Explanation & Elaboration

5. Intended improvement

1. Describes the specific aim (changes/improvements in care processes and patient outcomes) of the proposed intervention
2. Specifies who (champions, supporters) and what (events, observations) triggered the decision to make changes, and why now (timing)

Example

"For many years our busy MICU [medical intensive care unit] struggled with CR-BSIs [catheter-related bloodstream infections]. In 2002 the CR-BSI rate was 44% higher than the national median of 5.2 per 1000 catheter-days. Like many hospitals, we had historically focused on infection surveillance and staff education. However, we recognized that more innovative strategies were needed to tackle this ongoing complex problem. The impressive utility of CQI [continuous quality improvement] in other healthcare settings, coupled with successful reports from other high risk industries, encouraged us to consider a CQI approach..."

"Our primary goal was to show that real time measurement of CVC [central venous catheter] care was feasible in the MICU. We anticipated these new process measurements would guide CQI efforts and thereby lead to a reduced CR-BSI rate. To increase staff appreciation of the link between process measures and clinical outcomes, we fed bundled data back to providers."

"We assembled a voluntary interdisciplinary team with at least one MICU leader, infectious disease expert, front line staff member, and quality improvement expert. The team's goal was to develop a system for measuring the process of CVC care in real time with the understanding that this information would guide future improvement activities aimed at reducing infections. The team compiled a list of risk factors by reviewing the published literature on CR-BSIs, and then classified these risk factors depending on whether they occurred during the insertion or daily maintenance. When deciding where to focus their initial efforts, the team selected CVC insertion as the starting point. Several issues guided this decision: (1) most CVCs in the MICU were inserted by trainees and there was a high likelihood of practice variability; (2) there was strong evidence linking certain insertion behaviors with CR-BSIs; and (3) CVC insertion was easily defined and amenable to improvement." [21]

Elaboration

A quality improvement paper should describe the events or information that lead to the need for making a change. Authors should include specific data or other organizational factors that are relevant to the intended improvement. The idea for improving care rarely occurs isolated from other events. These authors acknowledge that infection surveillance and staff education efforts had been in place in the specified institution but were insufficient to reduce the rate of catheter-related infections. By describing existing and previous work to improve care, authors place the current effort in relation to former initiatives.

The aim of the improvement effort should be clearly described. As in this example, the statement contains information about the specific goal to be achieved and how this will be measured. The example above indicates that the project is the first part of a feasibility study to understand whether real-time measurement of catheter-related infections is possible. A second goal of the intended improvement is to assess whether the use of real-time measures will lead to reduction in the rate of infection.

In addition, authors should describe which aspect(s) of care was the focus of the intended improvement. The authors above choose to focus on the insertion of the central venous catheter, and they clearly describe the rationale for this choice both in terms of evidence from the existing literature and from local factors related to their intensive care environment.

Finally, a description of the intended improvement should include the people who were involved in the effort. These authors note four different members of the team and highlight their different roles. Including the roles of individuals who participate in an improvement effort provides the reader with information related to what expertise was brought to the group. Improvement efforts are often initiated by leaders in a unit, clinic, hospital or health care organization. If such institutional support or expectations exist for an intended improvement, stating these factors can assist the reader in understanding what other organizational factors may have facilitated the improvement effort.

References

21. Wall RJ, Ely EW, Elasy TA, et al. Using real time process measurements to reduce catheter related bloodstream infections in the intensive care unit. Quality & safety in health care. 2005;14(4):295-302.

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