Quality-improvement research evaluation

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Quality-improvement projects directly impact the quality of health care delivery. Health care research can provide the data necessary for the systematic change process to guide decision-making.

In this assignment, you will apply your skill in quality improvement, which is necessary for you to implement the policies and processes to fulfill the purpose of the organization you work in as a health care administrator. You will evaluate the relationship between quality-improvement projects and health care research. You will choose a peer-reviewed article about a research study and evaluate the application of risk- and quality-management concepts in the health care industry in this assignment.

Assignment Preparation
Search the University Library for a peer-reviewed article about a research study related to quality-improvement projects in health care.

Review Evaluating Research Critical-Thinking Prompts to ensure you have selected an article that is most appropriate for completing the assignment.

Assignment Directions
1,050-word evaluation of the quality-improvement projects in health care research study you selected.

Use the Evaluating Research Critical-Thinking Prompts as a guide for what to include in each section. You may find it helpful to respond to each prompt in this document and use it as an outline for your assignment. While this is a guide for the content needed for this assignment, it is not a template for the format.

Include the following headings and sections.

  • Research Steps: Provide the following:
  • Define the problem.
  • Explain the purpose of the research study.
  • Explain the study variables.
  • Explain the research question and/or hypothesis.
  • Research Methodology, Design, and Analyses: Explain the research methodology, design, and analyses.
  • Findings: Explain the research study’s findings.
  • Conclusion:
  • Summarize the research study’s recommendations.
  • Explain the impact of the research to risk management and quality management.
  • Cite sources to support your assignment.

    Format your assignment according to the attached

HCS/465 v7

Evaluating Research Critical-Thinking Prompts

HCS/465 v7

Page 2 of 2

Evaluating Research Critical-Thinking Prompts

Review the following prompts and examples to guide you in your evaluation of the research study you selected.

Research Steps

Define the problem.

Prompts:

· What is the problem identified in your chosen article? Example: The Ebola outbreak and its prevalence in West African nations

· Why is it a problem? Example: Ebola is a disease that is contracted from [finish the statement]. Its symptoms are [finish the statement]. [Insert information] amount of people die each year. This is a problem because [finish the statement].

· What is the problem that the article or research study is trying to resolve? Example: Ebola has spread among the West African people because of [insert reason]. This research seeks to identify solutions that will prevent it from spreading among the African people.

· Why is the problem important for health care administrators to study? The research article may not identify a specific reason the research is important to health care administrators. That is acceptable. Write about why a health care administrator would want to study this topic. How could knowledge of this topic help you as a health care administrator? Example: As an assistant manager of a nursing home, I know that many of the residents have watched the news reports on the Ebola outbreak in Africa and its potential outbreak in the United States. Because I know little about the disease and because I know the concern that the reporting of this disease has brought on the residents of the nursing home, I felt that it was my responsibility to know more about the disease and how to prevent its spread. Providing the residents with this knowledge can go a long way toward calming their fears and enabling them and their caregivers to take measures to prevent any outbreak.

Identify the purpose of the study.

Prompts: If the answers to these questions are not expressly stated in the article, consider its entirety and write what you think the answers are.

· What is the purpose of the study?

· What is the author trying to accomplish in this study?

Example: The purpose of the study was to create awareness of the Ebola outbreak, to provide statistical data to give an accurate account of the scope of the outbreak, and to identify known methods to minimize exposure, recognize symptoms, and prevent outbreaks.

Identify the study variables.

Prompt:

· What are the independent and dependent study variables?

· Independent variables represent inputs and can have any value.

· Dependent variables represent outputs or effects.


Example: The study collected data that observed changes in the number of people becoming infected by the Ebola virus by varying amounts of education/awareness being facilitated by the American Red Cross. The amount of education/awareness given by the American Red Cross is the independent variable, while the number of people who were or were not infected after public awareness efforts is the dependent variable.

Identify the research question and/or hypothesis.

