BMJ Open Quality最新文献

Drug-related deaths (DRDs) remain a global issue, with Scotland reporting the second-highest rate per million population. Although some areas have seen improvements, DRDs continue to rise in parts of the Scottish Highlands. Proactive outreach to those at highest risk is believed to reduce harm. This project tested and implemented a risk identification tool-the Trigger Checklist (TC)-to initiate assertive outreach in a remote Highland area by September 2023.The Model for Improvement was used to structure the improvement process. This included collaborative exploration of the problem and solution, development of the TC, devising a family of measures and Plan, Do, Study, Act cycles to structure interactive learning and refinement of the TC and outreach process. Data were collected on the number of completed TC, the percentage of those outreached within 48 hours and the number of days between incidents of non-fatal overdoses (NFOD). Timely staff experience feedback was gathered using a visual facial analogue scale.A standardised TC was devised and tested. 48 TCs were received over 8 months. Of those 100% (n=48) were assertively outreached within 48 hours of a TC referral. The median number of days between NFOD increased from 6.5 days (January-August 2022) to 23 days (September 2022-August 2023). There was an increase in the number of days between incidents of NFOD locally, with more than 90 days between two events (previously the maximum number reached was 48). For the duration of the project, the locality did not receive a DRD notification.There is a need to further test and standardise the use of the TC in other areas frequented by those most at risk of drug-related harm, such as the remote and rural emergency department.

The nursing process is sytematic patient centered care that promotes a holistic approach, enhances communication and collaboration among healthcare professionals and ensures the delivery of high-quality, individualised care. Despite different efforts to improve the nursing process in Wollega University Comprehensive Specialized Hospital, the rate of its implementation is very low due to different factors. This quality improvement project aimed to increase the rate of nursing process implementation at Wollega University Comprehensive Specialized Hospital from 1 August 2024 to 30 January 2025.The team project identified root causes by using a fishbone diagram and a driven diagram. Six interventions were introduced over 6 months using Plan-Do-Study-Act cycles. The interventions were training of nurses and leaders, shifting of nurses to wards with more workload, providing clear job descriptions for nurses, availing of protocols and work aids, availing of nursing process formats and providing regular supportive supervision.Finally, the rate of nursing process implementation increased from 27% to 87.5%, with assessment performed properly in 93%, diagnosis increased to 89.5%, planning reached 86.5%, implementation 85.5% and evaluation 83%. The highest (96%) performance was observed in the orthopaedic ward, whereas the lowest (79%) was in the gynaecological ward.This project improved the implementation of the nursing process, demonstrating the importance of capacity building for staff, leadership engagement, effective communication, regular discussion and supervision, as well as collecting feedback and incorporating it for the next interventions. The project significantly improved nursing process implementation by introducing change ideas, and it now needs to be expanded to other units. The management of the hospital and all stakeholders owned the project to maintain its sustainability.

Background: Patient-Reported Outcome Measures (PROMs) are vital for patient-centred care but face implementation challenges. Within the participating academic medical centre's spine care and pain management clinics, PROMs were collected but underused, indicating a quality gap.

Objective: To identify and compare physician and patient perspectives on priorities, barriers and preferences for PROM implementation to inform a quality improvement initiative.

Methods: We conducted a mixed-methods evaluation (October 2024-December 2024) in two outpatient clinics. Data included quantitative surveys assessing priorities and challenges from physicians (N=8) and patients (N=35), and qualitative data from physician meeting field notes, patient interaction field notes and open-ended survey responses. Quantitative data were analysed descriptively; qualitative data underwent thematic analysis. Findings were integrated using triangulation.

Results: Physicians and patients aligned on prioritising pain interference and physical function. However, patients prioritised pain severity and personal goals more highly than physicians. While 70% of patients found PROMs useful, only 24% reported discussing PROM findings with providers, and 75% of clinicians responded 'not at all confident' to a question about score interpretation. Implementation challenges diverged significantly: physicians universally (100%) cited perceived patient time burden as a barrier, but this concern was infrequently shared by patients (11.4%). Physicians also cited workflow integration as a barrier (87.5%), while patients primarily prioritised PROM format/design (37.1%) and relevance (28.6%). Five qualitative themes emerged across patients and physicians: (1) critiques of PROM content/fidelity; (2) disconnect between data collection and clinical integration; (3) prioritising function and patient-centred goals; (4) need for flexibility, customisation and communication and (5) system-level barriers influencing implementation.

Conclusions: Gaps exist between PROM collection and meaningful clinical use in this setting, driven by content limitations, workflow barriers, system issues and divergent stakeholder perspectives. Improving PROM implementation requires a multistakeholder approach prioritising function-focused, relevant measures integrated effectively into clinical workflows and support by system-level changes.

