We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.
To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure coreplatform@cambridge.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Poor quality of care is a leading cause of excess morbidity and mortality in low- and middle- income countries (L&MICs). Improving the quality of health care is complex, yet the health care sector has benefitted from many experiences in other industries and developed its own approaches to quality improvement (QI). It is challenging to identify what works in each situation, make the intended improvements, and ensure it is well measured and sustained. Yet there are several examples from L&MICs that offer a lot of learning and illustrate those factors that underpin successful experiences in QI. This Chapter looks at the evolution of QI in health care over time; the types of health care QI approaches, and their relationship with patient safety and UHC; the opportunities to address the commonly occurring health care quality and safety challenges, as well as what works or does not work in L&MICs.
Heart failure (HF) has a 2% prevalence in the population and is a major cause of morbidity and mortality. Multiple efforts have been made worldwide to improve quality of care and decrease unplanned readmissions for HF patients, one of which has been the introduction of specialist HF nurses (HFN) in primary health care. The present evidence on the benefits of HFN is contradicting. This study aims to evaluate the impact of a quality improvement intervention, availability of a HFN in Swedish primary care, on hospital readmissions.
Methods:
All patients over the age of 65 with a HF diagnosis and with complete information on availability of a HFN were included in this retrospective register-based study. Using propensity score matching (PSM) techniques, two comparable groups of 128 patients each were created according to the exposure status, availability or no availability of a HFN. The rate of readmission was compared between the groups.
Results:
Using PSM, 256 patients were matched, 128 in the HFN group and 128 in the no-HFN group. A total of 50% and 46.09% of patients in the HFN and no-HFN groups were readmitted, respectively. Mean number of readmissions per patient was 1.19 (SD 0.61) in the HFN group and 1.10 (SD 0.44) in the no-HFN group. Patients in the HFN had 17.6% higher odds of being readmitted during the study period, OR: 1.176 (CI: 0.716–1.932), and 3.8% lower odds of being readmitted within 30 days, OR: 0.962 (CI: 0.528–1.750).
Conclusions:
Availability of a HFN in primary care was not significantly associated with reduced readmissions for the patients included in this study. Further investigations are warranted looking at the impacts of availability and access to a HFN in primary care on readmissions and other patient outcomes.
Accurate anti-aquaporin-4 (AQP4) and anti-myelin oligodendrocyte glycoprotein (MOG) autoantibody assays are needed to effectively diagnose neuromyelitis optica spectrum disorder and MOG antibody-associated disease. A proportion of patients at our centre have been tested for anti-AQP4 and anti-MOG autoantibodies locally, followed by an outsourced test as part of real-world practice. Outsourced testing is costly and of unproven utility. We conducted a quality improvement project to determine the value of outsourced testing for anti-AQP4 and anti-MOG autoantibodies.
Methods:
All patients seen by Calgary neurological services who underwent cell-based testing for anti-AQP4 and/or anti-MOG autoantibodies at both MitogenDx (Calgary, AB) and Mayo Clinic Laboratories (Rochester, MN, USA) between 2016 and 2020 were identified from a provincial database. The interlaboratory concordance was calculated by pairing within-subject results collected no more than 365 days apart. Retrospective chart review was done for subjects with discordant results to determine features associated with discordance and use of outsourced testing.
Results:
Fifty-seven anti-AQP4 and 46 anti-MOG test pairs from January 2016 to July 2020 were analyzed. Concordant tests pairs comprised 54/57 (94.7%, 95%CI 88.9–100.0%) anti-AQP4 and 41/46 (89.1%, 95%CI 80.1–98.1%) anti-MOG results. Discordant anti-AQP4 pairs included two local weak positives (negative when outsourced) and one local negative (positive when outsourced). Discordant anti-MOG pairs were all due to local weak positives (negative when outsourced).
Conclusion:
Interlaboratory discordant results for cell-based testing of anti-AQP4 autoantibodies were rare. Local anti-MOG weak positive results were associated with discordance, highlighting the need for cautious interpretation based on the clinical context. Our findings may reduce redundant outsourced testing.
