What are the perceptions of faculty and academic leaders regarding the impact of accreditation on the continuous quality improvement process of undergraduate medical education programs at Caribbean medical schools?

BACKGROUND: Accreditation and regulation are meant for quality assurance in higher education. However, there is no guarantee that accreditation ensures quality improvement. The accreditation for Caribbean medical schools varies from island to island, and it could be mandatory or voluntary, depending on local government requirements. Caribbean medical schools recently attained accreditation status to meet the Educational Commission for Foreign Medical Graduates (ECFMG) requirements by 2024. Literature suggests that accreditation impacts ECFMG certification rates and medical schools' educational processes. However, no such study has examined accreditation's impact on continuous quality improvement (CQI) in medical schools. This study aims to gather the perceptions and experiences of faculty members and academic leaders regarding the impact of accreditation on CQI across Caribbean medical schools. METHODS: This qualitative phenomenological study inquiries about the perceptions and experiences of faculty and academic leaders regarding accreditation's impact on CQI. Purposive and snowball sampling techniques were used. Participants were interviewed using a semi-structured interview method. Fifteen participants were interviewed across ten Caribbean medical schools representing accredited medical schools, accreditation denied medical schools, and schools that never applied for accreditation. Interviews were audio recorded, and thematic data analysis was conducted. RESULTS: Thematic analysis yielded six themes, including accreditation and CQI, CQI irrespective of accreditation, faculty engagement and faculty empowerment in the CQI process, collecting and sharing data, ECFMG 2024 requirements, and organizational structure of CQI. CONCLUSIONS: There is ongoing quality improvement at Caribbean medical schools, as perceived by faculty members and academic leaders. However, most of the change process is happening because of accreditation, and the quality improvement is due to external push such as accreditation rather than internal motivation. It is recommended that Caribbean medical schools promote internal quality improvement irrespective of accreditation and embrace the culture of CQI.

Effect of Phenobarbital-Based Alcohol Withdrawal Protocol on Provider Practice and Patient Outcomes-A Quality Improvement Study.

Introduction: Alcohol is the most common substance use disorder in the United States. Despite this prevalence, there remains significant heterogeneity in medical management of alcohol withdrawal syndrome (AWS). While the 2020 American Society of Addition Medicine continues to recommend the use of benzodiazepines as first-line therapy for AWS, there is increasing use of phenobarbital in patients at high risk of severe AWS. Despite phenobarbital's favorable pharmacologic profile, historically, clinical utilization on general medicine services has been low and often restricted. In this project, we have examined practice patterns and associated clinical outcomes in adult patients experiencing AWS on the general medicine service pre and post implementation of a phenobarbital-based protocol for the treatment of severe AWS at our institution. Methods: This quality improvement study evaluated changes in management of AWS on general medicine units associated with implementation of a phenobarbital-based protocol and order set in the electronic medical record (EMR). Our primary outcome measures were receipt of a phenobarbital loading dose, concomitant benzodiazepine administration, and total benzodiazepine dose. Safety outcomes were also explored to assess clinical impacts of this protocol implementation. The project was determined "not research" by our Institutional Review Board. Results: Phenobarbital-protocol implementation was associated with increased frequency of receiving a phenobarbital loading dose (49.5% vs 9.4%; P < .001), decreased use of concomitant benzodiazepine/phenobarbital (4.3% vs 28.9%; P < .001), and decreased total benzodiazepine dose (7.8 vs 15.5 mg; P < .001). Regarding safety, there was no significant pre/post difference in the rate of ICU transfer, but among those transferred there was a trend toward decreased mechanical ventilation rate (100% vs 28.6%; P = .051), and a significantly reduced ICU length of stay (median 11 vs 3 days; P = .04). There were no pre/post differences in seizures, delirium or use of adjunct medications. Conclusions: This quality improvement study demonstrates a marked change in provider prescribing practices for treating AWS after implementation of an institutional phenobarbital-based protocol. We observed no difference in overall clinical outcomes after protocol implementation, although a larger follow-up study is needed to confirm this and to further explore the shorter ICU length of stay for patients with AWS postimplementation.

Hospital Acquired Venous Thromboembolism: A Preventability Assessment.

