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Background: For 2003-2008, ThedaCare, a community health system in Wisconsin, achieved significant improvements in quality and the elimination of waste through the development of an improvement system, which included Value Stream analysis, rapid improvement events, and projects applied to specific processes. However, to meet its continuous daily improvement goals, particularly the goal of increasing productivity by 10% annually, ThedaCare needed to change the way its managers and leaders (in its hospital division) conduct and manage their daily work. Accordingly, it developed its Business Performance System (BPS) to achieve and sustain continuous daily improvement. BUILDING THE BPS: ThedaCare devised a multipart pilot project, consisting of "learning to see" and then, "problem solving." On completion of the 15-week alpha phase (6 units) in July 2009, the BPS was spread to the beta pilot (12 units; September 2009-January 2010) and then to cohort 3 (10 units; September 2010-January 2011)., Results: Each alpha unit improved performance on (1) the key driver metric of increasing productivity from 2008 to year-end 2009 (by 1%-11%) and (2) its respective safety/ quality drivers over the respective 2008 baselines. For 2010, improvements across the alpha, beta, and cohort 3 units were found for 11 of the 14 safety/quality drivers-85% of the 11 customer satisfaction drivers, 83% of 6 people engagement drivers; and 48% of 23 financial stewardship drivers., Conclusions: The tools developed for the BPS have enabled teams to see, prioritize, and pursue continuous daily improvement opportunities. Unit leaders now have a structured management reporting system to reduce variation in their management styles. Leaders all now follow leadership standard work, and their daily work is now consistently aligned with the hospital and system strategy.

Intravenous iron therapy is widely used in the management of anemia in patients on hemodialysis, and anemia management protocols provide a standardized approach to IV iron therapy. The author's hemodialysis center implemented an initial anemia management protocol in 2004 based on the principles of a continuous quality improvement (CQI) program, detailed by Bowe and Ammel in the Nephrology Nursing Journal in 2005. Successive revision using the CQI process has resulted in additional benefits regarding patient outcomes, which are reported here. This article illustrates the value of a CQI program for maintaining and improving clinical outcomes in patients who have anemia and are undergoing hemodialysis.

Despite rapid growth in river restoration, few projects receive the necessary evaluation and reporting to determine their success or failure and to learn from experience. As part of the National River Restoration Science Synthesis, we interviewed 39 project contacts from a database of 1,345 restoration projects in Michigan, Wisconsin, and Ohio to (1) verify project information; (2) gather data on project design, implementation, and coordination; (3) assess the extent of monitoring; and (4) evaluate success and the factors that may influence it. Projects were selected randomly within the four most common project goals from a national database: in-stream habitat improvement, channel reconfiguration, riparian management, and water-quality improvement. Roughly half of the projects were implemented as part of a watershed management plan and had some advisory group. Monitoring occurred in 79% of projects but often was minimal and seldom documented biological improvements. Baseline data for evaluation often relied on previous data obtained under regional monitoring programs using state protocols. Although 89% of project contacts reported success, only 11% of the projects were considered successful because of the response of a specific ecological indicator, and monitoring data were underused in project assessment. Estimates of ecological success, using three criteria from Palmer and others (2005), indicated that half or fewer of the projects were ecologically successful, markedly below the success level that project contacts self-reported, and sent a strong signal of the need for well-designed evaluation programs that can document ecological success.

The communication and documentation of radiology preliminary and final interpretations for the identification of discrepancies failed to evolve with radiology's transition away from film. Processes should facilitate documentation and distribution of preliminary findings to multiple practitioners in real time and should provide timely communication and documentation of additional findings. The evolution of the electronic medical record and digital radiology images provided an opportunity to establish effective, safe, and efficient methods of communication and documentation. Froedtert Hospital (Milwaukee, WI) used the Six Sigma process to improve communication and documentation of radiologic findings. Root causes of problems were determined, hypotheses were tested, and new processes were piloted and implemented. Froedtert Hospital improved its process for documenting and communicating preliminary and final interpretations and identifying discrepancies.