Prompts:

· Was a research question or hypothesis provided in the article? If so, what is it? If not, why wasn’t one provided?

· What was the answer to the research question? Was the hypothesis accepted or rejected?

Example: The initial research question may be: What is the prevalence of Ebola in the West African nations after a new Centers for Disease Control and Prevention (CDC) protocol was implemented? The research explains in depth the living conditions that exist in the West African nations and why the disease is so prevalent. It further identifies and explains existing research conducted by the CDC that confirms the medical community’s awareness of the disease and established protocol to prevent it. The hypothesis can be: There is no statistically significant difference in Ebola prevalence after the CDC protocol was implemented.

Research Methodology, Design, and Analyses

Explain the research methodology, design, and analyses.

Prompts:

· Was the research qualitative, quantitative, or mixed methods? Explain your response.

· Which population or sample was studied?

· What was the sampling method and type?

· How long did the study take?

· How was the data collected?

· What type of statistical analysis was used?

Example: The research used quantitative data collected by the American Red Cross, the Centers for Disease Control and Prevention (CDC), and National Institute of Allergy and Infectious Diseases (NIAID). Data collection occurred over a 5-year period with help from 6 West African governments. The data tracked 100 residents from each country and monitored the spread of the disease among the citizens. Data analyses analyzed disease prevalence for decreases. Depending on Ebola prevalence, the research question can be answered. If Ebola prevalence decreased after implementing the CDC protocol, the hypothesis would be rejected.

Findings

Explain the research study’s findings.

Prompts:

· What were the research study’s findings?

· Were the research questions or hypotheses addressed?

Conclusion

Summarize the research study’s recommendations.

Prompts:

What were the research study’s recommendations?

Are the findings relevant to consumers, health care professionals, or both?

Explain the impact of the research to risk management and quality management.

Prompts:

How do the recommendations affect risk management and quality management in the health care environment?

How could you as a health care administrator use the information within this article as it relates to risk management and quality-improvement projects?

Example: The reporting of the Ebola outbreak in West Africa not only caused global panic, but also brought awareness of its cause and measures that can be taken to prevent its spread. The research conducted [finish statement]. As a health care administrator, I can use the information to [finish statement].

Copyright 2022 by University of Phoenix. All rights reserved.

Copyright 2022 by University of Phoenix. All rights reserved.

Running head: THE LOOK, THINK, ACT CYCLE 1

The Look, Think, Act Cycle

Angela M Miller

Your University

October 13, 2020

1.

THE LOOK, THINK, ACT CYCLE

Introduction

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work. In this

assignment we were asked to find two peer reviewed articles, one dissertation or thesis, one book

and one miscellaneous item. We were to complete an annotated bibliography, as well as compare

and contrast the selected items. Below you will find my work.

Research Steps

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work.

The Problem

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work. In this

assignment we were asked to find two peer reviewed articles, one dissertation or thesis, one book

and one miscellaneous item. We were to complete an annotated bibliography, as well as compare

and contrast the selected items. Below you will find my work.

The Purpose

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work.

2

THE LOOK, THINK, ACT CYCLE

The Variables

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work.

The Question/Hypothesis

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work.

Research Methodology Design and Analyses

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work.

Methodology

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work.

Population

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work.

Sampling Method

3

THE LOOK, THINK, ACT CYCLE

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work.

Length of the Study

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work.

Data Collection

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work.

Statistical Analysis

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work.

Findings

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work.

Findings of this study

4

THE LOOK, THINK, ACT CYCLE

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work.

Did the Author address the Question/Hypothesis

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work.

Conclusion

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work.

Recommendations

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work.

Relevancy

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work.

Health Care Usage

5

THE LOOK, THINK, ACT CYCLE

In this assignment we were asked to find two peer reviewed articles, one dissertation or

thesis, one book and one miscellaneous item. We were to complete an annotated bibliography, as

well as compare and contrast the selected items. Below you will find my work.

