A breakthrough series collaborative to increase patient participation with hemodialysis tasks: A stepped wedge cluster randomised controlled trial

Background Compared to in-centre, home hemodialysis is associated with superior outcomes. The impact on patient experience and clinical outcomes of consistently providing the choice and training to undertake hemodialysis-related treatment tasks in the in-centre setting is unknown. Methods A stepped-wedge cluster randomised trial in 12 UK renal centres recruited prevalent in-centre hemodialysis patients with sites randomised into early and late participation in a 12-month breakthrough series collaborative that included data collection, learning events, Plan-Study-Do-Act cycles, and teleconferences repeated every 6 weeks, underpinned by a faculty, co-production, materials and a nursing course. The primary outcome was the proportion of patients undertaking five or more hemodialysis-related tasks or home hemodialysis. Secondary outcomes included independent hemodialysis, quality of life, symptoms, patient activation and hospitalisation. ISRCTN Registration Number 93999549. Results 586 hemodialysis patients were recruited. The proportion performing 5 or more tasks or home hemodialysis increased from 45.6% to 52.3% (205 to 244/449, difference 6.2%, 95% CI 1.4 to 11%), however after analysis by step the adjusted odds ratio for the intervention was 1.63 (95% CI 0.94 to 2.81, P = 0.08). 28.3% of patients doing less than 5 tasks at baseline performed 5 or more at the end of the study (69/244, 95% CI 22.2–34.3%, adjusted odds ratio 3.71, 95% CI 1.66–8.31). Independent or home hemodialysis increased from 7.5% to 11.6% (32 to 49/423, difference 4.0%, 95% CI 1.0–7.0), but the remaining secondary endpoints were unaffected. Conclusions Our intervention did not increase dialysis related tasks being performed by a prevalent population of centre based patients, but there was an increase in home hemodialysis as well as an increase in tasks among patients who were doing fewer than 5 at baseline. Further studies are required that examine interventions to engage people who dialyse at centres in their own care.

Professionals’ experiences of using an improvement programme: applying quality improvement work in preschool contexts

BackgroundImprovement work can be used in preschools to enrich outdoor environment for children’s better health. Effective improvement work can facilitate the necessary changes, but little is known about professionals’ experiences of participation in improvement interventions. The aim was to evaluate how preschool staff experience quality improvement work, using the Breakthrough Series Collaborative improvement programme, to enhance outdoor environments.MethodsAn improvement intervention using a breakthrough collaborative was performed at 9 preschools in Sweden and examined with a longitudinal mixed method design. Staff completed questionnaires on 4 occasions (n=45 participants) and interviews took place after the intervention (n=16 participants).ResultsThe intervention was successful in the sense that the staff were content with the learning seminars, and they had triggered physical changes in the outdoor environment. They integrated the quality improvement work with their ordinary work and increasingly involved the children. The staff tested improvement tools but did not find them entirely appropriate for their work, because they preferred existing methods for reflection.ConclusionsThe challenges in quality improvement work seem to be similar across contexts. Using the Breakthrough Series Collaborative in a public health intervention is promising but needs to be integrated with preunderstandings, current reflections and quality tools and models.

Saving 20,000 Days and Beyond using breakthrough improvements: lessons from an adaption of the Breakthrough Series Collaborative

Objectives To report on selected findings from an evaluation of two consecutive quality improvement campaigns that adapted the Breakthrough Series Collaborative model to the broad topic of reducing demand for hospital care and reflect on lessons learned from their adaption of the model for subsequent collaborative improvement efforts. Methods We conducted a series of semi-structured interviews with Campaign sponsors and Collaborative team leaders as part of the broader realist evaluation of the two Campaigns. In addition, follow-up semi-structured interviews with Campaign sponsors and implementers were undertaken three years after the evaluation concluded (ex post evaluation interviews) to understand which adaptions to the Breakthrough Series Collaborative model had been the most influential. Results The interviews explored two features that differentiated the Campaigns from other Breakthrough Series Collaboratives. Firstly, the Campaigns enabled a diverse range of improvement solutions to be tested which had implications for the collaborative nature of the learning collaboratives. Secondly, two sequential Campaigns were implemented that incorporated common elements and provided the opportunity for the transfer of knowledge from one Campaign to the next. Conclusions Given widespread pressure to transform health care into a learning system, this paper provides a practical example of using cumulative insights to encourage the sustainability of collaborative improvement efforts. These insights centre on the gains from spreading improvement methodology throughout the organization and learning how to select and support successful collaborative teams.

