scholarly journals LO78: A qualitative evaluation of a mandatory provincial program auditing emergency department return visits

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S36
Author(s):  
H. Jalali ◽  
O. Ostrow ◽  
K. Dainty ◽  
B. Seaton ◽  
H. Ovens ◽  
...  
Keyword(s):  
Emergency Department ◽  
Quality Improvement ◽  
Large Scale ◽  
Structured Interview ◽  
Comparative Approach ◽  
Early Results ◽  
Return Visits ◽  
Quality Issues ◽  
The Impact ◽  
Sampling Approach

Introduction: The Ontario emergency department (ED) Return Visit Quality Program (RVQP) launched in 2016 and aims to promote continuous quality improvement (QI) in the province's largest EDs. The program mandates routine audits of cases involving patients who had ED return visits within 72hrs that led to admission to hospital, in order to identify quality issues that can be tackled through QI initiatives. Our objective was to formally evaluate how well the RVQP achieved its aim of promoting continuous QI at participating sites using the constructivist grounded theory. Methods: Using a semi-structured interview guide, we employed a maximum variation sampling approach to ensure diverse representation across several geographical and institutional experiences (e.g., urban vs. rural, academic vs. community). Selected RVQP program leads were invited to participate in a phone interview to yield maximal insight, additionally using a snowball sampling approach to reach non-lead physicians to capture the penetration of the program. Interviews were conducted until thematic saturation was reached and no new insights were gleaned. Interviews were initially cross-performed by two members of the research team, recorded, transcribed, and de-identified. Data analysis was conducted using a constant comparative approach through the development of a coding framework and triangulation with the respondents’ ED setting. We then grouped, compared and refined our analytic categories through an inductive, iterative approach. Results: Between June and August 2018, we interviewed 32 participants, including 21 RVQP program leads and 11 non-lead physicians, from a total of 23 diverse sites (out of 84). Our analysis suggests that the RVQP provides a structured method for EDs to frame the continuous collection of data in order to channel activities towards quality improvement projects based on identified needs. Success factors included: greater involvement with QI processes prior to the RVQP leading to more openness to improvement, a more collaborative approach to RVQP implementation which led to greater front-line workers’ understanding and engagement, and more resources dedicated to implementing the RVQP as well as tackling the quality issues it identified. Conclusion: This study evaluated the impact of an innovative and large-scale program aimed at improving the culture of quality in Ontario EDs. While the program is still relatively new, early results show that there are key elements of EDs that support building a culture of QI.

scholarly journals Qualitative evaluation of a mandatory provincial programme auditing emergency department return visits

BMJ Open ◽  
2021 ◽  
Vol 11 (4) ◽  
pp. e044218
Author(s):  
Lucas B Chartier ◽  
Hanna Jalali ◽  
M. Bianca Seaton ◽  
Howard Ovens ◽  
Bjug Borgundvaag ◽  
...  
Keyword(s):  
Emergency Department ◽  
Quality Improvement ◽  
Emergency Departments ◽  
Large Scale ◽  
Qualitative Evaluation ◽  
Snowball Sampling ◽  
Continuous Quality ◽  
Return Visits ◽  
Perceived Impact ◽  
Key Aspects

ObjectiveThe objective of this qualitative study was to evaluate the perceived impact and value of the Return Visit Quality Programme (RVQP), a mandatory province-wide emergency department audit programme.DesignWe employed an interpretive descriptive qualitative approach with maximum variation sampling to ensure diverse representation across several geographical and institutional factors. RVQP programme leads were invited to participate in semistructured interviews and snowball sampling was used to reach non-lead physicians to capture the perspectives of those working within the programme.SettingIn Ontario’s RVQP, participating emergency departments must audit their return visits resulting in admission to identify issues that can be addressed through quality improvement initiatives.ParticipantsBetween June and August 2018, we interviewed 32 participants (local programme leads and non-lead physicians) from 23 out of the 86 participating centres.ResultsParticipants’ perceived impact and value of the programme was associated with the existence (or absence) and nature of the local quality improvement culture, the implementation approach of the programme within their emergency departments, and key aspects of the programme pertaining to medicolegal concerns and resource availability.ConclusionsThis study of an innovative, large-scale programme aimed at promoting continuous quality improvement in emergency departments showed that while its perceived impact has been meaningful, there are key structural and operational elements that support and hinder this aim. Healthcare leaders should consider these findings when looking to implement large-scale audit or quality improvement programmes.

