Quality Initiative to Reduce Extrauterine Growth Restriction in Very Low Birth Weight Infants

BACKGROUND: We report a statewide quality improvement initiative aimed to decrease the incidence of extrauterine growth restriction among very low birth weight infants cared for in Tennessee NICUs. METHODS: The cohort consisted of infants born appropriate for gestational age between May 2016 and December 2018 from 9 NICUs across Tennessee. The infants were 23 to 32 weeks gestation and 500 to 1499 g birth weight. The process measures were the hours of life (HOL) when parenteral protein and intravenous lipid emulsion were initiated, the number of days to first enteral feeding, and attainment of full enteral caloric intake (110–130 kcal/kg per day). The primary outcome was extrauterine growth restriction, defined as weight <10th percentile for weight at 36 weeks postmenstrual age. Statistical process control charts and the Shewhart control rules were used to find special cause variation. RESULTS: Although special cause variation was not indicated in the primary outcome measure, it was indicated for the reduction in specific process measures: HOL when parenteral protein was initiated, HOL when intravenous lipid emulsion was initiated, and the number of days to attainment of full enteral caloric intake (among the hospitals considered regional perinatal centers). CONCLUSIONS: A statewide quality improvement initiative led to earlier initiation of parenteral and enteral nutrition and improved awareness of the importance of postnatal nutrition.

Efficiency and productivity of the Brazilian banks: A new approach based on two-stage network DEA

This article creates a conceptual model, called a network system, to represent the Brazilian banking production system, based on its internal operational processes. The first, called the intermediation process, measures a bank's efficiency in extending loans from its available resources. The second, called the revenue process, measures a bank's efficiency in earning profit, mainly from loans granted. We adopt a two-stage DEA model. In the first stage, a relational network DEA model measures both the network system efficiency scores and internal processes. This technique, associated with the Malmquist Index, assesses performance changes over time. In the second stage, these efficiency scores are considered dependent variables, such that Tobit models can determine how the Brazilian credit market's characteristics can explain the network system and internal processes' efficiency. Results show not only a growing trend toward greater efficiency in the revenue process, but also an increase in productivity accompanied by a decline in the intermediation process technology. Given the high banking spreads in Brazil, these results indicate deterioration in the quality of the credit portfolio and the prospect of future insolvency. We discuss implications of this scenario for domestic banks and collateral policy.

Impact of Statewide Prevention and Reduction of Clostridioides difficile (SPARC), a Maryland public health–academic collaborative: an evaluation of a quality improvement intervention

To evaluate changes in Clostridioides difficile incidence rates for Maryland hospitals that participated in the Statewide Prevention and Reduction of C. difficile (SPARC) collaborative. Pre-post, difference-in-difference analysis of non-randomised intervention using four quarters of preintervention and six quarters of postintervention National Healthcare Safety Network data for SPARC hospitals (April 2017 to March 2020) and 10 quarters for control hospitals (October 2017 to March 2020). Mixed-effects negative binomial models were used to assess changes over time. Process evaluation using hospital intervention implementation plans, assessments and interviews with staff at eight SPARC hospitals. Maryland, USA. All Maryland acute care hospitals; 12 intervention and 36 control hospitals. Participation in SPARC, a public health–academic collaborative made available to Maryland hospitals, with staggered enrolment between June 2018 and August 2019. Hospitals with higher C. difficile rates were recruited via email and phone. SPARC included assessments, feedback reports and ongoing technical assistance. Primary outcomes were C. difficile incidence rate measured as the quarterly number of C. difficile infections per 10 000 patient-days (outcome measure) and SPARC intervention hospitals’ experiences participating in the collaborative (process measures). SPARC invited 13 hospitals to participate in the intervention, with 92% (n=12) participating. The 36 hospitals that did not participate served as control hospitals. SPARC hospitals were associated with 45% greater C. difficile reduction as compared with control hospitals (incidence rate ratio=0.55, 95% CI 0.35 to 0.88, p=0.012). Key SPARC activities, including access to trusted external experts, technical assistance, multidisciplinary collaboration, an accountability structure, peer-to-peer learning opportunities and educational resources, were associated with hospitals reporting positive experiences with SPARC. SPARC intervention hospitals experienced 45% greater reduction in C. difficile rates than control hospitals. A public health–academic collaborative might help reduce C. difficile and other hospital-acquired infections in individual hospitals and at state or regional levels.