Background: The American Heart Association has a call to action to reduce hospital acquired venous thromboembolism (HA-VTE) by 20% by the year 2030. There is increasing recognition that quality improvement initiatives for VTE reduction should focus on reducing potentially preventable HA-VTE. The objective of our study was to determine what proportion of HA-VTE events are potentially preventable. Methods: This was a retrospective, single center pilot study of 50 patients with HA-VTE. Seven preventability factors were identified with a focus on VTE prescription and administration. Data were extracted through chart review using a systematic data collection form. The primary endpoint was the proportion of patients with potentially preventable HA-VTE. Descriptive statistics were used. Results: The median age was 66 years with an admission VTE risk level of moderate-high in 94%. Potentially preventable HA-VTE was found in 40% of cases. Missed doses occurred in 29.8% with a median of 2 missed doses and a range of 1 to 20. Patient refusal was the most common reason for missed doses in 71%. Delays in initiation occurred in 12.7%. Sixty percent of those on mechanical prophylaxis only had nonadherence. Conclusion: Forty percent of HA-VTE cases were potentially preventable. Missed doses was the most common preventability factor identified with patient refusal accounting for most missed doses.

Reducing the rate of central line-associated bloodstream infections; a quality improvement project.

BACKGROUND: The burden of central line-associated bloodstream infections is significant and has negative implications for healthcare, increasing morbidity and mortality risks, increasing inpatient hospital stays, and increasing the cost of hospitalization. Efforts to reduce the incidence of central line-associated bloodstream infections have utilized quality improvement projects that implement, measure, and monitor outcomes. However, variations in location, healthcare organization, patient risks, and practice gaps are key to the success of interventions and approaches. This study aims to evaluate interventions of a quality improvement project on the reduction of central line-associated bloodstream infection rates at a university teaching hospital. METHODS: This was a retrospective review of a quality improvement project that was implemented using the Plan-Do-Study-Act quality improvement cycle. Active surveillance of processes and outcomes was performed in the critical care areas; compliance to central line care bundles, and central line-associated bloodstream infections. Interrupted time series was used to analyze trends pre and post-intervention and regression modeling to estimate data segments preceding and succeeding the interventions. RESULTS: There were 350 central line insertions, 3912 catheter days, and 20 central line-associated bloodstream infection events during the intervention period. Compliance with central line care bundles was at 94%. There was a trend in the reduction of central line-associated bloodstream infections by 18% that did not reach statistical significance (p = 0.252). CONCLUSIONS: Improvement projects to reduce central line-associated bloodstream infections face challenges and complexities associated with implementing interventions in real-world healthcare settings. There is a great need to continuously monitor, evaluate, readjust, and adapt interventions to achieve desired results, sustain improvements in patient outcomes, and investigate reasons for non-adherence as keys to achieving desired outcomes.

Implementation and Evaluation of a Prior Authorization Workflow for New-Start Inpatient Medications in Preparation for Discharge.

Purpose: Medications that require prior authorization can complicate the discharge planning process. This study implemented and evaluated a process for identifying and completing prior authorizations during the inpatient setting prior to patient discharge. Methods: A patient identification tool was developed within the electronic health record to alert the patient care resource manager of inpatient orders for targeted medications that frequently require prior authorization with the potential to delay discharge. A workflow process using the identification tool and flowsheet documentation was developed to prompt the initiation of a prior authorization, if necessary. Following hospital-wide implementation, descriptive data for a 2-month period was collected. Results: The tool detected 1353 medications for 1096 patient encounters over the 2-month period. The most frequent medications identified included apixaban (28.1%), enoxaparin (14.4%), sacubitril/valsartan (6.4%), and darbepoetin (6.4%). For the medications identified, there were 93 medications documented in the flowsheet data for 91 unique patient encounters. Of the 93 medications documented, 30% did not require prior authorization, 29% had prior authorization started, 10% were for patients discharged to a facility, 3% were for home medications, 3% were medications discontinued at discharge, 1% had prior authorization denied, and 24% had missing data. The most frequent medications documented in the flowsheet included apixaban (12%), enoxaparin (10%), and rifaximin (20%). Of the 28 prior authorizations processed, 2 led to a referral to the Medication Assistance Program. Conclusion: The implementation of an identification tool and documentation process can help improve PA workflow and discharge care coordination.

