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Abstract: Lean has gained recognition in healthcare as a quality improvement tool. The purpose of this research was to examine the extent to which quality improvement projects in healthcare adhered to Lean's eight-step process. We analyzed 605 publications identified through a systematic literature review following PRISMA guidelines. Each publication was coded using a structured coding sheet. The most frequent type of publication reported empirical research (48.6%) and most of these (80.3%) shared the results of the Lean projects. Of the 237 publications reporting Lean projects, more than half (71.3%) used an experimental, one-site, pre/postdesign. The impact of the project was most often measured using a single metric (59.1%) that was operational (e.g., waiting time). Although most Lean project publications reported the use of tools to "break down the problem" (84.4%, Step 2) and "see countermeasures through" (70.0%, Step 6), fewer than half described using tools associated with each of the other steps. Projects completed an average of 2.77 steps and none of the projects completed all steps. Although some may perceive low adherence to the tenets of Lean as a deficiency, it may be that Lean approaches are evolving to better meet the needs of healthcare., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 National Association for Healthcare Quality.)

Introduction: The Centers for Disease Control and Prevention states that tobacco use is the largest and most preventable cause of disease and mortality in the United States. The Joint Commission implemented inpatient tobacco treatment measures (TTMs) in 2012 to encourage healthcare systems to create processes that help patients quit tobacco use through evidence-based care., Methods: A tobacco cessation care delivery system was implemented at James A. Haley Veterans' Hospital and Clinics, which included: standardized pathways within the Veterans Health Administration (VHA) electronic health record system to improve nicotine replacement therapy ordering; evidence-based tobacco cessation counseling; and improved care coordination for tobacco cessation treatment through the use of technological innovation., Results: Outcomes were obtained from the VHA quality metric reporting system known as Strategic Analytics for Improvement and Learning (SAIL). TOB-2 and TOB-3 (two Joint Commission inpatient TTMs) equivalent to tob20 and tob40 within SAIL improved by greater than 300% after implementation at James A. Haley Veterans' Hospital and Clinics., Conclusion: Implementation of a tobacco cessation care system at James A. Haley Veterans' Hospital and Clinics enhanced interdisciplinary coordination of tobacco cessation care and resulted in improvements of The Joint Commission inpatient TTMs by greater than threefold., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 National Association for Healthcare Quality.)

Background: Nationally, there is an expectation that residents and fellows participate in quality improvement (QI), preferably interprofessionally. Hospitals and educators invest time and resources in projects, but little is known about success rates or what fosters success., Purpose: To understand what proportion of trainee QI projects were successful and whether there were predictors of success., Methods: We examined resident and fellow QI projects in an integrated healthcare system that supports diverse training programs in multiple hospitals over 2 years. All projects were reviewed to determine whether they represented actual QI. Projects determined as QI were considered completed or successful based on QI project sponsor self-report. Multiple characteristics were compared between successful and unsuccessful projects., Results: Trainees submitted 258 proposals, of which 106 (41.1%) represented actual QI. Non-QI projects predominantly represented needs assessments or retrospective data analyses. Seventy-six percent (81/106) of study sponsors completed surveys about their projects. Less than 25% of projects (59/258) represented actual QI and were successful. Project category was predictive of success, specifically those aimed at preventive care or education., Conclusion: Less than a quarter of trainee QI projects represent successful QI., Implications: Hospitals and training programs should identify interventions to improve trainee QI experience.

Background: Communication failures between providers threaten patient safety., Purpose: We developed, implemented, and formatively evaluated the ED-PACT Tool, which uses the Veterans Health Administration's (VA) electronic health record to send messages from emergency department (ED) providers to primary care patient-aligned care team (PACT) registered nurses (RNs) for Veterans discharged home from the ED with urgent or specific follow-up needs., Methods: We used Plan-Do-Study-Act quality improvement methodology., Results: Between November 1, 2015, and November 30, 2017, the tool was used to send 4,899 messages in one local VA healthcare system (ED and associated primary care clinics). Formative evaluation revealed that providers and RNs perceive the tool as providing substantial benefit for coordinating post-ED care. Patient-aligned care team leaders reported that RN training and "buy-in" facilitated tool implementation, while insufficient staffing posed a barrier. Emergency department providers noted the advantage of having a standardized and reliable system for communicating with PACTs., Conclusions/implications: The ED-PACT Tool encapsulates several best practices (standardized processes, "closed-loop" communication, embedding into workflow) to facilitate communication between VA ED and follow-up care providers. Our development process illustrates key lessons in quality improvement and innovation implementation including the value of using rapid-cycle improvement methodology, with interprofessional collaboration and representatives from intended spread sites.

