Incorporating Quality Improvement Projects Into Stroke Care and Research
2022; Lippincott Williams & Wilkins; Volume: 53; Issue: 3 Linguagem: Inglês
10.1161/strokeaha.121.038204
ISSN1524-4628
AutoresMadalena Rosário, Ana Catarina Fonseca,
Tópico(s)Health Systems, Economic Evaluations, Quality of Life
ResumoHomeStrokeVol. 53, No. 3Incorporating Quality Improvement Projects Into Stroke Care and Research Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessResearch ArticlePDF/EPUBIncorporating Quality Improvement Projects Into Stroke Care and Research Madalena Rosário, MD and Ana Catarina Fonseca, MD, PhD Madalena RosárioMadalena Rosário https://orcid.org/0000-0001-7387-7186 Department of Neurology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal (M.R., A.C.F.). and Ana Catarina FonsecaAna Catarina Fonseca Correspondence to: Ana Catarina Fonseca, MD, PhD, Department of Neurology, Hospital de Santa Maria Avenida Professor Egas Moniz, 1640-035 Lisboa, Portugal. Email E-mail Address: [email protected] https://orcid.org/0000-0001-6913-5526 Department of Neurology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal (M.R., A.C.F.). Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal (A.C.F.). Originally published9 Feb 2022https://doi.org/10.1161/STROKEAHA.121.038204Stroke. 2022;53:e118–e121Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: February 9, 2022: Ahead of Print In all areas of medicine including in stroke, we strive towards continuously improving work methods and the quality of care that is delivered to our patients. Following this principle, quality improvement (QI) projects have become increasingly important. QI can be defined as the design, development, and evaluation of complex interventions aimed at the redesign of health care systems to produce improved process control measures and outcomes.1 Quality of care may refer to safety, effectiveness, patient centeredness, efficiency, equity of care, or timeliness.QI studies are a specific type of research with a particular methodology. They aim to improve performance and consequentially the quality of care. QI draws its evidence from many different disciplines including research on manufacturing and air traffic control as well as evidence-based medicine.Scientific societies like the American Heart Association and American Stroke association produce guideline recommendations for the treatment of patients with stroke/transient ischemic attack, taking into account scientific evidence. These establish what is the best medical care for stroke/transient ischemic attack patients at a given moment. One way how QI studies can be used is to operationalize guideline recommendations for use in clinical practice. They may be performed to evaluate and to modulate the gap between evidence-based medicine and clinical practice. Evidence shows that time to treatment is a key point to improve the outcome of patients with stroke submitted to revascularization procedures. A QI study could be performed in a given stroke center to evaluate the current door-to-needle time and to define and test an intervention to improve these time points.We aim to describe what QI studies are, to provide a general outline of their design and implementation steps, describe what are quality indicators and to provide examples of their application in the stroke field.What Are QI Studies?QI studies are typically focused on a well-defined problem happening at a local scale and shaped to account for internal attitudes and practices, addressing knowledge-action gaps in a determined environment. Their particular methodology is based on an iterative dynamic process in which the results of an intervention are quickly analyzed that way adjusting the primary hypothesis to maximize outcomes (Figure). This makes it possible to identify what works in a local context, allowing interventions that do not work to be discarded, and enabling those that appear promising to be optimized and customized.2,3Download figureDownload PowerPointFigure. Model for improvement. The left wheel includes the 3 main questions: (1) What are we trying to accomplish? (2) How will we know if a change is an improvement? (3) What changes can we make that will result in improvement?QI studies are one of the tools that are available to produce change in health care. Other approaches include clinical audit, service evaluation, clinical transformation, and research. QI studies are closely related to clinical audit, which can be the first step in a QI process. Audits may be used to determine where a QI intervention may be needed. Clinical audits are a form of quality assurance. Quality assurance is defined as all the planned and systematic activities implemented in a quality system so that quality requirements for a product or service will be fulfilled.4 Clinical audit can be done to identify improvement opportunities at a given time and setting or can be used during the iterative testing phase, to evaluate the impact of an intervention that is being tested. When compared with QI studies, clinical audits are more often clinically orientated and have a more formal standard to measure against. Clinical audits focus mainly on data collection and analysis without a well-developed