The Impact of Regional Citrate Anticoagulation on Magnesium Replacement During CRRT.

A patient admitted to the ICU with shock and acute kidney injury required continuous renal replacement therapy (CRRT). CRRT was initiated using regional citrate anticoagulation (RCA) with an initial magnesium (Mg) level of 1.7 mg/dL. Over 12 days the patient received 68 g of Mg sulfate. After 58 g the patient's Mg level was 1.4 mg/dL. On day 13, CRRT was changed to a heparin circuit from concerns of citrate toxicity. Over the next 7 days the patient required no Mg replacement with a mean Mg level of 2.22. This was significantly higher than the final 7 days on RCA (1.99; P = .00069). This case illustrates the challenges in maintaining Mg stores during CRRT. RCA is now the preferred method of circuit anticoagulation, with prolonged filter life and fewer bleeding complication compared to heparin circuits. Citrate inhibits coagulation within the circuit by chelating ionized calcium (Ca2+). Free Ca2+ and Ca-citrate complexes diffuse across the hemofilter with a percentual calcium loss as high as 70%, requiring continuous post-filter infusions of calcium to prevent systemic hypocalcemia. Magnesium loss during CRRT is also significant and may approach 15% to 20% of the total body pool within a week. Citrate chelates Mg with percentual losses comparable to calcium. Twenty-two CRRT patients on RCA had median losses >6 g/day. Doubling the Mg content in the dialyzate of 45 CRRT patients significantly improved Mg balance, but with the potential risk of increased citrate toxicity. A major obstacle to replacing Magnesium loss with the same precision as calcium is few hospitals can measure ionized Mg++ levels and must rely on total magnesium levels to guide replacement, despite a literature showing poor correlation with total body stores. Post-circuit continuous replacement of magnesium, as with calcium, in the absence of ionized magnesium levels would likely be very inexact and arduous. Being aware of the losses that can occur with CRRT, especially with RCA, and adjusting magnesium replacement empirically on rounds may be the only pragmatic action plan for this clinical issue.

Multimodal Intervention Assessing the Appropriateness of Acid Suppression Therapy is Associated With Reduced Prescriptions at the Time of Discharge for Hospitalized Inpatients.

Background: Acid suppression therapy (AST), including proton pump inhibitors and histamine 2 receptor antagonists, are an overused class of medications. When used inappropriately, AST leads to polypharmacy, increased healthcare costs, and possible negative health consequences. Objective: To assess whether an intervention including prescriber education combined with a pharmacist-driven protocol was effective in reducing the percentage of patients who were discharged with inappropriate AST. Methods: This was a prospective pre-post study of adult patients who were prescribed AST before or during their admission to an internal medicine teaching service. All internal medicine resident physicians received education on appropriate AST prescribing. During the 4-week intervention period, dedicated pharmacists assessed the appropriateness of AST and made recommendations regarding deprescribing if no appropriate indication was identified. Results: During the study period, there were 14 166 admissions during which patients were prescribed AST. Out of the 1143 admissions during the intervention period, appropriateness of AST was assessed by a pharmacist for 163 patients. AST was determined to be inappropriate for 52.8% (n = 86) of patients and discontinuation or de-escalate of therapy occurred in 79.1% (n = 68) of these cases. The percentage of patients discharged on AST decreased from 42.5% before the intervention to 39.9% after the intervention (P = .007). Conclusion: This study suggests that a multimodal deprescribing intervention reduced prescriptions for AST without an appropriate indication at the time of discharge. To increase the efficiency of the pharmacist assessment several workflow improvements were identified. Further study is necessary to understand the long-term outcomes of this intervention.

Evaluation of Detected Medication Errors Within the Operating Room at an Academic Medical Center.

