Developing a practice-based research network by integrating quality improvement: challenges and ingredients for success

Improving patient outcomes in community-based settings is the goal of both the Clinical Translational Science Award program and practice-based quality improvement (QI) programs. Given this common goal, integrating QI and outcomes research is a promising strategy for developing, implementing, and evaluating clinical interventions. This article describes the challenges and strengths illuminated by the conduct of a combined research/QI study in a nascent practice-based research network. Challenges include research's exclusion of clinic patients who might benefit from the intervention; QI programs' less uniform approach to intervention implementation; and the need for both academic and clinically relevant products and publications. A major strength is the increased likelihood of both engaging clinical practices in research and developing successful clinical interventions. Required elements for success include identification of enthusiastic clinical research "champions," involvement of researchers with clinical experience, and adequate funding to support both research and clinical resources and dissemination. Combined Ql/research projects in the practice-based research environment have the potential to improve and shorten the cycle from good idea to improved clinical outcomes in real-world settings.     

Research and quality improvement experience and knowledge: a nursing survey

fox j., bagley l., day s., holleran r. & handrahan d. (2011) Journal of Nursing Management 19 , 623–631
Research and quality improvement experience and knowledge: a nursing survey Aim To assess nursing staff’s background and research and quality improvement (QI) experience. Background In this corporation, participation in research and QI is encouraged, but little is known about nurses’ experiences. Methods A web-based survey was distributed. Nursing staffs from an academic/teaching medical centre and other intra-corporation non-academic facilities were compared. Results Respondents included: 148 (52.9%) medical centre and 132 (47.1%) non-medical centre subjects. Medical centre respondents had a higher proportion previously engaged in research, currently engaged in research and previously engaged in QI. Productivity (grant, published and presented) was low for both groups but statistically lower for the non-medical centre group. Medical centre employees used research resources more often than the non-medical centre. Time was the most frequently mentioned barrier to participation in research and QI initiatives. Conclusions A moderate proportion of respondents had research and QI experience, yet productivity and use of resources was low. Nurses at non-academically focused facilities were in most need of assistance. Familiarizing nurses with resources and providing protected time may increase productivity. Implications for nursing management Developing an infrastructure to support nursing research is a worthy goal. Information about interest and experience of nurses can aid management in determining how to focus financial resources.     

Sustainability in changing clinical practice promotes evidence-based nursing care

AIM: To examine the relationship between sustained work with quality improvement (QI) and factors related to research utilization in a group of nurses. DESIGN: The study was designed as a comparative survey that included 220 nurses from various health care organizations in Sweden. These nurses had participated in uniformly designed 4-day basic training courses to manage a method for QI. METHODS: A validated questionnaire covering different aspects of research utilization was employed. The response rate was 70% (154 of 220). Nurses in managerial positions at the departmental level were excluded. Therefore, the final sample consisted of 119 respondents. Four years after the training courses, 39% were still involved in audit-related activities, while 61% reported that they had discontinued the QI work (missing = 1). RESULTS: Most nurses (80-90%) had a positive attitude to research. Those who had continued the QI work over a 4-year period reported more activity in searching research literature compared with those who had discontinued the QI work (P = 0.005). The QI-sustainable nurses also reported more frequent participation in research-related activities, particularly in implementing specific research findings in practice (P = 0.001). Some contextual differences were reported: the QI-sustainable nurses were more likely to obtain support from their chief executive (P = 0.001), consultation from a skilled researcher (P = 0.005) and statistical support (P = 0.001). Within the broader health care organization, the existence of a research committee and a research and development strategy, as well as access to research assistant staff, had a tendency to be more common for nurses who had continued the QI work. CONCLUSION: Sustainability in QI work was significantly related to supportive leadership, facilitative human resources, increased activity in seeking new research and enhanced implementation of research findings in clinical practice. It appears that these factors constitute a necessary prerequisite for professional development and the establishment of evidence-based practice.     