Starting in 1991, the Medical College of Wisconsin's (MCW) primary care-focused faculty development programs have continuously evolved in order to sustain tight alignment among faculty members' needs, institutional priorities, and academic reward structures. Informed by literature on the essential competencies associated with academic success and using educational methods demonstrated to achieve targeted objectives, MCW's initial 1.5-day per month comprehensive faculty development programs prepared faculty as clinician-researchers, leaders, and educators. As institutional priorities and faculty roles shifted, a half-day per month advanced education program was added, and the comprehensive faculty development program transitioned to its current half-day per month program. Using a modular approach, this program focuses exclusively on clinician-educator competencies in curriculum, teaching, leadership, evaluation, and learner assessment. Instructional methods combine interactive, face-to-face sessions modeling a range of instructional strategies with between-session assignments now supported through an e-learning platform. All participants complete a required project, which addresses a divisional or departmental need, meets standards associated with scholarship, and is submitted to a peer-reviewed forum. To date, over 115 faculty members have enrolled in MCW's faculty development programs. Program evaluation over the 15-year span has served to guide program revision and to provide clear evidence of program impact. A longitudinal evaluation of comprehensive program graduates from 1993 to 1999 showed that 88% of graduates' educational projects were implemented and sustained more than one year after program completion. Since 2001, each participant, on average, attributes more than two peer-reviewed presentations and one peer-reviewed publication to program participation. Based on 15 years of evaluation data, five tenets associated with program success are outlined.

Objectives: This paper reports the characteristics of recent public health nursing (PHN) practice change experienced by staff-level public health nurses. Recommendations for improving PHN practice offered by study participants are reported and discussed., Design: A cross-sectional written survey was used to collect data from 424 public health nurses in 76 local health departments (LHDs) in Wisconsin (68% response rate) in 2003. Characteristics of practice change were identified using a 15-item-scaled response set. Recommendations on improving practice were made through responses to an open-ended survey question. Content analysis was conducted to identify major themes among the responses., Results: PHN practice has become more population focused. Major themes emerging from the recommendations for practice improvement included increasing system and organizational resources, expanding visibility of public health, and strengthening collaboration., Conclusions: Implications for practice include the need for continuing education in concepts and skills required for population-focused PHN practice, advocacy for more public health resources, and collaboration with academic partners for education and research.

A coordinated initiative for patients with heart failure was planned and implemented across this healthcare system to: (1) incorporate best evidence-based practice to rapidly stabilize the patient, and (2) establish early, coordinated patient education to promote self-care at home with the support of appropriate resources. Length of stay, readmission frequency, ACE inhibitor and beta blocker prescribing patterns at discharge were the outcomes selected for ongoing study and cross-site efforts toward improvement. These outcomes did improve following cross-site implementation with the collaboration of all appropriate disciplines and the coordination of new and existing services to serve this population.

Background: Hospital environments are too often characterized by delays for patients receiving diagnostic testing and prolonged waiting times to complete needed therapy. Frequently there is confusion in scheduling, related at least in part to the complex interplay of clinical acuity and highly individualized care. Luther Midelfort recently began to change the process of patient flow to improve access to care, optimize outcomes by enabling timely intervention, and decrease the wasting of resources., Unit Assessment Tool: The hospital developed a unit assessment tool based on the traffic light concept, which consisted of an assessment of current capacity and a graded, color-coded "workload tolerance" for each hospital unit. Each unit can instantly update its own status and query those of other work environments in the hospital., Experience With the Unit Assessment Tool: For most of the January-July 2001 period, there was generally a progressive decrease in the percentage of time that the units were coded as red (unit closed to new admissions), with concurrent increases in the percentage of time that the units were coded as green (unit open). Use of the tool appears to have contributed to a dramatic increase in staff satisfaction., Summary and Conclusions: The key to regulating patient flow has been to adopt a nursing-initiated capping trust policy whereby nurses are given the authority to limit new admissions. Initiatives are now under way to provide different units with novel models of resource sharing, ranging from flexible housekeeping to "flying nurse squads" to assist units that have become red.