Background: Medication errors are preventable events that lead to inappropriate medication use and potential patient harm. This is especially prevalent within the operating room (OR) where one practitioner is involved in the entire medication-use process. Despite recent implementation of BD Pyxis™ Anesthesia ES, Codonics Safe Label System, and Epic One Step at the University of Kentucky Healthcare (UKHC) to prevent medication errors, errors continue to be reported. Curatolo et al found human error was the most frequent cause of medication error within the OR. Clumsy automation may be an explanation for this, which imposes burdens and promotes work arounds. This study endeavors to assess potential medication errors via chart review to identify risk reduction strategies. Methods: This a single-center retrospective cohort review of patients admitted to a UK HealthCare Main Operating Room, defined OR1A-OR5A and OR7A-OR16A, who were administered medications from 8/1/2021 to 9/30/2021. Results: Over a 2-month period, 145 cases were conducted at UK HealthCare. Of the 145 cases, 98.6% (n = 143) involved a medication error and 93.7% (n = 136) of the errors involved a high-alert medication. The top 5 classes of drugs involved in errors were all high-alert medications. Lastly, 46.6% (n = 67) of cases had documentation that Codonics was utilized. In addition to analyzing medication errors, the financial analysis found that $3154.04 in drug cost was lost in the study period. When extrapolating these results to all BD™ Pyxis Anesthesia Machines at UK HealthCare, $107 237.36 of drug cost is potentially lost per year. Conclusions: These findings add to previous data that have described the increased rate of medication errors when conducting chart review rather than rely on self-reported data. In this study, 98.6% of all cases involved a medication error. In addition, these findings provide additional insight in the increased use of technology within the operating room despite medication errors still occurring. These results can be applied to like institutions to critically evaluate anesthesia workflow to determine risk reduction strategies.

Strategies to Enhance Patient Care and Compliance with Pain Order Duplications and Gaps.

According to the Joint Commission every patient has a right to pain management. Due to multimodal pain management, pain orders have the potential for duplication as well as gaps in therapy. At our institution, we evaluated pain orders and implemented strategies that aimed to reduce those gaps. We found that current ordering practices permitted the use of varying visual analog scale (VAS) ranges (e.g., VAS 1-3 and 1-5) which inherently increased the potential for duplicate therapies. When gaps in therapy occurred, medication orders for corresponding VAS scores were not available and thus, therapy was delayed. Additionally, current administration policies did not take into account patient preferences for less potent agents which can also cause a delay in care. In summary, simple strategies, discussed in this article, may be implemented at the hospital level to optimize patient care while maintaining recommendations by the Joint Commission for clear medication orders.

Comparison of Patiromer to Sodium Polystyrene Sulfonate in Acute Hyperkalemia.

Background: Patiromer and sodium polystyrene sulfonate (SPS) are cation-exchangers approved for the treatment of chronic hyperkalemia. Data regarding their efficacy acutely is lacking. Despite this, both drugs are frequently used in the emergent setting. Objective: The purpose of this study was to compare the potassium reduction of patiromer to SPS within 6 to 24 hours following a single dose. Methods: This retrospective quality improvement project included hyperkalemic patients receiving 1 dose of patiromer or SPS and had a second potassium level drawn in 6 to 24 hours. Doses of 8.4 g of patiromer and 15 g of SPS were considered "low dose" while 16.8 g of patiromer and 30 g of SPS were considered "high dose." The presence of a dose-response relationship was assessed through a linear regression analysis. Results: Mean (SD) potassium reduction was higher in SPS than patiromer [0.76 (0.63) mEq/L vs 0.32 (0.65) mEq/L, (P = .001)]. A dose response relationship was not demonstrated in low versus high dose groups [-0.21 (0.14), P = .13] and CKD, ESRD, and renal transplant patients when compared to patients with normal renal function [0.11 (0.17), P = .51, -0.07 (0.19), P = -0.07 (0.19), P = .73, and -0.10 (0.22), P = .65]. Conclusions: This study suggests a clinically significant reduction in potassium with SPS compared to patiromer. Although SPS was successful in demonstrating this outcome, due to well-documented adverse reactions in the literature and a time to onset of 6 hours, it cannot be recommended for use in acute hyperkalemia either.

Evaluating effectiveness of cognitive behavioral therapy within multimodal treatment for chronic groin pain after inguinal hernia repair.

