Integrated family delivered care project: Parent education programme

Parent education is one of the main “pillars” of Family Integrated Care (FIC); therefore it was considered central point in our Integrated Family Delivered Care (IFDC) programme. If parents are to be enabled, empowered to be “experts” in their baby's care and participate in the care team as equal partners, they will need to receive consistent and high quality information as well as a supportive education programme that has been tailored to meet their needs under their special circumstances in the neonatal unit. As part of the IFDC project, a complex experience co-designed training material was created which consist of several different learning opportunities from chapters in the mobile app, to one-to-one training, competency assessments and small group teaching based on a rolling weekly programme.     

Evaluation of parental experience post-discharge and development of a parent focus group

The aim of the Integrated Family Delivered Neonatal Care (IFDC) project is to improve parent-experience, parent-infant bonding, parental mental health, and infant health outcomes by pioneering a new care model at Imperial College Healthcare NHS Trust based on international evidence. It is particularly challenging to measure parent experience in neonatology, and there isn't a uniform internationally accepted tool for this. Understanding parents' experiences is vital to understand how quality of care can be improved. As parents are in a very vulnerable situation in the neonatal unit progressing on an often long, unpredictable and complicated journey, special approach and tools are needed to distill their overwhelming experience.Within the expanse of the Quality Improvement project we hoped to focus and achieve the following objectives:

• 1.To develop a sustainable feedback model for parent experience to collect feedback on neonatal care using validated tools.
• 2.To establish a parent focus group to collect feedback about our care and to create an experience co-designed parent educational material for our project.

     

Celebrating a fortnight of skin to skin holding

The fortnight of skin-to-skin holding was a great event held together with the formal launch of the Integrated Family Delivered Care (IFDC) project; emphasising the importance of staff supporting parents to be part of their babies’ care and the vital benefits that closeness of skin-to-skin care brings to their baby. Our aim was to showcase this event in order to reinforce skin-to-skin practice within our neonatal service with customised supporting material designed for this purpose. Supporting skin-to-skin holding is often the first step on the road to family integrated care.     

Family integrated care; A Florence Nightingale Foundation scholarship and international journey of discovery for improvement in neonatal care. A review of services

Family Integrated Care (FICare) is a philosophy and model of care that supports parents in becoming active members of the team caring for their baby now living in the neonatal intensive care unit. As nurses with over 25 years' experience in neonatal care and an enthusiasm to always enhance care for infants and their families, the authors wished to see first-hand how this model of care works. After being awarded a travel scholarship by the Florence Nightingale Foundation with funding by The Sandra Charitable Trust to research and study implementation of the Family Integrated Care (FICare) model, FICare is currently being implemented in the NICU at Derriford Hospital, Plymouth Hospitals NHS Trust.     

The Palliative Care—Promoting Access and Improvement of the Cancer Experience (PC-PAICE) Project in India: A Multisite International Quality Improvement Collaborative

Mentors at seven U.S. and Australian academic institutions initially partnered with seven leading Indian academic palliative care and cancer centers in 2017 to undertake a program combining remote and in-person mentorship, didactic instruction, and project-based learning in quality improvement (QI). From its inception in 2017 to 2020, the Palliative Care—Promoting Accesst and Improvement of the Cancer Experience Program conducted three cohorts for capacity building of 22 Indian palliative care and cancer programs. Indian leadership established a Mumbai QI training hub in 2019 with philanthropic support. In 2020, the project which is now named Enable Quality, Improve Patient care - India (EQuIP-India) focuses on both palliative care and cancer teams. EQuIP-India now leads ongoing Indian national collaboratives and training in QI and is integrated into India's National Cancer Grid. Palliative Care—Promoting Accesst and Improvement of the Cancer Experience demonstrates a feasible model of international collaboration and capacity building in palliative care and cancer QI. It is one of the several networked and blended learning approaches with potential for rapid scaling of evidence-based practices.     

