The Patient Care Notebook: quality improvement on a rehabilitation unit

BACKGROUND: Shortened lengths of stay in acute and rehabilitation hospitals, continuing financial pressures on all postacute care services, and increasing out-of-pocket health care costs for patients and families challenge rehabilitation hospitals' patient education and discharge planning processes. Spaulding Rehabilitation Hospital (Boston) introduced a patient care notebook in a 15-bed satellite unit and pilot tested its contribution to the patient education and discharge planning process. DEVELOPING THE NOTEBOOK: The three-ring binder notebook included sections on medical appointments and phone numbers, understanding illness and medical care, coping with illness, physical activities, recommendations for the home, and community resources, with both standard and patient-specific information. RESULTS: Most of the patients and caregivers who received the notebooks found them to be helpful, and most staff indicated that the notebook improved the teaching process. Telephone calls to the unit after home discharges decreased form 28 calls for 11 discharges to 6 calls for 21 discharges after the notebook began to be used regularly. DISCUSSION: Staff felt that the process of using the notebook helped focus attention on teaching during the entire course of a patient's hospitalization rather than just a day or two before discharge. The patient care notebook process is being introduced to the entire hospital and to all patients, regardless of discharge location and the patient's literacy or proficiency with English. CONCLUSION: In using the notebook, the QI team, and the entire unit staff, learned about the complexities of QI, patient education, and discharge planning. The notebook process was implemented throughout the hospital a little more than a year after the completion of the pilot project.     

Selecting quality improvement projects and product mix together in manufacturing: an improvement of a theory of constraints-based approach by incorporating quality loss

The quality of products and processes needs to be improved continuously in today's competitive environments. Unless these improvement efforts are focused properly, companies might not achieve desirable results in terms of sales, quality and productivity. Many quality improvement (QI) approaches have a limited evaluation of the factors involved in the selection of QI projects. Theory of constraints (TOC) has been proposed by some researchers as a remedy for the better selection of QI projects. However, these TOC-based approaches do not accurately capture ongoing product quality and its long-term effects on sales. Quality loss, on the other hand, can be used as a measure of customer dissatisfaction, which in turn determines the sales. The paper proposes an improvement of a TOC-based algorithm by incorporating quality loss with it. Using two simple manufacturing examples, it demonstrates that quality losses affect the product mix and QI project selection. It provides suggestions for further research directions for wider applicability of the proposed approach.     

Quality improvement in a managed care organization from a medical director's perspective: an interview with Bruce Perry. Interview by Douglas Roblin

BACKGROUND: In late 1994 the Quality Forum commissioned the Interdisciplinary Prevention Committee [IPC]. One of the IPC's charges was to identify priorities for QI in preventive health services. The IPC established priorities through a review of scientific literature, identification of national and state health initiative priorities, and consideration of what services to establish as priorities and of the practicality of implementing low-cost interventions to achieve specific QI goals. Breast cancer screening was selected as a top-ten priority for guideline development and for focused intervention because of the disease's prevalence, morbidity, and mortality and because of the fact that it is most treatable and curable when it is found early through routine screening. The national HEDIS (Health Plan Employer Data and Information Set; National Committee on Quality Assurance (NCQA), Washington, DC] result of 71%, reported in May 1995, provided our baseline performance measurement. This result fell short of our goal of being in the 90th percentile of performance on each HEDIS effectiveness of care measure. In August 1995 the Quality Forum accepted the IPC's recommendations, which had been endorsed by the department of medicine. These recommendations emphasized the importance of annual clinical breast exam and mammography for women of targeted age groups. In November 1997, a new "Excellence in Quality: HEDIS Improvement Team" began work. Its charge was to undertake analyses of underlying causes of reduced performance and to develop additional steps to improve performance by changes in care delivery processes in 1998. In March 1998 the Quality Forum's executive committee designated breast cancer screening one of the six organizationwide quality priorities for 1998 and designated two "owners" who would be accountable for this performance--the chief and director of radiology. RESULTS: The screening rate increased from 73.8% in 1996 to 84.0% in 1999. National benchmarks [90th percentile] in 1998 were 81% for commercially insured members and 84% for Medicare members. The 84% screening rate made the Georgia region the Kaiser Permanente national leader and put the region in the top 10% of all health plans in the United States. CONCLUSIONS: The program has achieved these results with a broad array of activities: Saturday hours, mobile mammography, medical record reminders (fuschia-colored inserts), patient and physician reminders, call-center outreach, provider feedback on performance, and provider financial incentives. Several of these innovations demonstrate the ability to integrate improved care management into evolving service delivery in Kaiser Permanente--such as use of call-center technologies and redesign of primary care delivery. While we cannot point to any one of these innovations as a key driver of improvement, it is clear that substantial improvements in care delivery can be achieved. All these activities are relatively low cost and easily implemented in other managed care organizations and in other areas of medical care.     