Developing a Practice‐Based Research Network by Integrating Quality Improvement: Challenges and Ingredients for Success

Improving patient outcomes in community‐based settings is the goal of both the Clinical Translational Science Award program and practice‐based quality improvement (QI) programs. Given this common goal, integrating QI and outcomes research is a promising strategy for developing, implementing, and evaluating clinical interventions. This article describes the challenges and strengths illuminated by the conduct of a combined research/QI study in a nascent practice‐based research network. Challenges include research''s exclusion of clinic patients who might benefit from the intervention; QI programs’ less uniform approach to intervention implementation; and the need for both academic and clinically relevant products and publications. A major strength is the increased likelihood of both engaging clinical practices in research and developing successful clinical interventions. Required elements for success include identification of enthusiastic clinical research “champions,” involvement of researchers with clinical experience, and adequate funding to support both research and clinical resources and dissemination. Combined Ql/research projects in the practice‐based research environment have the potential to improve and shorten the cycle from good idea to improved clinical outcomes in real‐world settings. Clin Trans Sci 2012; Volume 5: 351–355     

Key Characteristics of Rehabilitation Quality Improvement Publications: Scoping Review From 2010 to 2016

Objective

To characterize the peer-reviewed quality improvement (QI) literature in rehabilitation.

A qualitative study to identify opportunities for improving trauma quality improvement

Background

Quality improvement (QI) is a central tenant of trauma center accreditation in most countries, but its effectiveness is largely unknown. We sought to explore opportunities for improving trauma QI.

Methods

We performed a qualitative research study using grounded theory analyses of interviews with medical directors and program managers from 75 verified trauma centers sampled from the United States (n = 51), Canada (n = 14), and Australasia (Australia and New Zealand [n = 10]) to explore experiences with trauma QI activities and identify opportunities for improvement.

Results

Most trauma centers indicated that they perceived trauma QI to be important and devoted personnel for QI (data entry, data analyst, educator, nurse practitioner). Programs identified 5 principal opportunities to improve trauma QI: (1) ensure resource adequacy (human resources, registry maintenance, financial support, institutional support), (2) encourage stakeholder participation (engagement, communication, coordination), (3) ensure clinical relevance, (4) incorporate evidence-based tools, and (5) require provider and QI program accountability.

Conclusions

Quality improvement programs exist as accreditation requirements in most centers. However, trauma QI practices depend on a range of local and regional factors, and concrete opportunities for improvement that address impact and sustainability exist.     

Provider's Perspectives on Building Research and Quality Improvement Capacity in Primary Care: A Strategy to Improve Workforce Satisfaction

Objectives

Safety‐net populations are underrepresented in research and quality improvement (QI) studies despite the fact that safety‐net providers are uniquely positioned to engage in translational research. This study aimed to understand the current level of interest in, experience with, predicted career satisfaction associated with, and barriers experienced in conducting research and QI among primary care providers (PCPs) at 18 safety‐net practices in the Boston, Massachusetts area.

Methods

The Harvard Catalyst Safety‐net Infrastructure Initiative partnered with staff at a large academic public hospital system, including 15 primary care sites, to develop and administer an online survey. This survey was then adapted and administered at three other academically affiliated community health centers.

Results

Of the 260 providers surveyed, 136 (52%) responded. Nearly 80% reported interest in conducting either QI projects or clinical research and 95% of them believed it would enhance their career satisfaction. However, 63% did not report prior experience or training in research or QI and 93% reported at least one barrier to engagement.

Conclusion

While supporting safety‐net PCPs’ engagement in research and/or QI may improve career satisfaction there are numerous barriers that must be addressed to achieve this goal.     

Qualitätsindikatoren für die Versorgung von Patienten mit Rückenschmerzen

Introduction

Low back pain (LBP) is an epidemiologically and economically relevant health care problem appropriate for quality assurance approaches. Therefore an expert panel (AQUIK) of the National Association of Statutory Health Insurance Physicians has proposed three quality indicators (QI) for monitoring the quality of ambulatory care for LBP. The aim of this article is to present and evaluate the proposed QIs.

Material and methods

The three proposed QIs relating to red flags, imaging and sick leave certificates were evaluated with regard to the underpinning evidence, epidemiology and feasibility. Guidelines and original research as well results from surveys and observational studies evaluating adherence to LBP guidelines were used for assessment.

Results

The expert panel concluded that only the recording of red flags is a relevant and feasible QI. Despite a two-stage expert method the epidemiology of LBP, feasibility and existing routine health care data were not sufficiently taken into account. The author’s conclusion differs in two instances. The red flag concept is not sufficiently clinically validated and recordable to be used as a QI. Otherwise imaging is considered a suitable QI given the observed overuse and the availability of billing data.