Including a parental perspective in neonatal education

Post registration neonatal education in England is currently delivered in a number of settings including Higher Education Institutes and clinical areas and is currently being reviewed in relation to setting a national standard by Health Education England (NHS, 2022). Neonatal courses require constant updating to ensure that they reflect changes in clinical practice and use the most up to date evidence base. A recent example of evidence based clinical innovation is Family Integrated Care. This article will focus on how including a parental perspective within a post registration neonatal nursing course delivered by a Higher Education Institute can support the integration of Family Integrated Care within neonatal education.Family Integrated Care is a vital component of neonatal care, this needs to be mirrored within neonatal nurse education. Hearing a parent's perspective enables us to understand their requirements and experiences, this promotes improvements in neonatal care. Parental perspectives can be incorporated into education using a variety of methods that are suitable to both the student and parental requirements. Incorporating a parent's perspective is valuable for both the parents and the students. The impact on student knowledge is essential for their future roles.     

Addressing future demands: Nursing students,elders, and pet birds: A student-initiated quality improvement project

The purpose of this quality improvement (QI) project was to promote the enthusiasm of baccalaureate nursing students in providing service to older adults by using the concept of service learning as a teaching strategy. An additional goal of the student-initiated QI project, which later also included graduate social work students, was to explore the impact of caring for a pet for older adults in an assisted living facility (ALF). After completing a student-elder team QI project, nursing students' journals yielded three themes: Improved Communication Skills with Elders, Becoming Interested in The Eden Alternative^® Principles, and Skills in Implementing and Evaluating Interprofessional Interventions. Elders' anecdotal comments and interviews yielded four themes: Improved Self Care, Decreased Anxiety, Sense of Purpose, and Sense of Belonging. These outcomes demonstrate ways to drive student interest in interdisciplinary gerontological care and to promote elders' well-being when transitioning to residential care.     

Differentiating quality improvement from research.

Monitoring of quality of care has always been an important part of health care. Self-regulation and external standards require care providers to furnish safe environments for the patient. Similarities in methods used by quality improvement (QI) projects and clinical research have created some confusion in differentiating the two practices. This article reviews the current literature and differences between QI and research. In addition, the article identifies and discusses four criteria: intervention, risk, audience, and data source, which allow investigators to differentiate between the two practices and follow the appropriate procedures for project review.     

Curricular Revision to Increase Use of Quality Improvement Principles in Doctor of Nursing Practice Projects

BackgroundA gap was identified related to students’ use of quality improvement (QI) methodologies in their final project, so a curricular change was made to incorporate a health care QI methods course in the curriculum.MethodsWe compared the use of SMART (specific, measurable, achievable, relevant, and time-bound) aims and QI evaluation methodologies in doctor of nursing practice (DNP) project proposals in 2 cohorts before and after the curriculum change.ResultsA total of 88 DNP proposals were evaluated.ConclusionIncluding a QI course increased the use of SMART aims but did not influence the use of QI methodologies. Future interventions will target faculty development related to QI.     

Quality assessment in initial paediatric trauma care: Systematic review from prehospital care to the paediatric intensive care unit

Background

Trauma is the most common cause of death and disability in the paediatric population. There are a huge number of variables involved in the care they receive from health care professionals.

Aim

The aim of this study was to review the available evidence of initial paediatric trauma care throughout the health care process with a view to create quality indicators (QIs).

Study Design

A systematic review was performed from Cochrane Library, Medline, Scopus and SciELO between 2010 and 2020. Studies and guidelines that examined quality or suggested QI were included. Indicators were classified by health care setting, Donabedian's model, risk of bias and the quality of the publication with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment.

Results

The initial search included 686 articles, which were reduced to 22, with 15 primary and 7 secondary research articles. The snowball sampling technique was used to add a further seven guidelines and two articles. From these, 534 possible indicators were extracted, summarizing them into 39 and grouping the prehospital care indicators as structure (N = 5), process (N = 12) and outcome (N = 3) indicators and the hospital care indicators as structure (N = 4), process (N = 10) and outcome (N = 6) indicators. Most of the QIs have been extracted from US studies. They are multidisciplinary and in some cases are based on an adaptation of the QIs of adult trauma care.

