Engaging in quality improvement (QI) activities can help local and state health departments improve current processes, develop more effective new processes, increase leadership capacity, and prepare for public health accreditation. Public health organizations that have implemented QI processes have seen improvements in health outcome indicators, delivery of the 10 essential services, patient satisfaction, and performance management. Quality improvement is the foundation of the Public Health Accreditation Board‟s (PHAB) program and further pushes health departments, at both the local and state level, to adopt QI activities within their organizations. There are numerous potential benefits associated with accreditation in public health, one of the most important being that accreditation sets a benchmark for public health agencies. It also helps create a platform of continuous quality improvement that should increase efficiency, decrease waste, and improve health outcomes. The purpose of this study was to determine the current status of QI processes in a sample of regional and metro health departments across the state of Tennessee and to assess whether those health departments with a formal QI process demonstrate an increased readiness for public health accreditation compared to those without a formal QI process in place. A survey tool aimed at assessing QI processes and efforts within health departments including the organization‟s: 1) QI culture, 2) QI capacity and competency, 3) QI alignment and spread, and 4) readiness for public health accreditation was used. In addition to the survey tool, respondents were also asked about types of QI processes used within their health department and their associated outcomes. Initial results revealed that the majority of respondents reported high levels of QI maturity in their respective health department sites. However, further analysis of qualitative data indicated that most sites were engaged in quality assurance (QA) practices rather than true QI processes and activities. Overall, study results indicate that further training in QI practices is needed in order to enhance performance and align with PHAB standards. The results from this study could be used to help gauge QI processes and accreditation readiness at appropriate intervals following training and education.

Postpartum depression (PPD) is a mood disorder affecting approximately 20% of women within 6 months of delivery. Untreated PPD diminishes a woman's functioning and may result in short and long-term consequences for her infant. Screening with evidence-based tools can identify prenatal and postpartum women at risk for PPD, ensure early treatment, and limit adverse maternal and infant effects. Using Rosswurm and Larrabee's evidence-based practice model, a multidisciplinary team of 7 key stakeholders, including directors and a nurse from the departments of OB/GYN, Pediatrics, and Primary Care, a psychiatrist specializing in women's health, and a member of nursing leadership, formed to guide the project. The purpose of the project was to develop a quality improvement initiative to promote antenatal and postnatal screening for PPD in the practice setting that lacked an evidence-based tool. As a federally qualified health center, the practice setting serves an ethnically and racially diverse population, particularly at risk for PPD. Project team members evaluated and graded current literature using the Johns Hopkins Evidence-Based Practice Rating Scale. The Edinburgh Postnatal Depression Scale (EPDS) was introduced and a policy and procedure developed to guide PPD screening. A formative evaluation of the policy and procedure using the AGREE instrument validated development. Project team members strongly agreed to use the EPDS as a PPD screening tool in the clinic population. A summative evaluation supported DNP student leadership of the project. The project has increased awareness of PPD and screening in the practice setting and, focused on improvements in the lives of women, infants, and their families.

This thesis explored healthcare quality improvement, considering the general question of why the last decade's worth of quality improvement (QI) had not significantly improved quality and safety. The broad objective of the thesis was to explore how hospitals perform when completing QI projects and whether any organizational characteristics were associated with that performance. First the project evaluated a specific QI collaborative undertaken in the Veterans Affairs (VA) healthcare system. The goal of the collaborative was to improve patient flow throughout the entire care process leading to shorter hospital length of stay (LOS) and an increased percentage of patients discharged before noon. These two goals became the primary outcomes of the analysis, which were balanced by three secondary quality check outcomes: 30-day readmission, in-hospital mortality, and 30-day mortality. The analytic model consisted of a five-year interrupted time-series examining baseline performance (two-years prior to the intervention), the year during the QI collaborative, and then two-years after the intervention to determine how well improvements were maintained post intervention. The results of these models were then used to create a novel 4-level classification model. Overall, the analysis indicated a significant amount of variation in performance; however, sub-group analyses could not identify any patterns among hospitals falling into specific performance categories. Given this potentially meaningful variation, the second half of the thesis worked to understand whether specific organizational characteristics provided support or acted as key barriers to QI efforts. The first step in this process involved developing an analytic model to describe how various categories of organizational characteristics interacted to create an environment that modified a QI collaborative to produce measureable outcomes. This framework was then tested using a collection of variables extracted from two surveys, the categorized hospital performance from part one, and data mining decision trees. Although the results did not identify any strong associations between QI performance and organizational characteristics it generated a number of interesting hypotheses and some mild support for the developed conceptual model. Overall, this thesis generated more questions than it answered. Despite this feature, it made three key contributions to the field of healthcare QI. First, this thesis represents the most thorough comparative analysis of hospital performance on QI and was able to identify four unique hospital performance categories. Second, the developed conceptual model represents a comprehensive approach for considering how organizational characteristics modify a standardized QI initiative. Third, data mining was introduced to the field as a useful tool for analyzing large datasets and developing important hypotheses for future studies.

