Factors of a physician quality improvement leadership coalition that influence physician behaviour: a mixed methods study.

BACKGROUND: A coalition (Strategic Clinical Improvement Committee), with a mandate to promote physician quality improvement (QI) involvement, identified hospital laboratory test overuse as a priority. The coalition developed and supported the spread of a multicomponent initiative about reducing repetitive laboratory testing and blood urea nitrogen (BUN) ordering across one Canadian province. This study's purpose was to identify coalition factors enabling medicine and emergency department (ED) physicians to lead, participate and influence appropriate BUN test ordering. METHODS: Using sequential explanatory mixed methods, intervention components were grouped as person focused or system focused. Quantitative phase/analyses included: monthly total and average of the BUN test for six hospitals (medicine programme and two EDs) were compared pre initiative and post initiative; a cost avoidance calculation and an interrupted time series analysis were performed (participants were divided into two groups: high (>50%) and low (<50%) BUN test reduction based on these findings). Qualitative phase/analyses included: structured virtual interviews with 12 physicians/participants; a content analysis aligned to the Theoretical Domains Framework and the Behaviour Change Wheel. Quotes from participants representing high and low groups were integrated into a joint display. RESULTS: Monthly BUN test ordering was significantly reduced in 5 of 6 participating hospital medicine programmes and in both EDs (33% to 76%), resulting in monthly cost avoidance (CAN$900-CAN$7285). Physicians had similar perceptions of the coalition's characteristics enabling their QI involvement and the factors influencing BUN test reduction. CONCLUSIONS: To enable physician confidence to lead and participate, the coalition used the following: a simply designed QI initiative, partnership with a coalition physician leader and/or member; credibility and mentorship; support personnel; QI education and hands-on training; minimal physician effort; and no clinical workflow disruption. Implementing person-focused and system-focused intervention components, and communication from a trusted local physician-who shared data, physician QI initiative role/contribution and responsibility, best practices, and past project successes-were factors influencing appropriate BUN test ordering.

Developing and delivering a hybrid Cardiac Rehabilitation Phase II exercise program during the COVID-19 pandemic: a quality improvement program.

The COVID-19 pandemic resulted in the cessation of approximately 75% of cardiac rehabilitation (CR) programmes worldwide. In March 2020, CR phase II (CRP2) services were stopped in Qatar. Multiple studies had shown safety, effectiveness, reduced cost of delivery and improved participation with hybrid CR. A multidisciplinary team reviewed various alternative models for delivery and decided to implement a hybrid CRP2 exercise programme (HCRP2-EP) to ensure continuation of our patient care. Our aim was to enrol in the HCRP2-EP 70% of all eligible patients by 30 September 2020. Institute for Health Care Improvement's collaborative model was adopted. Multiple plan-do-study-act cycles were used to test change ideas. The outcomes of the project were analysed using standard run chart rules to detect the changes in outcomes over time. This project was implemented from March 2020, and the male patients enrolled between August 2020 and April 2021, with sustained monthly median enrolment above target of 70% throughout. As for our secondary outcome, 75.8% of the male patients who completed HCRP2-EP showed a meaningful change in peak exercise capacity of ≥10% (mean change 17%±6%). There were no major adverse events reported, and the median Patient Satisfaction Score was 96% well above the institutional target of 90%. This shows a well-designed quality improvement programme is an appropriate strategy for implementing HCRP2-EP in a clinical setting, and HCRP2-EP is a feasible, effective and safe intervention in eligible male patients with cardiovascular disease.

Hospital quality reporting in the pandemic era: to what extent did hospitals' COVID-19 census burdens impact 30-day mortality among non-COVID Medicare beneficiaries?

