Table 1 Summary of quality of care interventions included in review

A

[30] (Aghlmand et al., 2008)

•To improve the uptake of selected evidence based practices and more closely attend to identified women's needs and preferences

•n=89 women (pre-intervention) n=78 (post intervention)

Pre/post design

Interpersonal

Primary Outcome

•Identify women’s needs, values via interviews

•Women's satisfaction levels improved significantly on 16 of 20 compared with baseline

•Redesign care based on selected evidence-based recommendations and women's views

Other Outcomes

•Implement the new care model

•78% of studied women experienced care consistent with the new model and fewer women had a caesarean birth

•Measured the impact of the new care model on maternal satisfaction and caesarean birth rates utilising maternal surveys and medical record audit before and after implementation of the new care model

Conclusions

•Improved compliance with evidence-based guidelines and was associated with an improvement in women's satisfaction levels and a reduction in rates of caesarean birth

B

[24] (Kalisch et al., 2007)

•To determine the impact of an intervention designed to enhance teamwork and staff engagement on the rate of patient falls, patient satisfaction, the staff’s assessment of level of teamwork on their unit, and vacancy and turnover rates

•55 staff members on the unitV 32 registered nurses (RN), 2 licensed practical nurses, 15 certified nurse assistants (CNAs), and 6 unit secretaries

•Phased design

Interpersonal

Primary Outcome

•Focus groups were conducted to assess nature of teamwork on the unit as well as the staff educational needs in the area of teamwork

•Significantly lower patient fall rate staff ratings of improved teamwork on the unit

•Focus group data were compiled into a report which was presented in several feedback

•Each staff member then attended a day-long team training program

Other Outcomes

•Lower staff turnover and vacancy rates .

•Patient satisfaction ratings approached, but did not reach, statistical significance

•Rapid testing of ideas

Conclusions

•There is a continual need to work with staff in the areas of listening, feedback and conflict management

C

[27] (Curtis et al., 2008)

•To improve palliative care in the ICU

•Patients who died in the ICU were identified pre- (n= 253) and post-intervention (n=337)

Pre/post design

Interpersonal

Primary Outcome

•The family-QODD, showed a trend toward improvement but was not statistically significant Family satisfaction increased but not significantly

•The intervention consisted of clinician education, local champions, academic detailing, feedback to clinicians, and system support

Other Outcomes

•The nurse-QODD showed significant improvement and there was a significant reduction in ICU days prior to death (pre 7.2, post 5.8; p<0.01)

•Families completed Family Satisfaction (FS-ICU) and Quality of Dying and Death (QODD) surveys.

Conclusions

•Improving family ratings may require interventions that have more direct contact with family members

D

[26] (Kipp et al., 2001)

•To improve patient satisfaction, a significant quality outcome measure for healthcare providers

•500 bed community hospital

Pre/post design

Interpersonal•A multidisciplinary group was formed and comprised ED physicians, RNs, technicians, clerical staff, managers, and human resource development personnel •The group met monthly from April 1998 to October 1998 to develop the Nursing Caring Standards•The standards were derived from four previously established Department of Nursing Caring Standard

Primary Outcome

•ED patient satisfaction with the "care and concern by nurses" increased 6.6% after the caring standards were implemented

Other Outcomes N/A

Conclusions

•The development of concrete ED customer service standards appears to be effective in improving caring behaviours by staff and patient satisfaction

E

[25] (Oosthuizen et al., 2002)

•To improve the quality of care for diabetic patients

•n=23 doctors Phase 1 (n=31 patients) Phase 2 (n=32 patients)

Pre/post design

Interpersonal•A Diabetes Attitude Scale (DAS-3) and a Diabetes Practice Scale (DPS) were completed by each doctor before and after the interventional educational sessions •Data from diabetic patients in the wards were collected for 5 weeks before and 5 weeks after the interventional training •These two sets of data were compared to measure the effect of the interventional training

Primary Outcome

•Subscales of the DA5-3 showed a statistically significant improvement in attitude regarding seriousness of diabetes mellitus