The Merit-based Incentive Payment System: Pearson’s Chi-Square and Categorical Dependent Variable Models Analyzed for Domains—Effective Clinical Care and Efficiency/Cost Reduction

Background: Following the 2015 repeal of the Sustainable Growth Rate formula, the US Centers for Medicare & Medicaid Services’ formula under which physicians were reimbursed, two payment systems were put in place to incentivize physicians, one of which was the Merit-based Incentive Payment System (MIPS). MIPS emphasizes high-quality care that is accessible, affordable, and supports a healthier population. Objectives: This research aims to measure characteristics of MIPS relevant to National Quality Strategy (NQS) domains, quality measure types, and clinical specialties; categorize MIPS with NQS domains and quality measure types by MIPS specialty types; and quantify the relationship between MIPS specialties, measure types, and two NQS domains, Effective Clinical Care (ECC) and Efficiency/Cost Reduction (E/CR), for years 2017 through 2020. Methodology: The Pearson’s chi-square test examined distributions of the analyzed categorical variables. The Categorical Dependent Variable Method examined the association between the dependent and independent variables. Results: The Pearson’s chi-square test showed statistically significant distributions between ECC and E/CR when analyzed with the types of quality measures. There were more process measures (93.81% vs 89.64% [P=.000]) in 2018 versus 2017. This changed minutely with significantly less process measures (93.75% vs 93.81% [P=.000]) in 2019 versus 2018. Finally, measure types changed minutely but significantly with less process measures (93.81% vs 93.75% [P=.000]) in 2020 versus 2019. The regression model showed that ECC was significantly associated with outcome measures through all analyzed years of this research. Conclusion: The above findings show scope for including additional outcome measures, given its importance in MIPS. There is potential to increase the percentage allocation for reporting more outcome measures in quality. This re-allotment infers reporting more outcome measures aligning with priority outcome measures (PROMs). Re-allocating the incentive formula to report more outcome measures aligned with PROMs shows potential to increase reporting of more outcome measures under MIPS.

Patient-related healthcare disparities in the quality of acute hip fracture care: a 10-year nationwide population-based cohort study

ObjectivesTo characterise and quantify possible patient-related disparities in hip fracture care including temporal changes.DesignPopulation-based cohort study.SettingAll Danish hospitals treating patients with hip fracture.Participants60 275 hip fracture patients from 2007 to 2016.InterventionsQuality of care was defined as fulfilment of eligible care process measures for the individual patient recommended by an expert panel. Using yearly logistic regression models, we predicted the individual patient’s probability for receiving high-quality care, resulting in a distribution of adjusted probabilities based on age, sex, comorbidity, fracture type, education, family mean income, migration status, cohabitation status, employment status, nursing home residence and type of municipality. Based on the distribution, we identified best-off patients (ie, the 10% of patients with the highest probability) and worst-off patients (ie, the 10% of patients with the lowest probability). We evaluated disparities in quality of care by measuring the distance in fulfilment of outcomes between the best-off and worst-off patients.Primary and secondary outcome measuresThe primary outcome was fulfilment of all-or-none, defined as receiving all relevant process measures. Secondary outcomes were fulfilment of the individual process measures including preoperative optimisation, early surgery, early mobilisation, assessment of pain, basic mobility, nutritional risk and need for antiosteoporotic medication, fall prevention and a postdischarge rehabilitation programme.ResultsThe proportion of patients receiving high-quality care varied over time for both best-off and worst-off patients. The absolute difference in percentage points between the best-off and worst-off patients for receiving all-or-none of the eligible process measures was 12 (95% CI 6 to 18) in 2007 and 23 (95% CI 19 to 28) in 2016. Disparities were consistent for a range of care processes, including assessment of pain, mobilisation within 24 hours, assessment of need for antiosteoporotic medication and nutritional risk assessment.ConclusionsDisparity of care between best-off and worst-off patients remained substantial over time.