Forensic mental health services provide care to people in secure psychiatric hospitals and specialised community teams. Measuring outcomes is important to ensure such services perform optimally, however existing measures are not sufficiently comprehensive and are rarely patient reported.
Objectives
To examine a novel instrument for measuring outcomes in forensic mental health services, the FORensic oUtsome Measure (FORUM), which consists of a complementary patient reported questionnaire (FORUM-P) and clinician reported questionnaire (FORUM-C).
Methods
Inpatients at a forensic psychiatric service based in a regional healthcare organization in the UK completed the FORUM-P, while members of their clinical teams completed the FORUM-C. Patients and clinicians also provided feedback on the questionnaires.
Results
Sixty-two patients participated with a mean age of 41.0 years (standard deviation 11.3). For internal consistency, Cronbach’s alpha for the FORUM-P was 0.87 (95% confidence interval (CI) 0.80-0.93) and for the FORUM-C was 0.93 (95% CI 0.91-0.96). For test-retest reliability the weighted kappa for the FORUM-P was 0.44 (95% CI 0.24-0.63) and for the FORUM-C was 0.78 (95% CI 0.73-0.85). For interrater reliability of the FORUM-C the Spearman correlation coefficient was 0.47 (95% CI 0.18-0.69). The FORUM-P received an average rating of 4.0 out of 5 for comprehensiveness, 4.6 for ease of use and 3.9 for relevance, while the FORUM-C received 4.1 for comprehensiveness, 4.5 for ease of use and 4.3 for relevance.
Conclusions
Outcome measures in forensic mental health can be developed with good measures of reliability and validity, and can be introduced into services to monitor patient progress.
Effective diagnostic and treatment pathways for ADHD are needed in prison settings due to the high prevalence of ADHD and comorbidities in the prison population.
Objectives
In this presentation, we will describe two studies conducted in seperate London prisons in England. In the first study, the aim was to identify prisoners with ADHD with a focus on describing comorbidity. In the second study, using QI (quality improvement) methodology, the aim was to measure the practicability and effectiveness of a specialist ADHD diagnostic and treatment pathway for prisoners.
Methods
Two studies were carried out in two separate prisons in London. Firstly, data were collected to understand the prevalence of ADHD and the comorbidities. The second study used quality improvement (QI) methodology to assess the impact of a diagnostic and treatment pathway for prisoners with ADHD.
Results
Of the prisoners, 22.5% met the diagnostic criteria for ADHD. Nearly half of them were screened positive for autistic traits, with a higher prevalence of mental disorders among prisoners with ADHD compared to those without. The QI project led to a significant increase in the number of prisoners identified as requiring ADHD assessment but a modest increase in the number of prisoners diagnosed or treated for ADHD.
Conclusions
Despite various challenges, an ADHD diagnostic and treatment pathway was set up in a prison using adapted QI methodology. Further research is needed to explore the feasibility of routine screening for ADHD in prison and examine at a national level the effectiveness of current ADHD prison pathways.
Prostate cancer is a common malignancy with rising incidence in Western countries such as the United Kingdom. In localised disease there are a variety of curative treatment modalities. Patients can be referred for surgery, or for a combination of hormonal therapies and radiotherapy (external beam radiotherapy or brachytherapy). Each treatment option comes with side effects and in the case of radiotherapy one potential complication is bowel toxicity from radiation exposure. New technologies are being developed to try and mitigate the side effects and long term morbidity of this treatment, and to expand access to radiotherapy for patients who may previously have been excluded (i.e those with inflammatory bowel disease). Rectal Spacers are absorbable polyethylene glycol hydrogels injected into the perirectal space. These position the anterior rectal wall away from the prostate, subsequently minimising radiation dose to the rectum. Rectal Spacers have been introduced to National Healthcare Service (NHS) practice as part of the Innovation and Technology Payment (ITP) programme, however, their use is now under review.