Practice facilitation is an approach for advancing quality improvement (QI), but its success depends on effective relationships and communication among participants. Our goal was to identify patterns of contrasting perspectives on implementation issues between practice leaders and their practice facilitators, and factors that may contribute to them. We conducted individual interviews with practice leaders and the practice facilitators assigned to them as part of a program focused on preventive cardiology within primary care practices. We used summative content analysis to quantify the incidence of contrasting perspectives, and bivariate and qualitative analyses to explore relationships between contrasting perspectives and contextual factors. Among the 16 dyads, contrasting perspectives commonly related to the easiest or hardest QI interventions to implement (8 of 16 dyads) and the practice's success implementing interventions (5 of 16 dyads). There was a nonsignificant, inverse correlation (r = -0.19, p = .47) between the number of in-person QI visits from the facilitator and the total number of contrasting perspectives. Turnover of staff was frequently reported in dyads with contrasting perspectives. Although the impact of contrasting perspectives warrants additional study, planners of QI initiatives using practice facilitation should consider taking steps to minimize contrasting perspectives, or the potential adverse consequences of them, by addressing turnover challenges and encouraging opportunities to share perspectives.

The Model for Understanding Success in Quality (MUSIQ) is a framework of contextual factors for quality improvement (QI) projects. We sought to determine which MUSIQ contextual factors were associated with successful QI initiatives. In a cross-sectional survey study, at a 21-site, ambulatory, urban primary care network, a modified MUSIQ survey tool questionnaire was administered to QI team members. The primary analysis associated objective measures of QI success with MUSIQ contextual factors. Objective QI success was defined as reaching goal percentages of adult patients with diabetes achieving glycated hemoglobin less than 8% and/or pediatric patients who had received combination toddler vaccines. Objective outcomes were compared with a subjective, self-reported outcome measure of QI success because previous literature found subjective outcomes were associated with specific MUSIQ factors. In the 143 survey responses collected, across 21 sites, no contextual factors from the MUSIQ survey were associated with either the adult or pediatric objective measure of QI project success. In a post hoc analysis, objective and subjective measures of success were often not associated and/or negatively correlated. In conclusion, contextual factors were not associated with objective measures of QI outcomes, in contrast to previous studies finding associations with subjective QI outcome measures.

Introduction: Errors in communication during handoffs are a significant source of medical error and put patients at risk. The I-PASS system was designed to systematically communicate information to the oncoming healthcare provider and has been shown to decrease the risk of communication errors. The objective of this observational quality improvement study was to determine whether the addition of a partially automated, electronic handoff tool would further decrease errors in communication during transitions of care for inpatient medical teams., Methods: We created an electronic tool to incorporate user-generated patient information in the I-PASS format with automatically compiled data derived from the electronic medical record. Numbers of errors in the printed handoff document were recorded before and after intervention., Results: The first implementation cycle demonstrated an absolute risk reduction for written errors of 45.6% (95% confidence interval [CI] 39.2-51.2%) and a number needed to treat (NNT) of three patients. The second cycle showed an absolute risk reduction of 53.3% (95% CI 39.8-63.9%; NNT 2). Aggregate data showed an absolute risk reduction of 46.6% (95% CI 41.0-51.7%, NNT 3)., Conclusions: Improving the routine task of patient handoff through the thoughtful application of technology can yield benefits in terms of decreasing documentation errors and streamlining workflow before patient handoff.

Severe sepsis and septic shock cause significant morbidity and mortality with health care costs approximating $17 billion annually. The Surviving Sepsis Campaign 2012 recommended time-sensitive care bundles to improve outcomes for patients with sepsis. At our community teaching hospital, a review of sepsis management for patients admitted to a medical intensive care unit (ICU) between December 2015 and March 2016 found 70.8% compliance with timing of lactate draw, 65.3% compliance for blood cultures, and 51.4% compliance with antibiotic administration recommendations. Thus, a quality improvement initiative to improve detection and time to bundle completion for ICU-level patients was designed. Previous studies suggest that utilization of sepsis alert systems and sepsis response teams in the emergency department setting is associated with improved compliance with recommended sepsis bundles and improved hospital mortality. Therefore, a "sepsis alert" protocol was implemented that used both an electronic alert and an overhead team alert that mobilized nursing, pharmacy, phlebotomy, and a senior internal medicine resident to bedside. In addition, a template to document sepsis diagnosis and bundle adherence was created. After implementation, we noted improvement in appropriately timed serum lactate, 88.6% versus 70.8% (p = .008) with no significant improvements in blood cultures, antibiotic administration, or mortality.