HOME VISITS DURING THE FIRST MONTH OF DELIVERY FOR RECENTLY DELIVERED WOMEN IN UTTAR PRADESH, INDIA

2020 ◽  
Vol 6 (5) ◽  
pp. 1183-1189
Author(s):  
Dr. Tridibesh Tripathy ◽  
Dr. Umakant Prusty ◽  
Dr. Chintamani Nayak ◽  
Dr. Rakesh Dwivedi ◽  
Dr. Mohini Gautam
Keyword(s):  
Large Scale ◽  
National Level ◽  
Uttar Pradesh ◽  
Life Time ◽  
Structured Interview ◽  
The Other ◽  
Registration System ◽  
Action Group ◽  
Current Article ◽  
The Impact

The current article of Uttar Pradesh (UP) is about the ASHAs who are the daughters-in-law of a family that resides in the same community that they serve as the grassroots health worker since 2005 when the NRHM was introduced in the Empowered Action Group (EAG) states. UP is one such Empowered Action Group (EAG) state. The current study explores the actual responses of Recently Delivered Women (RDW) on their visits during the first month of their recent delivery. From the catchment area of each of the 250 ASHAs, two RDWs were selected who had a child in the age group of 3 to 6 months during the survey. The response profiles of the RDWs on the post- delivery first month visits are dwelled upon to evolve a picture representing the entire state of UP. The relevance of the study assumes significance as detailed data on the modalities of postnatal visits are available but not exclusively for the first month period of their recent delivery. The details of the post-delivery first month period related visits are not available even in large scale surveys like National Family Health Survey 4 done in 2015-16. The current study gives an insight in to these visits with a five-point approach i.e. type of personnel doing the visit, frequency of the visits, visits done in a particular week from among those four weeks separately for the three visits separately. The current study is basically regarding the summary of this Penta approach for the post- delivery one-month period.     The first month period after each delivery deals with 70% of the time of the postnatal period & the entire neonatal period. Therefore, it does impact the Maternal Mortality Rate & Ratio (MMR) & the Neonatal Mortality Rates (NMR) in India and especially in UP through the unsafe Maternal & Neonatal practices in the first month period after delivery. The current MM Rate of UP is 20.1 & MM Ratio is 216 whereas the MM ratio is 122 in India (SRS, 2019). The Sample Registration System (SRS) report also mentions that the Life Time Risk (LTR) of a woman in pregnancy is 0.7% which is the highest in the nation (SRS, 2019). This means it is very risky to give birth in UP in comparison to other regions in the country (SRS, 2019). This risk is at the peak in the first month period after each delivery. Similarly, the current NMR in India is 23 per 1000 livebirths (UNIGME,2018). As NMR data is not available separately for states, the national level data also hold good for the states and that’s how for the state of UP as well. These mortalities are the impact indicators and such indicators can be reduced through long drawn processes that includes effective and timely visits to RDWs especially in the first month period after delivery. This would help in making their post-natal & neonatal stage safe. This is the area of post-delivery first month visit profile detailing that the current article helps in popping out in relation to the recent delivery of the respondents.   A total of four districts of Uttar Pradesh were selected purposively for the study and the data collection was conducted in the villages of the respective districts with the help of a pre-tested structured interview schedule with both close-ended and open-ended questions.  The current article deals with five close ended questions with options, two for the type of personnel & frequency while the other three are for each of the three visits in the first month after the recent delivery of respondents. In addition, in-depth interviews were also conducted amongst the RDWs and a total 500 respondents had participated in the study.   Among the districts related to this article, the results showed that ASHA was the type of personnel who did the majority of visits in all the four districts. On the other hand, 25-40% of RDWs in all the 4 districts replied that they did not receive any visit within the first month of their recent delivery. Regarding frequency, most of the RDWs in all the 4 districts received 1-2 times visits by ASHAs.   Regarding the first visit, it was found that the ASHAs of Barabanki and Gonda visited less percentage of RDWs in the first week after delivery. Similarly, the second visit revealed that about 1.2% RDWs in Banda district could not recall about the visit. Further on the second visit, the RDWs responded that most of them in 3 districts except Gonda district did receive the second postnatal visit in 7-15 days after their recent delivery. Less than half of RDWs in Barabanki district & just more than half of RDWs in Gonda district received the third visit in 15-21 days period after delivery. For the same period, the majority of RDWs in the rest two districts responded that they had been entertained through a home visit.