Background: In 1998 SSM Health Care (St Louis) began a series of clinical collaboratives modeled after The Institute of Healthcare Improvement (Boston) Breakthrough Series. There are now four collaboratives, with 46 teams in progress, and four additional collaboratives are scheduled., Collaborative Topics and Structure: Each collaborative consists of three phases: the prework, active, and the continuous improvement phases. The structure of the collaboratives is quite similar to that of the Institute for Healthcare Improvement Breakthrough Series. However, the SSMHC collaboratives include a continuous improvement phase, which was designed to help maintain gains from the projects and to involve entities not originally involved in the collaborative. RESULTS OF COLLABORATIVES IN PROGRESS: Entity teams participating in multiple collaboratives seem to ascend a learning curve and become progressively more skilled in subsequent collaborative work. In Collaborative 1--Improving the Secondary Prevention of Ischemic Heart Disease--the participating entities showed significant improvement in cholesterol screening and treatment. In Collaborative 2--Improving Prescribing Practices--the collaborative teams also showed significant improvement, with a combined cost savings of approximately $450,000 per year. Collaboratives 3--Using Patient Information to Improve Care and Assure Success-and-4--Enhancing Patient Safety Through Safe Systems--are under way., Summary: The collaboratives accelerate improvement work through sharing of successes and failures and peer influence within a reinforcing environment. Most of the collaborative teams have reached their project goals, and the pace of clinical improvement work has accelerated since the start of the collaboratives. The collaboratives provide an environment for clinicians to constructively participate in improvement of patient care.

The effectiveness of a local collaborative quality improvement project in improving the management of postoperative pain for Wisconsin Medicare patients was assessed. Six quality indicators were evaluated on the basis of baseline data from 714 subjects at 15 collaborating hospitals and follow-up data from 406 subjects from the same 15 hospitals. After efforts to improve postoperative pain management, there was statistically significant improvement in all six quality indicators.

Background: Case studies from Project IMPROVE, the first randomized controlled trial to evaluate the effectiveness of continuous quality improvement (CQI) in primary care, were subjected to a qualitative analysis. Three questions were addressed: How does change in the health care environment affect a quality improvement (QI) process? How does clinic organization influence a QI process? and What is the impact of a QI process on clinic organization?, Method: Case studies were conducted in 6 clinics that had been randomly selected from the 22 clinics participating in the IMPROVE intervention. The case study data consisted of observations of CQI team meetings, open-ended interviews with 30 informants (team members plus others in the clinics), interviews with IMPROVE consultants, and documentation from the project. The data were analyzed to identify themes and generate concepts, assess and compare the informants' experiences, and develop a conceptual framework stimulated by research and theory literature., Results: Change and uncertainty in the health care environment both complicated the QI process and motivated participation in improvement. The smaller clinics appeared to have more difficulty with the QI process because of limited resources and lack of compatibility between the QI approach and their clinic organization. Project IMPROVE had two qualitative effects on clinics: increased awareness of preventive services and application of the CQI method to other problems and issues., Conclusion: QI initiatives can help clinics adapt to a changing health care environment and create functioning teams or groups that can address a variety of organization problems and tasks. The process should be flexible to accommodate varying organization structures and cultures.

Quality indicators and a quality monitoring system developed for use in the regulatory survey process offer a quality improvement tool for nursing home staff. The systematic use of resident assessment data can aid in the identification of quality of care problems and the determination of the nature of those problems. The approach is particularly useful in routine and special quality assurance efforts.

At St. Marys Hospital Medical Center in Madison, Wis., some 38% of i.v. antibiotics had more than a two-hour delay in initiating therapy or were not being administered within standard dosing schedules. QI team members developed a simple chart that reinforces the need to start the first dose as soon as possible and guides staff on staggering doses to transition dosing to a standard i.v. dosing schedule. The result--one problem virtually eliminated.

The article describes a unique decentralized wound care program instituted in a nursing home care unit of a Veterans Affairs hospital. This decentralized, interdisciplinary approach to wound care has been effective in reducing the incidence and prevalence of pressure ulcers in a nursing home population over the last 2 years. Prevention was a major focus of the program. The Braden scale was used to identify patients at risk for pressure ulcer formation; proper measures were introduced to reduce identified risk. This collaborative team effort led to improved patient care and decreased incidence and prevalence of pressure ulcers in this population.