion of knowledge and technology and a health care system that performs far below acceptable levels for ensuring patient safety and needs, front-line health care professionals must understand the basics of quality improvement methodologies and terminology. The goals of this review are to provide clinicians with sufficient information to understand the fundamentals of quality improvement, provide a starting point for improvement projects, and stimulate further inquiry into the quality improvement methodologies currently being used in health care. Key quality improvement concepts and methodologies, including plan-do-study-act, six-sigma, and lean strategies, are discussed, and the differences between quality improvement and quality-of-care research are explored.

Making noncatastrophic health care processes reliable: Learning to walk before running in creating high-reliability organizations.

Health care clinicians successfully apply proven medical evidence in common acute, chronic, or preventive care processes less than 80 percent of the time. This low level of reliability at the basic process level means that health care's efforts to improve reliability start from a different baseline from most other industries, and therefore may require a different approach. This paper describes The Institute for Healthcare Improvement's (IHI) current approach to improving health care reliability, including a useful nomenclature for levels of reliability, and a focus on improving reliability of basic health care processes before moving on to more sophisticated high reliability organization concepts. Early IHI work with a community of health care reliability innovators has identified four themes in health care settings that help to explain at least a portion of the gap in process reliability between health care and other industries. These include extreme dependence on hard work and personal vigilance, a focus on mediocre benchmark outcomes rather than process, great tolerance of provider autonomy, and failure to create systems that are specifically designed to reach articulated reliability goals. This paper describes our recommendations for the initial steps health care organizations' might take, based on these four themes, as they begin to move toward higher reliability.

A trigger tool to identify adverse events in the intensive care unit.

BACKGROUND: The Institute for Healthcare Improvement has tested and taught use of a variety of trigger tools, including those for adverse medication events, neonatal intensive care events, and a global trigger tool for measuring all event categories in a hospital. The trigger tools have evolved as a complimentary adjunct to voluntary reporting. The Trigger Tool technique was used to identify the rate of occurrence of adverse events in the intensive care unit (ICU), and a subset of ICUs described those events in detail. METHODS: Sixty-two ICUs in 54 hospitals (both academic and community) engaged in IHI critical care collaboratives between 2001 and late 2004. Charts were selected using a random sampling technique and reviewed using a two-stage process. RESULTS: The prevalence of adverse events observed on 12,074 ICU admissions was 11.3 adverse events/100 patient days. For a subset of 1,294 charts from 13 ICUs which were reviewed in detail, 1,450 adverse events were identified, for a prevalence of 16.4 events/100 ICU days. Fifty-five percent of the charts in this subset contained at least one adverse event. DISCUSSION: The Trigger Tool methodology is a practical approach to enhance detection of adverse events in ICU patients. Evaluation of these adverse events can be used to direct resource use for improvement work. The measurement of these sampled chart reviews can also be used to follow the impact of the change strategies on the occurrence of adverse events within a local ICU.

Improving hypertension control in diabetes: a multisite quality improvement project that applies a 3-step care bundle to a chronic disease care model for diabetes with hypertension.

Hypertension in diabetes patients leads to significant morbidity and mortality. Nonetheless blood pressure (BP) control in patients with diabetes remains disappointing. The authors applied a care bundle to decrease the proportion of patients with BP exceeding 130/80. Teams from 4 sites in 3 states (Minnesota, Florida, and Arizona) developed a bundle consisting of a standardized BP process, an order set, and a patient goal. Baseline data were collected in the first 12 weeks, followed by 6 weeks of implementing changes. The final 16 weeks represented the intervention. There was a statistically significant decrease in the proportion of patients with uncontrolled BP in 3 of 4 sites (P < .0001 in all 3 sites demonstrating improvement). There was a statistically significant improvement in the satisfaction survey (P = .0011). Implementing an evidence-based care bundle for hypertension in diabetes mellitus can improve BP outcomes.

Rethinking emergency department visits.

Efforts to date have been unable to reverse the trend of increased emergency department utilization. The Institute for Healthcare Improvement has developed a framework for reducing avoidable emergency department visits on the basis of the formation of local coalitions. These coalitions include interested partners approaching improvement by integrating community resources and nonmedical solutions. Targeted patient populations are identified via homogeneous characteristics. Open-ended interview questions are used to identify possible community and nonmedical solutions to complement medical strategies. This article describes the framework and process of testing. If validated, this approach will have significant policy implications.