Background: Low back pain (LBP) and low back related disorders are highly prevalent and associated with a considerable burden of pain, disability and work loss. People with a variety of low back-related complaints comprise a large proportion of referrals made to orthopedic surgeons and many of these patients are not considered to be surgical candidates or have not maximized their non-surgical options for managing their low back-related complaints. Objectives: We sought to evaluate the impact of a triage assessment program delivered by physiotherapists using a variety of approaches. Informed by a biopsychosocial model, the objectives of this dissertation were: 1) To determine the short term impact of a physiotherapy triage assessment for people with low back-related disorders on participant self-reported pain, function and quality of life and patient and referring practitioner satisfaction. 2) To determine which demographic, clinical, psychosocial and environmental factors are predictive of improved self-reported pain, function, quality of life and participant and referring practitioner satisfaction. 3) To determine the diagnostic and treatment recommendation concordance between physiotherapists and orthopaedic surgeons, using a newly developed clinical classification tool, for people presenting to a spinal triage assessment service with low back complaints. Methods: Two approaches were used to achieve the aforementioned objectives: a prospective observational study (n=115) to address the first two objectives and a sub-group reliability study (n=45) to address the third objective. Results: There was a mean overall significant improvement in the SF-36 Physical Component Summary at the 4-6 week post-test time point and relatively high satisfaction reported by participants and referring care providers. Qualitative analysis of comments revealed a variety of positive, negative and other contextual factors that may impact outcomes. A variety of different sociodemographic, psychological, clinical and other variables were associated with success or improvement in each respective outcome. There may be a potential mechanism of reassurance that occurs during the spinal triage assessment process as those with higher psychological distress were more likely to improve on certain outcomes. There was high diagnostic concordance between physiotherapists and an orthopaedic surgeon; however, there were more differences in management recommendations between the surgeon and a solo physiotherapist versus physiotherapists working in a collaborative team. Conclusions: A spinal triage assessment program delivered by physiotherapists has the potential to positively impact a variety of patient-related short term outcomes including satisfaction. Further study is needed to examine longer-term outcomes and which biopsychosocial factors may impact these outcomes.

Thesis (Ed. D.)--University of Missouri-Columbia, 2003. / Typescript. Vita. Includes bibliographical references (leaves 247-260). Also available on the Internet.

Thesis (Ed. D.)--University of Missouri-Columbia, 2003. / Typescript. Vita. Includes bibliographical references (leaves 247-260). Also available on the Internet.