6

THE LOOK, THINK, ACT CYCLE

References

7

1Alshammary SA, et al. BMJ Open Quality 2021;10:e001391. doi:10.1136/bmjoq-2021-001391

Open access

Enhancing palliative care occupancy and
efficiency: a quality improvement
project that uses a healthcare pathway
for service integration and
policy development

Sami Ayed Alshammary,1 Yacoub Abuzied ,2 Savithiri Ratnapalan3

To cite: Alshammary SA,
Abuzied Y, Ratnapalan S.
Enhancing palliative care
occupancy and efficiency: a
quality improvement project that
uses a healthcare pathway for
service integration and policy
development. BMJ Open Quality
2021;10:e001391. doi:10.1136/
bmjoq-2021-001391

Received 13 February 2021
Accepted 10 October 2021

1Department of Palliative Care,
Comprehensive Cancer Center,
King Fahad Medical City, Riyadh,
Saudi Arabia
2Department of Nursing,
Rehabilitation Hospital, King
Fahad Medical City, Riyadh,
Saudi Arabia
3Department of Pediatrics,
University of Toronto Dalla Lana
School of Public Health, Toronto,
Ontario, Canada

Correspondence to
Yacoub Abuzied;
[email protected] gmail. com

Original research

© Author(s) (or their
employer(s)) 2021. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ.

ABSTRACT
This article described our experience in implementing
a quality improvement project to overcome the bed
overcapacity problem at a comprehensive cancer centre in
a tertiary care centre. We formed a multidisciplinary team
including a representative from patient and family support
(six members), hospice care and home care services
(four members), multidisciplinary team development (four
members) and the national lead. The primary responsibility
of the formulated team was implementing measures to
optimise and manage patient flow. We used the plan–
do–study–act cycle to engage all stakeholders from all
service layers, test some interventions in simplified pilots
and develop a more detailed plan and business case for
further implementation and roll- out, which was used as
a problem- solving approach in our project for refining
a process or implementing changes. As a result, we
observed a significant reduction in bed capacity from 35%
in 2017 to 13.8% in 2018. While the original length of stay
(LOS) was 28 days, the average LOS was 19 days in 2017
(including the time before and after the intervention), 10.8
days in 2018 (after the intervention was implemented),
10.1 days in 2019 and 16 days in 2020. The increase in
2020 parameters was caused by the COVID- 19 pandemic,
since many patients did not enrol in our new care
model. Using a systematic care delivery approach by a
multidisciplinary team improves significantly reduced bed
occupancy and reduces LOS for palliative care patients.

PROBLEM STATEMENT
Palliative care is vital to enhance the quality of
life for curative patients, seriously ill patients,
patients in terminal stages or patients with
considerable pain, including patients with
cancer. In collaboration with other depart-
ments, the palliative care department (PCD)
provides inpatient and outpatient care to
optimise the target patients’ well- being.
Unfortunately, unexpected bed overcapacity
by palliative care patients has been observed
to highlight an urgent need for improvement.

The PCD is part of a comprehensive cancer
centre (CCC) at King Fahad Medical City
(KFMC), Riyadh, Saudi Arabia. KFMC is a

Ministry of Health tertiary care complex
hospital with 1200 beds. It served around 30
000 inpatients and 500 000 outpatients annu-
ally. The CCC is part of the national cancer
strategy and is considered a primary ministry
of a health reference centre for patients with
cancer from all Saudi Arabia regions. The
centre covers haematology, bone and marrow
transplant and medical oncology for adult
and paediatric patients, in addition to radi-
ation therapy and palliative treatment. The
total bed capacity for palliative care in CCC
represents 87 beds.