In-room display of day and time patient is anticipated to leave hospital: a "discharge appointment".

BACKGROUND: We learned from a focus group that many patients find discharge to be one of the least satisfying elements of the hospital experience. Patients cited insufficient communication about the day and time of the impending discharge as a cause of dissatisfaction. OBJECTIVE: In partnership with the Institute for Healthcare Improvement, Improvement Action Network collaborative, we tested the practicality of an in-room "discharge appointment" (DA) display. SETTING AND PATIENTS: Eight inpatient care units in 2 hospitals at an academic medical center (Mayo Clinic, Rochester, MN). INTERVENTION: DA displayed on a specially designed bedside dry-erase board. MEASUREMENTS: The primary outcome was the proportion of discharged patients who had been given a DA, including same-day DAs. Secondary outcomes were (1) the proportion of DAs scheduled before the actual dismissal day and (2) the timeliness of the actual departure compared with the DA. RESULTS: During the 4-month period, 2046 patients were discharged. Of those, 1256 patients (61%) were given a posted DA, of which 576 (46%) were scheduled at least a day in advance and 752 (60%) departed from the care unit within 30 minutes of the appointed time. CONCLUSIONS: With a program for in-room display of a DA in various hospital units, more than half the patients had a DA set, and most of the DA patients departed on time. Further investigation is needed to determine the effect of DAs on patient and provider satisfaction.

Using a unit assessment tool to optimize patient flow and staffing in a community hospital.

BACKGROUND: Hospital environments are too often characterized by delays for patients receiving diagnostic testing and prolonged waiting times to complete needed therapy. Frequently there is confusion in scheduling, related at least in part to the complex interplay of clinical acuity and highly individualized care. Luther Midelfort recently began to change the process of patient flow to improve access to care, optimize outcomes by enabling timely intervention, and decrease the wasting of resources. UNIT ASSESSMENT TOOL: The hospital developed a unit assessment tool based on the traffic light concept, which consisted of an assessment of current capacity and a graded, color-coded "workload tolerance" for each hospital unit. Each unit can instantly update its own status and query those of other work environments in the hospital. EXPERIENCE WITH THE UNIT ASSESSMENT TOOL: For most of the January-July 2001 period, there was generally a progressive decrease in the percentage of time that the units were coded as red (unit closed to new admissions), with concurrent increases in the percentage of time that the units were coded as green (unit open). Use of the tool appears to have contributed to a dramatic increase in staff satisfaction. SUMMARY AND CONCLUSIONS: The key to regulating patient flow has been to adopt a nursing-initiated capping trust policy whereby nurses are given the authority to limit new admissions. Initiatives are now under way to provide different units with novel models of resource sharing, ranging from flexible housekeeping to "flying nurse squads" to assist units that have become red.

Standardization as a mechanism to improve safety in health care.

BACKGROUND: A growing body of literature shows that when patterns of care are widely divergent, clinical outcomes suffer and, as a result, safety may be compromised. A multispecialty group at Luther Midelfort, Mayo Health System (LM, MHS) initiated efforts to reduce variance in the clinical practice patterns of providers. The pilot initiative, which entailed standardization of a sliding-scale insulin protocol, served as a template throughout the LM, MHS for reducing variance and enhancing safety. STANDARDIZING INSULIN ADMINISTRATION: A single sliding-scale insulin protocol for regular insulin use in appropriate patients was intended to decrease the number of hypoglycemic events. A six-week comparison revealed that in the protocol-driven standardized sliding-scale insulin group, two episodes of hypoglycemia occurred in 134 dosages administered versus 20 hypoglycemic events in 519 dosages administered in the traditional group (1.49 versus 3.85%, p < .04). Subsequent 30-month data months revealed a reduction in hypoglycemic episodes from 2.95% to 1.1%. MEDICATION USE PROBLEM: A reconciliation of medications initiative focused on clarifying, correcting, and specifying the medications patients were consuming at different intervals of their hospitalization and then amending the data in the medical record. In a seven-month chart audit, errors per 100 admissions decreased from 213 to fewer than 50 errors. DISCUSSION: Standardization efforts to increase uniformity of practice are worth considering in other practice areas to increase safety and possibly reduce costs.