Background: Elevated blood glucose in patients undergoing cardiac surgery pose increased risks of sternal incision infections, kidney disease, irregular heartbeats, extended hospital stays, and death. Elevated blood glucose also increases the costs of healthcare from prolonged lengths of stay and increased complications. The Surgical Care Improvement Project (SCIP) #4 performance measure is used to evaluate achievement of a target blood glucose control < 200 milligram/deciliter (mg/dl) post cardiac surgery on postoperative days 1 and 2. In the institution where this study was carried out, blood sugar control in the cardiac surgery patient has presented a challenge. Purpose: The purpose of this practice inquiry was to identify patient characteristics and outcomes in cardiac surgery patients who met the SCIP #4 performance measure versus those patients who did not. Methods: A retrospective nested case-control design was used. Risk factors for postoperative hyperglycemia and in-hospital outcomes were compared between cardiac surgery patients who were SCIP #4 met defined as 6AM BG ≤ 200 mg/dl on postoperative days 1 and 2 and those that were SCIP #4 not met, defined as 6AM BG > 200 mg/dl on postoperative days 1 or 2. Results: Results from this study showed that preoperative hemoglobin AIC and history of diabetes were two major contributors for SCIP #4 not-met status. There was a trend towards a longer length of stay in the SCIP #4 not met group as compared to the met group (9.01 ± 7.33 versus 7.30 ± 4.93 days, respectively; p = . 096). Mortality was 3 times more prevalent in the SCIP #4 not met than the met group (6.2% versus 2.1%, respectively); however, this different did not reach statistical significance (p = .129). Renal failure was four-fold more frequent in patients who were SCIP #4 not-met than who were SCIP #4 met (13.6% vs. 4.1%, respectively; p = 0.003). Conclusions: Results from this study showed that SCIP #4 not met is associated with development of postoperative renal failure in the hospital and a trend towards longer length of stay. History of diabetes and preoperative hemoglobin AIC level should be taken into consideration when evaluating strategies for managing hyperglycemia. Future research is needed to study the relationship between SCIP #4 met status and long-term outcomes. The use of preoperative hemoglobin A1C to identify patients at high risk for uncontrolled postoperative glucose and plan effective glucose control should be studied. Such study may include implementing intravenous insulin on all patients with diabetes and elevated hemoglobin A1C levels and comparing the short and long term outcomes.

No description available.

In this study, a tool is developed for determining priorities of quality improvement activities for manufacturing operations, for the purposes of both quality and throughput improvement. This tool utilizes Quality Function Deployment (QFD), Theory of Constraints (TOC), Statistical Process Control (SPC) and Failure Mode and Effects Analysis (FMEA) methodologies. The use of the tool is demonstrated on an example problem. The results obtained under different experimental conditions are compared with solutions of more popular, simple decision-making measures, and the optimal solutions obtained from a mathematical model. The analysis shows that the proposed tool gives close solutions to optimal, and it can easily be applied in a typical manufacturing setting. This study also demonstrates how various different methodologies can be integrated for the purposes of quality and throughput improvement in shorter times.

Background Syncope accounts for 0.6% to 1.5% of hospitalizations in the United States. We sought to determine the causes and predictors of 30‐day readmission in patients with syncope. Methods and Results We identified 323 250 encounters with a primary diagnosis of syncope/collapse in the 2013-2014 Nationwide Readmissions Database. We excluded patients younger than 18 years, those discharged in December, those who died during hospitalization, hospital transfers, and those whose length of stay was missing. We used multivariable logistic regression analysis to evaluate the association between baseline characteristics and 30‐day readmission. A total of 282 311 syncope admissions were included. The median age was 72 years (interquartile range, 58-83), 53.9% were women, and 9.3% had 30‐day readmission. The most common cause of 30‐day readmissions was syncope/collapse, followed by cardiac, neurological, and infectious causes. Characteristics associated with 30‐day readmissions were age 65 years and older (odds ratio [OR], 0.7; 95% confidence interval [CI], 0.6-0.7), female sex (OR, 0.9; 95% CI, 0.8-0.9), congestive heart failure (OR, 1.5; 95% CI, 1.2-1.9), atrial fibrillation/flutter (OR, 1.3; 95% CI, 1.3-1.4), diabetes mellitus (OR, 1.2; 95% CI, 1.2-1.3), coronary artery disease (OR, 1.2; 95% CI, 1.2-1.3), anemia (OR, 1.4; 95% CI, 1.4-1.5), chronic obstructive pulmonary disease (OR, 1.4; 95% CI, 1.3-1.4), home with home healthcare disposition (OR, 1.5; 95% CI, 1.5-1.6), leaving against medical advice (OR, 1.7; 95% CI, 1.6-1.9), length of stay of 3 to 5 days (OR, 1.5; 95% CI, 1.4-1.6) or >5 days (OR, 2; 95% CI, 1.8-2), and having private insurance (OR, 0.6; 95% CI, 0.6-0.7). Conclusions The 30‐day readmission rate after syncope/collapse was 9.3%. We identified causes and risk factors associated with readmission. Future prospective studies are needed to derive risk‐stratification models to reduce the high burden of readmissions. / Revisión por pares