Combined quality improvement ratio: a method for a more robust evaluation of changes in screening rates

INTRODUCTION: It has been proposed that a ratio of the discordant cells from a McNemar's Chi-square table be used as a measure of quality improvement, and that this measure be called the Quality Improvement Ratio (QuIR). As proposed, patients enrolled in only one year of a two-year study are excluded from the McNemar's table of the QuIR. Since the original proposal of the McNemar's Chi-square in 1947 included application to matched pair data, a more comprehensive analysis would be possible if the single-year enrollees were matched into pairs. METHODS: Patients enrolled in only the first study year are matched and paired with patients enrolled in only the second study year. The pairs are matched on variables important to the disease or process being evaluated. The matched pairs are combined with the repeatedly measured subjects to increase the statistical power of the analysis. The Combined Quality Improvement Ratio (CQuIR) is demonstrated with parameters from the original articles, in a--Markov chain Monte-Carlo simulation, so a direct comparison can be made. RESULTS: CQuIR improved statistical power, especially in simulations of small populations. In some simulations the statistical power was double that of the QuIR alone. DISCUSSION: Although the QuIR provides important information, the CQuIR allows more of the data to be used to evaluate the effect of interventions in policy, delivery, and practice. The increase in statistical power of the CQuIR over the QuIR can facilitate successful evaluation of health care services.     

Summarizing changes in an entire population: extensions to the quality improvement ratio

BACKGROUND: In an earlier article the use of the Quality Improvement Ratio (QuIR) was proposed as a way to assess whether an intervention improves preventive health practices. With this method, only members of a health plan observed both before and after an intervention are analyzed. Members observed in only one of the two periods are not included in the QuIR analysis. However, since membership in health plans is constantly changing, the QuIR analysis may exclude a substantial proportion of the total number of members studied. METHOD: To overcome this problem, an extension to the QuIR analysis, termed the Extended QuIR method, has been developed. Members are classified into two separate groups: those with data in both periods and those with data in only a single period. Members providing data in both periods are analyzed using the QuIR. Members studied in only a single period are analyzed using single-period analysis, described in this article. If the results of the two separate tests are consistent, both suggesting an improvement over time or both suggesting a deterioration, then the results of the two tests can be combined into an overall test to assess whether a change over time occurred. CONCLUSION: The Extended QuIR method, which combines the results of two separate analyses, should help clarify the effect of an intervention on improving preventive health practices in the overall population.     

Process failure modes and effects analysis (PFMEA): A structured approach for quality improvement in the metal forming industry

Failure modes and effects analysis (FMEA) is one potential tool with extended use in reliability engineering for the electrical and electronic components production field as well as in complicated assemblies (aerospace and automotive industries). The main purpose is to reveal system weaknesses and thereby minimize the risk of failure occurrence. The FMEA technique is used in the design stage of a system or product (DFMEA) as well as in the manufacturing process (PFMEA). Currently, the implementation of quality systems (such as ISO 9001, QS9000, TS 16949, etc.) requires the establishment of preventive procedures; therefore, the use of risk analysis methods, such as FMEA, is mandatory. This paper introduces the use of this technique in a critical process in the metal forming industry.     