Implementation of a regional quality improvement collaborative to improve care of people living with opioid use disorder in a Canadian setting

Background Although opioid agonist therapy is effective in treating opioid use disorders (OUD), retention in opioid agonist therapy is suboptimal, in part, due to quality of care issues. Therefore, we sought to describe the planning and implementation of a quality improvement initiative aimed at closing gaps in care for people living with OUD through changes to workflow and care processes in Vancouver, Canada. Methods The Best-practice in Oral Opioid agoniSt Therapy (BOOST) Collaborative followed the Institute for Healthcare Improvement’s Breakthrough Series Collaborative methodology over 18-months. Teams participated in a series of activities and events to support implementing, measuring, and sharing best practices in OAT and OUD care. Teams were assigned monthly implementation scores to monitor their progress on meeting Collaborative aims and implementing changes. Results Seventeen health care teams from a range of health care practices caring for a total of 4301 patients with a documented diagnosis of OUD, or suspected OUD based on electronic medical record chart data participated in the Collaborative. Teams followed the Breakthrough Series Collaborative methodology closely and reported monthly on a series of standardized process and outcome indicators. The majority of (59%) teams showed some improvement throughout the Collaborative as indicated by implementation scores. Conclusions Descriptive data from the evaluation of this initiative illustrates its success. It provides further evidence to support the implementation of quality improvement interventions to close gaps in OUD care processes and treatment outcomes for people living with OUD. This system-level approach has been spread across British Columbia and could be used by other jurisdictions facing similar overdose crises.

Reducing pressure ulcers across multiple care settings using a collaborative approach

In the UK, over 700 000 patients are affected by pressure ulcers each year, and 180 000 of those are newly acquired each year. The occurrence of pressure ulcers costs the National Health Service (NHS) more than 3.8 million every day. In 2004, pressure ulcers were estimated to cost the NHS £1.4–£2.4 billion per year, which was 4% of the total NHS expenditure.The impact on patients can be considerable, due to increased pain, length of hospital stay and decreased quality of life. However, it is acknowledged that a significant number of these are avoidable.In early 2015, it was identified that for the North East and North Cumbria region the incidence of pressure ulcers was higher than the national average. Because of this, a 2-year Pressure Ulcer Collaborative was implemented, involving secondary care, community services, care homes and the ambulance service, with the aim of reducing the percentage of pressure ulcers developed by patients within their care.The Breakthrough Series Collaborative Model from the Institute for Healthcare Improvement provided the framework for this Collaborative.In year 1, pressure ulcers were reduced by 36%, and in year 2 by 33%, demonstrating an estimated cost saving during the lifespan of the Collaborative of £513 000, and a reduction in the number of bed days between 220 and 352.

Improving patient satisfaction: the virtual breakthrough series collaborative

Purpose The purpose of this paper is to improve the Siloam Hospitals’ (SHs) patient satisfaction index (PSI) and overcome Indonesia’s geographical barriers. Design/methodology/approach The topic was selected for reasons guided by the Institute of Healthcare Improvement virtual breakthrough series collaborative (VBSC). Subject matter experts came from existing global quality development in collaboration with sales and marketing, and talent management agencies/departments. Patient satisfaction (PS) was measured using the SH Customer Feedback Form. Data were analysed using Friedman’s test. Findings The in-patient (IP) department PSI repeated measures comparison during VBSC, performed using Friedman’s test, showed a statistically significant increase in the PSI, χ2 = 44.00, p<0.001. Post hoc analysis with Wilcoxon signed-rank test was conducted with a Bonferroni correction applied, which resulted in a significant increase between the baseline and action phases (Z=3.317, p=0.003) between the baseline and continuous improvement phases (Z=6.633, p<0.001), and between the action and continuous improvement phases (Z=3.317, p=0.003), suggesting that IP PSI was continuously increasing during all VBSC phases. Like IP PSI, the out-patient department PSI was also continuously increasing during all VBSC phases. Research limitations/implications The VBSC was not implemented using a control group. Factors other than the VBSC may have contributed to increased PS. Practical implications The VBSC was conducted using virtual telecommunication. Although conventional breakthrough series might result in better cohesiveness and commitment, Indonesian geographical barriers forced an alternative strategy, which is much more cost-effective. Originality/value The VBSC, designed to improve PS, has never been implemented in any Indonesian private hospital group. Other hospital groups might also appreciate knowing about the VBSC to improve their PSI.