Conclusions

There was a clear gap and large variability between the indicators, as well as low-quality evidence. Future studies will validate indicators using the Delphi method.

Relevance to Clinical Practice

Design a QI framework that may be used by the health system throughout the process. Indicators framework will get nurses, to assess the quality of health care, detect deficient areas and implement improvement measures.     

Measuring the quality of care provided to community dwelling vulnerable elders dually enrolled in Medicare and Medicaid

CONTEXT: Small studies suggest that the quality of healthcare provided to older patients needs improvement. However, measuring the quality of care for larger groups of older adults is difficult. OBJECTIVE: To measure the quality of care in a community-dwelling vulnerable geriatric population using administrative data to apply quality indicators (QIs) from the Assessing Care of Vulnerable Elders project. DESIGN, SETTING, AND PARTICIPANTS: Cohort study of community-dwelling dual enrollees in Medicare and Medicaid, age 75 years and older, living in 19 California counties in 1999 and 2000. MAIN OUTCOME MEASURE: Measurement of care provided for 43 QIs by condition (eg, heart failure) and by intervention type (eg, medication use), and identification of care inaccessible to measurement by linked Medicare and Medicaid claims. RESULTS: A total of 43 out of 230 QIs were captured using linked claims data. The 100,528 patients triggered 930,753 QIs (9.3 QIs/person). The overall QI pass rate (ie, successful receipt of care) was 65%. QIs with the highest pass rates measured avoidance of adverse medications and appropriate medication use. Fewer than half of the QIs were passed for ischemic heart disease, stroke, and osteoporosis. Few QIs aimed at geriatric care could be measured and none assessed counseling, history taking, or information continuity. CONCLUSIONS: The use of claims data-derived quality-of-care process measures is feasible for the vulnerable older population, but requires development of data elements focused on geriatric care. QIs that could be applied to the older patients included in this study identified several areas of care that need improvement.     

Measuring the quality of dying and quality of care when dying in long-term care settings: a qualitative content analysis of available instruments

ContextLong-term care (LTC) settings have become a significant site for end-of-life care; consequently, instruments that assess the quality of dying and care may be useful in these settings.ObjectivesTo evaluate the content of available measurement instruments to assess the quality of dying and care when dying.MethodsQualitative content analysis to categorize items as structure of care, process of care, satisfaction with health care (the first three representing quality of care and its evaluation), quality of dying, or patient factors.ResultsInstruments that measure mostly quality of care and its evaluation are the Family Perception of Physician-Family Caregiver Communication, End-of-Life in Dementia (EOLD) Satisfaction With Care, Family Perception of Care Scale, Toolkit of Instruments to Measure End-of-Life Care after-death bereaved family member interview (nursing home version), and the Family Assessment of Treatment at the End-of-Life Short version. Instruments measuring quality of dying are the EOLD-Comfort Assessment in Dying, EOLD-Symptom Management, Mini-Suffering State Examination, and Palliative Care Outcome Scale. The Quality of Dying in Long-Term Care measures care and dying. The Minimum Data Set-Palliative Care measures mostly dying and patient factors. The instruments differ in dementia specificity, time of administration, and respondent.ConclusionInstruments that assess quality when dying differ in several ways and most do not measure a single construct, which is relevant to guiding and evaluating care. Comparing psychometric properties and usefulness of instruments that measure similar constructs is the next step in determining which are best suited for use in LTC.     

Long-term persistence of quality improvements for an intensive care unit communication initiative using the VALUE strategy

Purpose

Communication in the intensive care unit (ICU) is an important component of quality ICU care. In this report, we evaluate the long-term effects of a quality improvement (QI) initiative, based on the VALUE communication strategy, designed to improve communication with family members of critically ill patients.

Materials and Methods

We implemented a multifaceted intervention to improve communication in the ICU and measured processes of care. Quality improvement components included posted VALUE placards, templated progress note inclusive of communication documentation, and a daily rounding checklist prompt. We evaluated care for all patients cared for by the intensivists during three separate 3 week periods, pre, post, and 3 years following the initial intervention.

