The management of people on dialysis is complex and requires a multi-disciplinary multi-professional approach. Observational studies in dialysis care have demonstrated a correlation between key clinical indicators and survival. However, achieving change in such a complex setting is difficult, with limited evidence from controlled studies of the effectiveness of interventions to improve these indicators. There is little evaluation of how best to implement and sustain known best practice into clinical care. UK renal registry data shows that whilst overall standards have improved, variation between units remains unchanged. This variation demonstrates that feedback alone is not enough to implement best practise, and that it is also necessary to understand cultural, structural, organisational and process factors. Quality Improvement (QI) is the process by which change can be implemented in systems. Methodologies vary, and highlight the need for bespoke approaches tailored to fit the clinical context. In 2010 the Salford Royal renal network introduced a two-year programme of QI to improve clinical indicators in dialysis care. Results were followed up on completion of the programme to establish whether outcomes were sustained. This thesis starts with a literature review summarising the evidence to date on modifiable factors affecting outcomes in renal replacement therapy and the rationale for addressing these factors in our chronic dialysis population, the development of QI in healthcare, and the evidence for its use to improve outcomes in renal replacement therapy. The first aim of this thesis was to analyse the outcomes of the Salford quality improvement programme. This found that the programme was successful in improving attainment of clinical indicators, and there was evidence of a reduction in hospitalisation and its associated costs. The second aim was to analyse in more detail one aspect of the programme- reduction in peritonitis. Key themes that emerged from this were the role of audit and continuous measurement, the importance of local leadership, learning from best practice elsewhere, and a patient-centred approach to reducing avoidable harm. The last question centred on the sustainability of results. Review of two years' follow up data on urea reduction ratio and bacteraemia identified that whilst not all changes to practice were sustained, both improved clinical outcomes were broadly sustained. However, additional themes emerged from the analyses, highlighting the need to embed ongoing continuous review into practice. Finally, I have described potential future work arising from this thesis.

BACKGROUND: Problem Solving for Better Health (PSBH) aims to strengthen healthcare systems through a ‘bottom up’ approach, optimizing use of existing resources to solve problems in low-resource contexts. Between November 2021 and June 2022, the Government of Lesotho sought to train about 900 nurses in PSBH (PSBHN), collaborating with the Lesotho-Boston Health Alliance. This dissertation evaluated PSBHN implementation. METHODS: A mixed-methods single group pre-test, post-test design guided by the RE-AIM framework was employed. Change in problem-solving efficacy among nurses was assessed with Problem-Solving Inventory at baseline and 3–6 months post-training. We assigned quality scores for nurses’ planned quality improvement projects at training and assessed extent of project implementation 3–6-months later. We conducted in-depth interviews with the PSBHN implementers and nurses to understand experiences with PSBHN. Costs of implementation from a limited societal perspective and scenarios for future scale-up were estimated. We used Stata17, NVivo12 and Excel16 for data analyses. RESULTS: A total of 89 of the planned 900 nurses were trained (10%). Approximately 66% of nurses achieved a medium quality score for the project designed at training; 31% scored high. At follow up, no significant change in problem solving efficacy was observed (p=0.658), but nearly 50% of nurses had initiated their projects, with a 35% increase in project initiation odds for every one-unit increase in project quality score (p<0.014). Qualitatively, coworker and manager support, along with personal drive enabled nurses. Both trainees and the implementation team reported challenges related to funding and resources, competing interests, and lack of stakeholder support. The total financial and economic implementation costs were US$36,413 and US$41,784, respectively. A four-year scale-up was estimated at US$665,142 in 2023 present value, representing 0.4% of the 2023 government’s health sector budget. Two scale-up alternatives were considered: a minimal case scenario at US$222,428 and an ambitious case scenario, US$987,897, both in 2023 present value. CONCLUSION: Implementing costs are a modest proportion of the health budget, but challenges should be addressed to improve reach, adoption, and implementation effectiveness. Efforts to improve the quality of trainees’ planned projects and address barriers faced in the workplace could strengthen PSBHN implementation in Lesotho.

