Wilco C. Graafmans

Using quality indicators to improve hospital care: a review of the literature

PURPOSE To review the literature concerning strategies for implementing quality indicators in hospital care, and their effectiveness in improving the quality of care. DATA SOURCES A systematic literature study was carried out using MEDLINE and the Cochrane Library (January 1994 to January 2008). STUDY SELECTION Hospital-based trials studying the effects of using quality indicators as a tool to improve quality of care. DATA EXTRACTION Two reviewers independently assessed studies for inclusion, and extracted information from the studies included regarding the health care setting, type of implementation strategy and their effectiveness as a tool to improve quality of hospital care. RESULTS A total of 21 studies were included. The most frequently used implementation strategies were audit and feedback. The majority of these studies focused on care processes rather than patient outcomes. Six studies evaluated the effects of the implementation of quality indicators on patient outcomes. In four studies, quality indicator implementation was found to be ineffective, in one partially effective and in one it was found to be effective. Twenty studies focused on care processes, and most reported significant improvement with respect to part of the measured process indicators. The implementation of quality indicators in hospitals is most effective if feedback reports are given in combination with an educational implementation strategy and/or the development of a quality improvement plan. CONCLUSION Effective strategies to implement quality indicators in daily practice in order to improve hospital care do exist, but there is considerable variation in the methods used and the level of change achieved. Feedback reports combined with another implementation strategy seem to be most effective.

Implementing quality indicators in intensive care units: exploring barriers to and facilitators of behaviour change

BackgroundQuality indicators are increasingly used in healthcare but there are various barriers hindering their routine use. To promote the use of quality indicators, an exploration of the barriers to and facilitating factors for their implementation among healthcare professionals and managers of intensive care units (ICUs) is advocated.MethodsAll intensivists, ICU nurses, and managers (n = 142) working at 54 Dutch ICUs who participated in training sessions to support future implementation of quality indicators completed a questionnaire on perceived barriers and facilitators. Three types of barriers related to knowledge, attitude, and behaviour were assessed using a five-point Likert scale (1 = strongly disagree to 5 = strongly agree).ResultsBehaviour-related barriers such as time constraints were most prominent (Mean Score, MS = 3.21), followed by barriers related to knowledge and attitude (MS = 3.62; MS = 4.12, respectively). Type of profession, age, and type of hospital were related to knowledge and behaviour. The facilitating factor perceived as most important by intensivists was administrative support (MS = 4.3; p = 0.02); for nurses, it was education (MS = 4.0; p = 0.01), and for managers, it was receiving feedback (MS = 4.5; p = 0.001).ConclusionsOur results demonstrate that healthcare professionals and managers are familiar with using quality indicators to improve care, and that they have positive attitudes towards the implementation of quality indicators. Despite these facts, it is necessary to lower the barriers related to behavioural factors. In addition, as the barriers and facilitating factors differ among professions, age groups, and settings, tailored strategies are needed to implement quality indicators in daily practice.

Effect of a Multifaceted Performance Feedback Strategy on Length of Stay Compared With Benchmark Reports Alone: A Cluster Randomized Trial in Intensive Care*

Objective:To assess the impact of applying a multifaceted activating performance feedback strategy on intensive care patient outcomes compared with passively receiving benchmark reports. Design:The Information Feedback on Quality Indicators study was a cluster randomized trial, running from February 2009 to May 2011. Setting:Thirty Dutch closed-format ICUs that participated in the national registry. Study duration per ICU was sixteen months. Patients:We analyzed data on 25,552 admissions. Admissions after coronary artery bypass graft surgery were excluded. Intervention:The intervention aimed to activate ICUs to undertake quality improvement initiatives by formalizing local responsibility for acting on performance feedback, and supporting them with increasing the impact of their improvement efforts. Therefore, intervention ICUs established a local, multidisciplinary quality improvement team. During one year, this team received two educational outreach visits, monthly reports to monitor performance over time, and extended, quarterly benchmark reports. Control ICUs only received four standard quarterly benchmark reports. Measurements and Results:The extent to which the intervention was implemented in daily practice varied considerably among intervention ICUs: the average monthly time investment per quality improvement team member was 4.1 hours (SD, 2.3; range, 0.6–8.1); the average number of monthly meetings per quality improvement team was 5.7 (SD, 4.5; range, 0–12). ICU length of stay did not significantly reduce after 1 year in intervention units compared with controls (hazard ratio, 1.02 [95% CI, 0.92–1.12]). Furthermore, the strategy had no statistically significant impact on any of the secondary measures (duration of mechanical ventilation, proportion of out-of-range glucose measurements, and all-cause hospital mortality). Conclusions:In the context of ICUs participating in a national registry, applying a multifaceted activating performance feedback strategy did not lead to better patient outcomes than only receiving periodical registry reports.