Other Outcomes

•A trend towards improvement in attitude regarding need for special

training and patient autonomy

•Most of the items on the DPS improved significantly

Conclusions

•A short educational intervention resulted in an improvement in attitude, knowledge and clinical management of diabetic patients

F

[29] (Brown et al., 2007)

•To encourage uptake of childbirth companions in state hospitals

•Maternity staff at n=10 hospitals •n=200 women

RCT

Interpersonal •Educational intervention to promote childbirth companions

Primary Outcome

•No effect was demonstrated on the number of women having a companion

Other Outcomes

•No effect on being shouted at, left alone, not offered food or fluids or physically mistreated

•There was a statistically significant reduction in episiotomy

•Fewer women reported being mobile during the second stage of labour at the intervention hospitals

Conclusions

•Unable to determine whether the presence of a lay carer impacted on the humanity of care provided by health professionals

G

[28] (Schmied et al., 2009)

•To design, implement and evaluate strategies to improve the quality and content of hospital-based postnatal care

•146 women at baseline and 148 women post intervention completed a postal self-report questionnaire between 2–4 weeks postpartum

Pre/post design

Interpersonal •Compared the effect of multifaceted strategies on perceptions of quality and content of postnatal care, knowledge and experience of postnatal problems, parenting self-efficacy and breastfeeding outcomes •Key strategy implemented, ‘One-to-one time’, focused on providing women an uninterrupted period of time each day when a midwife would be available to discuss women’s concerns

Primary Outcome

•No significant differences between baseline and post intervention groups in perceived quality of care, breastfeeding outcomes and maternal self-efficacy

Other Outcomes

•Women experiencing health issues were more likely to report that they received good or excellent care post intervention

•Women were less likely to report excessive tiredness postintervention

•‘One-to-one time’ was not consistently implemented.

Conclusions

•Is potential for individualised care but institutions are difficult to change

H

[23] (Moffitt et al., 2009)

•To increase patient, physician, and staff satisfaction and to improve patient outcomes

•Not stated

Phased design

Interpersonal • Merger of a medical-oncology unit at a small community hospital

Primary Outcome

•The Medical unit demonstrated improvement in overall patient satisfaction

Other Outcomes

•A decrease in the change of shift report time and a staff that desires empowerment

Conclusions

•The results of the changes implemented on an medical oncology unit indicated improvements in physician, patient and nurse satisfaction

I

[22] (Wessels et al., 2010)

•To address the effect of an intervention in hospital structure (integration of three units into one) with the purpose of improving processes (increase meeting, cooperation and communication between professionals and patients) and its effect on the outcome (cancer patient satisfaction)

•Cancer patients (n=174, n = 97

Pre/post design

Interpersonal •Physical integration by bringing separately located units (outpatient clinic, day-care clinic, clinical ward) together in one wing of the hospital and adjustments in communication and coordination structures

Primary Outcome

•Patient satisfaction with care improved for six scales

Other Outcomes

•The most important improvement was found at the day-care clinic on aspects like ‘the degree in which the nurses were informed about a patients situation’, ‘privacy’, ‘interior design’, ‘quality of hospital equipment’,‘sanitary supplies’ and ‘waiting periods’.

•With regard to continuity and coordination of care, satisfaction increased for five items

Conclusions

Integration of three oncology units into one unit had a positive impact on care delivery processes and resulted in improved patient satisfaction concerning care and treatment

J

[37] (Varelas et al., 2004)

•To evaluate the impact of a newly appointed neurointensivist

•n=1,087 patients before appointment of neurointensivist and n=1,279 after

Observational cohort with historical controls

Technical •Analyzed patients before and after the neurointensivist’s appointment

Primary Outcome

•Unadjusted in-hospital mortality decreased

Other Outcomes

•Discharge home increased

•Significant reduction in risk of death during first 3 days of admission

Conclusions

•The institution of a neurointensivist-led team model was associated with an independent positive impact on patient outcomes

K

[35] (Nolan et al., 2005)

•To improve the quality of care for patients with acute myocardial infarction and heart failure

•n=Not stated

Phased design

Technical •Multidisciplinary initiative with a partnership of inpatient cardiology nursing and physician leadership