approach to the action section, making it less likely to produce changes in practice while QI refer to the techniques that are used by organizations to obtain continuous QI.The terms quality assurance and quality control are usually used interchangeably, however, there are differences. Quality control are observation techniques and activities used to fulfill requirements for quality.4 Quality control is measured internally by those that perform the work.What Is the Typical Outline of a QI Study?A variety of methodologies for QI have been developed. The model for improvement derived from the Institute for Healthcare Improvement is divided in 2 parts.3 Initially, 3 fundamental questions that help the team delineate the QI study should be asked. The problem being addressed should be chosen as well as the target population and timeframes for accomplishment of the study. Improving quality and safety in a particular area of health care frequently involves a project lasting a few months at least. It is also necessary to identify which quality indicators will be measured. Changes in these indicators will reflect the absence or presence of improvement. Knowing which change is necessary may result from a literature review or from feedback given by key stakeholders. Outreach visits and audit-feedback are examples of interventions/strategies that can be used to improve care.Planning what is the problem to be studied and how to address it can be done by using the SMART criteria. The aim of the study should be specific, measurable, achievable, realistic, and timely.5The second part of the model consists of a Plan-Do-Study-Act cycle. The planned changes should be tested in a real work setting. The results need to be observed to understand how outcomes can be improved.Several Plan-Do-Study-Act cycles may be required to detect or sustain QI. This pragmatic scientific method enables a rapid assessment and provides flexibility to adapt the changes according to feedback to ensure fit-for-purpose solutions are developed. The efficacy of specific QI interventions can be tested through randomized clinical trials or quasi-experimental including time-series and before-and-after analysis. Randomized clinical trials which frequently use a cluster design provide the highest level of evidence. Quasi-experimental designs being observational studies are subjected to a high risk of bias that can be minimized during study design.6The QASC study (Quality in Acute Stroke Care) is an example of a single-blind cluster randomized clinical trial in Australia that evaluated an intervention. Intervention clusters received treatment protocols to manage fever, hyperglycemia, and swallowing dysfunction with multidisciplinary team building workshops to address implementation barriers. Controls received only an abridged version of existing guidelines. This trial showed that implementation of multidisciplinary supported evidence-based protocols initiated by nurses delivered better patient outcomes after discharge from stroke units.7QI can use several tools to assist data analysis. Data collection system are computer applications that may help to facilitate data capture. Cause and effect and key driver diagrams can help to understand the possible reasons for a specific issue. Control charts may help to map variations on the established outcome over time.8 Two types of variations can be detected: special cause and common cause variation. Common cause variation is present when the chart of a process measure shows a random pattern of variation within the control limits. Special cause variation occurs when plotted points appear outside the control limits or have a nonrandom pattern of variation. Special cause variation should trigger an intervention.How Can You Implement a QI Study?Choosing the right problem to address is important, as it will stimulate the entire organization dealing daily with it. Listening to the staff's opinion as well as other important stakeholders will help to understand the real issues and motivate them to participate in the project. The problem to address may be a gap in quality care in a determined location. This gap frequently results from a difference between evidence and clinical care practice.Choosing the team that will participate is also a key point. It is important to assemble team members directly involved in the problem at hand. Ideally, the team should be diversified in function and incorporate members with experience in QI studies. Communication and engagement with stakeholders as well as ensuring adequate resources are important determinants of a successful QI study, QI studies take place in a real world setting which can correspond to a hospital, ward or general practice.Once the intervention is developed an iterative process begins, results will progressively appear. Complex, multicomponent interventions may be used. Results may allow to define an intervention to solve the primary problem. It is important to communicate improvements not just inside the organization/unit but also to the primary agents benefiting from this initiative to provide accountability for what is being shared.It may be necessary to periodically monitor the implemented changes in a