Enhancement in quality and productivity: a riskless approach based on optimum selection of tolerance and improvement strategies

The need of higher quality products from the customers and the tendency of industries to quality improvement for maintaining their competitive position over the long run are the main motives of using improvement methodologies. However, any use of improvement methodology besides its additional costs will also change the total variability of the process. Changes in total variability will affect the optimal value of tolerance as well as the quality of the product. Therefore, one of the main concerns of the producers is to find an effective way to manufacture their goods in a manner that reduces the production costs and gains customers’ satisfaction. To meet these goals, this study introduces an algorithm to propose a riskless approach of improvement that results in the maximum amount of net savings. It is shown that using appropriate improvement strategies simultaneous with a proper selection of tolerance have an important impact to enhance productivity and quality.     

Evaluating safety of tunneled small bore central venous catheters in chronic kidney disease population: A quality improvement initiative

Introduction: Peripherally inserted central venous catheters (PICCs) may adversely impact future successful arteriovenous fistulae (AVF). As part of a quality improvement project, the performance of tunneled small bore tunneled central venous catheters (TSB‐CVCs), as alternatives to PICCs, was evaluated. Methods: A retrospective observational study, involving individuals ≥18 years of age who underwent TSB‐CVC placement by Interventional Radiology at Mayo Clinic, Rochester, MN between 1/1/2010 and 8/30/2013. Findings: The study cohort included 92 patients with a median age of 55 (46–67) years, who underwent 108 TSB‐CVC placements. Baseline renal disease was present in 71% (77/108). Most TSB‐CVCs were placed in hospitalized patients (94%; 102/108); five French in diameter (61%; 66/108) and located in an internal jugular vein (84%; 91/108). Median catheter indwelling time was 20 (11–43) days (n = 84). TSB‐CVC‐related bloodstream infection, deep venous thrombosis (DVT), and superficial venous thrombosis (SpVT) rates per line were 0.009 (1/108), 0.018 (2/108), and 0.009 (1/108), respectively. Venous outcomes in a subgroup of 54 patients, who had documented PICC placements (n = 161) in addition to TSB‐CVC (n = 58) were compared. TSB‐CVC‐DVT rate was lower than the PICC‐DVT rate (0.017 [1/58] vs. 0.106 per line [17/161]; P = 0.04). The TSB‐CVC‐SpVT rate was not different from the PICC‐SpVT rate (0 [0/58] vs. 0.037 [6/161] per line; P = 0.14). Discussion: TSB‐CVCs demonstrated an excellent safety profile in our study. These catheters should be preferentially utilized for arm vein preservation in advanced kidney disease. Their impact on future AVF success needs further evaluation.     

Measuring antidepressant prescribing practice in a health care system using administrative data: implications for quality measurement and improvement

BACKGROUND: Up to one in eight Americans experiences an episode of depression that requires treatment in his or her lifetime. The direct and indirect costs associated with major depression are high but may be reduced with appropriate treatment. To decrease the probability of relapse, guidelines specify that treatment with antidepressant medications should continue for at least 4 months after symptom remission and that adequate doses of antidepressants be used. A study was conducted in 1997-1999 to examine how different specifications in the construction of quality of care measures for depression treatment influence conclusions about the adequacy of antidepressant prescribing practices. METHODS: Subjects were all adult members of two United Healthcare plans who each had at least one outpatient or inpatient claim with a diagnosis of depression during the years 1993-1995 and were continuously enrolled for 12 months. Pharmacy claims data were used to construct measures of duration of treatment, dose, and type of antidepressant. The effects of two different definitions of a new episode (4-month versus 9-month clean period) and two different ways of identifying an episode of depression (one visit versus two visits with a code for depression) were examined on conclusions about adequacy of antidepressant prescribing practices (dose and duration). Whether antidepressant type was related to the likelihood that antidepressants were prescribed at therapeutic doses was also examined. RESULTS: Patients with two or more visits with depression diagnosis codes were significantly more likely to receive antidepressants than those with only one visit, and were more likely to receive therapeutic doses at each time period (1-5 months). The duration of the clean period was not related to conclusions about therapeutic dosing. Among persons receiving antidepressants, those receiving selective serotonin reuptake inhibitors (SSRIs) were more likely to receive therapeutic doses and to continue treatment for at least 5 months than were those prescribed other classes of antidepressants. In multivariate analysis, being prescribed an SSRI versus another class of antidepressants was significantly associated with receiving both 1 month (OR = 7.3 [5.7-9.3]) and 5 months (OR = 2.0 [1.6-2.5]) of therapeutic treatment. DISCUSSION: Conclusions regarding the appropriateness of antidepressant prescribing can vary markedly, depending on how the quality measure is specified. Given that administrative data are and will continue to be used for both monitoring and quality improvement purposes in the short run, it is critical that we understand how variations in measurement specifications influence the conclusions that are drawn about treatment of depression in health plans.     

