Continuous quality improvement in the clinical setting: enhancing adoption

Our ability to involve physicians in Continuous Improvement depends on our understanding of (1) professional norms and behaviors, (2) how organizational structures and systems affect physicians, and (3) basic adoption processes within health care organizations and by their professionals.     

Continuous quality improvement of coded data: a data quality study for Category 650

The AHIMA Council on Coding and Classification conducted a study on the use of category code 650, "delivery in a completely normal case." The findings are presented here as a sample of a data quality study.     

The making and adoption of health data standards

Health data standards are key to the U.S. quest to create an aggregated, patient-centric electronic health record; to build regional health information networks; to interchange data among independent sites involved in a person's care; to create a population database for health surveillance and for bioterrorism defense; and to create a personal health record. This paper discusses why health data standards are required, the process of creating those standards, the groups creating those standards, and some of the problems and issues that are affecting the progress and acceptance of standards. It makes a recommendation for dealing with those issues.     

Implementing quality: a study of the adoption and implementation of quality standards in the contracting process in a general practitioner multifund

The increase in managerialism in the 1980s and the 1990 NHS reforms have had major implications for the regulation of providers. Purchasers of health care in the UK are now expected to specify three factors in their contracts: volume, cost and quality. This paper focuses on one of these: i.e. the quality standards purchasers now include within their health service contracts. The case study is of a general practitioner multifund and the analysis focuses on how quality standards are derived and adopted in outpatient contracts. The data were derived from in-depth face-to-face interviews with the key participants in the contracting process. The evidence shows that the standards were derived and adopted with very little participation from the providers. The impact of the quality standards on hospitals consultants' behaviour was negligible, there was very little monitoring of the standards by the multifund, and providers accepted standards which they knew they could not meet. It is concluded that this non-participatory method of developing the quality standards is likely to mean that their impact on service delivery will be limited.     

Adopting Deming's quality improvement ideas: a case study

Much has been written about quality guru W. Edward Deming's quality improvement ideas. But how can his concepts be applied to a health care setting? Michael Pugh, CEO of Parkview Episcopal Medical Center, Pueblo, CO, and key members of his staff talked with Hospitals about what happened when they applied Deming's ideas at their hospital.     

The Minnesota Clinical Comparison and Assessment Program: a resource for clinical quality improvement programs

Project Overview: MCCAP is a voluntary, statewide initiative of more than 50 hospitals designed to improve patient outcomes by reducing variation among healthcare providers. Elective cholecystectomy, both open and laparoscopic, has been one area of focus. Key Findings: Physicians are particularly interested in information about patient care that they do not routinely receive in a standardized format, such as the time required for patients to return to normal activities. Patients who did not meet guideline criteria but who were given prophylactic antibiotics prior to surgery experienced the same, minimal infection rate as patients who received no antibiotics prior to surgery. Participating hospitals are shifting their focus from looking at average occurrence rates (LOS, resource use by procedure) to identifying appropriate resource use. Although 82 percent of elective cholecystectomies met guideline requirements, 25 percent of all patients continue to experience their most distressing symptoms six months after surgery. Many physicians continue to use routine intraoperative cholangiography; however, MCCAP's guideline did a good job of differentiating patients who were more likely to benefit from the procedure from those who were not.     

The "new economics" of clinical quality improvement: the case of community-acquired pneumonia

Hospitals and health systems have developed substantial infrastructure, at significant expense, to improve care quality and support the collection and distribution of quality metrics. Yet providers often have little understanding of what return, if any, they have earned on the investment because they typically view quality improvement efforts simply as a cost of doing business. After analyzing data from 10,512 patients with community-acquired pneumonia, we found that better performance on two quality measures was associated with shorter length of stay and improved financial performance. For example, a one-day decrease in the time until patients were shifted from intravenous to oral antibiotics was associated with a 0.8-day reduction in length of stay and a nearly 60 percent increase in margins. Providers can adapt the methods we used to derive these findings to identify other quality metrics that simultaneously increase care quality and generate economic value. To derive maximum clinical and financial benefit, however, providers must ensure that clinical quality staff members are adequately supported and skilled to set priorities and to implement effective initiatives.     

Striving toward continuous quality improvement: a case study of Saint Mary's Hospital

This case analysis is the result of a year-long study designed to identify and assess the ingredients that led to the successful implementation of a continuous quality improvement (CQI) program at Saint Mary's Hospital in Grand Rapids, Michigan. The key ingredients of success included: (1) an organizational structure and leadership commitment for identifying and improving processes, (2) use of data-based statistical and analytical tools to study processes, (3) empowerment of teams of employees to take charge of the operations of their own work tasks in a manner that encourages continuous learning, (4) involvement of internal and external customers through the improvement process, and (5) development of effective measures for monitoring improvement. The benefits of the CQI efforts at Saint Mary's have been remarkable and hospital-wide.     

Aim for excellence: integrating accreditation standards into the continuous quality improvement framework

The Ottawa Hospital has developed a simple template incorporating specific key Canadian Council on Health Services Accreditation criteria that will allow clinical teams to annually self-assess their activities against the accreditation standards.     

It's in the cards: a practice-friendly, real-time data collection strategy for quality improvement

The heart of the Card Response Project, a six-step data collection strategy, is the clinician, armed with a pocket-sized card for rapid completion during clinic visits.     

Mortality Data System: a case study on municipalities with data underreporting

The study was part of a survey conducted in clusters of Brazilian municipalities (counties) characterized by serious underreporting of deaths, with the objective of estimating infant mortality in these areas in 2000. The article discusses the principal sources of information on infant deaths in these municipalities, as well as some problems related to the implementation of the Mortality Data System (SIM). The methodology included an active search for deaths in previously registered official and unofficial sources, which identified 344 deaths not processed in the SIM (66% of total deaths). There were a low percentage of deaths processed in the SIM and coming from official sources (notary public offices and healthcare facilities), thus highlighting problems with reporting of deaths, issuing of death certificates, and data flows. The important contribution by the Community Health Agents Program/ Family Health Program points to the need for active data search in this source as a routine activity in municipalities with underreporting of data. Insufficient training of professionals and high staff turnover were major issues in the system's deficient implementation.     

The empowering potential of quality improvement data.

Data are being used to redefine, transform, and empower the roles of providers, payers, and patients. The empowering potential of data on these three groups, and their changing roles are reviewed. The use of data to transform care and increase equality is not new, yet the comprehensive application of principles of continuous quality improvement to the delivery processes is just beginning. The approach to the quality improvement processes employed by peer review organizations includes idea capture, development of intuitively appealing quality indicators, formulating the intervention, formalizing the research architecture, and quantifying the impact of the interventions. The multifaceted interventions for improvement are discussed. The future of medicine includes a greater use of data and the quantitative sciences to inspire improvement across the health care delivery continuum.     

A local health department's journey to the summit: a case study of a decade of quality improvement

As the interest in quality improvement (QI) efforts in public health agencies gathers momentum, organizations looking to initiate or strengthen QI processes may benefit from learning about existing programs. This article serves as a case study for other agencies to consider as they embark upon their QI journey. Specifically, this article reviews more than a decade of QI efforts in a mid-sized local health department and highlights areas of success (including an annual QI summit), barriers to implementation of QI, and areas needing improvement.