continuous cycle, adjusting for new conditions or upcoming problems.3 An important element of improvement is continuous modification in response to the feedback received from outcomes analysis.What Type of Measures/Outcomes Can Be Used in QI Studies?Quality indicators are used in health care to measure, compare and improve quality of care. They are defined as measurable items referring to structures, process and outcomes of care.9Quality indicators should be relevant to the selected problem and field of application, reliable, and feasible. They also need to be easily understandable for providers and patients, changeable by behavior, achievable, and measurable with high validity.Implementation of quality indicators is a complex process that requires a scientific approach as well as testing and verification before their routine usage.10 Quality indicators can be defined taking into account scientific concept, own experience, results of literature search, discussion with experts, or using a Delphi method.10Quality indicators frequently use clinical practice guideline recommendation statements and research to generate a measurable action that a provider may perform. Examples of QI indicators of process that that can be used in the stroke field are door-to-needle time, antithrombotic medication prescribed within 48 hours of admission or deep venous thrombosis prophylaxis. Examples of outcomes of care include measurements of morbidity or mortality. Costs, service utilization or staff/patients' satisfaction are other possible indicators.How to Report a QI Study?There are guidelines for the report of QI studies. These are the Standards for QI Reporting Excellence guidelines. These are equivalents to CONSORT ([Consolidated Standards of Reporting Trials] randomized trials) and PRISMA ([Preferred Reporting Items for Systematic Reviews and Meta-Analyses] systematic reviews), but are designed for QI studies.Many health care institutions have processes for registering and tracking QI initiatives.QI Studies in StrokeQI studies can be performed at a local level, regionally, nationwide, or worldwide.Examples of QI studies that are currently being performed nationwide include the Get With The Guidelines study. It is a hospital-based QI initiative created by the American Stroke Association and American Heart Association to improve the care of patients with cardiac disease and stroke.The Angels Initiative that was implemented in 2016 is another example of a quality improvement initiative that has helped to improve the quality of care that patients with stroke receive worldwide. At a local level, a QI study could be implemented in a hospital, for example, to improve the detection and management of patients with acute stroke among hospitalized patients. In this case, interventions like staff education or establishment of a code stroke could be implemented. Quality indicators could be defined as the rate of hospitalized patients that receive intravenous thrombolysis for acute ischemic stroke before and after the intervention as well as the time to needle time.How Might New Technologies Influence QI Studies?In the future new technologies may help to improve QI studies by providing timely and reliable access to data namely data related to performance. Also, artificial intelligence methods like machine learning and deep learning methods may help to analyze the data collected through QI studies.ConclusionsThe ultimate goal of QI studies associated to stroke is to improve acute stroke services and, therefore, the quality of care that is provided to patients with stroke and transient ischemic attack. This meaningful and effective work is essential to ensure safety and quality of care. Increased publications of QI studies will help to strengthen the evidence for health care improvement.Article InformationSources of FundingNone.DisclosuresNone.Nonstandard Abbreviations and AcronymsQASCQuality in Acute Stroke CareQIquality improvementFootnotesFor Sources of Funding and Disclosures, see page e121.Correspondence to: Ana Catarina Fonseca, MD, PhD, Department of Neurology, Hospital de Santa Maria Avenida Professor Egas Moniz, 1640-035 Lisboa, Portugal. Email [email protected]ulisboa.ptReferences1. Toulany A, McQuillan R, Thull-Freedman J, Margolis P. Quasi-experimental designs for quality improvement research.Implement Sci2013; 8:S3.Google Scholar2. Portela M, Provonost P, Woodcock T, Carter P, Dixon-Woods M. How to study improvement interventions: a brief overview of possible study types.BMJ Qual Saf2015; 24:325–336. doi: 10.1136/bmjqs-2014-003620CrossrefMedlineGoogle Scholar3. Berman L, Raval MV, Goldin A. 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Quality indicators: a tool for quality monitoring and improvement.ISBT Science Series. 2012; 7:24–28. doi: 10.1111/j.1751-2824.2012.01584.xGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails March 2022Vol 53, Issue 3Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.121.038204PMID: 35135324 Originally publishedFebruary 9, 2022 Keywordsefficiencyresearchmedicinestrokesafetyquality improvementPDF download Advertisement SubjectsCerebrovascular Disease/StrokeQuality and Outcomes
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