Long-term patency of arteriovenous fistulas for hemodialysis: A decade's experience in a transplant unit

Background

The heterogeneous quality of studies on arteriovenous fistulas outcome, with variable clinical settings and large variations in definitions of patency and failure rates, leads to frequent misinterpretations and overestimation of arteriovenous fistula patency. Hence, this study aimed to provide realistic and clinically relevant long-term arteriovenous fistula outcomes.

Methods

We retrospectively analyzed all autologous arteriovenous fistulas at our center over a 10-year period (2012–2022). Primary and secondary patency analysis was conducted using the Kaplan–Meier method; multivariate analysis of variance was used to detect outcome predictors. Vascular access-specific endpoints were defined according to the European guidelines on vascular access formation.

Findings

Of 312 arteriovenous fistulas, 57.5% (n = 181) were radio-cephalic (RC_AVF), 35.2% (n = 111) brachio-cephalic (BC_AVF), and 6.3% (n = 20) brachio-basilic (BB_AVF). 6, 12, and 24 months follow-up was available in 290 (92.1%), 282 (89.5%), and 259 (82.2%) patients, respectively. Primary patency rates at 6, 12, and 24 months were 39.5%, 34.8%, and 27.2% for RC_AVF, 58.3%, 44.4%, and 27.8% for BC_AVF, and 40.0%, 42.1%, and 22.2% for BB_AVF (p = 0.15). Secondary patency rates at 6, 12, and 24 months were 65.7%, 63.8%, and 59.0% for RC_AVF, 77.7%, 72.0%, and 59.6% for BC_AVF, and 65.0%, 68.4%, and 61.1% for BB_AVF (p = 0.29). Factors associated with lower primary and secondary patency were hemodialysis at time of arteriovenous fistula formation (p = 0.037 and p = 0.024, respectively) and higher Charlson Comorbidity Index (p = 0.036 and p < 0.001, respectively). Previous kidney transplant showed inferior primary patency (p = 0.005); higher age inferior secondary patency (p < 0.001).

Discussion

Vascular access care remains challenging and salvage interventions are often needed to achieve maturation or maintain patency. Strict adherence to standardized outcome reporting in vascular access surgery paints a more realistic picture of arteriovenous fistula patency and enables reliable intercenter comparison.     

A ferrofluid guided system for the rapid separation of the non-magnetic particles in a microfluidic device

A microfluidic device was fabricated via UV lithography technique to separate non-magnetic fluoresbrite carboxy microspheres (approximately 4.5 microm) in the pH 7 ferrofluids made of magnetite nanoparticles (approximately 10 nm). A mixture of microspheres and ferrofluid was injected to a lithographically developed Y shape microfluidic device, and then by applying the external magnet fields (0.45 T), the microspheres were clearly separated into different channels because of the magnetic force acting on those non-magnetic particles. During this study, various pumping speeds and particle concentrations associated with the various distances between the magnet and the microfluidic device were investigated for an efficient separation. This study may be useful for the separation of biological particles, which are very sensitive to pH value of the solutions.     

A power quality monitoring system: a case study in DSP-basedsolutions for power electronics

Programmable digital signal processors (DSPs) are emerging as the processors of choice in monitoring and control of high-end power electronics systems. This paper adopts a case study approach to illustrate a development methodology for DSP-based solutions. The unique features of DSP chips that make them ideal for real-time applications are highlighted. Power electronics systems where DSPs have been used are indicated. A case study in which a DSP-based solution was developed for a power quality monitoring application is presented. Through the case study, the issues involved in adopting a system architecture, selecting a DSP, and developing software for an application are discussed. The methodology described in this paper presents broad guidelines which can be intelligently applied to develop DSP-based solutions to meet specific requirements     

Failure of a screw in a helicopter fuel-control unit: Was it the cause of a fatal crash?