Primary Outcome

•Dramatic trend upward in the discharge teaching and smoking-cessation counseling, Other Outcomes

•This inpatient leadership team analyzed clinical and operational processes, and revised and developed tools such as standard order sets, discharge instructions, clinical pocket guides, and daily monitoring logs

•Improvement in angiotensin-converting enzyme inhibitor use and left ventricular ejection fraction measurement

Conclusions

•At 12 months, quality improvements have been demonstrated

L

[34] (Scott et al., 2000)

•To improve quality of in-hospital care of patients with acute coronary syndromes

•n=1,594 from 3 hospitals

•Pre/post design

Technical

Primary Outcomes

•Increases occurred in the proportions of eligible patients: (i) undergoing timely ECG (ii) prescribed angiotensin-converting enzyme inhibitors and lipid-lowering agents

•Multi-improvement program: Clinical guidelines, reminder tools, and educational interventions; 6-monthly performance feedback; pharmacist mediated patient education program; and facilitation of multidisciplinary review of work practices

Other Outcomes

(iii) Increase in the number receiving cardiac counselling in hospital and referred to cardiac rehabilitation

Conclusions

•Multifaceted approaches can improve care processes for patients hospitalized with acute coronary syndromes.

•Care processes under direct clinician control changed more quickly than those reliant on complex system factors

M

[39] (Van Zyl et al., 2004)

•To determine if a physician education programme and a structured consultation schedule would improve the quality of diabetes patient care in a diabetes clinic

•n=141 patient and n=159 control

•Pre/post design

Technical

Primary Outcomes

•Three hundred patients were randomly selected for audit of their hospital records: 141 from the intervention and 159 from the control clinics

•Thereafter a physician training programme and a structured consultation schedule were introduced to the intervention clinic and maintained for a 1-year period

•The control clinic continued with care as usual. Process and outcome measures were determined at a post-intervention audit and compared between the two groups

•After intervention the intervention group had significantly higher process measure scores than the control group. HbA1c did not significantly differ between the two groups

Other Outcomes

•Consultation time was measured for both the intervention and control groups and data were compared

•The average number of clinic visits reduced over time for the intervention group compared with the control group, but the average consultation times were significantly longer

Conclusions

•The introduction of a physician education programme and a structured consultation schedule improved the quality of care delivered at a tertiary care diabetes clinic

N

[36] (Feldman et al., 2006)

•To improve the quality and consistency of care by adapting and adopting national guidelines

•1 academic medical college (November 2002 –July 2003)

Phased design

Technical

Primary Outcomes

•Multidisciplinary program

•Initiation phase, diagnostic engagement phase, design phase, implementation phase

•Improvement in several quality measures including increased use of beta blockers and angiotensin converting enzyme inhibitors for heart failure patients

Other Outcomes

•Reduced length of stay for heart failure and acute coronary syndrome patients, and increased satisfaction of the clinicians

Conclusions

•Individual physician’s unwillingness to embrace change was overcome with the development of faculty leadership skills and enhanced physician accountability

O

[33] (Mehta et al., 2002)

•To measure the effects of a quality improvement project on adherence to evidence-based therapies for patients with AMI

•Medicare and non-Medicare patients at baseline (n=735) and (n=914) at remeasurement

Pre/post design

Technical

Primary Outcomes

•The GAP project consisted of a kickoff presentation; creation of customized, guideline-oriented tools designed to facilitate adherence to key quality indicators

•Identification and assignment of local physician and nurse opinion leaders; grand rounds site visits

•Premeasurement and postmeasurement of quality indicators

•Increases in adherence to key treatments were seen in the administration of aspirin and blockers on admission and use of aspirin and smoking cessation (counseling) at discharge

Other Outcomes

•For most of the other indicators, nonsignificant but favorable trendstoward improvement in adherence to treatment goals were observed.

