Implementation of randomized quality improvement projects to evaluate routine hospital processes

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Hospitals routinely implement processes to increase the provision of high quality patient care, such as calling patients to encourage follow-up visits or providing doctors and nurses with notices in electronic health records to request reminders for vaccinations. But most of the time, hospitals can't tell if these processes work optimally. A program at NYU Langone Health, led by Leora Horwitz, MD, associate professor of health and population medicine and director of the Center for Healthcare Innovation and Delivery Science, addresses this question by implementing randomized quality improvement projects. She and her colleagues reported their findings in the September 19, 2019 issue of New England Journal of Medicine.

While private sector companies like Google and Amazon routinely incorporate randomized continuous quality improvement methods into their workflow, this is new ground for healthcare systems. The randomized quality improvement projects used by Horwitz and his colleagues evaluate the effectiveness of routine processes that hospital staff perform on a daily basis and allow staff to quickly improve their practices.

This program is important because there are always better ways to do things, but unless we have some data to show us that what we are doing is not fully effective, we have no incentive or inclination to find a better way to do it. Unless we study whether what we are doing works, we cannot allocate the resources we have in the most effective way. This means that we are not necessarily providing the best possible care to our patients. "

Leora Horwitz, MD, associate professor of health and population medicine and director of the Center for Healthcare Innovation and Delivery Science, NYU Langone Health

Horwitz has implemented randomized quality improvement projects throughout New York Langone – which include hospital units, outpatient clinics and emergency rooms – and has included efforts to improve care after hospitalization, increase reception of preventive screening recommended, capture results reported by patients and increase counseling on smoking cessation rates, among other topics. In one of these projects, which tested a new program to call patients after discharge from the hospital, patients with odd-numbered electronic records received calls, while those with even-numbered records did not receive calls. Another project, which examined telephone scripts used to remind patients of annual well visits, patients randomized to script A or B, and therefore each script was used every other week for several weeks.

Among the results there was the fact that changing the text of a request to provide advice on office cessation of tobacco produced a statistically significant increase in drug prescription rates. The modification of some sentences in the telephone awareness scripts has reduced the phone calls and increased the annual visits appointments.

The researchers also found that post-discharge telephone calls to patients were largely ineffective. Patients who received calls returned to the hospital at the same rate as those who did not receive calls. Patients who received calls also had the same levels of satisfaction with the hospital as those who did not receive calls.

With this knowledge, hospital staff now have options to determine where to focus their resources, says Horwitz. Call scripts may need to be changed or staff may need to call only high-risk patients instead of calling all patients.

"At NYU Langone Health, the well-being of our patients always comes first," says Andrew W. Brotman, MD, senior vice president and vice president of clinical affairs and strategy. "To fulfill our role as a health care learning system, we need to demonstrate the agility to adapt or modify any procedure so that it offers the maximum benefit to patients. Dr. Horwitz's work ensures that we are allocating staff resources in the most effective way possible. "

Horwitz points out that projects that test hospital procedures do not deprive patients of effective interventions. Rather, randomized tests are designed to help patients by quickly determining what works and then implementing the effective arm or modifying an ineffective process to function better. It also recognizes that there are important ethical considerations in doing this work.

"I believe we have an ethical responsibility to rigorously assess whether our operational interventions are effective, even when they may seem trivial, like call or mailing scripts that we send to people to get their colonoscopy," says Horwitz. "Otherwise, we cannot be sure of making the best out of our patients."

Randomization programs are designed to be easy to implement, says Horwitz. Staff must not use special randomization tools or maintain separate databases. The people who do the work only need to make small changes to their workflow, like changing the script they use from one week to the next.

"This can be done quite easily. It doesn't have to be a $ 10 million, 10-year NIH process," says Horwitz. "We can integrate these things in the normal way we do our work."

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