Introduction: Magnet Recognition is the highest distinction a healthcare organization can receive for excellence in nursing. Although Magnet status is generally associated with superior clinical outcomes and patient satisfaction, its association with performance on nationwide quality metrics is currently unknown., Methods: Within a propensity score-matched cohort, we compared performance on the Hospital-Acquired Condition Reduction Program (HACRP), Hospital Value-Based Purchasing (VBP), and Hospital Readmissions Reduction Program (RRP) initiatives., Results: The mean HACRP total performance score was inferior at Magnet versus non-Magnet hospitals (p < .001), and HACRP penalties were more likely to be levied against Magnet hospitals (p = .003). There was no significant difference according to Magnet status for VBP penalties after correcting for multiple comparisons (p = .049). There were no significant difference in RRP penalties according to Magnet status (p = .999)., Conclusions: Magnet hospitals performed worse on a number of hospitalwide quality metrics tied to reimbursement by the Centers for Medicare and Medicaid Service. Although Magnet hospitals are known for superior nursing care and organizational support for safety and quality improvement, this is not captured within these composite measures of quality, which can be influenced at many levels of care. These data underscore the need for comprehensive quality improvement across multiple domains of care outside of nursing., Level of Evidence: Level III, retrospective study.

Competency in interprofessional quality improvement and performance measurement is required by the Accreditation Council for Graduate Medical Education. We implemented an interprofessional quality improvement project to support trainee involvement in systems-level improvement to reduce hospital length of stay and engage trainees in efforts to improve the validity and reliability of clinical documentation contributing to risk-adjusted performance measures. The intervention had three components: daily interprofessional disposition huddles to discuss discharge needs, medical documentation curriculum to improve clinical data accuracy, and scheduled coding huddles to provide real-time feedback on documentation. Outcome measures included an unadjusted and risk-adjusted measure of hospital length of stay. Case severity index (CSI) served as a process measure. Statistical process control charts were used to measure change over time. The mean unadjusted length of stay decreased from 5.84 to 4.98 days. Both the unadjusted and the risk-adjusted length of stay measures exceeded the lower control limit of the statistical control chart. The CSI increased and exceeded the upper control limit of the statistical control chart. Improvements were sustained in the year following implementation. The intervention offers a model for academic institutions to satisfy new Common Program Requirements by engaging trainees in performance measurement and interprofessional improvement efforts.

Hypertension is a common problem and a major risk factor for cardiovascular disease. It is unclear whether efforts to control blood pressure (BP) known to be effective in integrated healthcare systems can be successfully implemented in an academic setting. We describe our experience implementing a multistep quality improvement program within an academic general medicine practice aimed at improving BP among patients with uncontrolled hypertension. Ensuring medical assistants were correctly measuring BP provided the basis for accurate data entry into the electronic medical record (EMR); our EMR-based registry data allowed us to feedback primary care provider (PCP) level data on BP control for panel management, which resulted in improvements in BP for a substantial proportion of patients, particularly for those with more practice visits. However, due to PCP, patient, and system barriers, our initial attempt to integrate a pharmacist into our team for hypertension management was only successful for a small number of patients who engaged in pharmacist in-person visits. Future improvement efforts will focus on addressing the barriers to more intensive BP management, integrating lessons from this experience. As chronic disease management shifts to a population-based model, team change will be a necessary component for achieving clinical improvement.