scholarly journals Applying quality improvement principles to improve accident and emergency department overcrowding and flow in Rwanda: a case study

2015 ◽  
Vol 4 (5) ◽  
pp. 47 ◽  
Author(s):  
Jean Claude Byiringiro ◽  
Rex Wong ◽  
Caroline Davis ◽  
Jeffery Williams ◽  
Joseph Becker ◽  
...  
Keyword(s):  
Emergency Department ◽  
Quality Improvement ◽  
Success Factors ◽  
Low Cost ◽  
Post Intervention ◽  
Triage System ◽  
Accident And Emergency ◽  
Number Of Patients ◽  
Accident And Emergency Department ◽  
The Impact

Few case studies exist related to hospital accident and emergency department (A&E) quality improvement efforts in lowerresourced settings. We sought to report the impact of quality improvement principles applied to A&E overcrowding and flow in the largest referral and teaching hospital in Rwanda. A pre- and post-intervention study was conducted. A linked set of strategies included reallocating room space based on patient/visitor demand and flow, redirecting traffic, establishing a patient triage system and installing white boards to facilitate communication. Two months post-implementation, the average number of patients boarding in the A&E hallways significantly decreased from 28 (pre-intervention) to zero (post-intervention), p < .001. Foot traffic per dayshift hour significantly decreased from 221 people to 160 people (28%, p < .001), and non-A&E related foot traffic decreased from 81.4% to 36.3% (45% decrease, p < .001). One hundred percent of the A&E patients have been formally triaged since the implementation of the newly established triage system. Our project used quality improvement principles to reduce the number of patients boarding in the hallways and to decrease unnecessary foot traffic in the A&E department with little investment from the hospital. Key success factors included a collaborative multidisciplinary project team, strong internal champions, data-driven analysis, evidence-based interventions, senior leadership support, and rapid application of initial implementation learnings. Results to date show the application of quality improvement principles can help hospitals in resource-limited settings improve quality of care at relatively low cost.

Abstract WP237: Improved Thrombolysis Rates and Quality of Care for Stroke Patients Through a Provincial Emergency Department Quality Improvement Initiative

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Devin R Harris ◽  
Robert Stenstrom ◽  
Eric Grafstein ◽  
Mark Collison ◽  
Grant Innes ◽  
...  
Keyword(s):  
Emergency Department ◽  
Quality Improvement ◽  
Quality Of Care ◽  
Performance Measures ◽  
Large Scale ◽  
Primary Outcome ◽  
Baseline Data ◽  
Quality Improvement Initiative ◽  
Stroke Patients

