Becker's Clinical Quality & Infection Control

15 Quality Improvement I n a blog post for Johns Hopkins' Arm- strong Institute, health services researcher Jill Marsteller, PhD, outlined steps that care teams can take to plan for success when design- ing quality improvement projects in order to bet- ter understand why an idea succeeds or falls short and how to effectively repeat it. "Care teams often come up with innovative ideas to prevent local harms, only to realize after some encouraging results that their intervention is something that might be spread beyond their walls," Ms. Marsteller writes. "Yet too often, weak study designs can make it hard to know why it worked, if it worked at all. The flaws can come in a number of forms, such as neglecting to consider and measure key variables, introducing too many interventions at once, and failing to collect suffi- cient data." Here are the five steps outlined by Ms. Marsteller to guide project design from the beginning, rather than as an afterthought. 1. Identify a conceptual framework. The framework should describe the system you hope to improve and take into consideration all of the factors that might influence your success. 2. Create a map of the process you aim to improve. Trace all of the steps required to make the goal outlined in the conceptual frame- work come to fruition. Be sure to consider the pre- existing characteristics of the system you hope to change. Review the current systems that may make the task easier or more difficult. 3. Match interventions to variables. Make sure the ideas for interventions are designed to directly meet the variables and potential issues that may arise. This can be done through inter- ventions over time, where incremental changes can be measured to determine the effective- ness of a variable, or the interventions can be enacted simultaneously in controlled segments within a system. 4. Don't just measure the main outcomes. Keep in mind to not only measure the success of the primary objectives, but to gather as much data as possible across the board. 5. Get assistance from a team. Involving the employees, whether administrators, physicians or frontline staff members, who will be affected by the design from the beginning, is critical. Teams can help with measurement, and those directly working with the variables and interventions be- ing tested know better than anyone the existing workflows and barriers to improvement. "Even if you don't plan to publish your results in an academic journal or seek a grant to spread your success across many hospitals or clinics," she writes, "developing your conceptual framework and measurement plan from the start can help you to avoid second-guessing. And if you do choose to share your success with the world — or the unit down the hall — you will have a better sense of what worked and why." n Don't Wait for Chance: 5 Steps to Purposefully Make Innovative Ideas Work By Max Green 'More Hands on Deck, More Often' may not Improve Quality of Care, Study Suggests By Max Green R esearchers from the Penn State Hershey (Pa.) Medical Center re- ported that the implementation of on-site overnight supervision from attending-level physicians has had no significant impact on clinical outcomes. The study, published in the Journal of General Internal Medicine, was the first to look at the impact of overnight academic hospitalist programs, which have been implemented by many hospitals in response to concerns for patient safety and quality of care. The researchers, led by Jed Gonzalo, MD, associate dean for health systems education at Penn State College of Medicine in Hershey, evaluated the effect of one such program established in September 2012. In order to compare outcomes from before and after, they analyzed patient records from April 2001 through May 2014 — 42 percent of patients were admitted before the OAH program began, and 58 percent were admitted after. The in-hospital mortality rate decreased from 1.1 percent prior to the intervention to 0.9 percent following the implementation of the pro- gram. The 0.2 percent difference is not considered statistically signifi- cant. "Given that regulatory bodies are pushing toward on-site house staff supervision, the medical education community needs to think about how to continue to allow autonomy for residents," Dr. Gonzalo said in statement. "For years, residents were on their own at night — they had to make decisions on their feet, because the buck stopped with them. Newer models of care at night have the potential to strip away resi- dency autonomy because they can lean on the attending now. How- ever, the other view is 'the more eyes, the better.' So it's a challenge we need to think more about to balance education and ideal patient outcomes." n

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