INTRODUCTION: The development of chronic groin pain after inguinal hernia repair is a complex problem with many potential factors contributing to its development. Surgical options for alleviation of symptoms are limited and only performed by a few centers dedicated to its treatment. Opportunities to apply the principles of a prehabilitation program, including Cognitive Behavioral Therapy (CBT), aim to improve the surgical outcomes for this condition. METHODS AND PROCEDURES: A multi-disciplinary hernia team has implemented a clinical quality improvement (CQI) effort in an attempt to better measure and improve outcomes for patients suffering with chronic groin pain after inguinal hernia repair. Between April 2011 and August 2018, 129 patients (157 groins) underwent surgical treatment for chronic groin pain after inguinal hernia repair. Data were collected to compare outcomes for those undergoing preoperative CBT and patients who did not have CBT prior to their operation. RESULTS: Of 129 total patients, baseline demographics were similar in terms of gender, age, and BMI. In total, 27 patients (32 groins) underwent prehabilitation with CBT (20.93%). We found none of the patients who underwent preoperative CBT had new postoperative pain and all patient procedures were able to be performed on an outpatient basis. Overall, 15 (14.7%) patients had no improvement in symptoms after surgery from the non-CBT group, whereas there was improvement in chronic pain for all patients who underwent CBT. CONCLUSION: This attempt at process improvement demonstrated beneficial effects for patients who had CBT as part of a prehabilitation program prior to a surgical procedure to attempt to relieve groin pain after inguinal hernia repair. As with any CQI analysis, other factors may have contributed to these outcomes and these results may be different in another local environment.

Ischemic Stroke Symptoms After Warfarin Reversal With 4-Factor Prothrombin Complex Concentrate Case Report.

Objective: An 83-year-old woman with atrial fibrillation on chronic warfarin therapy was given 4-factor prothrombin complex concentrate to reverse her warfarin for surgery. She had fallen off a step stool at home and fractured her left wrist which initially the surgeon was going to repair surgically. Method: The day after she received 4-factor prothrombin complex concentrate, she developed stroke-like symptoms, National Institutes of Health Stroke Scale (NIHSS) was 14, and met criteria for tissue plasminogen activator (tPA) administration. Tissue plasminogen activator was administered and she was transferred to the intensive care unit (ICU), per hospital protocol. Results: She remained in the ICU for 24 hours for follow-up and monitoring. Her warfarin was restarted and bridged with enoxaparin. She was not a candidate for antiplatelet therapy due to her history of a gastrointestinal (GI) bleed. Conclusion: At discharge, she had no residual effects from her stroke-like symptoms and a magnetic resonance imaging (MRI) of her brain was negative for an acute cerebrovascular accident (CVA).

Evaluation of a Hospital Pharmacist Annual Competency Program.

Purpose: The purpose of this project was to evaluate a pharmacist annual competency evaluation (PACE) program for pharmacists at a single site. The results of this evaluation will be utilized to understand the effectiveness of PACE and provide suggestions for programmatic improvement. Methods: The primary outcome of this study was to evaluate the change in pharmacist composite self-efficacy (PSE) scores before and 1 month after the PACE program. The composite score was composed of self-efficacy related to 5 different clinical tasks. The 5 tasks selected were advanced cardiac life support, chemotherapy, dofetilide, patient-controlled analgesia pump, and alteplase (tPA). Secondary outcomes included evaluating each component of the composite score at 1 month, changes in composite score and components at 1 year, and changes in the generalized self-efficacy (GSE) survey at 1 month. Last, themes were identified from a feedback questionnaire after completion of PACE. Results: For the primary endpoint, PSE composite scores increased by 12.6% from pre-PACE to post-PACE at 1 month (79.6 ± 12.2 vs 89.7 ± 5.8; P < .001). All components of the composite PSE score showed a statistically significant improvement from baseline to 1 month. At 1 year, tPA was the only clinical task that was statistically different from baseline. GSE scores increased by 11.4% from pre-PACE to post-PACE (31.6 ± 3.6 vs 35.4 ± 2.8). No pharmacists required remediation. Conclusion: The competency assessment program led to improvements in pharmacist self-efficacy in dealing with low-volume, high-risk clinical pharmacy tasks. Future studies could assess various forms of competency assessment and timing of these programs to determine the most effective way to ensure pharmacist competency.

