Improving Vitamin D Screening in a Pediatric Rheumatology Clinic Using Structured Quality Improvement Process
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SUBMITTER: Sarkissian A
PROVIDER: S-EPMC10997281 | biostudies-literature | 2022 Jan
REPOSITORIES: biostudies-literature
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Project description:IntroductionThe American Academy of Pediatrics recommends blood pressure screening at every health care encounter in children younger than 3 years if they have a history of prematurity or other neonatal complications requiring intensive care because these children have an increased risk for hypertension.MethodsA multidisciplinary team conducted a quality improvement initiative to improve blood pressure screening at a single-center outpatient neonatal follow-up clinic. We developed a focused intervention program including a standardized blood pressure measurement protocol, staff training and education, and streamlined documentation. We conducted two Plan-Do-Study-Act cycles from November 2019 to January 2021. The outcome measure was the percentage of patients with a blood pressure measurement. Process measures included the percentage of medical assistants educated on the new protocol, percentage of patients 3 years, and younger old with the first blood pressure measurement taken from the right arm, and the percentage of patients 1 year and younger with 3 documented blood pressures. The balancing measure was staff satisfaction with time to obtain vital signs. We used statistical process control charts and Wilcoxon rank-sum test.ResultsAt baseline, only 15.3% of patients had documented blood pressure. During the 10-month intervention period, there were 954 patient visits. Overall, blood pressure measurement increased to 54.7% with study interventions. The balancing measure was not negatively impacted.ConclusionsAfter implementing a program of focused interventions, we substantially improved the frequency of blood pressure measurements and increased adherence to American Academy of Pediatrics screening guidelines. Improved blood pressure screening allows us to identify and evaluate at-risk infants after hospital discharge.
| S-EPMC9197357 | biostudies-literature
Project description:ObjectiveThis quality improvement initiative aimed to increase the rate of provider screening and documentation of contraception use for reproductive-aged women seen in an academic rheumatology fellows' clinic to >50% by 24 weeks, with sustained improvement at one year.MethodsWith a multidisciplinary team, we devised and implemented six interventional cycles over 24 weeks informed by key stakeholder survey responses. The primary outcome measure was the percentage of eligible visits with contraception information documented in the structured electronic health record field. The smoking status documentation rate was tracked as a balancing measure, and the percentage of contraception documenters who were non-medical doctor (MD) clinical staff, the target group for the intervention, was tracked as a process measure. Outcome, process, and balancing measures were assessed every two weeks over one year.ResultsOver 24 weeks, the rate of contraception documentation increased from 11% to 54% (median 30%), and the median smoking status documentation rate was 88% (68%-97% range); the median rate of non-MD clinical staff documenters was 92% (70%-100% range). Interventions included an introductory educational session with documentation instruction and scripts to guide screening, email reminders from nursing leadership, and interim educational sessions. At one year, the contraception documentation rate was sustained at 50%.ConclusionA multicycle educational intervention led to an increase in the contraception documentation rate from 11% to 54% for reproductive-aged women seen in an academic rheumatology fellows' clinic over 24 weeks, with sustained improvement at one year. Future interventions will focus on increasing contraception counseling and referrals for patients in rheumatology clinics who were high risk.
| S-EPMC11755063 | biostudies-literature
Project description:Universal screening for adverse childhood experiences (ACEs) is recommended by the American Academy of Pediatrics due to downstream health risks. However, widespread screening practices have not been adopted.MethodsWe used quality improvement methods to establish ACEs screening in a busy pediatric clinic that serves primarily Medicaid-insured and Spanish-speaking patients. The final Plan-Do-Study-Act cycle included the screening of both the patient and his/her caregiver(s). ACEs scores were a process measure; balancing measures were the average time to screen, the number of referrals generated, and qualitative caregiver reception.ResultsWe screened 232 families, and the process maintained a ≥ 80% completion rate of ACEs screening for 1-month-old children and their caregivers during the final 10 weeks. 23% of caregivers had an ACEs score ≥ 4; overall, 6% were referred for further resources. The average time to discuss the screen was 86.78 seconds. The general caregiver reception was gratitude; 2% refused screening.ConclusionThis study demonstrates the feasibility of initiating ACEs screening of 1 age group and their caregivers using quality improvement methods.