OBJECTIVES: Highly visible hospital quality reporting stakeholders in the USA such as the US News & World Report (USNWR) and the Centers for Medicare & Medicaid Services (CMS) play an important health systems role via their transparent public reporting of hospital outcomes and performance. However, during the pandemic, many such quality measurement stakeholders and pay-for-performance programmes in the USA and Europe have eschewed the traditional risk adjustment paradigm, instead choosing to pre-emptively exclude months or years of pandemic era performance data due largely to hospitals' perceived COVID-19 burdens. These data exclusions may lead patients to draw misleading conclusions about where to seek care, while also masking genuine improvements or deteriorations in hospital quality that may have occurred during the pandemic. Here, we assessed to what extent hospitals' COVID-19 burdens (proportion of hospitalised patients with COVID-19) were associated with their non-COVID 30-day mortality rates from March through November 2020 to inform whether inclusion of pandemic-era data may still be appropriate. DESIGN: This was a retrospective cohort study using the 100% CMS Inpatient Standard Analytic File and Master Beneficiary Summary File to include all US Medicare inpatient encounters with admission dates from 1 April 2020 through 30 November 2020, excluding COVID-19 encounters. Using linear regression, we modelled the association between hospitals' COVID-19 proportions and observed/expected (O/E) ratios, testing whether the relationship was non-linear. We calculated alternative hospital O/E ratios after selective pandemic data exclusions mirroring the USNWR data exclusion methodology. SETTING AND PARTICIPANTS: We analysed 4 182 226 consecutive Medicare inpatient encounters from across 2601 US hospitals. RESULTS: The association between hospital COVID-19 proportion and non-COVID O/E 30-day mortality was statistically significant (p<0.0001), but weakly correlated (r2=0.06). The median (IQR) pairwise relative difference in hospital O/E ratios comparing the alternative analysis with the original analysis was +3.7% (-2.5%, +6.7%), with 1908/2571 (74.2%) of hospitals having relative differences within ±10%. CONCLUSIONS: For non-COVID patient outcomes such as mortality, evidence-based inclusion of pandemic-era data is methodologically plausible and must be explored rather than exclusion of months or years of relevant patient outcomes data.

Implementing criteria-led discharge for acute admissions to facilitate the elective recovery from COVID-19: an example in acute tonsillitis.

BACKGROUND: Healthcare systems face unprecedented numbers of patients waiting for elective treatments in the wake of the COVID-19 pandemic. Hospitals must urgently optimise patient pathways and build capacity to meet the populations health needs. Criteria-led discharge (CLD) is frequently used to optimise elective care pathways but may hold potential in discharging patients at the end of an acute hospital admission. METHODS: We conducted a quality improvement project to design and introduce a novel inpatient pathway using CLD for patients with severe acute tonsillitis. Our analysis compared the standardisation of treatment, length of stay, discharge time and readmission rate between those treated on the novel pathway compared with standard treatment. RESULTS: The study population included 137 patients admitted to a tertiary centre with acute tonsillitis. Introduction of the tonsillitis pathway using CLD resulted in a significant reduction in median length of stay from 24 hours to 18 hours. Of those treated on the tonsillitis pathway, 52.2% were discharged prior to midday compared with 29.1% who received standard treatment. No patient discharged using CLD required readmission. CONCLUSION: CLD is safe and effective at reducing length of stay in patients requiring acute hospital admission for acute tonsillitis. CLD should be used and evaluated in further novel patient pathways across different areas of medicine to optimise care and build capacity for provision of elective healthcare services. Further research is required to investigate safe and optimal criteria which indicate patients are fit for discharge.

Ophthalmology service recovery with 'general anaesthesia to local anaesthesia conversion' or GALA initiative: a new surgical service pilot.

We report on the establishment of "general anaesthesia (GA) to local anaesthesia (LA) conversion" or GALA initiative at Sheffield Teaching Hospitals NHS Foundation Trust. Through GALA initiative, long waiters for cataract surgery under GA or LA with intravenous sedation were counselled for LA surgery. With careful surgical planning and personalised solutions to LA barriers, LA-converted patients reported good visual and surgical experience outcomes. The GALA initiative reduced cataract surgery waiting times of participants by 11 weeks and increased GA list capacity by three to four theatre lists in its four months of pilot run. This initiative did not limit training opportunities for ophthalmology trainees whose training was affected significantly during the pandemic.

Access, relationships, quality and safety (ARQS): a qualitative study to develop an Indigenous-centred understanding of virtual care quality.

BACKGROUND: Among Indigenous peoples in Canada, access to high-quality healthcare remains an important determinant of health. The shift to virtual and remote-based approaches, expedited during the COVID-19 pandemic, influenced the ways in which individuals accessed care and the quality of care received. This study sought to determine which elements are required for effective and sustainable virtual care approaches for delivery of primary care to Indigenous patients and develop quality indicators grounded in Indigenous community and experience. We share a conceptual framework to understand how Indigenous patients access and define high-quality virtual care, grounded in Indigenous patient experiences and worldviews. METHODS: Using principles of patient-oriented research, we grounded this work in social justice and participatory action research. We sought to gain an in-depth understanding of the Indigenous experiences of virtual care and specifically of primary care. This was developed through semistructured interviews with Indigenous patients and Indigenous virtual primary care providers. RESULTS: Thirteen participants were interviewed between 5 August 2021 and 25 October 2021. Using Framework Analysis, we constructed four domains including access, relationships, quality and safety as being primary facets of defining high-quality Indigenous virtual primary care. DISCUSSION: The results presented here indicate that the shift to virtual care, largely seen in response to the COVID-19 pandemic, does not compromise quality of care, nor does it lead to negative patient experiences. Optimal care is possible in virtual settings for some care needs and types of appointments and has the potential to decrease barriers to access and improve patient experiences of safety and quality while facilitating patient/provider relationships. CONCLUSION: In summary, high-quality Indigenous virtual care benefits from attention to patients' experiences of access, relationships, safety and quality with their service providers and healthcare teams.