Conclusion

Deriving valid and pragmatic QI from LBP guidelines for evaluating care for LBP is difficult. The core messages of guidelines are only recommendations with limited precision and transferability to individual patients. For pragmatic reasons definition of an upper or lower proportion of patients receiving a given health care service is recommended instead of tedious individual evaluation. Reasonable estimates can be based on data from research on health care services. Because of this uncertainty QIs should be evaluated before they are used as a steering instrument.     

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.     

Quality Improvement in Nursing: Administrative Mandate or Professional Responsibility?

For professionals, providing quality service and striving for excellence are ethical responsibilities. In many hospitals in the United States, however, there is evidence indicating that current quality improvement (QI) involving nurses is not always driven by their professional accountability and professional values. QI has become more an administrative mandate than an ethical standard for nurses. In this paper, the tension between QI as nurses' professional ethics and an administrative mandate will be described, and the implicit ideal–reality gap of QI will be examined. The threat to professional nursing posed by the current approach to QI will be examined, and ways to incorporate nursing professional values in a practical QI effort will be explored.     

Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) for Quality Improvement of Pain Management in Hospitalized Adults: Preliminary Psychometric Evaluation

Quality improvement (QI) is a compilation of methods adapted from psychology, statistics, and operations research to identify factors that contribute to poor treatment outcomes and to design solutions for improvement. Valid and reliable measurement is essential to QI using rigorously developed and tested instruments. The purpose of this article is to describe the evolution of the American Pain Society Patient Outcome Questionnaire (APS-POQ) for QI purposes and present a revised version (R) including instrument psychometrics. An interdisciplinary task force of the APS used a step-wise, empiric approach to revise, test, and examine psychometric properties of the society's original POQ. The APS-POQ-R is designed for use in adult hospital pain management QI activities and measures 6 aspects of quality, including (1) pain severity and relief; (2) impact of pain on activity, sleep, and negative emotions; (3) side effects of treatment; (4) helpfulness of information about pain treatment; (5) ability to participate in pain treatment decisions; and (6) use of nonpharmacological strategies. Adult medical-surgical inpatients (n = 299) from 2 hospitals in different parts of the United States participated in this study. Results provide support for the internal consistency of the instrument subscales, construct validity and clinical feasibility.     

Quality improvement strategies for hypertension management: a systematic review

BACKGROUND: Care remains suboptimal for many patients with hypertension. PURPOSE: The purpose of this study was to assess the effectiveness of quality improvement (QI) strategies in lowering blood pressure. DATA SOURCES: MEDLINE, Cochrane databases, and article bibliographies were searched for this study. STUDY SELECTION: Trials, controlled before-after studies, and interrupted time series evaluating QI interventions targeting hypertension control and reporting blood pressure outcomes were studied. DATA EXTRACTION: Two reviewers abstracted data and classified QI strategies into categories: provider education, provider reminders, facilitated relay of clinical information, patient education, self-management, patient reminders, audit and feedback, team change, or financial incentives were extracted. DATA SYNTHESIS: Forty-four articles reporting 57 comparisons underwent quantitative analysis. Patients in the intervention groups experienced median reductions in systolic blood pressure (SBP) and diastolic blood pressure (DBP) that were 4.5 mm Hg (interquartile range [IQR]: 1.5 to 11.0) and 2.1 mm Hg (IQR: -0.2 to 5.0) greater than observed for control patients. Median increases in the percentage of individuals achieving target goals for SBP and DBP were 16.2% (IQR: 10.3 to 32.2) and 6.0% (IQR: 1.5 to 17.5). Interventions that included team change as a QI strategy were associated with the largest reductions in blood pressure outcomes. All team change studies included assignment of some responsibilities to a health professional other than the patient's physician. LIMITATIONS: Not all QI strategies have been assessed equally, which limits the power to compare differences in effects between strategies. CONCLUSION: QI strategies are associated with improved hypertension control. A focus on hypertension by someone in addition to the patient's physician was associated with substantial improvement. Future research should examine the contributions of individual QI strategies and their relative costs.     