| S-EPMC8678025 | biostudies-literature
Project description:ObjectiveThis quality improvement project evaluates the feasibility and sustainability of adopting the Patient Health Questionnaire (PHQ) depression screening tool into routine clinical care at a rheumatology fellows' inflammatory arthritis (IA) clinic at a large tertiary center. The aim was to achieve 50% compliance in documentation of PHQ after five months.MethodsProviders received a 30-minute education on the importance of depression screening in patients with IA. A week after the education, two-step depression screening with the PHQ-2 followed by the PHQ-9 was implemented. Nurses performed PHQ-2 at each IA clinic visit verbally and documented the results while rooming patients using an electronic health record (EHR) dotphrase. Patients completed paper forms of the PHQ-9 only if the PHQ-2 score was positive for depression. Fellows then reviewed the PHQ-9 during the clinic visit and documented it using a separate EHR dotphrase. We tracked both PHQ-2 and PHQ-9 documentation rates as the key outcome measures.ResultsBefore to the intervention, depression documentation rate was only 2%. After initial poor participation, nurses achieved the aim after repeated reminders and ongoing education by the senior nurse. Fellows failed to achieve the aim despite repeated reminders and education. Lack of time during clinic visit was found to be the biggest challenge.ConclusionSustained adoption of the PHQ was difficult to achieve. Additional support at the health systems level that prioritizes depression screening may need to take place. Additional research demonstrating improved IA outcomes in screened patients may also be helpful to gain more buy-in from providers.
| S-EPMC11694136 | biostudies-literature
Project description:ObjectivesDischarge of hospitalized pediatric patients may be delayed for various "nonmedical" reasons. Such delays impact hospital flow and contribute to hospital crowding. We aimed to improve discharge efficiency for our hospitalized pediatric patients by using an iterative quality improvement (QI) process.MethodsOpportunities for improved efficiency were identified using value stream mapping, root cause, and benefit-effort analyses. QI interventions were focused on altered physician workflow, standardized discharge checklists, and physician workshops by using multiple plan-do-study-act cycles. The primary outcome of percentage of discharges before noon, process measure of percentage of discharges with orders before 10 am, and balancing measures of readmission rate, emergency department revisit rate, and parent experience survey scores were analyzed by using statistical process control. The secondary outcome of mean length of stay was analyzed using t tests and linear regression.ResultsImplementation of our interventions was associated with special cause variation, with an upward shift in mean percentage of discharges before noon from 13.2% to 18.5%. Mean percentage of patients with discharge orders before 10 am also increased from 13.6% to 23.6% and met rules for special cause. No change was detected in a control group. Adjusted mean length of stay index, 30-day readmissions, and parent experience survey scores remained unchanged. Special cause variation indicated a decreased 48-hour emergency department revisit rate associated with our interventions.ConclusionsAn iterative QI process improved discharge efficiency without negatively affecting subsequent hospital use or parent experience. With this study, we support investment of resources into improving pediatric discharge efficiency through value stream mapping and rapid cycle QI.
| S-EPMC7041555 | biostudies-literature
Project description:Obstructive sleep apnoea (OSA) is more prevalent in patients with hypertension (HTN), and associated morbidities include stroke, heart failure and premature death. In the Internal Medicine Clinic (IMC), over 70% of the patients had a diagnosis of HTN and obesity. We identified a lack of OSA screening in patients with HTN. The aim of this quality improvement (QI) was to increase OSA diagnosis to 5% from the baseline rate of less than 1% in patients with HTN between the ages of 18 and 75 years over 6 months at IMC. We used the Plan-Do-Study-Act (PDSA) method. The QI team performed root cause analysis to identify materials/methods, provider and patient-related barriers. PDSA cycle included: (1) integration of customised workflow of loud Snoring, Tiredness, Observed apnea, high blood Pressure (STOP)-Body mass index (BMI), Age, Neck circumference, and Gender (BANG) OSA screening tool in the electronic health record (EHR); (2) physician education of OSA and EHR workflow; and (3) completion of STOP survey by patients, which was facilitated by nursing staff. The outcome measure was the percentage of OSA diagnosis in patients with HTN. The process measures included the percentage of patients with HTN screened for OSA and the increase in sleep study referrals in hypertensive patients with STOP-BANG score of ?3. Increase in patient wait time and cost of sleep study were the balance measures. Data analysis was performed using weekly statistical process control chart. The average increase in OSA screening rate using the STOP-BANG tool was 3.88%. The significant variation seen in relation to PDSA cycles was not sustainable. 32% of patients scored ?3 on the STOP-BANG tool, and 10.4% had a confirmed diagnosis of OSA. STOP-BANG tool integration in the EHR and a team approach did not result in a sustainable increase in OSA screening. OSA diagnosis was increased to 3.3% in IMC patient population within the 6-month period. The team identified multiple barriers to screening and diagnosis of OSA in the IMC.
| S-EPMC5717931 | biostudies-literature
Project description:Our multi-disciplinary neurology team were dissatisfied with long access times for consultation for new referrals. We participated in a rapid process improvement workshop and a structured improvement process. Over a six-month period we were able to reduce our access time for initial appointment for patients with suspected movement disorders from 133 to 20 days. We implemented a 'carousel' multi-disciplinary appointment and a standardised clinic form that improved the flow of patients and that we estimate will save 150 hours of physician time and 320 hours of administrative time per year.