Background: The care of stroke patients in the emergency department (ED) is time sensitive and complex. We sought to improve quality of care for stroke patients in British Columbia (B.C.), Canada, emergency departments. Objectives: To measure the outcomes of a large-scale quality improvement initiative on thrombolysis rates and other ED performance measures. Methods: This was an evaluation of a large-scale stroke quality improvement initiative, within ED’s in B.C., Canada, in a before-after design. Baseline data was derived from a medical records review study performed between December 1, 2005 to January 31, 2007. Adherence to best practice was determined by measuring selected performance indicators. The quality improvement initiative was a collaboration between multidisciplinary clinical leaders within ED’s throughout B.C. in 2007, with a focus on implementing clinical practice guidelines and pre-printed order sets. The post data was derived through an identical methodology as baseline, from March to December 2008. The primary outcome was the thrombolysis rate; secondary outcomes consisted of other ED stroke performance measures. Results: 48 / 81 (59%) eligible hospitals in B.C. were selected for audit in the baseline data; 1258 TIA and stroke charts were audited. For the post data, 46 / 81 (57%) acute care hospitals were selected: 1199 charts were audited. The primary outcome of the thrombolysis rate was 3.9% (23 / 564) before and 9.3% (63 / 676) after, an absolute difference of 5.4% (95% CI: 2.3% - 7.6%; p=0.0005). Other measures showed changes: administration of aspirin to stroke patients in the ED improved from 23.7% (127 / 535) to 77.1% (553 / 717), difference = 53.4% (95% CI: 48.3% - 58.1%; p=0.0005); and, door to imaging time improved from 2.25 hours (IQR = 3.81 hours) to 1.57 hours (IQR 3.0), difference = 0.68 hours (p=0.03). Differences were found in improvements between large and small institutions, and between health regions. Conclusions: Implementation of a provincial emergency department quality improvement initiative showed significant improvement in thrombolysis rates and adherence to other best practices for stroke patients. The specific factors that influenced improvement need to be further explored.

scholarly journals P016: Low risk ankle rule, high reward-a quality improvement initiative to reduce ankle x-rays in the pediatric emergency department

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S83 ◽  
Author(s):  
F. Al-Sani ◽  
M. Ben-Yakov ◽  
G. Harvey ◽  
J. Gantz ◽  
D. Jacobson ◽  
...  
Keyword(s):  
Emergency Department ◽  
Quality Improvement ◽  
Tertiary Care ◽  
Pediatric Emergency ◽  
Ankle Injuries ◽  
Pediatric Emergency Department ◽  
X Rays ◽  
X Ray ◽  
Return Visits ◽  
Unnecessary Testing

Introduction: Our tertiary care institution embarked on the Choosing Wisely campaign to reduce unnecessary testing, and selected the reduction of ankle x-rays as part of its top five priority initiatives. The Low Risk Ankle Rule (LRAR), an evidence-based decision rule, has been derived and validated to clinically evaluate ankle injuries which do not require radiography. The LRAR, is cost-effective, has 100% sensitivity for clinically important ankle injuries and reduces ankle imaging rates by 30-60% in both academic and community setting. Our objective was to significantly reduce the proportion of ankle x-rays ordered for acute ankle injuries presenting to our pediatric Emergency Department (ED). Methods: Medical records were reviewed for all patients presenting to our tertiary care pediatric ED (ages 3- 18 years) with an isolated acute ankle injury from Jan 1, 2016-Sept 30, 2016. Children with outside imaging, an injury that occurred &gt;72 hours prior, or those who had a repeat ED visit for same injury were excluded. Quality improvement (QI) initiatives included multidisciplinary staff education about the LRAR, posters placed within the ED highlighting the LRAR, development of a new diagnostic imaging requisition for ankle x-rays requiring use of the LRAR and collaboration with the Division of Radiology to ensure compliance with new requisition. The proportion of patients presenting to the ED with acute ankle injuries who received x-rays was measured. ED length of stay (LOS), return visits to the ED and orthopedic referrals were collected as balancing measures. Results: At baseline 88% of patients with acute ankle injuries received x-rays. Following our multiple interventions, the proportion of x-rays decreased significantly to 54%, (p&lt;0.001). This decrease in x-ray rate was not associated with an increase in ED LOS, ED return visits or orthopedic referrals. There was an increase uptake of the dedicated x-ray requisition over time to 71%. Conclusion: This QI initiative to increase uptake of the LRAR, resulted in a significant reduction of ankle x-rays rates for children presenting with acute ankle injuries in our pediatric ED without increasing LOS, return visits or need for orthopedic referrals for missed injuries. Just as in the derivation and validation studies, the reductions have been sustained and reduced unnecessary testing and ionizing radiation.