ABSTRACT Background: Diabetes has become an epidemic in the United States, affecting nearly 30 million people per year (National Center for Chronic Disease Prevention and Health Promotion [NCCDPHP], 2014). Type 2 Diabetes Mellitus (T2DM) disproportionately affects Hispanics. The American Diabetes Association (ADA) has established diabetes care guidelines that focus on improving diabetes care and patient outcomes. Quality improvement (QI) efforts have been developed and proven effective at targeting specific diabetes care indicators. Problem: Wesley Health Center (WHC) has identified deficiencies in select ADA diabetes quality care indicators of ophthalmologist referral, annual foot exam, smoking cessation counseling and pneumococcal vaccines for all patients with T2DM (ADA,2015). Design: A QI project applying the Plan-Do-Study-Act (PDSA) cycle was implemented to improve the select diabetes quality care indicators of ophthalmologist referral, annual foot exam, smoking cessation counseling and pneumococcal vaccines for all patients with T2DM. Setting: WHC, a community health center located in Phoenix, Arizona, services mostly uninsured and underinsured Hispanic patients. Intervention: One PDSA cycle was carried out utilizing the fishbone diagram in an effort to identify root cause of the stated problem. The team of stakeholders identified modifications of the current electronic adult template as a key contributing factor. Workflow process changes that complemented the new modifications to the template were also made. The intervention was carried out for six (6) weeks with weekly stakeholder meetings. Expected Outcome: To improve select ADA diabetes quality care indicators for adult patients with T2DM within six (6) weeks of implementation by at least 10% from baseline. Results: Errors in data querying parameters limited data accuracy and interpretation thus the impact of the intervention was not able to be evaluated. Significance: QI interventions are important to nursing practice because they emphasize the importance of a doctorally prepared Advanced Practice Nurse (APRN) to be able to identify a problem in clinical practice and carry out a QI intervention in an effort to improve patient care and outcomes. A QI intervention provides the DNP prepared APRN an opportunity to synthesize into one project the skills and knowledge learned throughout their DNP program.

Despite the ongoing initiatives of quality improvement collaboratives in healthcare which reflect various multifaceted intervention packages, clear evidence of the effectiveness of the model itself is lacking. Little is known about the true impact of the collaborative approach on improvement outcomes or how specific components are actually implemented within participating organizations. This dissertation reports on empirical qualitative research undertaken to investigate “how” healthcare providers and management describe the experience of being involved in a collaborative network for quality improvement. Using a process evaluation of a sample QI collaborative, this research reveals that frontline staff do not feel the need to conform or be identical to their peer organizations; rather they feel that by participating with them that their high level of care is finally recognized. In addition, the existing communication structure is ineffective for staff engagement and a “QI bubble” seems to exist in terms of knowledge transfer and the idea of collaboration bears out more internally in increased intra-team cooperation than externally between organizations or units. Selected theoretical perspectives from the fields of sociology and organizational behaviour are used as an analytic framework from which the author posits that based on the findings from this case study that in fact collaboratives may not actually function by any of the commonly held assumptions of legitimization, communication and collaboration. A conceptual framework for how these constructs are related in terms of QI collaborative design is proposed for future testing. With further work and on-the-ground testing of this model and relational hypotheses, this research can help the QI community develop a more functional theory of collaborative improvement and use mixed methods evaluation to better understand complex QI implementation.

Despite the ongoing initiatives of quality improvement collaboratives in healthcare which reflect various multifaceted intervention packages, clear evidence of the effectiveness of the model itself is lacking. Little is known about the true impact of the collaborative approach on improvement outcomes or how specific components are actually implemented within participating organizations. This dissertation reports on empirical qualitative research undertaken to investigate “how” healthcare providers and management describe the experience of being involved in a collaborative network for quality improvement. Using a process evaluation of a sample QI collaborative, this research reveals that frontline staff do not feel the need to conform or be identical to their peer organizations; rather they feel that by participating with them that their high level of care is finally recognized. In addition, the existing communication structure is ineffective for staff engagement and a “QI bubble” seems to exist in terms of knowledge transfer and the idea of collaboration bears out more internally in increased intra-team cooperation than externally between organizations or units. Selected theoretical perspectives from the fields of sociology and organizational behaviour are used as an analytic framework from which the author posits that based on the findings from this case study that in fact collaboratives may not actually function by any of the commonly held assumptions of legitimization, communication and collaboration. A conceptual framework for how these constructs are related in terms of QI collaborative design is proposed for future testing. With further work and on-the-ground testing of this model and relational hypotheses, this research can help the QI community develop a more functional theory of collaborative improvement and use mixed methods evaluation to better understand complex QI implementation.

No description available.

Currently, UK healthcare is encountering an unprecedented quality crisis, especially considering the overwhelming challenge of improving patient care in the face of growing demands and limited resources. Although past efforts to adopt Total Quality Management (TQM) initiatives have failed to produce desired results, this thesis investigates the limitations of TQM applicability and explores the development of an innovative Quality Improvement model germane to a healthcare context. By integrating TQM with concepts from Corporate Social Responsibility (CSR), Complexity Theory (CT) and Knowledge Management (KM) a novel TQM conceptual framework, called EALIM—Ethical, Adaptive, Learning and Improvement Model—was devised. Using an Action Research (AR) study, EALIM was implemented within a private healthcare firm by working collaboratively with organisational members over a period of eighteen months. The study included gathering qualitative data in three AR cycles: 1) pre-implementation, 2) implementation and 3) post-implementation. The first cycle involved gathering data to form a baseline assessment of the organisation, which was used to provide feedback to top management on areas for improvement. In the second cycle, an action plan was developed with top managers and EALIM’s implementation was examined. In the third cycle, further data were gathered and findings were evaluated against the baseline assessment from the first cycle to identify the overall impact of EALIM on the organisation. Findings indicated that EALIM’s adoption generated a moral perception of the organisation, a learning culture, increased organisational commitment and an improvement in patient self-advocacy and independence. Factors that contributed to these outcomes were top management commitment, employee empowerment, the use of trans-disciplinary groups and practice-based training. However, other findings indicated that poor leadership and staff nurses’ use of managerial control created variability in service quality. These findings suggest that while EALIM can lead to organisational improvement, the commitment of all internal stakeholders is required to achieve sustainable quality patient care.