Hospital-acquired pressure injuries (HAPIs) occur in 3%-34% of patients admitted to hospitals worldwide. Early intervention of an HAPI prevention process can help prevent or reduce HAPIs. The aim of this study was to develop a hospital unit-specific quality improvement process (QIP) focused on sacral HAPI prevention. A sudden increase in sacral HAPIs within an acute care intensive care unit (ICU) during 2022 at a 308-bed acute care hospital prompted concern with current practices in patient turning and repositioning. Within a Plan-Do-Check-Act format QIP in an adult ICU-specific QIP, the following areas were addressed (1) assessment planning using staff surveys, fishbone diagram, run chart data collection and failure mode effect analysis, (2) do processes with staff education, product utilisation that included glide sheets, 30° offloading wedges and drypads, and flow revamp, (3) ongoing data review through run chart interpretation and (4) acting within the multidisciplinary team to hold the gain. Following initial implementation of the 30° offloading wedges during January 2023, the rate of sacral HAPIs decreased from 18 to 4.6 per 1000 patient days per month. During a 3-month period that included full implementation of an ICU-specific QIP and use of glide sheets, 30° offloading wedges and drypads, the total number of sacral HAPIs decreased to one. Overall, the mean rate of sacral HAPIs per 1000 patient days per month decreased from 4.49±5.31 during 2022 to 2.30±2.21 during 2023, representing an approximate decrease of 50%. The total number of sacral HAPIs decreased from 24 in 2022 to nine in 2023. The improvement has been sustained with one HAPI noted for 2024 and zero HAPIs for 2025 through April. The implementation of an ICU-specific QIP and combined use of friction-reducing glide sheets, 30° offloading wedges and full body drypads was successful at decreasing the sacral HAPIs.

Introduction: Quality Improvement Plans (QIPs) can improve healthcare quality by raising awareness and providing a focus for improvement efforts. The physician-led quality committee at our institution set out to improve the previously heterogenous quality and content of clinical department QIPs and increase alignment between clinical department and hospital quality improvement (QI) priorities. We describe these initiatives and assess their impact on the quality of departmental QIPs.

Methods: The Physician Quality Committee at our academic tertiary care hospital implemented a series of interventions, including a peer-to-peer feedback mechanism, longitudinal education and coaching, standardised QI project templates and efforts to facilitate culture change. The QIPs from 13 clinical departments were reviewed for the years before (2018-2019) and after the interventions (2022-2023) and scored according to a structured rubric, created by consensus among physician quality leads. Data are reported as means and medians (IQR). A Wilcoxon signed-rank test was used to evaluate for statistical significance. A Likert-scale survey was used to assess physician QI leads' perception of the impact of the initiatives.

Results: The mean score on the structured rubric was 4.4/12 for the QIPs from 2018 to 2019 and 8.0/12 for the QIPs from 2022 to 2023 (Z=3.06, p=0.0005). The median score (25th, 75th percentile) in 2018-2019 was 4.5 (3.5, 5.13), which increased to 8.5 (7.0, 9.0) in 2022-2023. The survey response for physician QI leads was 10/13 (76.9%). The most positive response was the QI lead's knowledge and understanding of how to structure a QI project (mean score of 4.4/5); the least positive response was related to departmental focus and clarity regarding QI priorities (mean score of 3.9/5).

Conclusions: Multifaceted physician-led interventions resulted in improvements in the quality and content of clinical department QIPs, improved physician knowledge of QI methodology, enhanced focus and clarity around departmental QI priorities, and improved awareness of hospital-wide improvement efforts.

Eating disorders affect 1%-4% of the population and anorexia nervosa has the highest mortality rate of all mental disorders. Medical Emergencies in Eating Disorders guidelines guide the management of severely medically unwell patients with anorexia nervosa who require medical admission. Locally, incidents had raised concerns around deviations in care locally from guideline-based care, and we aimed to improve care and seek full compliance with guidelines.The management of patients with severe eating disorders in the past year at our hospital was evaluated, and the Hospital Information System was interrogated for patients with eating disorders who might not have been identified clinically. In consultation with staff, a pathway was agreed to optimise identification and treatment of eating disorders in patients presenting to hospital. We developed a resource pack to guide care and delivered education to relevant clinical areas: emergency department, general medicine and psychiatry, including using simulation-based training where appropriate.Concordance with guideline-based care rose from 27% prior to this intervention to 100% afterwards. Each new patient with a suspected eating disorder represented a new plan-do-see-act cycle, allowing development of the project with each episode of patient care. There was an improvement in overall confidence in the identification and management of eating disorder in the hospital.This process highlighted that implementing a small change in patient care requires extensive consultation. The patient story was key to engaging stakeholders as it illustrated the impact on the individual patient. At 6-month follow-up, six patients have been treated via the pathway. These numbers may seem small, but this is a rare condition with a high mortality rate, and there is no room for error. The project has improved the management of patients with severe eating disorders in the general hospital setting.