The Impact of a Large-Scale Power Outage on Hemodialysis Center Operations

2013 ◽  
Vol 28 (6) ◽  
pp. 543-546 ◽  
Author(s):  
Mahshid Abir ◽  
Sophia Jan ◽  
Lindsay Jubelt ◽  
Raina M. Merchant ◽  
Nicole Lurie
Keyword(s):  
Large Scale ◽  
Structured Interview ◽  
Study Cohort ◽  
Power Outages ◽  
Publication Type ◽  
Emergency Plans ◽  
Power Outage ◽  
Stage Renal Disease ◽  
End Stage ◽  
The Impact

AbstractIntroductionOn June 29, 2012, mid-Atlantic storms resulted in a large-scale power outage affecting up to three million people across multiple (US) states. Hemodialysis centers are dependent on electricity to provide dialysis care to end-stage renal disease patients. The objective of this study was to determine how the power outage impacted operations in a sample of hemodialysis centers in the impacted regions.MethodsThe sample consisted of all hemodialysis centers located in the District of Columbia and a total of five counties with the largest power losses in West Virginia, Virginia, and Maryland. A semi-structured interview guide was developed, and the charge nurse or supervisor in each facility was interviewed. The survey questions addressed whether their centers lost power, if so, for how long, where their patients received dialysis, whether their centers had backup generators, and if so, whether they had any problems operating them, and whether their center received patients from other centers if they had power.ResultsCalls were placed to 90 dialysis centers in the sampled areas and a 90% response rate was achieved. Overall, hemodialysis operations at approximately 30% (n = 24) of the centers queried were impacted by the power outage. Of the 36 centers that lost power, 31% (n = 11) referred their patients to other dialysis centers, 22% (n = 8) accommodated their patients during a later shift or on a different day; the rest of the centers either experienced brief power outages that did not affect operations or experienced a power outage on days that the center is usually closed. Some centers in the study cohort reported receiving patients from other centers for dialysis 33% (n = 27). Thirty-two percent (n = 26) of the centers queried had backup generators on site. Eleven percent (n = 4) of the centers experiencing power outages reported that backup generators were brought in by their parent companies.ConclusionsComprehensive emergency planning for dialysis centers should include provisions for having backup generators on site, having plans in place for the timely delivery of a generator during a power outage, or having predesignated backup dialysis centers for patients to receive dialysis during emergencies. Most dialysis centers surveyed in this study were able to sustain continuity of care by implementing such pre-existing emergency plans.AbirM, JanS, JubeltL, MerchantR, LurieN. The impact of a large-scale power outage on hemodialysis center operations. Prehosp Disaster Med. 2013;28(6):1-4.

Effect of Lean method implementation in the histopathology section of an anatomical pathology laboratory

2007 ◽  
Vol 61 (11) ◽  
pp. 1193-1199 ◽  
Author(s):  
S S Raab ◽  
D M Grzybicki ◽  
J L Condel ◽  
W R Stewart ◽  
B D Turcsanyi ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Large Scale ◽  
Turnaround Time ◽  
Full Time ◽  
Pathology Laboratory ◽  
Quality Improvement Process ◽  
The Mean ◽  
Work Units ◽  
The Impact ◽  
Productivity Ratio