Readmissions are an important quality measure for public reporting, payment, and collaborative research. Lack of measure standardization may lead to inconsistent reporting of outcomes across study sites. In this study, we examined the impact of measurement variability on reporting of a single readmission metric, 30-day all-condition readmission rates (ARRs). We conducted a secondary database analysis of 2006-2008 Medicaid Analytic eXtract data merged from four states of children younger than 21 years. We calculated 30-day ARRs for this cohort using three previously described models varying in their inclusions and exclusions of index hospitalizations and readmissions. The 30-day ARR was highest for the model allowing each readmission to serve as an index admission for subsequent readmissions (ARR: 7%); intermediate for the model allowing one index admission and more than one readmissions in each 30-day period (ARR: 6.2%); and lowest for the model allowing only one readmission in each 30-day period (ARR: 5.6%). Similar variation was seen when stratifying patients by individual diagnostic groups. In conclusion, measurement variability impacts reported outcomes of a single readmission metric. To improve the value of readmission as a quality metric, stakeholders engaged in multisite quality improvement or research should ensure that definitions are standardized across sites.

Older Veterans are increasingly undergoing surgery and are at particularly high risk of postoperative morbidity and mortality. Prehabilitation has emerged as a method to improve postoperative outcomes by enhancing the patient's preoperative condition. We present data from our prehabilitation pilot project and plans for expansion and dissemination of a nationwide quality improvement effort. The infrastructure of the existing Veterans Affairs (VA) Gerofit health and exercise program was used to create our pilot. Pilot patients were screened for risk of postoperative functional decline, assessed for baseline physical function, enrolled in a personalized exercise program, and prepared to transition into the hospital for surgery. Patients (n = 9) completed an average of 17.7 prehabilitation sessions. After completing the program, 55.6% improved in ≥2 of the 5 fitness assessments completed. Postoperative outcomes including complications, 30-day mortality, and 30-day readmissions were better than predicted by the National Surgical Quality Improvement Program Surgical Risk Calculator. We have obtained institutional support for implementing similar prehabilitation programs at VA hospitals nationally through our designation as a VA Patient Safety Center for Inquiry. This is the first multi-institutional prehabilitation program for frail, older Veterans and represents an essential step toward optimizing surgical care for this vulnerable population.

Introduction: Measurement-based care (MBC) is commonly used to manage medical illness, whereas only about 20% of psychiatric care providers use MBC. One aim of the partnership between the Birmingham Veterans Affairs Medical Center (BVAMC) and the University of Alabama at Birmingham School of Nursing (UAB SON) is to provide MBC to Veterans. The goal is to describe the efficacy of MBC in the treatment of Veterans by psychiatric-mental health nurse practitioner (PMHNP) residents., Purpose: By teaching PMHNP residents evidence-based assessment, they gain tools to shorten time to remission of depression, anxiety, and posttraumatic stress disorder., Methods: Residents administered the Patient Stress Questionnaire (PSQ), an MBC tool that assesses depression, anxiety, trauma-related symptoms, and alcohol use, to patients of the Residency Continuity Clinic (RCC). Patient Stress Questionnaire scores from March 2016 to May 2018 were analyzed using paired t tests., Results: Analysis revealed a downward trend in PSQ scores over time, suggesting improvement in psychiatric symptoms. Depressive and anxiety symptoms decreased significantly., Conclusions/implications: This quality project highlights the utility of MBC by PMHNP residents in an RCC. Measurement-based care tools can be quickly and easily administered with little impact on workflow. Use of validated screening tools can enhance care, engage patients, and improve patient outcomes.

HRSA supported health centers have a long history of participating in ambulatory care accreditation; however, there is a dearth of information on the relationship between accreditation and quality of care. We conducted a cross-sectional study of 1,202 health centers, using multivariate regression to estimate the association between accreditation and 14 clinical quality measures, controlling for patient and organizational characteristics. We also predicted national estimates of accreditation-related improvement in quality. Adjusted analyses show that accredited health centers achieved higher performance on adult weight screening and follow-up (coef = 0.037, p < .05), tobacco cessation intervention (coef = 0.042, p < .05), and use of lipid-lowering therapy (coef = 0.028, p < .05). Study results show that universal accreditation could result in additional 552,087 adult patients receiving weight screening and follow-up, 157,434 receiving tobacco cessation intervention and 25,289 receiving lipid-lowering therapy. This is the first national study to examine the impact of accreditation on health center quality of care. Findings suggest that HRSA support for accreditation has the potential to improve quality of care and as a result, reduce health disparities in underserved communities across the United States. Further research is necessary to identify specific elements of accreditation that have the greatest impact on quality of care.

This department column highlights translation of research into healthcare quality practice. Achieving the highest quality in healthcare requires organizations to understand care delivery and to develop and design process efficiencies. The improvement process may be enhanced through a partnership between the healthcare facility and an affiliated school of nursing. The purpose of this article was to describe the process for developing a large-scale improvement project focused on enhancing care transitions within an academic medical center using an academic-practice partnership model.

