A report card on continuous quality improvement

Study protocol for type II hybrid implementation-effectiveness trial of strategies for depression care task-sharing in community health stations in Vietnam: DEP Project

BACKGROUND

It is not clear what the most effective implementation strategies are for supporting the enactment and sustainment of depression care services in primary care settings. This type-II Hybrid Implementation-Effectiveness study will compare the effectiveness of three system-level strategies for implementing depression care programs at 36 community health stations (CHSs) across 2 provinces in Vietnam.

METHODS

In this cluster-randomized controlled trial, CHSs will be randomly assigned to one of three implementation conditions: (1) Usual Implementation (UI), which consists of training workshops and toolkits; (2) Enhanced Supervision (ES), which includes UI combined with bi-weekly/monthly supervision; and (3) Community-Engaged Learning Collaborative (CELC), which includes all components of ES, combined with bi-monthly province-wide learning collaborative meetings, during which cross-site learning and continuous quality improvement (QI) strategies are implemented to achieve better implementation outcomes. The primary outcome will be measured based on the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation quality, and Maintenance) using indicators on implementation, provider, and client factors. The secondary outcome examines factors associated with barriers and facilitators of quality implementation, while the tertiary outcome evaluates the incremental cost-effectiveness ratio of services provided in the ES and CELC conditions, relative to UI condition for depression care. A total of 1,296 clients receiving depression care at CHSs will be surveyed at baseline and 6-month follow-up to assess mental health and psychosocial outcomes (e.g., depression and anxiety severity, health function, quality of life). Additionally, 180 CHS staff and 180 non-CHS staff will complete pre- and post-training evaluation and surveys at baseline, 6, 12, and 24 months.

DISCUSSION

We hypothesize that the additional implementation supports will make mental health service implementation superior in the ES and CELC arms compared to the UI arm. The findings of this project could identify effective implementation models and assess the added value of specific QI strategies for implementing depression care in primary care settings in Vietnam, with implications and recommendations for other low- and middle-income settings. More importantly, this study will provide evidence for key stakeholders and policymakers to consider policies that disseminate, scale up, and advance quality mental health care in Vietnam.

TRIAL REGISTRATION

NCT04491045 on Clinicaltrials.gov. Registered July 29, 2020.

Evaluating quality improvement at scale: A pilot study on routine reporting for executive board governance in a UK National Health Service organisation

BACKGROUND

Quality improvement (QI) in healthcare is a cultural transformation process. We explored how routine reporting could be developed to aid visibility of the process for QI governance.

METHOD

A retrospective evaluation of QI projects in a large healthcare organisation was conducted. We used an online survey so that the data accrual process resembled routine reporting to help identify implementation challenges. A purposive sample of QI projects was targeted to maximise contrast between projects that were or were not successful as determined by the resident QI team. To hone strategic focus in what should be reported, we also compared factors that might affect project outcomes.

RESULTS

Out of 52 QI projects, 10 led to a change in routine practice ('adoption'). Details of project outcomes were limited. Project team outcomes, indicative of capacity building, were not systematically documented. Service user involvement, quality of measurement plan, fidelity of plan-do-study-act (PDSA) cycles had a major impact on adoption.

CONCLUSION

Designing a routine reporting framework requires an iterative process to navigate data accrual demands. A retrospective evaluation, as in this study, can yield empirical insights to support development of QI governance, thereby honing the implementation science of QI in a healthcare organisation.

Avoiding Retained Surgical Items at an Academic Medical Center: Sustainability of a Surgical Quality Improvement Project

Unintentionally retained surgical items (RSIs) are a serious complication representing a surgical "Never" event. The authors previously reported the process and significant improvement over a 3-year multiphased quality improvement RSI reduction effort that included sponge-counting technology. Herein, they report the sustainability of that effort over the decade following the formal quality improvement project conclusion. This retrospective analysis includes descriptive and qualitative data collected during RSI event root cause analysis. Between January 2009 and December 2019, 640 889 operations were performed with 24 RSIs reported. The resulting RSI rate of 1 per 26 704 operations represent a 486% performance improvement compared to the preintervention rate of 1 per 5500 operations. The interval, in days, between RSI events increased to 160 from 26 during the preintervention phase. Cotton sponges were the most retained RSI despite the use of sponge-counting technology. A significant and sustained reduction in RSI is possible after designing a sustainable comprehensive multidisciplinary effort.