NEW APPROACHES TO THE DEVELOPMENT OF STATE PROGRAMS OF THE RUSSIAN FEDERATION AND THE FIRST EXPERIENCE OF THEIR PRACTICAL IMPLEMENTATION

Resolution of the Government of the Russian Federation No. 786 of May 26, 2021 «On the Management System of State Programs of the Russian Federation» (hereinafter — Resolution No. 786) approved new rules for the development, implementation, monitoring and evaluation of the effectiveness of state programs of the Russian Federation. In the development of the resolution, the Order of the Ministry of Economic Development of the Russian Federation No. 500 dated August 17, 2021 adopted methodological recommendations for the development and implementation of state programs of the Russian Federation that meet new requirements. Programs should acquire a homogeneous structure that includes five main elements: a list of strategic priorities, a passport of the state program containing goals and indicators with their decomposition by region, passports of federal, departmental projects and complexes of process measures (structural elements of the state program), plans for the implementation of structural elements and a regulatory «substrate» — acts necessary for the implementation of the program. For each state program, as well as its individual elements, a list of socially significant indicators linked to national development goals should be formed. In all state programs, the project part will be allocated, providing for the implementation of specific tasks and obtaining unique results for a limited period of time. One of the first (if not the first) to approve the updated version of the State Program for the Development of Agriculture and Regulation of Agricultural Products, Raw Materials and Food Markets (hereinafter also referred to as the State Program, Program), which comes into force on January 1, 2022. On the example of the updated version of the State Program, the article provides a critical and constructive analysis of systemic problems that may arise in the development of state programs of the Russian Federation as part of the implementation of a new system of program-targeted management.

STEPP IN: A Multicenter Quality Improvement Collaborative Standardizing Postoperative Handoffs

OBJECTIVE To reduce care failures by 30% through implementation of standardized communication processes for postoperative handoff in NICU patients undergoing surgery over 12 months and sustained over 6 months. METHODS Nineteen Children’s Hospitals Neonatal Consortium centers collaborated in a quality improvement initiative to reduce postoperative care failures in a surgical neonatal setting by decreasing respiratory care failures and all other communication failures. Evidence-based clinical practice recommendations and a collaborative framework supported local teams’ implementation of standardized postoperative handoff communication. Process measures included compliance with center-defined handoff staff presence, use of center-defined handoff tool, and the proportion of handoffs with interruptions. Participant handoff satisfaction was the balancing measure. Baseline data were collected for 8 months, followed by a 12-month action phase and 7-month sustain phase. RESULTS On average, 181 postoperative handoffs per month were monitored across sites, and 320 respondents per month assessed the handoff process. Communication failures specific to respiratory care decreased by 73.2% (8.2% to 4.6% and with a second special cause signal to 2.2%). All other communication care failures decreased by 49.4% (17% to 8.6%). Eighty-four percent of participants reported high satisfaction. Compliance with use of the handoff tool and required staff attendance increased whereas interruptions decreased over the project time line. CONCLUSIONS Team engagement within a quality improvement framework had a positive impact on the perioperative handoff process for high-risk surgical neonates. We improved care as demonstrated by a decrease in postoperative care failures while maintaining high provider satisfaction.