Background:In the USA, the lack of processes standardisation in histopathology laboratories leads to less than optimal quality, errors, inefficiency and increased costs. The effectiveness of large-scale quality improvement initiatives has been evaluated rarely.Aim:To measure the effect of implementation of a Lean quality improvement process on the efficiency and quality of a histopathology laboratory section.Methods:A non-concurrent interventional cohort study from 1 January 2003 to 31 December 2006 was performed, and the Lean process was implemented on 1 January 2004. Also compared was the productivity of the Lean histopathology section to a sister histopathology section that did not implement Lean processes. Pre- and post-Lean specimen turnaround time and productivity ratios (work units/full time equivalents) were measured. For 200 Lean interventions, a 5-part Likert scale was used to assess the impact on error, success and complexity.Results:In the Lean laboratory, the mean monthly productivity ratio increased from 3439 to 4074 work units/full time equivalents (p<0.001) as the mean daily histopathology section specimen turnaround time decreased from 9.7 to 9.0 h (p = 0.01). The Lean histopathology section had a higher productivity ratio compared with a sister histopathology section (1598 work units/full time equivalents, p<0.001) that did not implement Lean processes. The mean impact, success and complexity of interventions were 2.4, 2.7 and 2.5, respectively. The mean number of specific error causes affected by individual interventions was 2.6.Conclusion:It is concluded that Lean process implementation improved efficiency and quality in the histopathology section.

scholarly journals An Interdisciplinary Academic Detailing Approach to Decrease Inappropriate Medication Prescribing by Physician Residents for Older Veterans Treated in the Emergency Department

2017 ◽  
Vol 32 (2) ◽  
pp. 167-174 ◽  
Author(s):  
Jason M. Moss ◽  
William E. Bryan ◽  
Loren M. Wilkerson ◽  
Heather A. King ◽  
George L. Jackson ◽  
...  
Keyword(s):  
Older Adults ◽  
Emergency Department ◽  
Quality Improvement ◽  
Older Adult ◽  
Quality Improvement Project ◽  
Beers Criteria ◽  
Potentially Inappropriate Medications ◽  
Academic Detailing ◽  
Improvement Project ◽  
The Impact

Objective: To evaluate the impact of an academic detailing intervention delivered as part of a quality improvement project by a physician–pharmacist pair on (1) self-reported confidence in prescribing for older adults and (2) rates of potentially inappropriate medications (PIMs) prescribed to older adults by physician residents in a Veteran Affairs emergency department (ED). Methods: This quality improvement project at a single site utilized a questionnaire that assessed knowledge of Beers Criteria, self-perceived barriers to appropriate prescribing in older adults, and self-rated confidence in ability to prescribe in older adults which was administered to physician residents before and after academic detailing delivered during their emergency medicine rotation. PIM rates in the resident cohort who received the academic detailing were compared to residents who did not receive the intervention. Results: Sixty-three residents received the intervention between February 2013 and December 2014. At baseline, approximately 50% of the residents surveyed reported never hearing about nor using the Beers Criteria. A significantly greater proportion of residents agreed or strongly agreed in their abilities to identify drug–disease interactions and to prescribe the appropriate medication for the older adult after receiving the intervention. The resident cohort who received the educational intervention was less likely to prescribe a PIM when compared to the untrained resident cohort with a rate ratio of 0.73 ( P < .0001). Conclusion: Academic detailing led by a physician–pharmacist pair resulted in improved confidence in physician residents’ ability to prescribe safely in an older adult ED population and was associated with a statistically significant decrease in PIM rates.

scholarly journals Galaxy Clustering in the Southern Hemisphere

1995 ◽  
Vol 148 ◽  
pp. 510-521
Author(s):  
C.A. Collins
Keyword(s):  
Correlation Function ◽  
Large Scale ◽  
Spatial Correlation Function ◽  
Galaxy Surveys ◽  
Early Results ◽  
The Galaxy ◽  
Angular Correlation Function ◽  
Number Counts ◽  
The Impact ◽  
The Universe

AbstractIn this paper some of the major results from the COSMOS and APM digitised galaxy surveys are presented. The main motivation behind these catalogues was to study large-scale structure in the universe. We begin by outlining the importance of such studies to cosmology and discussing the early results from the visually compiled galaxy catalogues. The impact of the digitised catalogues is demonstrated by focussing on three key areas of research; the galaxy-galaxy two-point angular correlation function, the cluster-cluster spatial correlation function, and galaxy number counts.

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