• Medicare patients in GAP hospitals showed a significant increase in the use of aspirin at discharge

• Use of aspirin on admission, ACE inhibitors at discharge, and documentation of smoking cessation also showed a trend for greater improvement among GAP hospitals compared with control hospitals, although none of these were statistically significant

Conclusions

•Implementation of guideline-based tools for AMI may facilitate quality improvement among a variety of institutions, patients, and caregivers

P

[31] (Halm et al., 2004)

•To evaluate the impact of a multifactorial intervention to improve the quality,efficiency, and patient understanding of care for community-acquired pneumonia

•Four academic health centres (n= 1,013) before intervention and (n=1,081) after

•Time series cohort

Technical

Primary Outcome

•Increased the use of guideline recommended antimicrobial therapy

Other Outcomes

•Borderline decrease in the proportion of patients being discharged prior to becoming clinically stable

•A multidisciplinary team of opinion leaders developed evidence-based treatment guidelines and critical pathways, conducted educational sessions with physicians, distributed pocket reminder cards, promoted standardized orders, and developed bilingual patient education materials

•No improvements in the other targeted indicators, including time to first dose of antibiotics, proportion receiving antibiotics within 8 h, timely switch to oral antibiotics, timely discharge, length of stay, or patient education outcomes

Conclusions

•Modest improvement on some quality indicators, but no effect on resource use or patient knowledge of their disease

Q

[32] (Meehan et al., 2001)

•To improve process-of-care performance and to decrease length of stay for patients hospitalized with community-acquired pneumonia

•n=1,242 patients at baseline, n=1,146 at follow up

•Pre/post design

Technical

Primary Outcomes

•Interventions included feedback of performance data, dissemination of an evidence-based pneumonia critical pathway and sharing of pathway implementation experiences (hospitals)

•Improvements were noted in antibiotic administration within 8 hours of hospital arrival, oxygenation assessment within 24 hours of hospital arrival and length of stay 7 days to 5 days

Other Outcomes

•There were no significant changes in blood culture collection within 24 hours of hospital arrival, blood culture collection before antibiotic administration, 30- day mortality, or 30-day readmission rates

Conclusions

•Statewide improvements were demonstrated in the care of hospitalized pneumonia patients concurrent with a multifaceted quality improvement intervention

R

[38] (Choma et al., 2009)

• To improve hypertension care at Veterans Affairs– Tennessee Valley Healthcare System

•2 teaching hospitals, 5 community-based outpatient clinics, and 4 contract clinic sites

Pre/post design

Technical

Primary Outcome

•Multiple Interventions

•There was an absolute improvement of 4.2% in BP

Conclusions

•Observation time was 40 weeks (14 weeks preintervention, 8 weeks intervention implementation, and 18weekspostintervention), during which there were 55 586 unique clinic visits for hypertension

•After implementing small, focused, and inexpensive interventions, BP control improved 4.2%, thereby improving the quality of hypertension care

S

[41] (Koplan et al., 2008)

•To assess the effect of adding tobacco order set to an existing computerized order-entry system

•7,278 of 17,530 admissions

Pre/post design

Technical

Outcomes

•Intervention increased the proportion of admitted patients who were referred for smoking counselling and had Nicotine Replacement Therapy ordered

•Adding a brief tobacco order set to an existing computerized order-entry system

Other Outcomes

•Hospital’s performance on the smoking cessation quality measure improved

Conclusions

•Hospital’s provision of evidence-based tobacco treatment helped to improve its performance on a publicly reported quality measure

•Provides a model for US hospitals seeking to improve their quality of care for inpatients

T

[40] (Smith et al., 2004)

•To use a focused change programme (the Better Births Initiative) to influence obstetric practice at 10 hospitals in Gauteng, South Africa

•Postnatal women were at baseline (n = 247) and •Follow-up (n = 215) focus group discussions (n= 8) with labour ward staff •Key labour ward staff at each site (n = 14).

Pre/post design

Technical

Primary Outcomes

•Providers at some sites reduced the use of enemas, shaving and episiotomy

Other Outcomes

•Workshops for staff on obstetric practices

• Increased use of oral fluids and companionship during labour

Conclusions

•An interactive approach to implementing evidence-based practice can influence health professionals' decisions to change practice, and that good working relationships and enthusiastic staff are central to effective change