Transitioning EPMA applications in a large multisite teaching hospital.

INTRODUCTION: University Hospitals of Leicester (UHL) has co-developed and deployed a novel Electronic Prescribing and Medicines Administration (EPMA) application as part of the trust electronic patient record (EPR) programme that meets specific clinical demands and interoperability standards of the National Health Service (NHS) despite clinical pressures from the COVID-19 pandemic. METHODS: Following an initial limited pilot deployment, a big-bang whole site-based approach allowed transition of 1844 acute adult inpatients beds from an existing standalone EMPA to the new system. This project used a frontline driven and agile management strategy. Clinical risk was managed using a combination of standard risk logs, robust clinical prototyping and robust disaster recovery plans. Early engagement with clinical teams allowed for advanced product configuration before live deployment and reduced the need for sustained transition support for clinical staff. RESULTS: An iterative, well-governed approach, led by a combination of information technology (IT) and clinical staff with a responsive vendor, enabled a complex new EPMA system in a large acute NHS trust to be deployed with limited resources despite the ongoing COVID-19 pandemic. DISCUSSION: The development and deployment of EMPA and EPR systems across NHS trusts is a key enabler for better healthcare delivery. This case study shows it is possible to deploy a new clinical IT system at scale without interruption of clinical services and with a relatively modest deployment team. Sustainability of the project was also ensured through a clear clinically led governance structure to manage risk quickly and carry lessons learnt onto new developments.

Effectiveness of a population-based integrated care model in reducing hospital activity: an interrupted time series analysis.

Objectives: First impact assessment analysis of an integrated care model (ICM) to reduce hospital activity in the London Borough of Hillingdon, UK. Methods: We evaluated a population-based ICM consisting of multiple interventions based on self-management, multidisciplinary teams, case management and discharge management. The sample included 331 330 registered Hillingdon residents (at the time of data extraction) between October 2018 and July 2020. Longitudinal data was extracted from the Whole Systems Integrated Care database. Interrupted time series Poisson and Negative binomial regressions were used to examine changes in non-elective hospital admissions (NEL admissions), accident and emergency visits (A&E) and length of stay (LoS) at the hospital. Multiple imputations were used to replace missing data. Subgroup analysis of various groups with and without long-term conditions (LTC) was also conducted using the same models. Results: In the whole registered population of Hillingdon at the time of data collection, gradual decline over time in NEL admissions (RR 0.91, 95% CI 0.90 to 0.92), A&E visits (RR 0.94, 95% CI 0.93 to 0.95) and LoS (RR 0.93, 95% CI 0.92 to 0.94) following an immediate increase during the first months of implementation in the three outcomes was observed. Subgroup analysis across different groups, including those with and without LTCs, showed similar effects. Sensitivity analysis did not show a notable change compared with the original analysis. Conclusion: The Hillingdon ICM showed effectiveness in reducing NEL admissions, A&E visits and LoS. However, further investigations and analyses could confirm the results of this study and rule out the potential effects of some confounding events, such as the emergence of COVID-19 pandemic.

Improving access to Hackney Integrated Learning Disability Service

Aims Improving access to Hackney Integrated Learning Disability Service (ILDS) using quality improvement (QI) methodology by reducing the time taken to complete eligibility assessment by 50% by April 2021, while improving service user and staff experience. Background Referrals to ILDS require assessment of eligibility. It was noted that there was significant waiting time between referral and eligibility assessment, exacerbated by the COVID-19 pandemic. Quality Network for Community Learning Disability Services guidelines suggest waiting times for those accessing adult learning disability (LD) community services be locally agreed, although there is limited literature on this topic. Methods All staff members across the multidisciplinary team were invited to participate in the QI project. We defined outcome measures as days from referral to allocation of eligibility assessment to staff member and to completion of eligibility assessment, comparing referrals received before and after start of the project. The key change ideas tested using Plan-Do-Study-Act cycles were: (1) eligibility screening checklist, (2) eligibility assessments drop-in sessions for staff, (3) formal training for ILDS staff, (4) eligibility screening allocation system, (5) template letters for eligibility decisions, (6) new ILDS referral form, (7) workshops for local general practitioners. Results Time taken to eligibility assessment allocation decreased from median of 184 (mean=183.5 +/- 109.8) to 13 days (mean=19.9 +/- 26.4) (93% reduction). Time to completion of eligibility assessment decreased from a median of 271 (mean=296.0 +/- 133.8) to 63 days (mean=75.7 +/- 34.8) (77% reduction). We received positive feedback from staff and service users regarding the new eligibility process. Conclusions We report waiting times for accessing our community adult LD services and effective strategies for reducing this. We recommend similar services use a QI methodology to reduce waiting times and improve the experience of staff and service users.