In the Kingdom of Saudi Arabia, there has not been a systematic effort to evaluate the problems of medical error and patient safety as critical issues in healthcare organizational ethics. This dissertation aims to pursue the impact of the original IOM report on this crucial topic by adopting what have been done in the American healthcare system in order to gain insight for the Saudi Arabian healthcare system. This dissertation examines the functions of continuous quality improvement in the healthcare environment of Saudi Arabia through the lens of the organization’s moral agency. This dissertation identifies several areas in Saudi healthcare organizations that are in need of improvement. As a result, this paper makes several recommendations that systematically address patient safety and medical error so that the system can be free from adverse events and medical errors. This dissertation argues that Saudi healthcare organizations have an ethical responsibility to continuously improve the system of healthcare in order to enhance patients’ safety and to reduce medical errors. This dissertation also recommends that Saudi health organizations foster a culture of safety as part of their ethical responsibility toward the customers they serve. Therefore, Saudi healthcare organizations should have an active, anonymous, and confidential reporting system; an open communication and collaboration between healthcare professionals; and create a non-punitive system. In addition, this dissertation argues in favor of patients’ involvement in the treatment process, and for having an ethics committee in Saudi healthcare organizations. / McAnulty College and Graduate School of Liberal Arts; / Health Care Ethics / PhD; / Dissertation;

Background: Electronic Health Records (EHR) are digital versions of patients' charts (HealthIT.gov, 2013). The government has incentivized current use to allow all healthcare organizations to progress from paper charting. Goals of EHR adoption include improving workflow, documentation, and to improve the quality of care being provided (Weiner, Fowles, & Chan, 2012). Objective: The purpose of this DNP project was to conduct a readiness assessment of the asthma and allergy specialty organization's staff members to identify perceived barriers and advantages of adopting an EHR. Design: This project was guided by the Institute for Healthcare Improvement (IHI) Model for Improvement (Institute for Healthcare Improvement [IHI], 2016). This model was incorporated with the PDSA cycle and DOQ-IT EHR Implementation Roadmap. Descriptive statistics were used for data analysis. Setting: Allergy and asthma specialty practice consisting of 12 clinics within the Denver Metro and Northern Colorado area. Participants: 155 members of the organization including physicians, nurse practitioners, physician assistants, nurses, medical assistants, front office and administrative staff. Measurements: 60 out of 155 staff members completed the readiness assessment survey from HealthInsight (HealthInsight, n.d.).Results: A response rate of 38.7% (n=60) of participants completed the readiness assessment survey. The top two barriers were medical records being unavailable (n= 48, 80%) and the inability to read what is written in the medical record (n= 51, 85%). The top barrier for adopting EHR is having the system freeze or crash (n=36, 65%), followed by, 22 participants or 40% stating EHR is depersonalizing in an exam room. The highest advantage identified was the reduction in paper-based medical charting and filing (n=56, 93%). The second highest advantage was more timely access to patient records (n=55, 92%).Conclusion: Perceived barriers and advantages for EHR adoption within the organization are similar to what literature has currently identified. The information gained from this study will provide a better understanding of the decision and adoption process. The information will help the organization decide whether or not to adopt EHR and how to successfully move through the DOQ-IT EHR Implementation Roadmap, IHI Model for Improvement and PDSA cycle.

Thesis (M.A.) / Boston Medical Center’s pediatric outpatient clinic has resident clinic flow problems that negatively affect its patient care level. Due to system backup, in August 2012, resident patients spent an average of 71 minutes in the clinic for a scheduled 20-minute appointment. This study used quality improvement methodology (QI) to investigate potential solutions to the clinic flow problems. Our aim was, by May 2013 decrease the average patient time-in-clinic for resident vaccination patients between 2 and 30 months of age by 20%. Using Plan-Do-Study-Act (PDSA) cycles within QI, the research team implemented three interventions between August 2012 and May 2013 that focused on improving communication between members of the clinic medical team. Throughout the year, the research team measured the time-in-clinic for the patient population, plotted the data with run charts, and determined if the interventions resulted in a corresponding decrease in time. By May 2013, the interventions resulted in an average decrease in time across all resident classes. First years showed a 4.5% decrease. Second years showed a 5.7% decrease. Third years showed a 20% decrease. While these decreases are significant, due to time limitations, we could not determine if the interventions resulted in a lasting improvement to clinic flow. / 2031-01-01