Quality Improvement

Using quality improvement methods for evaluating healthcare

by A. Niroshan Siriwardena

Current state and future possibilities for ambient intelligence to support improvements in the quality of health and social care

by A. Niroshan Siriwardena

Report on National Ambulance Service Clinical Performance Indicators Baseline audit: May–September 2008

by A. Niroshan Siriwardena

To cannulate or not to cannulate? Variation, appropriateness and potential for reduction in cannulation rates by ambulance staff [conference abstract]

by A. Niroshan Siriwardena

Emerging technologies for developing and improving patients' health experience

by A. Niroshan Siriwardena

Expert Panel Meeting Advancing the Science of Continuous Quality Improvement

by Susanne Hempel

Rubenstein, L (Principal Investigator). Hempel, S. (Co-Principal Investigator), Danz, M., Foy, R., & Shekelle, P. Final Progress Report
Expert Panel Meeting Advancing the Science of Continuous Quality Improvement. Prepared for AHRQ, Grant Award Number: 1R13HS018139-01, May 2011.

Purpose: To facilitate a generalizable approach to identifying and assessing CQI publications supporting reliable,... more Purpose: To facilitate a generalizable approach to identifying and assessing CQI publications supporting reliable, effective, and efficient continuous quality improvement (CQI) studies.

Scope: As part of an ongoing initiative we sought input for research and practice in quality improvement.

Methods: We convened a panel of key stakeholders to discuss the identification and assessment of CQI studies.

Results: We held a 1.5 day meeting in August 2009 and a second meeting in September 2009 at RAND, Santa Monica, CA. The meeting was attended by Drs. David Atkins, Martin Eccles, Frank Davidoff, Robert Lloyd, Shirley Moore, David Stevens, Susanne Salem-Schatz, and Ed Wagner and from the project team Dr. Lisa Rubenstein, Dr. Paul Shekelle, Dr. Susanne Hempel, Dr. Robbie Foy, Dr. Margie Danz, Breanne Johnsen and Aneesa Motala. In addition, the project consultants Drs. Brian Mittman and Melissa Farmer were present and Dr. Judy Sangl (AHRQ), Dr. Lawrence Kleinman, Dr. Howard Saft and Dr. Heather Kaplan participated as guests. Participants discussed strategies for the identification of CQI studies, definitions of CQI, and established quality criteria as well as unique CQI issues. The relevance and timeliness of the publication of validated electronic search strategies for identifying CQI literature; the need for published screening and assessment tools to reliably categorize CQI publications; the level of adherence to a minimum quality criteria set (MQCS) in current literature and the relationships between quality criteria and CQI study outcomes were further pertinent topics.

What context features might be important determinants of the effectiveness of patient safety practice interventions?

by Susanne Hempel

Taylor SL, Dy S, Foy R, Hempel S, McDonald KM, Ovretveit J, Pronovost PJ, Rubenstein LV, Wachter RM, Shekelle PG. BMJ Qual Saf. 2011 May 26. [Epub ahead of print]

Background Differences in contexts (eg, policies, healthcare organisation characteristics) may explain variations in... more Background Differences in contexts (eg, policies, healthcare organisation characteristics) may explain variations in the effects of patient safety practice (PSP) implementations. However, knowledge of which contextual features are important determinants of PSP effectiveness is limited and consensus is lacking on a taxonomy of which contexts matter. Methods Iterative, formal discussions were held with a 22-member technical expert panel composed of experts or leaders in patient safety, healthcare systems, and methods. First, potentially important contextual features were identified, focusing on five PSPs. Then, two surveys were conducted to determine the context likely to influence PSP implementations. Results The panel reached a consensus on a taxonomy of four broad domains of contextual features important for PSP implementations: safety culture, teamwork and leadership involvement; structural organisational characteristics (eg, size, organisational complexity or financial status); external factors (eg, financial or performance incentives or PSP regulations); and availability of implementation and management tools (eg, training organisational incentives). Panelists also tended to rate specific patient safety culture, teamwork and leadership contexts as high priority for assessing their effects on PSP implementations, but tended to rate specific organisational characteristic contexts as high priority only for use in PSP evaluations. Panelists appeared split on whether specific external factors and implementation/management tools were important for assessment or only description. Conclusion This work can guide research commissioners and evaluators on the contextual features of PSP implementations that are important to report or evaluate. It represents a first step towards developing guidelines on contexts in PSP implementation evaluations. However, the science of context measurement needs maturing.