Added sugars and sugar-sweetened beverage consumption, dietary carbohydrate index and depression risk in the Seguimiento Universidad de Navarra (SUN) Project.

The association between added sugars or sugar-sweetened beverage consumption and the risk of depression, as well as the role of carbohydrate quality in depression risk, remains unclear. Among 15 546 Spanish university graduates from the Seguimiento Universidad de Navarra (SUN) prospective cohort study, diet was assessed with a validated 136-item semi-quantitative FFQ at baseline and at 10-year follow-up. Cumulative average consumption of added sugars, sweetened drinks and an overall carbohydrate quality index (CQI) were calculated. A better CQI was associated with higher whole-grain consumption and fibre intake and lower glycaemic index and consumption of solid (instead of liquid) carbohydrates. Clinical diagnoses of depression during follow-up were classified as incident cases. Multivariable time-dependent Cox regression models were used to estimate hazard ratios (HR) of depression according to consumption of added sugars, sweetened drinks and CQI. We observed 769 incident cases of depression. Participants in the highest quartile of added sugars consumption showed a significant increment in the risk of depression (HR=1·35; 95 % CI 1·09, 1·67, P=0·034), whereas those in the highest quartile of CQI (upper quartile of the CQI) showed a relative risk reduction of 30 % compared with those in the lowest quartile of the CQI (HR=0·70; 95 % CI 0·56, 0·88). No significant association between sugar-sweetened beverage consumption and depression risk was found. Higher added sugars and lower quality of carbohydrate consumption were associated with depression risk in the SUN Cohort. Further studies are necessary to confirm the reported results.

Implementation of continuous quality improvement in Aboriginal and Torres Strait Islander primary health care in Australia: a scoping systematic review.

BACKGROUND: Continuous Quality Improvement (CQI) programs have been taken up widely by Indigenous primary health care (PHC) services in Australia and there has been national policy commitment to support this. However, international evidence shows that implementing CQI is challenging, impacts are variable and little is known about the factors that impede or enhance effectiveness. A scoping review was undertaken to explore uptake and implementation in Indigenous PHC, including barriers and enablers to embedding CQI in routine practice. We provide guidance on how research and evaluation might be intensified to support implementation. METHODS: Searches were conducted in MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews. Key websites and publications were handsearched. Studies conducted in Indigenous PHC which demonstrated some combination of CQI characteristics and assessed some aspect of implementation were included. A two stage analysis was undertaken. Stage 1 identified the breadth and focus of literature. Stage 2 investigated barriers and enablers. The Framework for Performance Assessment in PHC (2008) was used to frame the analysis. Data were extracted on the study type, approach, timeframes, CQI strategies, barriers and enablers. RESULTS: Sixty articles were included in Stage 1 and 21 in Stage 2. Barriers to implementing CQI processes relate primarily to professional and organisational processes and operate at multiple levels (individual, team, service, health system) whereas barriers to improved care relate more directly to knowledge of best practice and team processes that facilitate appropriate care. Few studies described implementation timeframes, number of CQI cycles or improvement strategies implemented and only two applied a change theory. CONCLUSION: Investigating barriers and enablers that modify implementation and impacts of CQI poses conceptual and methodological challenges. More complete description of CQI processes, implementation strategies, and barriers and enablers could enhance capacity for comparisons across settings and contribute to better understanding of key success factors.

Utilization of Lean Techniques in Pharmacy Residency Training: Modifying the PGY1 Management and Leadership Experience.