Peripheral intravenous catheters (PIVCs) are common devices used across many healthcare settings. This quality improvement project aims to proactively remove PIVCs as soon as possible by empowering nurses and providers to clinically evaluate the necessity of every PIVC on a daily basis on a general hospital medical unit. Specific criteria were established to assess PIVC necessity. Cases of PIVCs not meeting established criteria are escalated to providers for a decision point. The PIVC removal times documented within the electronic medical record were analyzed to compare precriteria PIVC dwell times to postcriteria dwell times. The time between removal of a patient's last PIVC and patient discharge was analyzed to determine if more PIVCs are being removed sooner after becoming clinically unnecessary. Significantly fewer PIVCs (decrease of 14.4%) are being removed on the day of discharge in the postintervention time frame, whereas more PIVCs are being removed one (increase of 5.5%) or two (increase of 4.0%) days before the day of discharge. A strategic project to critically evaluate PIVCs on a daily basis and remove PIVCs not meeting criteria for use was successful in proactively removing PIVCs. Hospitals should evaluate PIVC practice, monitor daily usage, and strategically intervene to remove unneeded PIVCs.

Introduction: In 2013, the American College of Cardiology and American Heart Association updated the cholesterol guideline. Despite strong evidence supporting the recommendations, a discernible gap exists in the number of residents who practice them. Our study aimed to identify barriers hindering residents from guideline implementation., Methods: Twenty eight residents were administered a preintervention and postintervention questionnaire to identify barriers in guideline application. The questionnaire was categorized into three barriers: knowledge, attitude, and behavior. A multifaceted educational intervention consisting of directed teaching sessions and supervised patient encounters was conducted., Results: Our analysis showed that our residents lacked awareness, familiarity, and self-efficacy in using the cholesterol guideline. The intervention led to significant improvements in awareness (79% vs. 43%, p = .0129), familiarity (61% vs. 29%, p = .0306), and self-efficacy (65% vs. 16%, p = .0018) and achieved a 31% increase in knowledge (p = .0001), 38% in attitude (p = .0001), and 20% in behavior (p = .019). The overall improvement in scores averaged 30% (p = .0001)., Conclusion: Our quality improvement initiative successfully improved our resident's comprehension and applicability of the 2013 ACC/AHA cholesterol guideline. We recommend a multifaceted educational approach tailored toward addressing specific barriers to improve the practice of evidence-based medicine.

Introduction: Dehydration is a potentially preventable complication post-tonsillectomy and can result in an Emergency Department visit and/or readmission. Our objectives were to identify risk factors for dehydration readmissions and develop interventions to prevent them., Methods: We used retrospective chart reviews to determine if increased intravenous (IV) hydration post-tonsillectomy prevented hospital readmissions for dehydration. All children aged 1-18 years who underwent tonsillectomy between July 1, 2007 and September 30, 2015 were included in this quality improvement study. Using the Pediatric Health Information System database, patients who experienced a readmission for dehydration within 72 hours of surgery were identified and validated with internal data. We analyzed the pre-implementation and post-implementation readmission rates after standardization of increased IV fluids (1.5 times maintenance). An interrupted time series analysis was used to estimate the effects of our hydration initiative., Results: Of 11,157 patients who underwent tonsillectomy during the study period, 96 (0.9%) met the criteria for readmissions for dehydration. The pre-implementation readmission rate was 1% compared to 0.2% post-implementation, a reduction of 82%., Conclusions: The hydration initiative was associated with a significant decrease in hospital readmissions. This safe, low-cost, easy-to-implement approach to preventing dehydration post-tonsillectomy could be explored at other institutions.

Background: Performance feedback is central to data-driven models of quality improvement, but the use of claims-based data for feedback has received little attention., Purpose: To examine the challenges, uses, and limitations of quarterly Medicare claims-based performance feedback reports generated for practices participating in the Comprehensive Primary Care (CPC) initiative from 2012 to 2015., Methods: Mixed methods study of nearly 500 CPC practices in seven regions, combining pilot testing; systematic monitoring; surveys; in-depth interviews; user feedback; and input from data feedback team., Results: Designing reports required addressing issues about timing, data completeness and reliability, variations in patient risk across practices, and use of benchmarks and metrics understandable to users. Practices' ability to use reports constructively depended on their experience, analytic resources, expectations, and perceptions about the role of primary care in improving reported outcomes., Conclusions: Generating claims-based feedback reports that support practices' quality improvement efforts requires a significant investment of analytic expertise, time, resources, continuous improvement, and technical assistance., Implications: Claims-based performance feedback can provide insight into patterns of patients' care across provider settings and opportunities for improvement, but practices need data from other sources to manage patients in real time or assess the short-term effects of specific changes in care delivery.