Prudent healthcare in practice: integration of audiology services into primary care.

BACKGROUND: Swansea Bay University Health Board (SB UHB) has been trialling a primary care audiology pathway since 2016. The pathway enables patients with hearing, tinnitus or wax problems to be triaged directly to the audiology department acting as the first point of contact, freeing up general practitioners, Ear, Nose and Throat consultants and nurses to see patients with more complex health conditions. PURPOSE: To evaluate the efficiency of the SB UHB primary care audiology pathway. PARTICULAR FOCUS: Clinical outcomes of patients seen through the SB UHB primary care audiology pathway. OVERVIEW: The vast majority of patients seen through the SB UHB primary care audiology pathway are managed without the need for onward referral (≥87%).

Patterns, appropriateness and outcomes of peripherally inserted central catheter use in Brazil: a multicentre study of 12 725 catheters.

BACKGROUND: Little is known about peripherally inserted central catheter (PICC) use, appropriateness and device outcomes in Brazil. METHODS: We conducted an observational, prospective, cohort study spanning 16 Brazilian hospitals from October 2018 to August 2020. Patients ≥18 years receiving a PICC were included. PICC placement variables were abstracted from medical records. PICC-related major (deep vein thrombosis (DVT), central line-associated bloodstream infection (CLABSI) and catheter occlusion) and minor complications were collected. Appropriateness was evaluated using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). Devices were considered inappropriate if they were in place for <5 days, were multi-lumen, and/or were placed in patients with a creatinine >2.0 mg/dL. PICCs considered appropriate met none of these criteria. Mixed-effects logistic regression models adjusting for patient-level and hospital-level characteristics assessed the association between appropriateness and major complications. RESULTS: Data from 12 725 PICCs were included. Mean patient age was 66.4±19 years and 51.0% were female. The most common indications for PICCs were intravenous antibiotics (81.1%) and difficult access (62.7%). Most PICCs (72.2%) were placed under ultrasound guidance. The prevalence of complications was low: CLABSI (0.9%); catheter-related DVT (1.0%) and reversible occlusion (2.5%). Of the 12 725 devices included, a total of 7935 (62.3%) PICCs were inappropriate according to MAGIC. With respect to individual metrics for appropriateness, 17.0% were placed for <5 days, 60.8% were multi-lumen and 11.3% were in patients with creatinine >2.0 mg/dL. After adjusting for patient and hospital-level characteristics, multi-lumen PICCs considered inappropriate were associated with greater odds of major complications (OR 2.54, 95% CI 1.61 to 4.02). CONCLUSIONS: Use of PICCs in Brazilian hospitals appears to be safe and comparable with North America. However, opportunities to improve appropriateness remain. Future studies examining barriers and facilitators to improving device use in Brazil would be welcomed.

Consent for orthopaedic trauma surgery during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has brought a series of new challenges to the management of surgical patients. The consent process relies on a foundation of open and non-coerced discussion between clinician and patient, which includes all the potential risks of surgery. This must be updated to incorporate the additional risks of surgery during the pandemic including infection with the SARS-CoV-2 and increased risks of complications with the potential requirement for intensive care support. AIM: The aim of this multi-cycle quality improvement project was to ensure all patients were fully informed of the risks of developing COVID-19 and the possible need for intensive care unit (ICU) support. METHODS: We investigated the quality of the consent process for patients undergoing surgery for trauma at our major trauma centre. Our baseline data collection included a review of all orthopaedic trauma consent forms over a 4-week period in March 2020. We subsequently undertook three further Plan-Do-Study-Act (PDSA) cycles over separate 4-week periods. First, in June 2020, after education measures and presentation of baseline data, second in July 2020 after further education and regular digital reminders were sent to staff, and third in September 2021 after the implementation of an electronic consent form. RESULTS: At baseline, only 2.6% of consent forms mentioned the risk of COVID-19 and none mentioned the risk of requiring ITU support. Through three PDSA cycles this increased to 97% of cases where consent forms displayed the additional risks of COVID-19 and the potential need for ITU admission. CONCLUSION: Our quality improvement project improved the informed consent procedure at our trust. By incorporating these additional risks into the template of an electronic consent form, we hope to achieve sustained improvement in practice.