Purpose: The purpose of this study was to utilize lean process improvement principles to enhance the health-system pharmacy administration learning experience within a postgraduate year 1 (PGY1) residency program. Summary: The Richard L. Roudebush VA Medical Center adopted the use of lean to improve customer service and workplace efficiency. The Residency Advisory Council, overseeing the 6 pharmacy residency programs, felt that training residents in a proven process improvement technique would benefit the service and assist in developing problem-solving skills. Yellow Belt training was incorporated into the residency programs in 2012, and the Yellow Belt project for the 2014-2015 residency class was the modification of the PGY1 Health-System Pharmacy Administration learning experience. Residents focused on a few key areas as part of their completion plan: educating residents and preceptors on the importance of leadership activities, establishing a list of consistent topic discussions to be held during the administration learning experience, confirming a topic list for the pharmacy practice management and leadership seminars, piloting collaborative precepting for the administration experience, revising the staff development program, and increasing resident involvement in the PGY1 interview process. Two portions of the project lacked effective and timely communication, and as a result, those areas were not fully implemented. The remainder of the items achieved 100% completion. Conclusion: Lean techniques were effectively utilized within a residency program to enhance the health-system pharmacy administration learning experience. Successful implementation of lean requires engagement of stakeholders within the health-system, timely communication, frequent reassessments, and accountability.

Laparoscopic approach for the treatment of chronic groin pain after inguinal hernia repair : Laparoscopic approach for inguinodynia.

BACKGROUND: Traditional methods of clinical research may not be adequate to improve the value of care for patients with complex medical problems such as chronic pain after inguinal hernia repair. This problem is very complex with many potential factors contributing to the development of this complication. METHODS: We have implemented a clinical quality improvement (CQI) effort in an attempt to better measure and improve outcomes for patients suffering with chronic groin pain (inguinodynia) after inguinal hernia repair. Between April 2011 and June 2016, there were 93 patients who underwent 94 operations in an attempt to relieve pain (1 patient had two separate unilateral procedures). Patients who had prior laparoscopic inguinal hernia repair (26) had their procedure completed laparoscopically. Patients who had open inguinal hernia repair (68) had a combination of a laparoscopic and open procedure in an attempt to relieve pain. Initiatives to attempt to improve measurement and outcomes during this period included the administration of pre-operative bilateral transversus abdominis plane and intra-operative inguinal nerve blocks using long-acting local anesthetic as a part of a multimodal regimen, the introduction of a low pressure pneumoperitoneum system, and the expansion of a pre-operative questionnaire to assess emotional health pre-operatively. RESULTS: The results included the assessment of how much improvement was achieved after recovery from the operation. Forty-five patients (48%) reported significant improvement, 39 patients (41%) reported moderate improvement, and 10 patients (11%) reported little or no improvement. There were 3 (3%) complications, 13 (11%) hernia recurrences, and 15 patients (13%) developed a new pain in the inguinal region after the initial pain had resolved. CONCLUSIONS: The principles of CQI can be applied to a group of patients suffering from chronic pain after inguinal hernia repair. Based on these results additional process improvement ideas will be implemented in an attempt to improve outcomes.

Closing the patient experience chasm: A two-level validation of the Consumer Quality Index Inpatient Hospital Care.

BACKGROUND: Evaluation of patients' health care experiences is central to measuring patient-centred care. However, different instruments tend to be used at the hospital or departmental level but rarely both, leading to a lack of standardization of patient experience measures. OBJECTIVE: To validate the Consumer Quality Index (CQI) Inpatient Hospital Care for use on both department and hospital levels. DESIGN: Using cross-sectional observational data, we investigated the internal validity of the questionnaire using confirmatory factor analyses (CFA), and the generalizability of the questionnaire for use at the department and hospital levels using generalizability theory. SETTING AND PARTICIPANTS: 22924 adults hospitalized for ≥24 hours between 1 January 2013 and 31 December 2014 in 23 Dutch hospitals (515 department evaluations). MAIN VARIABLE: CQI Inpatient Hospital Care questionnaire. RESULTS: CFA results showed a good fit on individual level (CFI=0.96, TLI=0.95, RMSEA=0.04), which was comparable between specialties. When scores were aggregated to the department level, the fit was less desirable (CFI=0.83, TLI=0.81, RMSEA=0.06), and there was a significant overlap between communication with doctors and explanation of treatment subscales. Departments and hospitals explained ≤5% of total variance in subscale scores. In total, 4-8 departments and 50 respondents per department are needed to reliably evaluate subscales rated on a 4-point scale, and 10 departments with 100-150 respondents per department for binary subscales. DISCUSSION AND CONCLUSIONS: The CQI Inpatient Hospital Care is a valid and reliable questionnaire to evaluate inpatient experiences in Dutch hospitals provided sufficient sampling is done. Results can facilitate meaningful comparisons and guide quality improvement activities in individual departments and hospitals.