Indwelling catheter placement is a modifiable risk factor for urethral trauma. We implemented a multidisciplinary Foley Project protocol in June 2015, which consisted of a system-wide catheter education program, difficult urinary catheterization (DUC) algorithm, and skilled catheter nursing team to improve patient outcomes. A retrospective review of male DUC consults between June 2014 and September 2015 was performed. The preprotocol group includes consults received from June 2014 to May 2015. The postprotocol group includes consults received from June 2015 to September 2015. There were 74 patients in the preprotocol and 18 patients in the postprotocol group. The overall incidence rates of catheter-associated trauma during placement were 41.1% in the preprotocol and 5.9% in the postprotocol groups (p = .005). In the preprotocol group, 53.4% required a procedure by a urologist, whereas only 11.8% of patients in the postprotocol group required a procedure (p = .002). The Foley Project protocol reduced the frequency of catheter-associated trauma and procedures.

Expert groups recommend annual chest computed tomography for lung cancer screening (LCS) in high-risk patients. Lung cancer screening in primary care is a complex process that includes identification of the at-risk population, comorbidity assessment, and shared decision making. We identified three key processes required for high-quality screening implementation in our academic primary care practice: (1) systematic collection of lifetime cumulative smoking history to identify potentially eligible patients; (2) visit-based clinical reminders and order sets embedded in the electronic health record (EHR); and (3) tools to facilitate shared decision making and appropriate test ordering. We applied quality improvement techniques to address gaps in these processes. Over 12 months, we developed and implemented a nurse protocol for collecting complete smoking history and entering that data into discrete EHR fields. We obtained histories on over 50% of the clinic's more than 2,300 known current and former smokers, aged 55-80 years. We then built and pilot tested an automated visit-based reminder (VBR) system, driven by the discrete smoking history data. The VBR included an order set and template for documentation of shared decision making. Physicians interacted with the VBR in approximately 30% of opportunities for use. Further work is needed to better understand how to systematically provide appropriate LCS in primary care environments.

Objective: Postprocedure infection complicates nearly 5% of abortions. Multiple organizations endorse prophylactic antibiotics to reduce infection risk with surgical abortion, but the adherence rate remains unknown for women who obtain antibiotics at a pharmacy and take them at home before their procedure. Our objective was to evaluate the effect of quality improvement interventions on antibiotic utilization and preoperative documentation for women undergoing surgical abortion at our academic institution., Methods: An initial quality evaluation of antibiotic utilization by women who had abortions in our operating room between April 2012 and June 2013 revealed suboptimal antibiotic adherence and poor physician documentation. To address these issues, we recommended patients to fill prescriptions at the pharmacy located in the same building as our clinic and created a standard preoperative template for the medical record. We reexamined outcomes for women having abortions from April 2014 to June 2015., Results: Antibiotic adherence increased from 81% to 90% (p < .001). The proportion of patients not receiving antibiotics decreased from 2.4% to 0.5% (p = .01). Adherence documentation rates improved from 69% to 99% (p < .001)., Conclusions: Using an easily accessible pharmacy and a standard preoperative template improves utilization of prophylactic antibiotics for patients undergoing abortions in the operating room.

This article describes the experiences of a quality improvement team that used small cycles of change to improve the emergency department (ED) of an academic medical center. The role of EDs in the provision of healthcare continues to increase in importance. ED bottlenecks contribute to long waits and diminished outcomes for ED patients as well as more system-wide issues, such as inefficiencies in inpatient admission processes. The purpose of this "ED Operational Efficiency Project" was to reduce lengths of stay (LOS) for low-acuity patients. The team used lean management techniques to both improve services and shift the ED culture to prioritize continuous quality improvement. The goal to reduce LOS by 30% was met as the result of several inter=related projects (or small cycles of change). Key lessons include monitoring metrics, communicating with teams and target populations, learning from initial failures, using small wins to increase momentum, and anchoring changes.