Methodology and Results:
In this editorial we conduct a narrative review of some of the available evidence for Rectal Spacers, discuss their utilization within the NHS and the barriers to their wider use. We also explore preliminary dosimetry and quality of life data for use of Rectal Spacers in our centre where we have been part of the NHS ITP programme. Dosimetry data and Quality of life questionnaires were gathered from 22 treated patients and 11 matched controls. This indicated lower radiation doses to the prostate in those treated with Rectal Spacers.
Conclusion:
Rectal Spacers are an effective method to reduce radiation dose to the prostate in men treated for localised prostate cancer, however, their use remains under review in the NHS and there are a variety of barriers to upscaling their use.
The discipline of medicine advances through research. The medical education community worldwide recognizes that the evolving field of medicine and its progress requires that medical students participate in research. Undergraduate research during premedical and/or medical studies influences the practice of clinical medicine and facilitates the development of physician-scientists. The essential nature of the discipline, the structures and length of medical education worldwide, and the opportunities for research activity are important to understand. Implementation programs that use a competency-based medical education approach find that research is important for meeting medical board competencies. Curricular and research participation barriers exist, but models that integrate research and provide mentored experiences within the academic and training environment can decrease these barriers. Further growth of research preparation in medicine and enhancement of competencies is possible through assessment and continuous quality improvement.
Paediatric patients with tracheostomies are a vulnerable group. During the coronavirus disease 2019 pandemic, healthcare workers can be anxious about viral transmission from secretions and aerosols emerging from the open airway. This paper aims to share a systematic approach to decrease staff exposure and optimise care of these patients.
Methods
Three documents were developed: a generic tracheostomy management plan detailing troubleshooting; a personalised management plan with customised recommendations; and a guide for tracheostomy tube change to minimise aerosol production.
Results
The plan was distributed to 31 patients (age range, 11 months to 17 years) including 23 (74.2 per cent) with uncuffed tubes and 9 (29 per cent) on long-term ventilation. There have been 10 occasions in which the plan was utilised and influenced management.
Conclusion
A structured approach to emergency presentations during the coronavirus disease 2019 pandemic may safeguard paediatric patients from unnecessary manipulation of their tracheostomy tube, minimise viral exposure and allow provision of expeditious care.
Delays in the diagnosis and therapy of benign paroxysmal positional vertigo can greatly impact quality of life and increase healthcare costs for patients. This study aimed to appraise the quality of clinical practice guidelines for the diagnosis and management of benign paroxysmal positional vertigo.
Methods
A comprehensive database search of clinical practice guidelines was completed up to 30 October 2021. Four independent reviewers used the Appraisal of Guidelines for Research and Evaluation II instrument in the quality appraisal.
Results
The highest score was in ‘clarity and presentation’ (58.33 ± 22.7). The lowest score was in ‘applicability’ (13.96 ± 30.1). Overall, four clinical practice guidelines were ‘low quality’ and only one guideline was ‘high quality’.
Conclusion
This review identified a significant lack of quality in clinical practice guideline development for benign paroxysmal positional vertigo, highlighting the need for a more rigorous approach for future guideline development.
An early warning tool, the Congenital Heart Assessment Tool (CHAT), was designed in 2012 to support parental preparation before discharge, enhancing understanding of their infant’s complex CHD, the signs of deterioration to look out for and to support decision-making at home. Acceptability and feasibility of the tool were tested during 2013–2015 in a single centre.
Aim of this project:
To evaluate the wider implementation across four children’s cardiac centres of the CHAT for infants with complex CHD in the community setting.
Design:
A four-centre collaborative mixed-methods quality improvement project funded by The Health Foundation, during 2016–2018. A plan, do, study, act cycle of improvement was employed. This article reports on the planning phases, creation of a modified tool (CHATm); and the implementation phases, including retrospective case note review using CHATm; tabletop simulation exercise using CHATm and clinical implementation of CHATm.
Results:
Key findings included the benefit of using CHATm simulation for practitioners; the effectiveness of CHATm in predicting amber and red triggers, indicating parental actions and escalation of concerns to professionals. Parents using CHATm found it enhanced knowledge in preparation for going home, supported decision-making, and discussions with health care professionals.