Based on the available logistic patient’s
information, the PCD established a plan to
have an occupancy rate of around 10% of
all beds in CCC for palliative care patients.
However, we observed that palliative care
patients occupied 35%–50% of all CCCs,
representing around 300% of allocated to
palliative care patients. This bed overca-
pacity leads to hospital- wide logistic and clin-
ical burdens. It contributed to an increased
burden on human resources, leading to staff
shortage and increasing healthcare providers’
workload. Besides, bed overcapacity disrupts
other services such as the emergency depart-
ment, internal medicine and surgery by
displaced patients with cancer and unplanned
emergency room (ER) visits. Concurrently,
we observed a prolonged length of stay (LOS)
for palliative care patients with a LOS average
of 28 days. Figure 1 shows the problem high-
lights and critical challenging.

The quality team at PCD realised the
burden of this problem. We implemented a
quality improvement project to reduce the
overbed capacity for palliative care patients
from 35% in January 2017 by 10% by May
2018 in CCC. We aimed to reduce palliative
care patients’ average LOS (ALOS) from 28
days in January 2018 by 20% in May 2018.

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2 Alshammary SA, et al. BMJ Open Quality 2021;10:e001391. doi:10.1136/bmjoq-2021-001391

Open access

BACKGROUND
Palliative care aims to improve the quality of life for both
patients and families. It focuses on preventing and miti-
gating suffering from physical, psychological, social or
spiritual symptoms associated with life- threatening condi-
tions.1 Palliative care is provided by a multidisciplinary
team, as it requires integration and management for
multiple internal and external services and entities.

Integration of palliative care into public health systems
and other care levels is an ethical responsibility,2 yet
more than 85% of patients globally who need palliative
care cannot reach it.1 Improving access to palliative care
requires increasing the capacity of an existing programme
and developing healthcare programmes. More attention
should be given to understanding and organising palli-
ative care, training healthcare providers and providing
public education. Decision- makers should address the
multidisciplinary healthcare professions, policy and
procedures, required resources, required knowledge and
skills and education.1 3

Ignoring the current state resources, prioritising bed
allocation, targeted stakeholders or the required skills
and knowledge will lead to misusing or overusing the
resources. For example, many of the available beds are
occupied by patients requiring alternative care levels or
receiving in- hospital care when not needed (unneces-
sarily occupying of bed).

Struggling with bed congestion (overcapacity) is a
global problem for the healthcare system. Usually is
reflected by mismatches between capacity and demand
while providing care.4 5 It contributed to a chronic bed
shortage, staff shortage and increased the burden on
other departments, leading to overcrowded, delay in care
and financial consequences, insufficient coordination
between departments and prolonged LOS.6–8

Healthcare management identifies the way a healthcare
facility is organised and coordinated. It contributed to
finding solutions in different healthcare areas, including
bed capacity and LOS. For example, management of
bed overcapacity varied according to specified problems
or departments (one size does not fit all). The different
intervention has been applied to manage overcapacity
problems. Examples of these strategies include the

overcapacity management model,4 dynamic inpatient bed
management by reducing non- emergency department
(ED) admissions,8 full capacity protocol,9 diagnostic-
therapeutic- assistance path,10–12 discharge lounge,13 bed
huddles,14 reopening previously closed beds or adding
new beds5 or forecasting modelling framework.15 These
interventions focused on expanding, reducing the
boarding time, reducing the LOS, improving patients’
flow, free up available spaces or forecasting modelling.

Palliative care aims to support people with complex
needs by providing care by different specialties. Using
a multidisciplinary team and integrating a structured
method to assess and treat palliative care patients is
essential to ensure consistency and a systematic approach
in delivering palliative care.16 We believe that a system-
atic care delivery approach for improving an existing
capacity is necessary to provide the proper care, right
place and right time. There was a real need to improve
palliative care bed occupancy and efficiency in order to
provide proper care for all patients and the projected
proposal was strongly agreed upon and supported by
the leaders, where this will improve palliative care in
general, mainly bed occupancy and cost- effectiveness.
Where our aim was to reduce the overbed capacity
for palliative care patients in CCC. Also, we aimed to
reduce the ALOS of palliative care patients, as well as
their cost- effectiveness. From the start, we established
a plan that included frequent multidisciplinary meet-
ings to ensure the success, development and sustain-
ability of our project, as well as an evaluation process of
weekly challenges, obstacles and accomplishments. The
assumptions were that by having an organised team and
support from the institution and leader, the outcomes
would be as predicted and ideal. This article described
our experience implementing a quality improvement
project to overcome the bed overcapacity problem at a
CCC in a tertiary care centre. This article followed the
Standards for Quality Improvement Reporting Excel-
lence (SQUIRE) guidelines.17 The SQUIRE guidelines
provide a framework to report on new insights into how
healthcare is improved. They are intended for reports
describing healthcare workers’ quality, safety and value
at the system level.