Investigations into a fatal helicopter crash centered around the failure of a cadmium-plated, non-conforming, steel screw in a fuel-control unit. The present study, which includes a critical evaluation of previous investigations, was undertaken with the aim of getting more definitive answers as to whether the screw failed in flight due to hydrogen-embrittlement or stress-corrosion cracking, or whether the screw failed due to liquid-metal embrittlement during a post-crash fire. Previous investigations had not resulted in any consensus regarding the mode of failure or whether the failure was responsible for the crash.     

Regional citrate anticoagulation in CVVH: A new protocol combining citrate solution with a phosphate‐containing replacement fluid

Regional citrate anticoagulation (RCA) is a valid anticoagulation method in continuous renal replacement therapies (CRRT) and different combination of citrate and CRRT solutions can affect acid‐base balance. Regardless of the anticoagulation protocol, hypophosphatemia occurs frequently in CRRT. In this case report, we evaluated safety and effects on acid‐base balance of a new RCA‐ continuous veno‐venous hemofiltration (CVVH) protocol using an 18 mmol/L citrate solution combined with a phosphate‐containing replacement fluid. In our center, RCA‐CVVH is routinely performed with a 12 mmol/L citrate solution and a postdilution replacement fluid with bicarbonate (protocol A). In case of persistent acidosis, not related to citrate accumulation, bicarbonate infusion is scheduled. In order to optimize buffers balance, a new protocol has been designed using recently introduced solutions: 18 mmol/L citrate solution, phosphate‐containing postdilution replacement fluid with bicarbonate (protocol B). In a cardiac surgery patient with acute kidney injury, acid‐base status and electrolytes have been evaluated comparing protocol A (five circuits, 301 hours) vs. protocol B (two circuits, 97 hours): pH 7.39 ± 0.03 vs. 7.44 ± 0.03 (P < 0.0001), bicarbonate 22.3 ± 1.8 vs. 22.6 ± 1.4 mmol/L (NS), Base excess ?2.8 ± 2.1 vs. ?1.6 ± 1.2 (P = 0.007), phosphate 0.85 ± 0.2 vs. 1.3 ± 0.5 mmol/L (P = 0.027). Protocol A required bicarbonate and sodium phosphate infusion (8.9 ± 2.8 mmol/h and 5 g/day, respectively) while protocol B allowed to stop both supplementations. In comparison to protocol A, protocol B allowed to adequately control acid‐base status without additional bicarbonate infusion and in absence of alkalosis, despite the use of a standard bicarbonate concentration replacement solution. Furthermore, the combination of a phosphate‐containing replacement fluid appeared effective to prevent hypophosphatemia.     

The strain reduction and quality improvement in ZnO film by a 30° in-plane rotation with respect to the Al2O3 substrate

The in-plane orientation of epitaxial ZnO thin film on Al₂O₃(0 0 0 1) was determined by azimuthal scan of X-ray diffraction. Comprehensive structural characterizations, including the lattice strain in perpendicular direction, the defect density, were obtained from high resolution X-ray diffraction. It's found that a 30° rotation in ZnO against Al₂O₃, resulting in ZnO〈1 1 2 0〉//Al₂O₃〈1 0 1 0〉, can efficiently reduce the strain and defects in ZnO layer. Consequently, the optical property is significantly improved.     

The application of SVR model in the improvement of QbD: a case study of the extraction of podophyllotoxin

In order to make a further optimization of process design via increasing the stability of design space, we brought in the model of Support Vector Regression (SVR). In this work, the extraction of podophyllotoxin was researched as a case study based on Quality by Design (QbD). We compared the fitting effect of SVR and the most used quadratic polynomial model (QPM) in QbD, and an analysis was made between the two design spaces obtained by SVR and QPM. As a result, the SVR stayed ahead of QPM in prediction accuracy, the stability of model and the generalization ability. The introduction of SVR into QbD made the extraction process of podophyllotoxin well designed and easier to control. The better fitting effect of SVR improved the application effect of QbD and the universal applicability of SVR, especially for non-linear, complicated and weak-regularity problems, widened the application field of QbD.