Conclusion:
Using the CHATm clinically identified the need to develop a structured model of assessment of parental suitability for home-monitoring programmes. A robust and nationally agreed training programme for all staff using CHATm was recommended to ensure successful and complete implementation in practice.
CHD was the most prevalent congenital anomaly (60.9 per 10,000, 95% CI 59.0–62.8) in England in 2018, with 1767 babies born with severe cardiac defects. The 30-day survival rates for complex procedures continue to improve; however despite care advances, the early post-operative period and first year of life remain a critical time for these infants. The Congenital Heart Assessment Tool was developed to support parental decision-making, standardise care provision, improve communication, and the safety and quality of care.
Aim:
To further evaluate the Congenital Heart Assessment Tool.
Design:
A four centre collaborative mixed-methods quality improvement project funded by The Health Foundation, involving eight phases conducted during 2016–2018. Phases six to eight (clinical simulation exercise, parent workshop, and updated tool) are reported in this paper.
Results:
Four themes emerged from the clinical simulation exercise (phase six) including: improving documentation; preparation of parents; preparation of health care professionals; and communication. One main theme emerged from the parent workshop (phase seven): “what parents know versus what professionals know [about CHD]”.
Conclusion:
These phases further validated the effectiveness of the CHATm in terms of triggering amber and red indicators and demonstrated parents’ ability to identify deterioration in their infant’s clinical condition. Recommendations arising from the quality improvement project enabled the project team to create an updated version of the Congenital Heart Assessment Tool, CHAT2.
Clinical psychologists may work in a variety of settings, but the challenges of working in private practice can be beyond the experience of a trainee. Thus the chapter outlines the conduct in a private practice. It describes the important role of promotion and community education to engage with key stakeholders. The chapter highlights the added value of an evidence-based approach to practice and quality improvement, as they improve accountability and allow the demonstration of effectiveness. The chapter discusses the impact of the need to monitor costs and to adopt a business mentality. It concludes by describing two models for maintaining research engagement while in private practice.
The science-informed approach to clinical practice is founded upon ongoing quality improvement and involves key skills that allow clinical psychologists to confidently provide services in a competitive health care market. Thus, programme evaluation is a core clinical psychology competency but needs to be provided via a co-design framework. The chapter outlines how co-designed programme evaluation addresses patients’ needs in five steps: (i) asking the right questions, (ii) developing an evaluation plan, (iii) collecting and analysing data to produce usable findings, (iv) translating the findings into recommendations for action, and (v) advocating and promoting change. The chapter illustrates how empirically-based programme evaluation supports accountable clinical practice, both at the level of the individual patient and at the aggregate level of the service provider or agency.
Depression is a widespread comorbidity associated with a number of neurological disorders. Untreated depression has negative impacts on patients with neurological disorders, including intensification of pain, increase in symptomatology, impaired quality of life, and nonadherence to treatment. Nonadherence can lead to disease progression, resulting in poor outcomes. Early detection of depression and prompt intervention can substantially impact the mortality, morbidity, and disease burden of this at-risk population. The American Academy of Neurology recommends screening for neurological disease-specific depression comorbidities, while the United States Preventive Services Task Force recommends routine depression screening for the general adult population. However, fewer than 5% of adults are screened in primary care, and as many as 50% of patients remain undiagnosed without a standardized program. Specialty neurology clinic visits could be a point of screening for high-risk neurology patients to positively affect outcomes. A review of the literature supports using a validated tool such as the Patient Health Questionnaire (PHQ-9) to screen for depression in outpatient settings. This quality improvement project was implemented at a private neurology practice that currently has no formalized protocol to identify depressive symptomatology. The PHQ-9 was integrated into the review of systems for patients meeting inclusion criteria with the aim of screening 90% of patients and referring 90% of those who screen positive to mental health services. Descriptive data were used to evaluate current practice status and indications for change. A total of 476 patients were seen during the time frame for this quality improvement inquiry. There were 100 patients excluded related to cognitive impairment for a sample total of n = 376. Over a period of 30 days, the goal was to screen 90% of patients. Despite challenges related to the impact of COVID-19 on the practice’s delivery of care, 83.2% of patients received screening, which was 92% of our goal. Of those screened and diagnosed with depression, 100% were referred to a mental health provider, thereby exceeding the goal. An unanticipated outcome was that 46.3% of patients diagnosed with depression declined a referral to mental health.