Failure to place evidence at the centre of quality improvement remains a major barrier for advances in quality improvement

Mondoux and Shojania (M&S) issued a critique of our call to unify all disciplines of relevance for quality improvement (QI). They do not challenge the need for alignment of different fields that have played roles in the QI space. They selected to focus their critique on our views that ultimately the discipline of QI should be based on the principles of evidence‐based medicine (EBM) and decision sciences. In our response, we reaffirm our calls to help achieve needed alignment and integration of all disciplines of importance to QI through “a unifying framework for improving health care” with EBM and decision sciences at helm. Challenging the importance of placing QI on solid empirical basis is misguided: As QI is all about measuring and consequently improving clinical care, acting on reliable evidence must remain its “cornerstone”. Apparent differences in our views appears to be due to our focus on what care should be delivered, while M&S concentrate on how that care should be delivered. The former is the domain of a narrowly defined EBM, while the latter is the realm of improvement/implementation science—which, we argue, should also be evidence‐based. QI initiatives are fundamentally local activities, and regulators would be most helpful if they require each institution to provide an annual plan of its top QI activities not included in the existing mandated list of performance measures. Finally, we addressed a number of specific QI initiatives highlighted by M&S—use of opioids, handwashing, venous‐thromboembolism prophylaxis, hip replacement, and perioperative beta‐blockers—to show that they would have been carried differently if they were based on the principles of EBM. Thus, the failure to place evidence at the centre remains a major barrier for advances in QI.     

Algorithms to qualify respiratory data collected during the transport of trauma patients

We developed a quality indexing system to numerically qualify respiratory data collected by vital-sign monitors in order to support reliable post-hoc mining of respiratory data. Each monitor-provided (reference) respiratory rate (RR(R)) is evaluated, second-by-second, to quantify the reliability of the rate with a quality index (QI(R)). The quality index is calculated from: (1) a breath identification algorithm that identifies breaths of 'typical' sizes and recalculates the respiratory rate (RR(C)); (2) an evaluation of the respiratory waveform quality (QI(W)) by assessing waveform ambiguities as they impact the calculation of respiratory rates and (3) decision rules that assign a QI(R) based on RR(R), RR(C) and QI(W). RR(C), QI(W) and QI(R) were compared to rates and quality indices independently determined by human experts, with the human measures used as the 'gold standard', for 163 randomly chosen 15 s respiratory waveform samples from our database. The RR(C) more closely matches the rates determined by human evaluation of the waveforms than does the RR(R) (difference of 3.2 +/- 4.6 breaths min(-1) versus 14.3 +/- 19.3 breaths min(-1), mean +/- STD, p < 0.05). Higher QI(W) is found to be associated with smaller differences between calculated and human-evaluated rates (average differences of 1.7 and 8.1 breaths min(-1) for the best and worst QI(W), respectively). Establishment of QI(W) and QI(R), which ranges from 0 for the worst-quality data to 3 for the best, provides a succinct quantitative measure that allows for automatic and systematic selection of respiratory waveforms and rates based on their data quality.     

Biological properties of novel antistaphylococcal quinoline-indole agents

The antibacterial properties of novel quinoline-indole (QI) agents were examined. QI agents demonstrated potent bactericidal activities against Staphylococcus aureus, killing by lytic and nonlytic mechanisms. S. aureus mutants resistant to a lytic QI agent (SEP 155342) and a nonlytic QI agent (SEP 118843) arose at frequencies of 1.4 x 10(-9) and 1.2 x 10(-8), respectively, by selection at four times the MICs. Mutants resistant to QI agent SEP 155342 were unstable, but mutants resistant to QI agent SEP 118843 displayed stable resistance. Mutants resistant to QI agent SEP 118843 were not cross resistant to other inhibitors, including QI agent SEP 155342. Addition of QI agents SEP 118843 and SEP 155342 at four times the MIC caused nonspecific inhibition of several macromolecular biosynthetic pathways in S. aureus. Within 10 min, QI agents SEP 118843 and SEP 155342 both interfered with bacterial membrane integrity, as measured by uptake of propidium iodide. Agents from the two classes of the QI agents probably kill staphylococci by separate mechanisms which, nevertheless, both involve interference with cytoplasmic membrane function. Precise structure-activity relationships for the division of QI agents into two classes could not be determined. However, lytic activity was often associated with substitution of a basic amine at position 4 of the quinoline nucleus, whereas compounds with nonlytic activity usually contained an aromatic ring with or without a methoxy substituent at position 4. Nonlytic QI agents such as SEP 118843 may possess selective activity against the prokaryotic membrane since this compound failed to lyse mouse erythrocytes when it was added at a concentration equivalent to four times the MIC for S. aureus.     