Results

Care delivery was assessed in 38 patients and their families in the pre-intervention sample, 27 in the post-intervention period, and 41 in follow-up. Process measures of communication showed improvement across the evaluation periods, for example, daily updates increased from pre 62% to post 76% to current 84% of opportunities.

Conclusions

Our evaluation of this quality improvement project suggests persistence and continued improvements in the delivery of measured aspects of ICU family communication. Maintenance with point-of-care-tools may account for some of the persistence and continued improvements.     

Evaluating the implementation of confusion assessment method‐intensive care unit using a quality improvement approach

Quality improvement (QI) is a way through which health care delivery can be made safer and more effective. Various models of quality improvement methods exist in health care today. These models can help guide and manage the process of introducing changes into clinical practice. The aim of this project was to implement the use of a delirium assessment tool into three adult critical care units within the same hospital using a QI approach. The objective was to improve the identification and management of delirium. Using the Model for Improvement framework, a multidisciplinary working group was established. A delirium assessment tool was introduced via a series of educational initiatives. New local guidelines regarding the use of delirium assessment and management for the multidisciplinary team were also produced. Audit data were collected at 6 weeks and 5 months post‐implementation to evaluate compliance with the use of the tool across three critical care units within a single hospital in London. At 6 weeks, in 134 assessment points out of a possible 202, the tool was deemed to be used appropriately, meaning that 60% of patients received timely assessment; 18% of patients were identified as delirious in audit one. Five months later, only 95 assessment points out of a possible 199 were being appropriately assessed (47%); however, a greater number (32%) were identified as delirious. This project emphasizes the complexity of changing practice in a large busy critical care centre. Despite an initial increase in delirium assessment, this was not sustained over time. The use of a QI model highlights the continuous process of embedding changes into clinical practice and the need to use a QI method that can address the challenging nature of modern health care. QI models guide changes in practice. Consideration should be given to the type of QI model used.     

High-fidelity simulation improves confidence in nursing students

AimConfidence is a key component for effective, safe clinical performance. High-fidelity simulation has been shown to be very useful in developing and increasing confidence. The purpose of this quality improvement (QI) project was to investigate nursing students' confidence levels before and after implementing a high-fidelity obstetrics simulation.MethodsThis quantitative, quasi-experimental QI project evaluated a simulation intervention on the impact on student confidence (n = 30) using the C-Scale pre- and post-intervention.ResultsA statistically significant difference was found using the Wilcoxon Rank Sum test, (z = -4.46, p<.0001).ConclusionsThe results of the QI project indicate that student confidence can be improved with the simulated learning environment. Improving confidence can transfer to improved patient care and safe clinical performance.     

Inside the health disparities collaboratives: a detailed exploration of quality improvement at community health centers

BACKGROUND: Quality improvement collaboratives (QICs) based on the Chronic Care Model (CCM) are widely used models for improving medical care, but there has been little information to date about the specific projects undertaken by participants in these collaboratives and their outcomes. OBJECTIVES: To describe initiatives undertaken by community health centers (CHCs) participating in QICs (the Health Disparities Collaboratives) for asthma, cardiovascular disease, or diabetes, and to determine whether particular features of these initiatives were associated with improvement in health care processes or outcomes. RESEARCH DESIGN: Observational cohort study. DATA SOURCES/STUDY SETTING: Reports of quality improvement (QI) activities and clinical data from 40 CHCs participating in Health Disparities Collaboratives, 2000-2002. MEASURES: Clinical quality scores based on indicators of chronic disease care. RESULTS: Participating CHCs undertook an average of 44 QI activities per center (range, 8-84). These interventions were distributed broadly throughout the elements of the CCM, with particular emphasis on patient registry development and linkages to the surrounding community. Fifty-three percent of the interventions were fully institutionalized and 28% were evaluated by the centers. We found no relationships between improvement in quality and markers of QI activity quantity, intensity, or CCM category. CONCLUSIONS: Organizations participating in QICs fully integrate the CCM components into their QI activities. However, it remains unclear how specific activities pursued under the guidance of the CCM and QICs contribute to quality improvement.     