Conducting Online Expert Panels: A Feasibility and Experimental Replicability Study

by Susanne Hempel

Conducting Online Expert Panels: A Feasibility and Experimental Replicability Study. Dmitry Khodyakov, Susanne Hempel, Lisa Rubenstein, Paul Shekelle, Robbie Foy, Susanne Salem-Schatz, Sean O'Neill, Margie Danz and Siddhartha Dalal. BMC Medical Research Methodology 2011, 11:174 doi:10.1186/1471-2288-11-174. Published: 23 December 2011

Background

This paper has two goals. First, we explore the feasibility of conducting online expert panels... more Background

This paper has two goals. First, we explore the feasibility of conducting online expert panels to facilitate consensus finding among a large number of geographically distributed stakeholders. Second, we test the replicability of panel findings across four panels of different size.
Method

We engaged 119 panelists in an iterative process to identify definitional features of Continuous Quality Improvement (CQI). We conducted four parallel online panels of different size through three one-week phases by using the RAND's ExpertLens process. In Phase I, participants rated potentially definitional CQI features. In Phase II, they discussed rating results online, using asynchronous, anonymous discussion boards. In Phase III, panelists re-rated Phase I features and reported on their experiences as participants.
Results

66% of invited experts participated in all three phases. 62% of Phase I participants contributed to Phase II discussions and 87% of them completed Phase III. Panel disagreement, measured by the mean average deviation from the median (MAD-M), decreased after group feedback and discussion in 36 out of 43 judgments about CQI features. Agreement between the four panels after Phase III was fair (four-way kappa = 0.36); they agreed on the status of five out of eleven CQI features. Results of the post-completion survey suggest that participants were generally satisfied with the online process. Compared to participants in smaller panels, those in larger panels were more likely to agree that they had debated each others' view points.
Conclusion

It is feasible to conduct online expert panels intended to facilitate consensus finding among geographically distributed participants. The online approach may be practical for engaging large and diverse groups of stakeholders around a range of health services research topics and can help conduct multiple parallel panels to test for the reproducibility of panel conclusions.

The adoption, local implementation and assimilation into routine nursing practice of a national quality improvement programme: the Productive Ward in England

by Peter Griffiths

Morrow, E., Robert, G., Maben, J., & Griffiths, P. (2012). Implementing large-scale quality improvement – lessons from The Productive Ward: Releasing time to care™ International Journal of Health Care Quality Assurance, 25(4), 237-253.

Abstract
Purpose – This paper aims to focus on facilitating large-scale quality improvement in health care, and... more Abstract
Purpose – This paper aims to focus on facilitating large-scale quality improvement in health care, and specifically understanding more about the known challenges associated with implementation of lean innovations: receptivity, the complexity of adoption processes, evidence of the innovation, and embedding change. Lessons are drawn from the implementation of The Productive Ward: Releasing Time to Care™ programme in English hospitals.

Design/methodology/approach – The study upon which the paper draws was a mixed-method evaluation that aimed to capture the perceptions of three main stakeholder groups: national-level policymakers (15 semi-structured interviews); senior hospital managers (a national web-based survey of 150 staff); and healthcare practitioners (case studies within five hospitals involving 58 members of staff). The views of these stakeholder groups were analysed using a diffusion of innovations theoretical framework to examine aspects of the innovation, the organisation, the wider context and linkages.

Findings – Although The Productive Ward was widely supported, stakeholders at different levels identified varying facilitators and challenges to implementation. Key issues for all stakeholders were staff time to work on the programme and showing evidence of the impact on staff, patients and ward environments.

Research limitations/implications – To support implementation, policymakers should focus on expressing what can be gained locally using success stories and guidance from “early adopters”. Service managers, clinical educators and professional bodies can help to spread good practice and encourage professional leadership and support. Further research could help to secure support for the programme by generating evidence about the innovation, and specifically its clinical effectiveness and broader links to public expectations and experiences of healthcare.