A Quality Improvement Initiative to Reduce Postoperative Delirium among Cardiac Surgery Patients

Patients following cardiac surgery commonly experience post-operative delirium (POD) during their postoperative hospital stay. A multifaceted, specialty wide, quality improvement (QI) project was undertaken for patients experiencing POD. The goal was to develop a reduction in POD care bundle (rPOD-a structured patient care program) that encompasses efficient preoperative risk factor identification and a postoperative patient-care process to ensure early POD identification and treatment. The following steps were taken to implement the rPOD care bundle including: (a) Developing a quality driven, evidence-based guideline for the perioperative cardiac surgery health care team, (b) identifying and addressing local barriers to implementation, (c) selecting performance measures to assess intervention adherence and patient outcomes, and (d) ensuring that all patients receive the interventions through staff engagement and education, and regular project evaluation. Trends of process measures and quality improvement measures were examined. An increasing trend in the rate of postoperative delirium screening during implementation of rPOD intervention was demonstrated. This quality improvement study provides a bases for future postoperative delirium reduction interventions.

Abstract 10508: Variation in Community and Emergency Medical Systems Processes for Out-of-Hospital Cardiac Arrest During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis

Introduction: Bystander cardiopulmonary resuscitation (B-CPR) with early defibrillation and immediate emergency medical services (EMS) care significantly increases a victim's chance of survival from out-of-hospital sudden cardiac arrest (OHCA). Few studies have assessed the overall effect of the COVID-19 pandemic on the prehospital chain of survival. Objectives: We sought to quantify the effect of the COVID-19 pandemic on prehospital processes including B-CPR, bystander defibrillation, community characteristics, and EMS process measures. We hypothesized that B-CPR rates would decrease and OHCA occurring in the home would increase during the pandemic. Methods: We conducted a systematic review and meta-analysis of studies identified through 05/03/2021. We examined 5 bibliographic databases and searched terms including cardiac arrest, OHCA, and COVID-19. Data were abstracted and independently coded. Subgroup analysis and meta-regression analysis were performed. Our primary outcome was B-CPR; our secondary outcomes were community processes and EMS characteristics. Results: The original search yielded 966 articles; 20 articles were included in our analysis. Studies originated from 10 different countries and were retrospective in study design. There was no difference in B-CPR rates during COVID-19 compared to Pre-COVID-19 (OR: 0.94 (0.80-1.11), p=0.46). Patients had a 1.38 (1.11-1.71) higher likelihood of having an OHCA at home during COVID-19 compared to Pre-COVID-19 (p=0.01). Receipt of bystander defibrillation was significantly lower during COVID-19 compared to Pre-COVID-19 (OR: 0.65 (0.48-0.88), p=0.01). There was a significant increase in EMS call to arrival time during COVID-19 compared to Pre-COVID-19 (Mean difference in minutes= 0.27 (0.13-0.40), p<0.01). Statistical heterogeneity was moderate-to-high; findings were robust to sensitivity analyses with no publication bias detected. Conclusion: B-CPR rates remained unchanged during the pandemic, while OHCA in the home increased. Bystander defibrillation decreased, while EMS response time increased during the pandemic. These findings may inform future public programing, particularly to consider interventions to improve the prehospital chain of survival.

General Concept of Business Process Measures in the Circular Economy

The presented research has been embedded in a dynamically developing circular economy. Nowadays, it is more and more often referred to as an alternative economy model to the linear economy model. The principal aim of the research is to develop a general concept of business process measures. It was built on five key principles. They are (1) the principle of Institutional Determinants of Business Processes, (2) the principle of rational change of state, (3) the principle of incorrect definition of determinants, (4) the principle of rational determinants and (5) the principle of the intensity of the impact of determinants. The research mainly used the extensive literature on the subject, which was primarily aimed at showing the context of the circular economy. The concept itself mainly uses the methods and principles of process management. The rules of the Petri nets were used to define the key principles of the presented concept. Ultimately, it turned out that the proposed approach to business measurements can be helpful in managing environmental, social and governance factors also in small- and medium-sized enterprises. The most important result of the research can be presented in a specific theorem. The effective achievement of business process goals, in a circular economy, may depend on the adaptation and use of a wide stream of institutional determinants that make up a holistic environment for socio-economic phenomena taking place in the company. This may be possible thanks to the use of the general concept of business process metrics, which allows identifying and eliminating negative internal and external effects.