Are better ratings of the patient-provider relationship associated with higher quality care for depression?

BACKGROUND: The interpersonal patient-provider relationship (PPR) is an essential part of health care quality, particularly for patients with depression, yet little is known neither about how to measure this relationship nor about its association with quality of care. OBJECTIVES: To evaluate properties of patient rating measures, understand the relation between 2 types of ratings, and determine the association of ratings with quality depression care. SETTING AND PARTICIPANTS: 1,104 patients with current depressive symptoms and lifetime or 12-month disorder identified through screening 27,332 consecutive primary care visitors in 6 managed care organizations participating in Partners in Care (PIC). DESIGN: Cross-sectional analysis of 18-month data (collected in 1998) after the start of PIC depression quality improvement (QI) interventions (in which clinics were randomized to 1 of 2 QI interventions or usual care). MEASURES: Patient ratings of the interpersonal relationship with the primary care provider and satisfaction with health care, and quality of depression care indicators. ANALYSIS: Factor analysis and multitrait scaling to evaluate the psychometric properties of multiitem constructs and analysis of covariance to evaluate associations between patient ratings and quality. RESULTS: Patient ratings had high internal consistency and met criteria for discriminant validity tapping unique aspects of care. Patients receiving quality care, especially for medication use, had significantly higher ratings of the interpersonal relationship (by 22% to 27% of a SD) and were more satisfied (by 26% to 34% of a SD) than patients who did not receive quality care. CONCLUSIONS: Ratings of the interpersonal relationship and satisfaction measure distinct aspects of care and are positively associated with quality care for depression.     

Optimizing safe,comfortable ICU care through multi-professional quality improvement: just DO it

Translating research to the bedside can present significant challenges in the complex ICU environment. In this issue of Critical Care, de Jong and colleagues report on a quality improvement project (NURSE-DO) that led to a decrease in severe pain and serious adverse events during nursing care procedures in their ICU. In this commentary we describe three aspects of this quality improvement study that we think contributed to the overall success of the NURSE-DO project: the hospital environment and culture; multi-professional partnerships; and an evidence-based structured approach.Translating research to the bedside can present significant challenges in the complex ICU environment, resulting in a lag between evidence and clinical practice, particularly in multifactorial issues such as pain management. Despite research acknowledging pervasive pain in critically ill patients and clinical practice guidelines recommending routine assessment and pre-emptive treatment, barriers still exist in treating pain with analgesics in the ICU. Most commonly, an underappreciation of pain, concern of serious adverse events, and lack of a structured approach prevent effective pain management in the ICU.In this issue of Critical Care, de Jong and colleagues report on a quality improvement (QI) project (NURSE-DO) that led to a decrease in severe pain and serious adverse events during nursing care procedures in their ICU [1]. In this commentary we describe three aspects of this QI study that we think contributed to the overall success of the NURSE-DO project: the hospital environmental and culture; multi-professional partnerships; and a structured approach.     

Applying the Advancing Excellence in America's Nursing Homes Circle of Success to improving and sustaining quality

Looking forward to the Quality Assurance Performance Improvement (QAPI) program to be implemented and required in 2014, and as nursing home staff provide care for residents with increasingly complex health issues, knowledge of how to implement quality improvement (QI) is imperative. The nursing home administrator and director of nursing (DON) provide overall leadership, but it is the primary responsibility of the DON and other registered nurse staff to implement and manage the day to day QI process. This article describes potential roles of nursing leaders and key components of a QI project using a pressure ulcer case study exemplar to illustrate a quality improvement process. The authors suggest specific methods that RN leaders can employ using the Advancing Excellence Campaign Circle of Success as an organizing framework along with evidence-based resources. Nursing home leaders could use this article as a guideline for implementing any clinical quality improvement process.