Originality/value – This paper draws lessons from the implementation of The Productive Ward programme in England, which can inform the implementation of other large-scale programmes of quality improvement in health care.

The Management of Quality

by Peter Mellalieu

Mellalieu, P. J. (1978). The Management of Quality. Wellington, New Zealand: Productivity Centre, Department of Trade & Industry.

For a case example, see:
Mellalieu, P. J. (1978). Case study: Total Quality Control at W Graham Hitchins Ltd. Productivity & Technology, NZ Department of Trade & Industry, 1(78), 8–10. Retrieved from http://unitec.academia.edu/PeterMellalieu/Papers/1571203/Case_study_Total_Quality_Control_at_W_Graham_Hitchins_Ltd

Introduces a practical approach to managing the quality of products and services throughout the entire value chain... more Introduces a practical approach to managing the quality of products and services throughout the entire value chain from design through delivery and service. Focusses especially on the needs of small-medium enterprise and short-run manufacturing or bespoke services.

Beyond FMEA: The Structured What-If Technique (SWIFT)

by Alan Card

Card AJ, Ward JR, Clarkson PJ. Beyond FMEA: The Structured What-If Technique (SWIFT). Journal of Healthcare Risk Management. 2012;31(4):23-9.

If you would like a copy of the final published version of this paper, and do not have access to the Journal of Healthcare Risk Management, feel free to write me at: alan.j.card [at] gmail.com.

Although it is probably the best-known Prospective Hazard Analysis (PHA) tool, Failure Mode and Effects Analysis... more Although it is probably the best-known Prospective Hazard Analysis (PHA) tool, Failure Mode and Effects Analysis (FMEA) is far from the only option available. This paper introduces one of the alternatives: The Structured What-If Technique (SWIFT). SWIFT is a flexible, high-level risk identification technique that can be used on a standalone basis, or as part of a staged approach to make more efficient use of bottom-up methods like FMEA.

In this paper we describe the method, assess the evidence related to its use in healthcare using a systematic literature review, and suggest ways in which it could be better adapted for use in the healthcare industry. Based on the limited
evidence available, it appears that healthcare workers find it easy to learn, easy to use, and credible. Especially when used as part of a staged approach, SWIFT appears capable of playing a useful role as component of the PHA
armamentarium.

Review of the Evidence on Falls Prevention in Hospitals

by Susanne Hempel

Susanne Hempel, Sydne Newberry, Zhen Wang, Paul G. Shekelle, Roberta M. Shanman, Breanne Johnsen, Tanja Perry, Debra Saliba, David A. Ganz (2012). Review of the evidence on falls prevention in hospitals. RAND Working Paper WR907.

To facilitate the development of a hospital falls prevention resource guide, the authors systematically reviewed and... more To facilitate the development of a hospital falls prevention resource guide, the authors systematically reviewed and documented the existing evidence base for interventions to prevent falls in hospitals, provided an overview of the performance of existing tools with known measurement properties, and compiled available online resources. The search identified a large number of published fall prevention intervention evaluations. Almost all interventions were multi-component in nature and included fall risk assessments and education for staff and patients and/or families. Intervention complexity and organizational implications varied widely. The review also identified a wide variety of tools for the prevention of falls in hospitals; the majority of the documented tools were fall risk assessment scales. Very few tools, such as the Morse Fall Scale and the STRATIFY scale, have been applied in a number of studies and have generalizable reliability and validity estimates. The documented evidence-based interventions and tools may assist in the development of programs to prevent falls in hospitals. Which tools and interventions are suitable for use in individual hospitals must be evaluated in the context of existing approaches, resources, and individual needs. The identified material will be integrated into the AHRQ toolkit as resources to guide fall prevention approaches for hospitals.

Eight Steps to a Chart Audit for Quality

by Victoria S Kaprielian

Successful Risk Assessment May Not Always Lead To Successful Risk Control: A Systematic Literature Review of Risk Control after Root Cause Analysis

by Alan Card

Alan J. Card, James Ward, P. John Clarkson. Successful Risk Assessment May Not Always Lead To Successful Risk Control: A Systematic Literature Review of Risk Control after Root Cause Analysis. Journal of Healthcare Risk Management. 2012;31(3):6-12.