MEASUREMENTS
For this project, we collected data before and after the
initiation of the quality improvement project. We calcu-
lated the CCC bed occupancy rate by palliative care
patients monthly. Then, we divided the mean number of
monthly beds occupied by palliative care patients by the
total number of all CCC beds (87 beds). We also calcu-
lated the entire LOS days and the average LOS for pallia-
tive care patients in CCC by reviewing the date of hospital
admissions and hospital discharges. Also, we calculated
the average monthly number of unplanned ER visits by
palliative care patients (table 1).

Figure 1 2017 statistics and key challenges. MDT,
multidisciplinary team; PCA, patient control analgesia.

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3Alshammary SA, et al. BMJ Open Quality 2021;10:e001391. doi:10.1136/bmjoq-2021-001391

Open access

ER visits of 2020 are mostly patients who were not
recruited into our new model of care. Therefore, we
expect this indicator to lag behind 8–12 months.

We calculated the cost of care for admitted palliative
care patients by multiplying the total number of patient’s
days by the estimated cost per patient. To meet our project
goals for reducing bed overcapacity and LOS for palliative
care patients, we planned to start measuring from January
2017 and continue counting until December 2020 (1000
days for PC transformation). Measuring project indica-
tors over a long time will allow us to observe the improve-
ment and observe its sustainability. Data were collected by
trained staff from the quality improvement team at PCD.

Baseline measurement showed that the average
number of beds used by palliative care patients in CCC

was 30, representing 35% of CCC bed occupancy. This
rate exceeds three times the planned rate of 10% of CCC
beds by palliative care patients. The baseline average LOS
was 28 days. The number of unplanned ER visits was 7.9 in
2017. The cost of care for admitted palliative care patients
in CCC was US$18 170 000.

Patient and public involvement
Patients were not specifically included in the analysis
since all statistics were gathered from the department’s
database, including data on admissions and discharges
during their stay at the hospital if their permission is not
necessary as the approval received from the department
chair.

Design
Understanding the system’s complexity and its interac-
tion is crucial for successfully implementing any quality
improvement project.18 Palliative care is a complex
setting requiring a multidisciplinary team and a system-
atic approach to assess and treat patients.16 Similarly,
solving problems and improving the palliative care setting
processes required a systematic approach involving
all stakeholders. Therefore, we initiated a future state
pathway map for the palliative care process (figure 2). We
formed a multidisciplinary team, including a represent-
ative from patients and family support (six members),
hospice care and home care services (four members),
multidisciplinary team development (four members)
and the national lead. The primary responsibility of the
formulated team was implementing measures to optimise
and manage patient flow.

To measure our quality improvement project’s effec-
tiveness on the process, we implemented a pre and post
quasi- experimental design, in which the observations are
made before and after the intervention. We analysed the

Table 1 Unplanned emergency room visits by palliative
care patients

2017 2018 2019 2020

January 5 5 8 7

February 8 5 7 4

March 5 9 7 6

April 9 5 4 11

May 10 9 2 9

June 9 7 11 13

July 9 5 8 6

August 9 6 9 9

September 13 4 8 10

October 6 5 5 12

November 5 3 9 7

December 7 4 9 7

Annual average 7.92 5.58 7.25 8.42

Figure 2 Future state pathway map—palliative care.