Background: National performance measurement programs used to improve quality and/or accountability are prevalent. Professional society-based programs largely assess practice or provider performance. We tested the limitations of the Quality Oncology Practice Initiative (QOPI), a well-established program., Methods: We investigated the potential limitations of the QOPI limited sampling strategy and end-of-life (EOL) metrics through a retrospective review of all decedents meeting the QOPI eligibility criteria at a large three-site community oncology practice. Relative precision for each EOL metric was measured and simulated scenarios modeled via log-normal distributions were compared., Results: A total of 246 deaths were identified; only 14% of decedents were included in the QOPI limited sample. Important differences in relative precision between samples were evident. Chemotherapy administered at the EOL was 2.8 times greater among the full cohort compared to the sample., Conclusion: The limited sampling strategy demonstrated the lack of precision explained by sampling variability confounded in smaller sample sizes. Our analyses demonstrated that practices reporting the same metric may stem from very different underlying distributions, which limits the ability to understand complex practice patterns and improve care. These findings may be of significance to other performance measurement programs that utilize similar testing strategies.

Healthcare providers have increased the use of quality improvement (QI) techniques, but organizational variables that affect QI uptake and implementation warrant further exploration. This study investigates organizational characteristics associated with clinics that enroll and participate over time in QI. The Network for the Improvement of Addiction Treatment (NIATx) conducted a large cluster-randomized trial of outpatient addiction treatment clinics, called NIATx 200, which randomized clinics to one of four QI implementation strategies: (1) interest circle calls, (2) coaching, (3) learning sessions, and (4) the combination of all three components. Data on organizational culture and structure were collected before, after randomization, and during the 18-month intervention. Using univariate descriptive analyses and regression techniques, the study identified two significant differences between clinics that enrolled in the QI study (n = 201) versus those that did not (n = 447). Larger programs were more likely to enroll and clinics serving more African Americans were less likely to enroll. Once enrolled, higher rates of QI participation were associated with clinics' not having a hospital affiliation, being privately owned, and having staff who perceived management support for QI. The study discusses lessons for the field and future research needs.

Context: The goal of this article is to provide a succinct scan of the literature as it relates to the current thinking and practice in large-scale improvement initiatives in healthcare., Method: We employed a scan of the literature using a modified Delphi technique. A standard review form was used. The scan was limited to large-scale spread efforts in hospitals and healthcare systems. Each of the main factors that emerged during the scan was linked to secondary factors and organized using a driver diagram., Findings: Four primary drivers (factors) emerged during our scan that inform large-scale change initiatives in healthcare: Planning and Infrastructure; Individual, Group, Organizational, and System Factors; The Process of Change; and Performance Measures and Evaluation., Conclusion: Our scan identified a tremendous amount of work being done around the world to improve healthcare. In general, our findings suggest these initiatives tend to be fragmented from an implementation standpoint. We identified primary and secondary drivers (factors) that can be used by those responsible for implementing large-scale improvement initiatives both at a strategy level and in their daily work. These drivers could serve as a "checklist" of ideas to consider in different testing and implementation situations., (© 2011 National Association for Healthcare Quality.)

This was an evaluation of the efforts of five hospitals that participated in a collaborative aimed at improving patient flow and reducing emergency department (ED) crowding. Interviews with hospital implementation team members were conducted at two separate times, and multivariate linear regression models and bivariate logistic models were constructed to assess changes in ED length of stay (LOS) and left without being seen (LWBS). By the end of the collaborative, four of the five hospitals had at least one fully implemented improvement strategy. Those hospitals experienced modest improvements in patient flow: a hospital that implemented front-end improvements and devoted additional resources to fast track had a 51-min reduction in ED LOS, another that implemented only front-end improvements had a 9-min reduction in LOS, a third hospital that improved communication between the ED and inpatient units to facilitate admissions decreased LWBS from 0.6% to 0.4%, and a fourth hospital reduced LOS by 59 min for mid-acuity patients by establishing a new care process for them. Results suggest that relatively small changes may lead to improvements in measures of patient flow that are modest, at best., (© 2011 National Association for Healthcare Quality.)