Root cause analysis is perhaps the most widely used tool in healthcare risk management, but does it actually lead to... more Root cause analysis is perhaps the most widely used tool in healthcare risk management, but does it actually lead to successful risk control? Are there categories of risk control that are more likely to be effective? And do healthcare risk managers have the tools they need to support the risk control process? This systematic review examines how the healthcare sector translates risk analysis to risk control action plans and examines how to do better. It suggests that the hierarchy of risk controls should inform risk control action planning and that new tools should be developed to improve the risk control process.

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Wiley's copyright policies do not allow me to post the published version of the paper, but they do allow me to send out individual copies. So if you don't have access to the Journal of Healthcare Risk Management and would like a copy of this article, please email me at:
alan [dot] j [dot] card [at] gmail [dot] com

Quality matters. Italy's intra-industry trade with Eastern Europe over the years 1988–1995

by Francesco Pastore

Co-authored with Anna Maria Ferragina,
Studi Economici, 60(84/3): 97-119.

This paper studies the main changes observed over the period 1988-1995 in the Italian trade with several Central and... more This paper studies the main changes observed over the period 1988-1995 in the Italian trade with several Central and Eastern European (CEE) economies. The analysis is carried out using several methods. The first method consists of calculating the weight and the evolution of high and low quality intra-industry trade. The second method consists of looking at the features assumed by the trade reorientation using a Constant Market Share Analysis, able to break down the growth in CEE exports to Italy into a “demand” and a “competitiveness” share. Once verified the dominance of the latter, the paper tests by means of regression analysis to what extent the increased competitiveness has been determined by increased price competitiveness (term of trade effect) as opposed to quality upgrading. No evidence is found of the latter. A test of the employment effects associated with different sources of trade with the CEECs confirms the importance of monitoring the evolution of vertical and horizontal intra-industry trade and its impact on the adjustment process.

Towards a new paradigm in health research and practice? Collaborations for Leadership in Applied Health Research and Care

by Graham Martin

Martin GP, McNicol S, Chew S. Towards a new paradigm in health research and practice? Collaborations for Leadership in Applied Health Research and Care. Journal of Health Organization & Management in press. Please contact author for a copy.

Purpose: CLAHRCs are a new UK initiative to promote collaboration between universities and healthcare organisations in... more Purpose: CLAHRCs are a new UK initiative to promote collaboration between universities and healthcare organisations in carrying out and applying the findings of applied health research. But they face significant, institutionalised barriers to their success. This paper analyses these challenges and discusses prospects for overcoming them.
Design: We draw on in-depth qualitative interview data from the first round of an ongoing evaluation of one CLAHRC to understand the views of different stakeholders on its progress so far, challenges faced, and emergent solutions.
Findings: The breadth of CLAHRCs’ missions seems crucial to mobilise the diverse stakeholders needed to succeed, but also produces disagreement about what the prime goal of the Collaborations should be.  A process of consensus building is necessary to instil a common vision among CLAHRC members, but deep-seated institutional divisions continue to orient them in divergent directions, which may need to be overcome through other means.
Originality/value: Our analysis suggests some of the key means by which those involved in joint enterprises such as CLAHRCs can achieve consensus and action towards a current goal, and offers recommendations for those involved in their design, commissioning and performance management.

DEFINING CONTINUOUS QUALITY IMPROVEMENT (CQI) FOR HEALTH CARE DELIVERY

by Susanne Hempel

FINAL NARRATIVE REPORT DEFINING CONTINUOUS QUALITY IMPROVEMENT (CQI) FOR HEALTH CARE DELIVERY ID 67890

This project aims to provide a framework for the identification, classification, and evaluation of quality improvement... more This project aims to provide a framework for the identification, classification, and evaluation of quality improvement initiatives

On Quality and Standards in Research Training

by Nigel Palmer

Palmer, N. (2011). On Quality and Standards in Research Training. Melbourne, Australia: Centre for the Study of Higher Education.

An edited version of this paper first appeared in The Australian online Friday November 18th, 2011.