| S-EPMC4652694 | biostudies-literature
Project description:BackgroundSurgery is a cornerstone of treatment for malignancy. However, significant variation has been reported in patterns and quality of cancer care for important health outcomes, including perioperative mortality. Surgical process improvement tools (SPITs) have been developed that focus on enhancing the processes of care at the point of care, as a means of quality improvement. This study describes SPITs and develops a conceptual framework by synthesizing the available literature on these novel quality improvement tools.MethodsA scoping review was conducted based on instruments developed for quality improvement in surgery. The search was executed on electronically indexed sources (MEDLINE, EMBASE, and the Cochrane library) from January 1990 to March 2011. Data were extracted, tabulated and reported thematically using a narrative synthesis approach. These results were used to develop a conceptual framework that describes and classifies SPITs.Results232 articles were reviewed for data extraction and analysis. SPITs identified were classified into 3 groups: clinical mapping tools, structure communication tools and error reduction instruments. The dominant instrument reported were clinical mapping tools, including: clinical pathways (113, 48%), fast track (46, 20%) and enhanced recovery after surgery protocols (36, 15%). Outcomes reported included: length of stay (174, 75%), readmission rates (116, 50%), morbidity (116, 50%), mortality (104, 45%), and economic (60, 26%). Many gaps in the literature were recognized.ConclusionWe have developed a conceptual framework of SPITs and identified gaps in current knowledge. These results will guide the design and development of new quality instruments in surgery.
| S-EPMC4112620 | biostudies-literature
Project description:BackgroundTransabdominal pelvic ultrasound (TPUS) is the diagnostic test of choice for the evaluation of ovarian torsion, a time-sensitive surgical emergency. A full bladder is required to visualize the ovaries. Bladder filling is a time-consuming process leading to delays to TPUS, poor visualization of ovaries requiring repeat studies, and prolonged emergency department length of stay (ED LOS). The primary objective was to decrease the time to TPUS by standardizing the bladder filling process.MethodsThis quality improvement initiative occurred at a single, academic, quaternary-care children's hospital ED and utilized the Institute for Healthcare Improvement Model for Improvement with sequential plan-do-study-act cycles. The first set of interventions implemented in August 2021 included a new electronic order set and bladder scan by ED nurses. Subsequent plan-do-study-act cycles aimed to decrease the time to intravenous fluid, decrease fluid requirement, and decrease the need for intravenous fluid. The primary outcome measure was the monthly mean time to TPUS. Secondary outcome measures included monthly mean ED LOS and percentage of repeat TPUS. We performed data analysis with statistical process control charts to assess for system change over time.ResultsThe preintervention baseline included 292 ED encounters more than 10 months, and postintervention analysis included 526 ED encounters more than 16 months. Time to TPUS decreased (138-120 min), ED LOS decreased (372-335 min), and repeat TPUS decreased (18% to 4%). All changes met the rules for special cause variation.ConclusionsStandardizing the bladder filling process was associated with decreased time to TPUS, ED LOS, and repeat TPUS.
| S-EPMC10715784 | biostudies-literature
Project description:IntroductionParticipation in quality improvement (QI) projects is required of pediatric residents, and evidence-based medicine has highlighted the importance of providing residents with experiential practice in this realm. Embedding QI projects within a continuity clinic provides residents an opportunity for meaningful involvement in QI efforts.MethodsA QI curriculum was implemented within a pediatric residency program that included an introductory lecture on QI principles and participation in resident-led, team-based QI projects at an outpatient clinic. Residents designed, implemented, and analyzed projects beginning in their intern year. Projects operated on an accelerated, 6-month time frame, allowing residents to complete multiple projects over the course of their residency. Resident QI knowledge was assessed before and after an introductory lecture with the Quality Improvement Knowledge Application Tool (QIKAT). Resident feedback was solicited 1 year following curriculum implementation via anonymous online surveys.ResultsResidents completed four QI projects that produced meaningful improvements in clinic processes and patient care. QIKAT scores significantly increased after the introductory lecture. Residents reported that the curriculum afforded them increased confidence to implement plan-do-study-act cycles and improve patient care in their future practices. Qualitative feedback highlighted the team-based structure, participation in multiple projects, and visible direct impacts on patient care as strengths of the curriculum. Increased involvement of clinic staff, scheduling concerns, and improved communication were areas for improvement.DiscussionOur model for integrating resident-led QI projects into an ambulatory clinic rotation is feasible and has been well received by residents and impactful on clinic processes and care.
| S-EPMC6342353 | biostudies-literature