Evidence of the impact of public reporting of health care performance on quality improvement is not yet sufficient for definitive conclusions to be drawn, despite the important policy implications. This study explored the association of public reporting of performance indicators of long-term care facilities in Canada with performance trends. We considered 16 performance indicators in long-term care in Canada, 8 of which are publicly reported at a facility level, whereas the other 8 are not publicly reported, between the fiscal years 2011–2012 and 2018–2019. Data from 1,087 long-term care facilities were included. Improving trends were observed among publicly reported indicators more often than among indicators that were not publicly reported. Our analysis also suggests that the association between publication of data and improvement is stronger among indicators for which there was no improvement prior to publication and among the worst performing facilities.
As part of a quality improvement project beginning in October 2011, our centre introduced changes to reduce radiation exposure during paediatric cardiac catheterisations. This led to significant initial decreases in radiation to patients. Starting in April 2016, we sought to determine whether these initial reductions were sustained.
Methods:
After a 30-day trial period, we implemented (1) weight-based reductions in preset frame rates for fluoroscopy and angiography, (2) increased use of collimators and safety shields, (3) utilisation of stored fluoroscopy and virtual magnification, and (4) hiring of a devoted radiation technician. We collected patient weight (kg), total fluoroscopy time (min), and procedure radiation dosage (cGy-cm2) for cardiac catheterisations between October, 2011 and September, 2019.
Results:
A total of 1889 procedures were evaluated (196 pre-intervention, 303 in the post-intervention time period, and 1400 in the long-term group). Fluoroscopy times (18.3 ± 13.6 pre; 19.8 ± 14.1 post; 17.11 ± 15.06 long-term, p = 0.782) were not significantly different between the three groups. Patient mean radiation dose per kilogram decreased significantly after the initial quality improvement intervention (39.7% reduction, p = 0.039) and was sustained over the long term (p = 0.043). Provider radiation exposure was also significantly decreased from the onset of this project through the long-term period (overall decrease of 73%, p < 0.01) despite several changes in the interventional cardiologists who made up the team over this time period.
Conclusion:
Introduction of technical and clinical practice changes can result in a significant reduction in radiation exposure for patients and providers in a paediatric cardiac catheterisation laboratory. These reductions can be maintained over the long term.
Research in cardiac care has identified significant gender-based differences across many outcomes. Women with heart disease are less likely both to be diagnosed and to receive standard care. Gender-based disparities in the prehospital setting are under-researched, but they were found to exist within rates of 12-lead electrocardiogram (ECG) acquisition within one urban Emergency Medical Services (EMS) agency.
Study Objective:
This study evaluates the quality improvement (QI) initiative that was implemented in that agency to raise overall rates of 12-lead ECG acquisition and reduce the gap in acquisition rates between men and women.
Methods:
This QI project included two interventions: revised indications for 12-lead acquisition, and training that highlighted sex- and gender-based differences relevant to patient care. To evaluate this project, a retrospective database review identified all patient contacts that potentially involved cardiac assessment over 18 months. The primary outcome was the rate of 12-lead acquisition among patients with qualifying complaints. This was assessed by mean rates of acquisition in before and after periods, as well as segmented regression in an interrupted time series. Secondary outcomes included differences in rates of 12-lead acquisition, both overall and in individual complaint categories, each compared between men/women and before/after the interventions.
Results:
Among patients with qualifying complaints, the mean rate of 12-lead acquisition in the lead-in period was 22.5% (95% CI, 21.8% - 23.2%) with no discernible trend. The protocol change and training were each associated with a significant absolute level increase in the acquisition rate: 2.09% (95% CI, 0.21% - 4.0%; P = .03) and 3.2% (95% CI, 1.18% - 5.22%; P = .003), respectively. When compared by gender and time period, women received fewer 12-leads than men overall, and more 12-leads were acquired after the interventions than before. There were also significant interactions between gender and period, both overall (2.8%; 95% CI, 1.9% - 3.6%; P < .0001) and in all complaint categories except falls and heart problems.