In October 2011 the Australian Government released Defining Quality, a consultation paper focussing on quality aspects... more In October 2011 the Australian Government released Defining Quality, a consultation paper focussing on quality aspects around research training. The paper addresses the quality of the physical and intellectual environment, the flexibility and ‘fit’ of the scheme and its broader fitness for purpose in supporting research education. A second paper, due for release in June 2012, is set to address technical aspects of the scheme, including options for how results from the Federal Government’s research quality measurement exercise, the Excellence in Research for Australia Initiative (ERA), may influence funding allocations under the RTS scheme. While addressing different issues, the two papers are related. Funding formulae are typically associated with measures of performance, and those in turn are taken as measures of quality. Conceptions of what constitutes quality are therefore likely to inform the indicator mix which will eventually determine the distribution of federally funded places and possibly also scholarships from 2013. Before jumping to conclusions regarding the prospect that ERA may determine the allocation of federally funded research higher degree places or scholarships, it is important to be clear on three very important points:

1. Firstly that quality and performance are not the same;
2. Secondly that ERA currently measures neither when it comes to research training;
3. Thirdly there are existing dimensions and characteristics associated with a quality research training environment (as outlined in Appendix I); and
4. Finally, the possibility of identifying an activity or characteristic as either a threshold or a performance standard does not in itself mean that it should become one.

The Defining Quality consultation paper is the first part of a two-stage consultation process informing review of the Federal Government’s scheme for funding research education: the Research Training Scheme (RTS) (DIISR, 2011a). The RTS is the national tuition scheme for domestic places in research masters and PhD study, which alongside the Australian Postgraduate Award scheme is the principal support program for research education in Australia (DIISR, 2011c). Review of the RTS comes as part of the Federal Government’s Research Workforce Strategy (DIISR, 2011b). The Defining Quality consultation paper is well prepared and development of the Strategy has been an example of best practice in public policy development. However, this initiative is due to intersect with two other Federal Government initiatives: the Excellence in Research for Australia Initiative (ERA) and the formation of the new Tertiary Education Quality and Standards Agency (TEQSA) (ARC, 2011; Australian Government, 2011b). This intersection will have important implications for the definition and measurement of quality and standards in research training in Australia, and for prospects for continued innovation and improvement in this area in the future.

The purpose of this paper is to highlight some important considerations in the intersection between the RTS, ERA and the implementation of the proposed Standards Framework under the new Tertiary Education Quality and Standards Agency (TEQSA). It also aims to inform discussion on the definition and measurement of aspects of a quality research education environment more broadly.

A framework for classifying patient safety practices: results from an expert consensus process.

by Susanne Hempel

BMJ Qual Saf. 2011 Jul;20(7):618-24. Epub 2011 May 24.
A framework for classifying patient safety practices: results from an expert consensus process.
Dy SM, Taylor SL, Carr LH, Foy R, Pronovost PJ, Ovretveit J, Wachter RM, Rubenstein LV, Hempel S, McDonald KM, Shekelle PG.

Objective Development of a coherent literature evaluating patient safety practices has been hampered by the lack of an... more Objective Development of a coherent literature evaluating patient safety practices has been hampered by the lack of an underlying conceptual framework. The authors describe issues and choices in describing and classifying diverse patient safety practices (PSPs). Methods The authors developed a framework to classify PSPs by identifying and synthesising existing conceptual frameworks, evaluating the draft framework by asking a group of experts to use it to classify a diverse set of PSPs and revising the framework through an expert-panel consensus process. Results The 11 classification dimensions in the framework include: regulatory versus voluntary; setting; feasibility; individual activity versus organisational change; temporal (one-time vs repeated/long-term); pervasive versus targeted; common versus rare events; PSP maturity; degree of controversy/conflicting evidence; degree of behavioural change required for implementation; and sensitivity to context. Conclusion This framework offers a way to classify and compare PSPs, and thereby to interpret the patient-safety literature. Further research is needed to develop understanding of these dimensions, how they evolve as the patient safety field matures, and their relative utilities in describing, evaluating and implementing PSPs.

Using service incidents to identify quality improvement points

by Andrew Lockwood