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4 Alshammary SA, et al. BMJ Open Quality 2021;10:e001391. doi:10.1136/bmjoq-2021-001391

Open access

data over time and presented them using run charts and
tables. To ensure that the improvement is related to the
intervention, we measured the data for a long time; more
specifically, we measured the data in 4 years (2017–2020).
To make our intervention sustainable, we developed and
implemented relevant tools, policies and procedures.
We set goals for a 100- day plan to complete our inter-
vention (figures 3 and 4). In addition, we calculated and
compared the cost of care.

Strategy
Our smart aim was to reduce the overbed capacity for
palliative care patients from 35% in January 2018 to 10%
by May 2018 in CCC. Also, we aimed to reduce the ALOS

of palliative care patients from 28 days in January 2018
by 20% in May 2018. Plan–do–study–act cycle was used
as a problem- solving approach in our project for refining
a process or implementing changes to enlist the partic-
ipation of all stakeholders from all service tiers. Some
interventions were tested in simpler pilots and a more
comprehensive strategy and business case was developed
for future implementation and roll- out. We set goals for
a 100- day plan to complete our intervention (implemen-
tation of the future state pathway, as well as policies and
procedures that support and stabilise the pathway). At
the end of 100 days, the team had:

► Engaged all stakeholders from all services.
► Tested some interventions in simplified pilots.
► Developed a more detailed plan and business case for

further implementation and roll- out.
Our initial step was to engage multiple stakeholders from
different layers. As a result, for example, we have begun
to impact engagement with and the effectiveness of family
meetings positively.

► Identify and enlist a team of people with the appro-
priate skills to deliver the immediate programme
requirements, share roles and responsibilities and
agree on capacity.

► Assign a project manager with the skills and capacity
to lead the programme and liaise directly with the
vision realisation office (VRO).

► Agree on the governance structure, including
enlisting the right people with the required authority/
permissions.

Figure 3 Implementation plan. KPIs, key performance indicators; VRO, vision realisation office.

Figure 4 Effort impact diagram. MDT, multidisciplinary
team; PCA, patient control analgesia.

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5Alshammary SA, et al. BMJ Open Quality 2021;10:e001391. doi:10.1136/bmjoq-2021-001391

Open access

► Develop and establish a reporting mechanism and
rhythm that underpins programme activity.

► Assign focus areas to individuals (or workstream
leaders).

► Develop current milestones and immediate tasks.
► Develop high- level plans with estimated milestones

and gateway points.
► Assign communications owner and liaise with VRO.
► Conduct stakeholder analysis, populating templates

with VRO.
► Agree on communications strategy and develop a first

draft of the plan.
► Review data collection requirements—for example,

key performance indicators (KPIs) or to test interven-
tion hypothesis.

RESULTS
Our primary outcome measures were the average
number of beds occupied by palliative care patients
in CCC and their average LOS. We also calculated the
average number of unplanned ER visits and the cost of
care. We observed a significant reduction in bed capacity
from 35% in 2017 to 13.8% in 2018. The LOS was 28 days
before implementing the intervention. The average LOS
was 19 days in 2017 (before and after the intervention),
10.8 days in 2018 (after implementing the intervention),
10.1 days in 2019 and 16 days in 2020. These data are
presented in a run- chart (figure 5). The average number
of unplanned visits decreased from 7.9 in 2017 to 5.5 in
2018 and 7.3 in 2019. However, it was increased in 2020 to
8.7 (figure 5). The total annual cost was reduced by 69%,
from US$19 642 000 to US$5 438 600.

Controlling the sustainability of the process was
evidenced by the preservation of reducing all measures
over the years. However, due to the COVID- 19 pandemic,
many patients were not recruited into our new care
model. Because of this reason, the measures of 2020 were
increased in comparison to previous years. Therefore, we
expect this indicator to lag behind 8–12 months.

Lessons and limitations
The primary objective of this project was to enhance palli-
ative care occupancy and efficiency. The outcome showed

significant improvement as the average of occupied beds
by palliative care patients reduced from 35% to 13.8% in
CCC.