Redesigning care to support earlier discharge from a neonatal intensive care unit: a design thinking informed pilot.

BACKGROUND: Preterm infants may remain in neonatal intensive care units (NICUs) to receive proper nutrition via nasogastric tube feedings. However, prolonged NICU stays can have negative effects for the patient, the family and the health system. AIM: To demonstrate how a patient-centred, design thinking informed approach supported the development of a pilot programme to enable earlier discharge of preterm babies. METHOD: We report on our design thinking-empathy building approach to programme design, initial outcomes and considerations for ongoing study. RESULTS: Through the use of design thinking methods, we identified unique needs, preferences and concerns that guided the development of our novel early discharge programme. We found that stable, preterm infants unable to feed by mouth and requiring nasogastric tubes can be cared for at home with remote patient monitoring and telehealth support. In addition, novel feeding strategies can help address parental preferences without compromising infant growth. CONCLUSION: A patient-centred, design thinking informed approach supported the development of a pilot programme to enable earlier discharge of preterm babies. The programme resulted in a reduced length of stay, thereby increasing NICU bed capacity and limiting hospital turn-aways.

Teledermatology to reduce face-to-face appointments in general practice during the COVID-19 pandemic: a quality improvement project.

Teledermatology is an important subspecialty of telemedicine that continues to evolve with advances in telecommunication and mobile phone technology. A 19-week primary care quality improvement project collected baseline data and tested three change ideas, using the Model for Improvement method, with primary and secondary aims: to increase the weekly percentage of remote dermatological consultations with supporting images that were successfully concluded remotely to greater than 80% and to reduce the weekly percentage of dermatological face-to-face consultations to less than 50%. We hypothesised that by improving the quality of patient images and the confidence of reception staff in triaging skin complaints, there would be a decrease in the weekly number of face-to-face dermatological appointments, thereby decreasing the risk of COVID-19 transmission within the practice and community. Two change ideas focused on supporting patients to improve image quality by introducing '4 Key Instructions' and a patient information leaflet (PIL). The third focused on increasing reception staff confidence in triaging skin complaints by introducing a triage pathway guidance tool. A total of 253 dermatological consultations were analysed: 170 of these were telephone consultations with 308 supporting images. Process measures showed clear improvements in the quality of images provided by patients which likely contributed to an increase in completed remote consultation. Our primary outcome measure was achieved. Our secondary outcome measure suggested that in the absence of high-quality images, it might not be possible to reduce dermatological face-to-face consultations much below 50% in primary care. Process measures showed clear improvements in the quality of images provided by patients which likely contributed to the increase in remote consultation. The implications of these findings for the theory of change are discussed.

Quality framework for remote antenatal care: qualitative study with women, healthcare professionals and system-level stakeholders.

BACKGROUND: High-quality antenatal care is important for ensuring optimal birth outcomes and reducing risks of maternal and fetal mortality and morbidity. The COVID-19 pandemic disrupted the usual provision of antenatal care, with much care shifting to remote forms of provision. We aimed to characterise what quality would look like for remote antenatal care from the perspectives of those who use, provide and organise it. METHODS: This UK-wide study involved interviews and an online survey inviting free-text responses with: those who were or had been pregnant since March 2020; maternity professionals and managers of maternity services and system-level stakeholders. Recruitment used network-based approaches, professional and community networks and purposively selected hospitals. Analysis of interview transcripts was based on the constant comparative method. Free-text survey responses were analysed using a coding framework developed by researchers. FINDINGS: Participants included 106 pregnant women and 105 healthcare professionals and managers/stakeholders. Analysis enabled generation of a framework of the domains of quality that appear to be most relevant to stakeholders in remote antenatal care: efficiency and timeliness; effectiveness; safety; accessibility; equity and inclusion; person-centredness and choice and continuity. Participants reported that remote care was not straightforwardly positive or negative across these domains. Care that was more transactional in nature was identified as more suitable for remote modalities, but remote care was also seen as having potential to undermine important aspects of trusting relationships and continuity, to amplify or create new forms of structural inequality and to create possible risks to safety. CONCLUSIONS: This study offers a provisional framework that can help in structuring thinking, policy and practice. By outlining the range of domains relevant to remote antenatal care, this framework is likely to be of value in guiding policy, practice and research.