Process evaluation of a tailored multifaceted feedback program to improve the quality of intensive care by using quality indicators

Background In multisite trials evaluating a complex quality improvement (QI) strategy the ‘same’ intervention may be implemented and adopted in different ways. Therefore, in this study we investigated the exposure to and experiences with a multifaceted intervention aimed at improving the quality of intensive care, and explore potential explanations for why the intervention was effective or not. Methods We conducted a process evaluation investigating the effect of a multifaceted improvement intervention including establishment of a local multidisciplinary QI team, educational outreach visits and periodical indicator feedback on performance measures such as intensive care unit length of stay, mechanical ventilation duration and glucose regulation. Data were collected among participants receiving the intervention. We used standardised forms to record time investment and a questionnaire and focus group to collect data on perceived barriers and satisfaction. Results The monthly time invested per QI team member ranged from 0.6 to 8.1 h. Persistent problems were: not sharing feedback with other staff; lack of normative standards and benchmarks; inadequate case-mix adjustment; lack of knowledge on how to apply the intervention for QI; and insufficient allocated time and staff. The intervention effectively targeted the lack of trust in data quality, and was reported to motivate participants to use indicators for QI activities. Conclusions Time and resource constraints, difficulties to translate feedback into effective actions and insufficient involvement of other staff members hampered the impact of the intervention. However, our study suggests that a multifaceted feedback program stimulates clinicians to use indicators as input for QI, and is a promising first step to integrating systematic QI in daily care.

Differences in patient outcomes and chronic care management of oral anticoagulant therapy: an explorative study

BackgroundThe oral anticoagulant therapy - provided to prevent thrombosis - is known to be associated with substantial avoidable hospitalization. Improving the quality of the oral anticoagulant therapy could avoid drug related hospitalizations. Therefore, this study compared the patient outcomes between Dutch anticoagulant clinic (AC) regions taking the variation in chronic care management into account in order to explore whether chronic care management elements could improve the quality of oral anticoagulant therapy.MethodsTwo data sources were combined. The first source was a questionnaire that was send to all ACs in the Netherlands in 2008 (response = 100%) to identify the application of chronic care management elements in the AC regions. The Chronic Care Model of Wagner was used to make the concept of chronic care management operational. The second source was the report of the Dutch National Network of ACs which contains patient outcomes of the ACs.ResultsPatient outcomes achieved by the ACs were good, yet differences existed; for instance the percentage of patients in the appropriate therapeutic ranges varied from 67 to 87% between AC regions. Moreover, differences existed in the use of chronic care management elements of the chronic care model, for example 12% of the ACs had multidisciplinary meetings and 58% of the ACs had formal agreements with at least one hospital within their region. Patient outcomes were significantly associated with patient orientation and the number of specialized nurses versus doctors (p-values < 0.05). Furthermore, the overall extent to which chronic care management elements were applied was positively associated with patient outcomes (p-values < 0.05).ConclusionsSubstantial differences in the patient outcomes as well as chronic care management of oral anticoagulant therapy existed. Since our results showed a positive association between overall application of chronic care management and patient outcomes, additional research is needed to fully understand the working mechanism of chronic care management.

Needs and barriers to improve the collaboration in oral anticoagulant therapy: a qualitative study

BackgroundOral anticoagulant therapy (OAT) involves many health care disciplines. Even though collaboration between care professionals is assumed to improve the quality of OAT, very little research has been done into the practice of OAT management to arrange and manage the collaboration. This study aims to identify the problems in collaboration experienced by the care professionals involved, the solutions they proposed to improve collaboration, and the barriers they encountered to the implementation of these solutions.MethodsIn the Netherlands, intensive follow-up of OAT is provided by specialized anticoagulant clinics (ACs). Sixty-eight semi-structured face-to-face interviews were conducted with 103 professionals working at an AC. These semi-structured interviews were transcribed verbatim and analysed inductively. Wagners chronic care model (CCM) and Cabanas framework for improvement were used to categorize the results.ResultsAC professionals experienced three main bottlenecks in collaboration: lack of knowledge (mostly of other professionals), lack of consensus on OAT, and limited information exchange between professionals. They mentioned several solutions to improve collaboration, especially solutions of CCMs decision support component (i.e. education, regular meetings, and agreements and protocols). Education is considered a prerequisite for the successful implementation of other proposed solutions such as developing a multidisciplinary protocol and changing the allocation of tasks. The potential of the health care organization to improve collaboration seemed to be underestimated by professionals. They experienced several barriers to the successful implementation of the proposed solutions. Most important barriers were the lack motivation of non-AC professionals and lack of time to establish collaboration.ConclusionsThis study revealed that the collaboration in OAT is limited by a lack of knowledge, a lack of consensus, and a limited information exchange. Education was identified as the best way to improve collaboration and considered a prerequisite for a successful implementation of other proposed solutions. Hence, the implementation sequence is of importance in order to improve the collaboration successfully. First step is to establish alignment regarding collaboration with all involved professionals to encounter the lack of motivation of non-AC professionals and lack of time.