Our quality improvement project uses a systematic
care delivery approach that requires the interactions
of a multidisciplinary team. This approach significantly
reduced the LOS for palliative care patients and reduced
the annual cost of care. Using a systematic way to solve
problems or improve palliative care settings is essential
as palliative care requires multiple stakeholders’ coopera-
tion and interactions.16 In addition, previous studies high-
lighted the importance of proactive and multidisciplinary
care in reducing LOS and hospital expences.19

An altered discharging plan can increase LOS and
increase the bed occupancy rate where the bed utilisation
will be affected, hence increasing the cost.20 The process
of discharging patients is complicated as it requires coor-
dination from a multidisciplinary group, including physi-
cians, nurses, ancillary service staff, patients, and families.
This study provides a set of measures that are within the
hospital’s control to improve LOS. This project was initi-
ated to decrease bed overcapacity, reduce the LOS, and
provide the tools to develop and implement relevant poli-
cies and procedures.

Our results should be interpreted in light of their
strengths and weaknesses. The studies that discussed
quality improvement projects for bed overcapacity are
limited. This article discussed applying a systematic care
delivery approach model to promote palliative care’s
capacity and efficiency. Our results emphasised that using
a systematic approach by engaging a multidisciplinary
team improved bed capacity, LOS and the cost of care.
Also, our results assured that this approach is sustainable
over time. However, plans should be set to overcome
emergent challenges such as what happened during the
COVID- 19 pandemic.

The main limitation is represented in the nature of the
pre and post quasi- experimental design. Thus, it is chal-
lenging to know the exact responsible factor for process
improvement, mainly when using interventions with
multiple combinations. Besides, it is not easy to control
various confounders over time.21 However, measuring the
intervention’s effectiveness over a long time may reduce
the burden of these limitations, especially in continuous
improvement.

CONCLUSION
A systematic care delivery approach by including
a multidisciplinary team improves a palliative care
setting’s capacity and efficiency. This approach signif-
icantly enhances bed overcapacity and reduces LOS.
Providing tools, policies and procedures will help in
the sustainability of the project over time. Due to the
significant project outcome, sharing this intervention
will help measure, validate and improve it when used
by others.

Figure 5 Length of Stay (LOS) run chart.

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6 Alshammary SA, et al. BMJ Open Quality 2021;10:e001391. doi:10.1136/bmjoq-2021-001391

Open access

Acknowledgements The authors would like to thank King Fahad Medical City
through the research centre for technical support.

Contributors The research team designed and led the study’s design and the
article’s preparation; also carried out data extraction and analysis and carried out
a systematic review of the literature for data retrieval. The final version of this
manuscript was read and approved by all authors. Before submission, all listed
authors have approved the manuscript, including the names and data included and
the graphs. All of the writers got input and helped shape the research, review and
manuscript. SAA and SR designed and directed the presented study. YA and SAA
wrote the manuscript with input from SAA. All the authors contributed to sample
preparation. YA and SAA collected the data. YA performed the calculations and
designed the figures. SAA supervised the project. Both SAA and YA contributed to
the final version of the manuscript.

Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not- for- profit sectors.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.

Patient consent for publication Not applicable.

Ethics approval The Institutional Review Board at King Fahad Medical City gave
ethical approval for this study. The authors used primary data collected by the
research team. The chairperson of the respective departments granted approval for
collecting data.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement Data are available upon reasonable request.

Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non- commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.

ORCID iD
Yacoub Abuzied http:// orcid. org/ 0000- 0003- 1388- 4549

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  • Enhancing palliative care occupancy and efficiency: a quality improvement project that uses a healthcare pathway for service integration and policy development
    • Abstract
    • Problem statement
    • Background
    • Measurements
      • Patient and public involvement
      • Design
      • Strategy
    • Results
      • Lessons and limitations
    • Conclusion
    • References
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