This study tested the feasibility of a quality improvement (QI) program that provided first and second year medical students with education in QI processes and demonstrate their utility within the framework of a real-world QI project. Medical students assessed the use of the Surgical Safety Checklist at The Ohio State University Medical Center. Before performing audits students were required to complete a self-paced online program that provided preliminary education in QI, patient safety, leadership, teamwork, and patient-centered care. A 2.5-hr orientation introduced basic operating room protocol, and the surgical checklist audit tool. Orientation included a multimedia simulation of checklist usage and a role-playing exercise simulating its use. Students completed pre- and postparticipation assessments. Results included an increased knowledge of QI methodology, an improved understanding of the evidence supporting the need for QI projects within health systems, and a greater awareness of available QI projects. Students' perspectives changed to indicate an increased belief that QI is the responsibility of all health professionals including physicians, administrators and other staff. This study concluded that QI education can be effectively disseminated to medical students early in their education using existing online tools and experiential QI projects, and can result in actionable QI data supporting hospital improvement initiatives., (© 2012 National Association for Healthcare Quality.)

This study describes the types of events leading to the performance of root cause analyses (RCA) and the implementation rate and quality of the action plans developed for RCAs performed at a free standing children's hospital. Twenty serious adverse events resulting in RCAs took place between January 2007 and June 2009. A wide variety of events triggered RCAs however, 30% involved medication errors. Seventy-eight action plans were developed with an average of 3.9 ± 1.3 per RCA. Action plans were classified as weaker 46% of the time, intermediate 44% of the time, and stronger 10% of the time. Intermediate or stronger action plans were developed to address 90% of the events. Ninety-five percent of the action plans were implemented. This study demonstrates that RCA can be effectively utilized to consistently generate moderate and high impact action plans to address a diverse array of adverse events within a children's hospital. Near complete implementation of action plans can be achieved., (© 2011 National Association for Healthcare Quality.)

One of the most challenging problems facing healthcare providers is to determine the actual cost for their procedures, which is important for internal accounting and price justification to insurers. The objective of this paper is to find suitable categories to identify the diagnostic outpatient medical procedures and translate them from functional orientation to process orientation. A hierarchal task tree is developed based on a classification schema of procedural activities. Each procedure is seen as a process consisting of a number of activities. This makes a powerful foundation for activity-based cost/management implementation and provides enough information to discover the value-added and non-value-added activities that assist in process improvement and eventually may lead to cost reduction. Work measurement techniques are used to identify the standard time of each activity at the lowest level of the task tree. A real case study at a private hospital is presented to demonstrate the proposed methodology., (© 2011 National Association for Healthcare Quality.)

Using the classical process improvement framework of Plan-Do-Study-Act (PDSA), the diagnostic radiology department of a tertiary hospital identified several patient cycle time reduction strategies. Experimentation of these strategies (which included procurement of new machines, hiring of new staff, redesign of queue system, etc.) through pilot scale implementation was impractical because it might incur substantial expenditure or be operationally disruptive. With this in mind, simulation modeling was used to test these strategies via performance of "what if" analyses. Using the output generated by the simulation model, the team was able to identify a cost-free cycle time reduction strategy, which subsequently led to a reduction of patient cycle time and achievement of a management-defined performance target. As healthcare professionals work continually to improve healthcare operational efficiency in response to rising healthcare costs and patient expectation, simulation modeling offers an effective scientific framework that can complement established process improvement framework like PDSA to realize healthcare process enhancement., (© 2011 National Association for Healthcare Quality.)

Most older adults are admitted to home health care with some functional impairment related to chronic illness and/or hospitalization. This article describes: (1) the impact of a quality improvement initiative (QI) on functional outcomes of older, chronically ill patients served by a large homecare organization; and (2) key implementation challenges affecting intervention outcomes. Over 6,000 patients were included in two dissemination phases. Phase 1 randomly assigned service delivery teams to intervention (QI) or usual care (UC). Phase 2 spread the intervention to UC teams. Phase 1 yielded statistically significant, albeit modest, functional improvements among intervention team patients relative to UC. Phase 2 improvements in the original intervention group were smaller, suggesting some regression to the mean. UC teams did not "catch up" when exposed to the intervention in Phase 2. Analysis of the implementation process suggested that modification of improvement strategies and "dilution" of peer-to-peer communication hindered additional Phase 2 improvements. The findings highlight the challenges of relying on peer-to-peer spread, and of distinguishing the core elements of an effective improvement strategy that must be spread consistently from those that can be adapted to variations within and across organizations., (© 2011 National Association for Healthcare Quality.)