G
uidelines for Completion of Quality Improvement Project Report
If you are reporting a quality improvement project, begin
with item 1 below and complete all items for which information is available. If a one or
more steps have not been finished please mark as "to be completed".
Graphical display of data should be attached to the report form.
It is recommended that reports be submitted in electronic
form (via email, if possible) to William Barron, M.D. or LuAnn Vis, Center for Clinical
Effectiveness.
1. Opportunity / AIM statement with Measurable
Goal
- The opportunity or problem statement is a brief, clear description of
the issue studied.
- The desired outcome is the specific, measurable objective or goal of
the project.
Example:
Approximately 70% of patients with neutropenia and fever receive
antibiotics more than one hour after ordering. This delay leads to an increase in
mortality and greater use of hospital resources. The goal of this project is to achieve
administration of antibiotics in this patient population within 60 minutes following a
physician order and to thereby reduce mortality, length of stay, and charges per
admission.
2. Most likely causes
- Describe the cause(s) thought to be responsible for the opportunity
/problem noted above.
- Describe the manner in which the most likely cause was identified,
e.g. data, literature, opinion of local experts, etc.
Example:
Nurses and physicians caring for patients with neutropenic fever at
Loyola believed that delays in antibiotic administration were due to (1) suboptimal
accessibility of antibiotics and (2) a lack of awareness of staff about the serious
consequences of delayed antibiotic administration.
3. Potential Solutions and Data Needed for Evaluation
- Utilizing the most-likely causes identified in step 2,
list potential solutions that may result in the desired outcome(s). Such solutions may be
based on experience of others, published reports, and/or best guesses of those with
knowledge of the issue. Following this, choose one or more solutions that can be
reasonable instituted.
Example:
(1) Develop a definition of neutropenic
fever
(2) Develop a practice guideline for use of
antibiotics in patients with neutropenic fever
(3) Develop a policy for use of the pneumatic tube
system for antibiotic delivery
(4) Educate physicians and nurses about
neutropenic fever and the new guidelines for antibiotic administration
- For each solution to be implemented, identify the data
needed to determine if the change has lead to an improvement. Data collected should
be the absolute minimum and of importance to patients and to the people doing the
work. Once the required data elements have been specified, the source of these data must
be identified or developed.
Example:
(1) Quarterly reports of all patients admitted
with neutropenic fever (CCE FORCE database)
(2) Charges and length of stay for patients
admitted with neutropenic fever (CCE FORCE database)
(3) Time between antibiotic order and
administration (chart review)
(4) Mortality rate (chart review)
4.Solutions Implemented
- List the solutions implemented and date of implementation.
5a. Results - Attach data in graph form.
- Present quantitative results, including statistical analysis if
appropriate, of the most important study outcomes. It is strongly suggested that results
be presented in graphical format to highlight changes over time (contact the CCE at
6-3290 if assistance with graphical presentation and/or statistical analysis is desired).
Attach no more than three additional pages to present results. Please avoid inclusion of
spreadsheets containing large amounts of data – such information is often very
difficult to interpret.
5b. Data Analysis
- Provide a narrative description of the findings to accompany each of
the graphics presented above.
Example:
(1) Prior to implementation of the new approach 20% of patients on
the inpatient unit received antibiotics within 1 hour. Following implementation 85% of
these patients received antibiotics within this time frame.
(2) Length of stay decreased from an average of 6.0 to 5.0 days and
charges declined from $13,808/case to 11,481/case.
(3) Mortality rate for neutropenic fever decreased from 8% to 4%.
6. Conclusions and Next Steps
- Describe, based on the data analysis, whether or not the change(s)
made produced the desired improvement and what next steps you plan. Next steps may include
but are not limited to the following:
- Broad implementation if the initial change was done on a small scale
- Attempt at another solution if the project was not successful
- Continued data collection to monitor whether the observed improvement
is sustained
- No additional activity is planned. If this is the case, please provide
rationale for ending the project.
Example:
Following implementation of a program to expedite
administration of antibiotics to patients with neutropenia and fever, mortality and
resource utilization improved dramatically.
Next steps include expanding data collection and analysis to
the emergency department and home care settings. Data collection and analysis on the
inpatient unit will continue to determine if the progress made is sustained.
|
