Critique of Quality Improvement Strategy

HQPS Assignment #1: Critique of Quality Improvement Strategy

DESCRIPTION: The clinical environments you will encounter have many systems in place that are designed to support high quality patient care, such as ongoing quality improvement efforts, or the systems put in place by previous quality improvement initiatives. You may come into direct contact with these systems but some may not be readily apparent. Asking the residents, faculty and staff you work with about the strategies and systems they encounter can help you better understand how these work including both their positive and negative aspects. You are encouraged to draw from examples that are directly relevant to patients whom you cared for (though this is not required).

EXPECTATION: The assignments should be written as a succinct 1-2 page paper, single spaced. The paper should not exceed 3 pages, single spaced (including references). The addition of tables/graphs are not expected and should only be utilized if they would significantly impress upon a key point that would not be able to be described succinctly.  The students should follow the format of the sample response included below.

SUBMISSION: Your assignment is due by 5pm Friday, August 18, 2017 on Canvas in the “Health & Society – Class of 2019” course site. For questions about submission, email Terry Long (Terry.Long@Northwestern.edu). For questions about the assignment content, email Dr. Sangeeta Schroeder (SKSchroeder@luriechildrens.org). Please include your name as the file name and within the document.  

ASSIGNMENT PROMPTS:

1. Pick a specific Quality Improvement strategy that is in place to improve the healthcare quality given to patients. It should be one that is in the healthcare you work in, or that is described in the literature that supports a specific quality objective.

• Provide a general description of the quality improvement strategy including the setting in which it occurs.
• Below is a table of common examples. The QI strategy chosen does not have to be from the below list.
• Many interventions/strategies will combine several approaches.  If you choose a topic where multiple strategies are in use, describe how the different components interconnect.
• Remember, a policy statement is rarely considered a QI strategy. ***

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1. Describe the specific clinical quality problem addressed by the QI strategy identified in #1.

• Is the clinical topic sufficiently important? Is there a burden of disease that is ameliorable if quality is improved?
• Is there consensus about what constitutes high quality care?
• Is the scientific evidence base robust?
• Are evidence-based guideline(s) present and if so what is their quality?
• Does the QI strategy represent current knowledge?

1. Describe the specific objectives (these are either processes of care, or outcomes of care) that are addressed by the QI strategy

• Are the objectives addressed by the QI strategy processes or outcomes?  
• If the target of the QI strategy is a change in a process: is the relationship between the process and clinical outcomes well supported? This can be answered in either section 2 above or here in section 3.

1. Describe how well the QI Strategy works to accomplish the objectives. You may base your reflections on your own experiences, discussions with care providers or through examining the literature.

• What are the likely positive effects? (Improved quality, efficiency, etc.)
• What are real or potential negative effects (e.g., opportunity cost/burden on providers, promote inappropriate or over use, introduce new errors or direct harm, other unintended consequences)?

RESPONSE EXAMPLE:

Example: Direct observation of hand hygiene with feedback to providers as a QI strategy to improve handwashing rates.

1. During medicine wards at NM, I observed inpatient medicine units at NM employing direct observation and provider feedback to improve hand washing. A NM staff member stationed adjacent to patient care areas, such as in the hall way or in the hemodialysis unit, observed clinical team members as they came in or out of patient-care areas. Observers provided real-time feedback. Through discussion with other NM staff, I learned that hospital administration also tracked the rates of hand washing and provided feedback to unit leaders about teams’ performance in aggregate.

1. This is an important topic for quality improvement because 1) there is substantial morbidity and mortality caused by hospital acquired infections with nosocomial organism, 2) hand decontamination practices exist that can effectively reduce the rates of infections, and 3) these practices are under used by providers. Nosocomial organisms cause blood stream infections, urinary tract infections, hospital acquired pneumonia and wound infections.  In the US there are approximately 60 nosocomial blood stream infections per 10,000 hospital admissions and many are due to antibiotic resistant organisms.1 Hospital-acquired pneumonia occurs in 4 to 7 per 1000 hospitalizations and are frequently due to antibiotic resistant organisms. Drug resistant strains are frequently transmitted on the hands of healthcare workers or through contact with contaminated surfaces. There is ample evidence that healthcare workers do not perform hand hygiene practices routinely. A recent trial to improve hand hygiene in U.K. hospitals showed baseline compliance rates of only 50-70%.2 Methods to improve hand hygiene practices have been studied multiple times. The literature is somewhat heterogeneous, but overall, performance feedback has been shown to be effective at changing hand hygiene behaviors.3 Many but not all studies that successfully improved hand hygiene also yielded significant reductions in infection rates.4 There is a strong consensus in the scientific literature and practice guidelines that routine hand decontamination is of clinical value.

1. The objective of this QI strategy is to improve the process of provider hand decontamination (using antiseptic gel, or soap and water) before patient contact. An improvement in this process is tied to improvement in the clinical outcomes as hand decontamination would be expected to reduce the transmission of dangerous nosocomial organisms from one patient to the next (such as antibiotic resistant staph aureus or Klebsiella pneumoniae). This in turn should reduce the rate of hospital acquired infections with antibiotic resistant nosocomial organisms.

1. Based on my assessment of the experience of the team, being watched did seem to provide a compelling incentive to comply with the hand hygiene practices. This observation is consistent with the published literature summarized in reference 3 that suggests providing healthcare providers with feedback about their performance on hand washing is effective. However the impact of feedback is not always large. In the cluster randomized stepped wedge trial of Fuller et al. a large scale implementation of a feedback intervention had positive but only modest-sized effects, and compliance rates after the intervention remained well below 100%.2 It seems unlikely that interventions using feedback alone will completely solve this problem.  In addition, even perfect hand hygiene would likely not completely eliminate nosocomial transmission unless efforts to identify and address other modes of transmission, such as on provider clothing, medical equipment, or surfaces, were adequately addressed at the same time.

There could be unanticipated negative consequences of taking this approach. Feedback could reduce providers’ morale and engender negative views towards the institution, particularly if the feedback is delivered in a way that causes too much embarrassment. Also if some providers find 100% compliance with hand hygiene practices too onerous (particularly if they have cuts or rashes that make using hand sanitizer painful), may reduce their number of contacts with patients (thus potentially omitting other important aspects of care).  I did not identify documented evidence of these potential adverse effects in the literature, and overall, these concerns seem small in comparison to the potential benefits.