Development of outcome measurement tools for the integrated family delivered care project

The Integrated Family Delivered Care Project (IFDC) aims to empower parents to become experts in their baby's care, and create an ethos, which truly reflects and responds to the families' unique needs. This quality improvement project was developed based on emerging evidence from research studies, which has demonstrated the effectiveness of Family Integrated Care (FIC) model. Although this programme was designed as a quality improvement (QI) project using QI tools to avoid the inflexibility and certain barriers that academic research and randomised studies are associated with it is imperative that we collect reliable data on the effect of this new care model. As part of the IFDC project, a set of pre-defined outcome measures will be collected for infants enrolled in the IFDC project; these measures will be compared with retrospective matched controls cared in traditional neonatal care settings.     

医学领域质量改进与卓越质量改进报告规范

近年来,质量改进方法学在各领域的应用日益增多,其在医学领域的应用也逐渐受到重视。医学领域的质量改进是在需达到的医疗目标指引下,采用不断循环改进的方法将现有知识转化为临床实践,通过可量化改进指标的变化验证所采取的改进措施是否有效,从而完善医疗过程、改善医疗质量。本文介绍医疗领域质量改进项目的结构及论文报告规范,包括标题与摘要、引言、方法、结果、讨论部分的内容及要素,并举例解析,为医护人员开展医疗领域质量改进研究提供参考。     

Using Quality Indicator Codes to Identify Patients’ Fall Risk in Inpatient Rehabilitation Facilities

ObjectiveTo discover if quality indicator (QI) codes are associated with patient falls in inpatient rehabilitation facilities (IRFs).DesignThis retrospective cohort study explored differences between patients who fell and those who did not fall. We analyzed potential associations between QI codes and falls using univariable and multivariable logistic regression models.SettingWe collected data from electronic medical records at 4 IRFs.ParticipantsIn 2020, our 4 data collection sites admitted and discharged a total of 1742 patients older than 14 years . We only excluded patients (N=43) from statistical analysis if they were discharged before admission data had been assigned.InterventionsNot applicable.Main Outcome MeasuresUsing a data extraction report, we collected age, sex, race and ethnicity, diagnosis, falls, and QI codes for communication, self-care, and mobility performance. Staff documented communication codes on a 1-4 scale and self-care and mobility codes on a 1-6 scale, with higher codes representing greater independence.ResultsNinety-seven patients (5.71%) fell in the 4 IRFs over a 12-month period. The group who fell had lower QI codes for communication, self-care, and mobility. When adjusting for bed mobility, transfer, and stair-climbing ability, low performance with understanding, walking 10 feet, and toileting were significantly associated with falls. Patients with admission QI codes below 4 for understanding had 78% higher odds of falling. If they were assigned admission QI codes below 3 for walking 10 feet or toileting, they had 2 times greater odds of falling. We did not find a significant association between falls and patients’ diagnosis, age, sex, or race and ethnicity in our sample.ConclusionsCommunication, self-care, and mobility QI codes appear to be significantly associated with falls. Future research should explore how to use these required codes to better identify patients likely to fall in IRFs.     

Clinical trial of umbilical artery Doppler waveform quality indices.

The ability of two Doppler waveform quality indices to discriminate between high- and low-quality waveforms was tested using 427 sets of umbilical artery Doppler waveforms from patients. The waveforms had been acquired using a 4-MHz continuous-wave Doppler unit. The quality indices (QI) were based on an assessment of the degree of noise of the maximum frequency envelope of the waveforms, and were first a correlation between successive waveform envelopes (QI1), and, second, a sum of local linearity measures (QI2). The sets of waveforms were graded subjectively according to the clarity of the outline of the waveforms, the degree of interference in the region of the spectrum above the outline, and in terms of the degree of variability caused by fetal breathing. At 90% sensitivity for detection of low-quality waveforms according to a high envelope clarity score, the specificities were 68.2% and 52.7%, respectively, for QI1 and QI2. QI1 was independent from pulsatility index and waveform length, but showed strong dependence on fetal breathing. QI2 showed strong independence from pulsatility and fetal breathing and reasonable independence from waveform length. Both QI1 and QI2 performed poorly when there was a large degree of noise in the region of the spectrum above the envelope; however, this poor performance was often related to the inability of the maximum frequency follower to estimate correctly the maximum frequency envelope in those conditions so that the high waveform quality values reflected the erroneous calculation of pulsatility index in those cases.