Piloting a generic cancer consumer quality index in six European countries.

BACKGROUND: Accounting for patients' perspective has become increasingly important. Based on the Consumer Quality Index method (founded on Consumer Assessment of Healthcare Providers and Systems) a questionnaire was recently developed for Dutch cancer patients. As a next step, this study aimed to adapt and pilot this questionnaire for international comparison of cancer patients experience and satisfaction with care in six European countries. METHOD: The Consumer Quality Index was translated into the local language at the participating pilot sites using cross-translation. A minimum of 100 patients per site were surveyed through convenience sampling. Data from seven pilot sites in six countries was collected through an online and paper-based survey. Internal consistency was tested by calculating Cronbach's alpha and validity by means of cognitive interviews. Demographic factors were compared as possible influencing factors. RESULTS: A total of 698 patients from six European countries filled the questionnaire. Cronbach's alpha was good or satisfactory in 8 out of 10 categories. Patient satisfaction significantly differed between the countries. We observed no difference in patient satisfaction for age, gender, education, and tumor type, but satisfaction was significantly higher in patients with a higher level of activation. CONCLUSION: This European Cancer Consumer Quality Index(ECCQI) showed promising scores on internal consistency (reliability) and a good internal validity. The ECCQI is to our knowledge the first to measure and compare experiences and satisfaction of cancer patients on an international level, it may enable healthcare providers to improve the quality of cancer care.

The Michigan Spine Surgery Improvement Collaborative: a statewide Collaborative Quality Initiative.

OBJECT Given the scrutiny of spine surgery by policy makers, spine surgeons are motivated to demonstrate and improve outcomes, by determining which patients will and will not benefit from surgery, and to reduce costs, often by reducing complications. Insurers are similarly motivated. In 2013, Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) established the Michigan Spine Surgery Improvement Collaborative (MSSIC) as a Collaborative Quality Initiative (CQI). MSSIC is one of the newest of 21 other CQIs that have significantly improved-and continue to improve-the quality of patient care throughout the state of Michigan. METHODS MSSIC focuses on lumbar and cervical spine surgery, specifically indications such as stenosis, disk herniation, and degenerative disease. Surgery for tumors, traumatic fractures, deformity, scoliosis, and acute spinal cord injury are currently not within the scope of MSSIC. Starting in 2014, MSSIC consisted of 7 hospitals and in 2015 included another 15 hospitals, for a total of 22 hospitals statewide. A standardized data set is obtained by data abstractors, who are funded by BCBSM/BCN. Variables of interest include indications for surgery, baseline patient-reported outcome measures, and medical history. These are obtained within 30 days of surgery. Outcome instruments used include the EQ-5D general health state score (0 being worst and 100 being the best health one can imagine) and EQ-5D-3 L. For patients undergoing lumbar surgery, a 0 to 10 numeric rating scale for leg and back pain and the Oswestry Disability Index for back pain are collected. For patients undergoing cervical surgery, a 0 to 10 numeric rating scale for arm and neck pain, Neck Disability Index, and the modified Japanese Orthopaedic Association score are collected. Surgical details, postoperative hospital course, and patient-reported outcome measures are collected at 90-day, 1-year, and 2-year intervals. RESULTS As of July 1, 2015, a total of 6397 cases have been entered into the registry. This number reflects 4824 eligible cases with confirmed surgery dates. Of these 4824 eligible cases, 3338 cases went beyond the 120-day window and were considered eligible for the extraction of surgical details, 90-day outcomes, and adverse events. Among these 3338 patients, there are a total of 2469 lumbar cases, 862 cervical cases, and 7 combined procedures that were entered into the registry. CONCLUSIONS In addition to functioning as a registry, MSSIC is also meant to be a platform for quality improvement with the potential for future initiatives and best practices to be implemented statewide in order to improve quality and lower costs. With its current rate of recruitment and expansion, MSSIC will provide a robust platform as a regional prospective registry. Its unique funding model, which is supported by BCBSM/BCN, will help ensure its longevity and viability, as has been observed in other CQIs that have been active for several years.