Systematic quality improvement in healthcare: clinical performance measurement and registry-based feedback

The work in this thesis showed that some aspects of care quality cannot be fully captured by one measure, that the positive impact of registry-based feedback on clinical performance is not self-evident, and that it is difficult to build a strong evidence base on how this impact can be increased. Yet, based on our work, we can also conclude that it is feasible to validly measure part of a complex concept like patient experience, and that extending a registry-based feedback strategy can motivate and support clinicians to systematically improve their practice. These promising results merit further investigation on how to apply these tools more effectively, so that clinical performance measurement and feedback can become reliable approaches to improve the quality of healthcare

A multifaceted feedback strategy alone does not improve the adherence to organizational guideline-based standards: a cluster randomized trial in intensive care

Contains fulltext : 155179.pdf (publisher's version ) (Open Access)BACKGROUND: Organizational data such as bed occupancy rate and nurse-to-patient ratio are related to clinical outcomes and to the efficient use of intensive care unit (ICU) resources. Standards for these performance indicators are provided in guidelines. We studied the effects of a multifaceted feedback strategy to improve the adherence to these standards. METHODS: In a cluster randomized controlled study design the intervention ICUs received extensive monthly feedback reports, they received outreach visits and initiated a quality improvement team. The control ICUs received limited quarterly feedback reports only. We collected primary data prospectively within the setting of a Dutch national ICU registry over a 14-month study period. The target indicators were bed occupancy rate (aiming at 80 % or below) and nurse-to-patient ratio (aiming at 0.5 or higher). Data were collected per 8-h nursing shift. Logistic regression analysis was performed. For both study end points, the odds ratios (OR) for improvements at follow-up versus at baseline were calculated separately for control and intervention ICUs. RESULTS: We analyzed data on 67,237 nursing shifts. The bed occupancy rate did not improve in the intervention group compared to baseline (adjusted OR 0.88; 95 % confidence interval (CI), 0.62-1.27) or compared to control group (OR 0.67; 95 % CI 0.39-1.15). The nurse-to-patient ratio did not improve (OR 0.72; 95 % CI 0.41-1.26 compared to baseline and OR 0.65; 95 % CI 0.35-1.19 compared to control group). CONCLUSIONS: A multifaceted feedback intervention did not improve the adherence to guideline-based standards on the organizational issues bed occupancy rate and nurse-to-patient ratio in the ICU. The reasons may be a limited confidence in data quality, the lack of practical tools for improvement, and the relatively short follow-up. TRIAL REGISTRATION: ISRCTN: ISRCTN50542146

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

Item does not contain fulltextBACKGROUND: 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

Patient activation and its association with symptom burden and quality of life across the spectrum of chronic kidney disease stages in England.

Background The knowledge, skills, and confidence to manage one’s own health is termed patient activation and can be assessed using the Patient Activation Measure (PAM). This measure is increasingly recommended for use in chronic kidney disease (CKD), but there is a need to better understand patient activation within this population. This work aimed to explore the association of PAM with patient-reported outcomes, namely symptom burden and health-related quality of life (HRQoL), to understand the relationship between patient activation and outcomes which are of importance to people with CKD. Methods Non-dialysis, dialysis, and kidney transplant patients from 14 renal units across England completed a survey comprising questionnaires assessing patient activation, symptom burden, and HRQoL. Latent class analysis (LCA) was used to determine HRQoL and symptom burden subgroups in the data. Multinomial logistic regression analyses were performed to investigate the associations between patient activation and symptom burden and HRQoL classes separately, adjusting for age, gender, ethnicity, deprivation and treatment modality. Results Three thousand thirteen participants (mean age 61.5 years, 61.8% males, and 47% haemodialysis) were included in the analysis. Patient activation was strongly associated with both the HRQoL and symptom burden classes identified, with highly activated patients more likely to report higher HRQoL (P = < 0.0001; OR 29.2, 95% CI 19.5–43.9) and fewer symptoms (P = < 0.0001; OR 25.9, 95% CI 16.8–40.2). Conclusion Lower activation levels are associated with a higher symptom burden and reduced HRQoL across the trajectory of CKD stages and treatment modalities. Therefore, targeted and holistic self-management support focussing on improving activation may have the potential to improve aspects of health experience which are valued by individuals living with kidney disease

Barriers to implementing a fistula-first policy in Europe

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