Background: Manual inventory management in hospital storerooms often relies on visual estimation, leading to inaccuracies and inefficiencies such as overstocking and out-stocking. Our audit revealed that a medical inpatient unit incurs weekly consumable costs of QAR 31 000 (US$8500), underscoring the financial impact of these inefficiences. While traditional Kanban systems have proven financially effective in specialty units, their use in inpatient settings is limited, and data on their financial impact in Middle Eastern and North African (MENA) healthcare systems are scarce. This study aims to redesign the traditional Kanban system and evaluate its long-term financial and operational impact.

Methods: We applied the Model for Improvement framework while using Plan-Do-Study-Act cycles to test and refine interventions. The traditional Kanban system was redesigned by introducing replenishment triggers, adopting bin systems, implementing Kanban boards, and standardizing Kanban quantities based on the frequency of consumable use. Impact was assessed using statistical process control charts generated with QI Macros software. Outcome measures included total weekly consumable costs; process measures assessed staff compliance with the Kanban system; and balance measures tracked out-stocking rates and staff satisfaction.

Results: Over three years, the modified Kanban system reduced weekly costs by 40-50%, from QAR 31 000 (US$8500) to QAR 19 000 (US$5100) during testing and stabilised at QAR 16 000 (US$4300) post-implementation. Staff satisfaction increased from 79% to 90%, driven by improved workflow and inventory tracking. Out-stocking rates declined from 0.04 to 0.02 per 1000 inpatient days during testing, ultimately reaching near zero after implementation. Compliance improved from 76% to 95%, directly contributing to both cost savings and operational efficiency.

Conclusion: The modified Kanban system effectively reduces costs, enhances staff satisfaction and improves operational efficiency by minimising stockouts. This study underscores the value of quality improvement and lean methodologies, such as Kanban, in optimising healthcare supply chains and reducing waste.

Background: Having initially done our critical appraisal of various studies, we found that geriatric wards have a higher prevalence of delirium and dementia. Among this older population, sensory aids were found to be important in orientating delirious patients, and deficits in vision/hearing were associated with an increased risk of delirium. Delirium and dementia are associated with increased morbidity and mortality. This quality improvement project aimed to increase staff awareness of patient sensory aid needs and thus improve patient care as a result.

Methods: We started off with a driver diagram to identify what the primary and secondary drivers are for improving the quality of care for patients with sensory impairment. Of the drivers discussed, we believed that we could have a meaningful impact on improving sensory impairment awareness among the multidisciplinary team (MDT) on the ward. We then went through our Plan, Do, Study, Act (PDSA) cycles, which were as follows: PDSA cycle 1, where I and my two colleagues educated the MDT on how to use the electronic patient records property form checklist, which was being underused. This form tracks whether patients require sensory aids. We did three teaching sessions during board rounds and audited the use of this form over time. PDSA cycle 2 used a laminated bedside checklist that is filled in by the MDT and is used as a visual reminder of the patient's sensory impairment status.

Results: The EPR form completion rate increased by 14% over a period of 4 weeks, although this was not statistically significant. 18% of the bedside checklists were filled in, which was statistically significant. Both interventions in combination led to a statistically significant increase in sensory impairment awareness, with a 32% decrease in sensory aid unknown rates, a 40% decrease in dementia unknown rates and a 56% decrease in both sensory and dementia unknown rates. Delirium status was not formally assessed in this QIP due to documentation inconsistencies; however, its relevance remains acknowledged.

Drowning is the leading cause of death in children 1-4 years old in the USA. Paediatricians play an important role in giving anticipatory guidance on drowning prevention. This quality improvement initiative aimed to increase the rate of drowning prevention counselling with provision of educational materials to caregivers of children aged 0-10 years during clinical encounters in an outpatient setting.We refined a previously published Texas state educational programme that included evidence-based counselling strategies across three Plan Do Study Act (PDSA) cycles, with the addition of preintervention baseline counselling phase during expansion of the programme nationally to 17 and 21 states in 2022 and 2023, respectively. All participating paediatricians in office-based, urgent care and emergency settings completed demographic, preintervention and postintervention and programme evaluation surveys. Paediatricians in office-based settings (majority of participants) tracked counselling rate across baseline and three PDSA cycles. Caregivers completed postintervention surveys on knowledge and anticipated behaviour change. Drowning prevention education was supplemented by materials provided to caregivers including brochures and wearable water watcher tags to promote adult supervision.During the first 2 years of national expansion, 120 physicians and 7886 caregivers participated in the programme. Provision of drowning prevention educational materials to caregivers significantly closed an existing gap. Less than 25% of caregivers reported receipt of brochure/checklist and only 6% water watcher tag at baseline; compared with 98% and over 90%, respectively, after PDSA 3 in both years. 69.3% of physicians were able to efficiently counsel on drowning prevention within 2 mins in 2022 versus 82.1% in 2023 (p value<0.001). Most caregivers found the counselling helpful and planned to use the water safety strategies. We demonstrated a significant increase in mean counselling rate from preintervention phase (26.8%) through end of PDSA 3 (64.9%) in this national programme.