Quality improvement methods in child health

Overview & Definition

A ward has too many children receiving antibiotics they do not need. A neonatal unit wants fewer central-line infections. An asthma service is tired of repeat admissions. These are not research questions and they are not single incident reports — they are quality problems, and they are solved with quality improvement methods. This leaf teaches you how to design, lead and judge a QI project in child health. Deep human-factors theory lives on the patient-safety page; research appraisal on the evidence-based-medicine page. [1] [2]

Quality improvement (QI) is the combined and unceasing efforts to make changes that lead to better patient outcomes, better system performance and better professional development. Berwick framed improvement as a system we lead deliberately, not an accident we wait for. [1] [2]

The key distinction the viva tests: QI is not research. Research generates generalisable new knowledge for a population; QI improves care here, now, for these children, using methods designed for fast local learning. QI is not clinical audit. Audit measures practice against an external standard at a point in time; QI actively tests changes to move practice toward a better state, iteratively. QI is not innovation. Innovation invents something new; QI usually adapts and tests changes that are already known to work. [1] [8]

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1. [1]Berwick DM A primer on leading the improvement of systems. BMJ, 1996.PMID 8595340
2. [2]Berwick DM Developing and testing changes in delivery of care. Annals of internal medicine, 1998.PMID 9537939
3. [3]Berwick DM, Nolan TW, Whittington J The triple aim: care, health, and cost. Health affairs (Project Hope), 2008.PMID 18474969
4. [4]Kilo CM Improving care through collaboration. Pediatrics, 1999.PMID 9917480
5. [5]Horbar JD, Rogowski J, Plsek PE, Delmore P Collaborative quality improvement for neonatal intensive care. NIC/Q Project Investigators of the Vermont Oxford Network. Pediatrics, 2001.PMID 11134428
6. [6]Rogowski JA, Horbar JD, Plsek PE, Baker LS Economic implications of neonatal intensive care unit collaborative quality improvement. Pediatrics, 2001.PMID 11134429
7. [7]Sharek PJ, Parast LM, Leong K, Coombs J Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a Children's Hospital. JAMA, 2007.PMID 18029830
8. [8]Taylor MJ, McNicholas C, Nicolay C, Darzi A Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ quality & safety, 2014.PMID 24025320
9. [9]Thor J, Lundberg J, Ask J, Olsson J Application of statistical process control in healthcare improvement: systematic review. Quality & safety in health care, 2007.PMID 17913782
10. [10]Ogrinc G, Armstrong GE, Dolansky MA, Singh MK SQUIRE-EDU (Standards for QUality Improvement Reporting Excellence in Education): Publication Guidelines for Educational Improvement. Academic medicine, 2019.PMID 30998575
11. [11]Pronovost P, Needham D, Berenholtz S, Sinopoli D An intervention to decrease catheter-related bloodstream infections in the ICU. The New England journal of medicine, 2006.PMID 17192537
12. [12]Starmer AJ, Spector ND, Srivastava R, West DC Changes in medical errors after implementation of a handoff program. The New England journal of medicine, 2014.PMID 25372088
13. [13]Dukhovny D, Buus-Frank ME, Edwards EM, Ho T A Collaborative Multicenter QI Initiative to Improve Antibiotic Stewardship in Newborns. Pediatrics, 2019.PMID 31676682