What makes an effective Quality Improvement Manager? A qualitative study in the New Zealand Health System

Purpose Quality improvement is an international priority, and health organisations invest heavily in this endeavour. Little, however, is known of the role and perspectives of Quality Improvement Managers who are responsible for quality improvement implementation. We explored the quality improvement managers’ accounts of what competencies and qualities they require to achieve day-to-day and long-term quality improvement objectives. Design Qualitative exploratory design using an interpretivist approach with semi-structured interviews analysed thematically. Setting and participants. Interviews were conducted with 56 quality improvement managers from 15 (out of 20) New Zealand District Health Boards. Participants were divided into two groups: traditional and clinical quality improvement managers. The former group consisted of those with formal quality improvement education—typically operations managers or process engineers. The latter group was represented by clinical staff—physicians and nurses—who received on-the-job training. Results Three themes were identified: quality improvement expertise, leadership competencies and interpersonal competencies. Effective quality improvement managers require quality improvement experience and expertise in healthcare environments. They require leadership competencies including sense-giving, taking a long-term view and systems thinking. They also require interpersonal competencies including approachability, trustworthiness and supportiveness. Traditional and clinical quality improvement managers attributed different value to these characteristics with traditional quality improvement managers emphasising leadership competencies and interpersonal skills more than clinical quality improvement managers. Conclusions We differentiate between traditional and clinical quality improvement managers, and suggest how both groups can be better prepared to be effective in their roles. Both groups require a comprehensive socialisation and training process designed to meet specific learning needs.

Practical Strategies to Enhance Resident Engagement in Clinical Quality Improvement

BackgroundEngaging residents in meaningful QI is difficult. Challenges include competing demands, didactics which lack connection to meaningful work, suboptimal experiential learning, unclear accountability, absence of timely and relevant data, and lack of faculty coaches and role models. This paper describes practical strategies to address common challenges to resident engagement in QI, illustrated through the experience of one residency education program.Methods62 categorical residents in the University of Missouri Internal Medicine residency participated in a longitudinal QI curriculum integrated into residency clinic assignments with dedicated QI work sessions and brief just-in-time didactics with mentorship from faculty coaches. Residents completed at least two PDSA cycles for their projects. The experience included clear expectations and tools for accountability. Project criteria included importance to patients, residents and the institution. Residents had access to data related to their own practice. A pre-post survey asked residents to self-assess their level of interest and engagement in QI on a 5-point Likert scale, with 1=least desired and 5=most desired result. Data were analyzed by paired t-test. ResultsAll 62 residents participated in the program as members of ten teams. 40/62 residents completed both pre- and post-surveys. Items related to self-assessment of QI in clinical work all changed in the desired direction: likelihood of participation (3.7 to 4.1, p=0.03), frequency of QI use (3.3 to 3.9, p=0.001), and opinion about using QI in clinical work (3.9 to 4.0, p=0.21). Resident assessment of QI priority in clinical work did not change.ConclusionsWe implemented practical strategies to overcome common challenges to successfully engaging residents in clinical quality improvement. These strategies included QI work integrated into routine clinical assignments, just-in-time didactics, experiential learning with clear expectations and strategic project selection, timely and pertinent data from the residents’ own practice, and real-time faculty coaching.

The origins and development of the Cardiac Neurodevelopmental Outcome Collaborative: creating innovative clinical, quality improvement, and research opportunities

Compared to the general population, individuals with complex congenital heart disease are at increased risk for deficits in cognitive, neurodevelopmental, psychosocial, and physical functioning, resulting in a diminished health-related quality of life. These deficits have been well described over the past 25 years, but significant gaps remain in our understanding of the best practices to improve neurodevelopmental and psychosocial outcomes and health-related quality of life for individuals with paediatric and congenital heart disease. Innovative clinical, quality improvement, and research opportunities with collaboration across multiple disciplines and institutions were needed to address these gaps. The Cardiac Neurodevelopmental Outcome Collaborative was founded in 2016 with a described mission to determine and implement best practices of neurodevelopmental and psychosocial services for individuals and their families with paediatric and congenital heart disease through clinical, quality improvement, and research initiatives. The vision is to be a multi-centre, multi-national, multi-disciplinary group of healthcare professionals committed to working together and partnering with families to optimise neurodevelopmental outcomes for individuals with paediatric and congenital heart disease through clinical, quality, and research initiatives, intending to maximise quality of life for every individual across the lifespan. This manuscript describes the development and organisation of the Cardiac Neurodevelopmental Outcome Collaborative.

1157. GET IT OUT! Nurses and Clinical Quality Improvement Specialists Drive Initiative to Reduce Standardized Utilization Ratios for Indwelling Urinary Catheters in Hospitalized Patients

Background Urinary tract infections (UTIs) account for 34% of all healthcare-associated infections (HAI). Urinary catheters (UC) are placed in 15–25% of hospitalized patients and >75% of HAI UTIs are UC-related. Bacteria introduced via UC can colonize the bladder within 3 days. So, the greatest risk factor for acquiring a catheter-associated urinary tract infection (CAUTI) is prolonged use of indwelling UC. Nursing (RN) staff noted inconsistency with appropriate use of UC and commonly UC remained in place well after their original indication had expired. Methods As part of a multi-faceted approach for quality improvement and patient safety, we rolled out an Agency for Healthcare Research and Quality (AHRQ)-based initiative to reduce UC days/Standardized Utilization Ratio (SUR). Daily critical reviews of the indication for UC were conducted by two groups. First, frontline night shift RN staff identified patients who no longer had a valid justification for continued UC. They handed-off the information to day-shift RNs, who recommend removal of UC during daily rounds with the physician teams. A second review was performed by Clinical Quality Improvement Specialists (CQIS) based on defined criteria from our nursing decatheterization protocol. Their discontinue UC recommendations were also sent to the care teams. The critical reviews of UC for CAUTI reduction started with 4 ICUs in August 2018, with additional ICUs added in December, January and March. Monthly UC SURs were tracked Results Figure 1 shows the number of UCs recommended for removal by RNs vs. CQIS (bars), as well as the percent discordance between RNs and CQIS (line). CQIS identified many more removable UCs than the RNs (888 vs. 256). 211 UC were removed after RN recommendations, and an additional 386 UCs were removed as a result of the CQIS audits. Figure 2 shows the marked corresponding decline in our SUR over this intervention. Conclusion As more units participated in the initiative, we saw increasing numbers of “discontinue UC” recommendations. Over time there was also a moderate decrease in the discordance between RN and CQIS recommendations for UC removal. CQIS routinely identified many more UCs to be removed compared with RNs, and more than doubled the number of discontinued UC. Notably, the UC SUR markedly improved, decreasing from 0.98 to 0.78. Disclosures All authors: No reported disclosures.