Conclusion:
This QI project resulted in an increase in 12-leads acquired. Pre-existing gaps in rates of acquisition between men and women were reduced but did not disappear. On-going research is examining the reasons behind these differences from the perspective of prehospital providers.
First-year cardiology fellows must quickly learn basic competency in echocardiography during fellowship orientation. This educational process was disrupted in 2020 due to the coronavirus pandemic, as our hands-on echocardiography teaching transitioned from practice on paediatric volunteers to simulation-based training. We previously described an improvement in echocardiographic completeness after implementation of a standardised imaging protocol for the performance of acute assessments of ventricular function. Herein, we assessed whether this improvement could be sustained over the two subsequent years, including the fellowship year affected by the pandemic. Echocardiograms performed by first-year paediatric cardiology fellows to assess ventricular function were reviewed for completeness. The frequency with which each requested component was included was measured. A total demographic score (out of 7) and total imaging score (out of 23) were calculated. The pre-protocol years (2015–2017) were compared to the post-protocol years (2018–2020), and the pre-COVID years (2018–2019) were compared to the year affected by COVID (2020). There was a sustained improvement in completeness after protocol implementation with improvement in the demographic score (median increasing from 6 to 7, p < 0.001) and imaging score (median increasing from 13 to 16, p < 0.001). More individual components showed a statistically significant increase in frequency compared to our prior publication. The COVID pandemic resulted in very few differences in completeness. Demographic reporting improved modestly (p = 0.04); the imaging score was unchanged (p = 0.59). The only view obtained less frequently was the apical two-chamber view. A standardised imaging protocol allowed sustained improvements in echocardiographic completeness despite the disruption of fellowship orientation by COVID-19.
Introduces the basic concepts of quality improvement: structure, process, and outcomes; and the importance of considering them early in your developments. Explores the relevance of a Plan-Do-Study-Act cycle with examples from various Geriatric ED initiatives. Outlines some essential metrics that are relevant in every Geriatric ED and a process for tracking specific metrics within certain initiatives. Describes ways you can track your data – manual, chart review, data dashboard, electronic health record redesign.
To determine the association between delay in transfer to a central stroke unit from peripheral institutions and outcomes.
Methods:
We conducted a retrospective cohort study of all patients with acute stroke, admitted to a comprehensive stroke center (CSC) from three emergency departments (EDs), between 2016 and 2018. The primary outcomes were length of stay, functional status at 3 months, discharge destination, and time to stroke investigations.
Results:
One thousand four hundred thirty-five patients were included, with a mean age of 72.9 years, and 92.4% ischemic stroke; 663 (46.2%) patients were female. Each additional day of delay was associated with 2.0 days of increase in length of stay (95% confidence interval [CI] 0.8–3.2, p = 0.001), 11.5 h of delay to vascular imaging (95% CI 9.6–13.4, p < 0.0001), 24.2 h of delay to Holter monitoring (95% CI 7.9–40.6, p = 0.004), and reduced odds of nondisabled functional status at 3 months (odds ratio 0.98, 95% CI 0.96–1.00, p = 0.01). Factors affecting delay included stroke onset within 6 h of ED arrival (605.9 min decrease in delay, 95% CI 407.9–803.9, p < 0.0001), delay to brain imaging (59.4 min increase in delay for each additional hour, 95% CI 48.0–71.4, p < 0.0001), admission from an alternative service (3918.7 min increase in delay, 95% CI 3621.2–4079.9, p < 0.0001), and transfer from a primary stroke center (PSC; 740.2 min increase in delay, 95% CI 456.2–1019.9, p < 0.0001).
Conclusion:
Delay to stroke unit admission in a system involving transfer from PSCs to a CSC was associated with longer hospital stay and poorer functional outcomes.