Context in Implementation Science

Changing health care delivery systems and processes of care to improve health care quality is complex. What is done (intervention) is equally important as how it is done (implementation) and where it is done (context). Furthermore, it has been consistently observed that among groups participating in multisite quality improvement (QI) efforts and implementation studies, significant heterogeneity in the improvements is seen. Our objective is to provide a step-by-step guide to assist both researchers and groups practicing QI on the frontlines in addressing context in planning, implementing, and disseminating their QI and implementation interventions. We discuss in depth a sample of the >60 available dissemination and implementation frameworks that consider context. We then provide an approach to addressing context in QI and implementation initiatives and discuss an application of this approach, using a published study as an example. Finally, we discuss next steps for the field of context and implementation science. Data from networks of health systems working together on QI are needed on both network-wide rates of process and outcome measures. Also needed are segmented/stratified data that inform our understanding of the influence of context on successful implementation in subgroups. Finally, multisite prospective studies are needed to develop an in-depth understanding of how specific context and implementation factors affect the successful spread of proven interventions.

Relational interventions for organizational learning: An experience report

INTRODUCTION

Quality improvement and implementation science practitioners identify relational issues as important obstacles to success. Relational interventions may be important for successful performance improvement and fostering Learning Health Systems.

METHODS

This case report describes the experience and lessons learned from implementing a relational approach to organizational change, informed by Relational Coordination Theory, in a health system. Structured interviews were used to obtain qualitative participant feedback. Relational Coordination was measured serially using a validated seven-item survey.

RESULTS

An initial, relational intervention on one unit promoted increased participant engagement, self-efficacy, and motivation that led to the spontaneous, emergent dissemination of relational change, and learning into other parts of the health system. Staff involved in the intervention reported increased systems thinking, enhanced focus on communication and relationships as key drivers for improvement and learning, and greater awareness of organizational change as something co-created by staff and executives.

CONCLUSIONS

This experience supports the hypothesis that relational interventions are important for fostering the development of Learning Health Systems.

An empirical examination of the relationship between benchmarking, innovation culture and organisational performance using structural equation modelling

Purpose

Police agencies are under pressure to improve their performance and provide outstanding services for the community. In response, academics and practitioners have called to adopt effective methods that help these agencies to achieve their goals. Studies reported that benchmarking has a role to improve organisational performance. However, poor evidence of using benchmarking within police agencies and very few studies examine the relationship between it and police performance. Motivated by this gap, this study aims to explore and examine this relationship under the mediating role of innovation culture.

Design/methodology/approach

A quantitative methodology was utilised in this study. Data used to examine the hypotheses were obtained from the departments and stations of the Dubai Police Force (DPF), and the population comprised head section officers. A total of 338 questionnaires were distributed to respondents, 252 of which were returned. The hypothesised relationships were tested with the data collected by SPSS and SmartPLS statistical software.

Findings

Findings clearly show that benchmarking is directly and indirectly associated with the organisational performance of the DPF through innovation culture. Results support the notion that innovation culture facilitates the implementation of proper benchmarking projects in the DPF, which positively affects different aspects of its performance.

Research limitations/implications

This study includes several limitations. Specifically, the generalisability of the findings should be considered. The analysis applies only to the DPF in the UAE. Thus, investigating and analysing variables in different police agencies in the UAE or internationally would be valuable.

Practical implications

Several recommendations are provided in relation to the obtained results to assist managers and decision makers in the DPF and other police agencies. This study includes suggestions for improving police performance by establishing an innovation culture and adopting benchmarking practices.

Originality/value

Although several contributions indicated that benchmarking and innovation culture is a key determinant of success, the literature lacks empirical studies investigating this link in the police field. This study is the only one to date that examined this relationship in police services. Accordingly, this study seeks to bridge this gap and delivers empirical evidence and theoretical insight to better understand this relationship.

Leveraging digital transformation to empower clinical governance: enhancement in intermediate clinical endpoints and patients' survival after implementation of a continuous quality improvement program in a large dialysis network

BACKGROUND

Treatment of end-stage kidney disease patients is extremely challenging given the inter-connected functional derangements and comorbidities characterizing the disease. Continuous Quality Improvement (CQI) in healthcare is a structured clinical governance process helping physicians adhere to best clinical practices. The digitization of patient medical records and data warehousing technologies has standardized and enhanced the efficiency of the CQÍs evidence generation process. There is limited evidence that ameliorating intermediate outcomes would translate into better patient-centered outcomes. We sought to evaluate the relationship between Fresenius Medical Care (FME) medical patient review CQI (MPR-CQI) implementation and patients' survival in a large historical cohort study.

METHODS

We included all incident adult patients with 6 months survival on chronic dialysis registered in the EMEA region between 2011-2018. We compared medical Key Performance Indicator (KPI) target achievements and 2-year mortality for patients enrolled prior and after to MPR-CQI policy onset (Cohort A and Cohort B). We adopted a structural equation model where MPR-CQI policy was the exogenous explanatory variable, KPI target achievements the mediator variable, and survival was the outcome of interest.

RESULTS

4.270 patients (Cohort A: 2.397; Cohort B: 1.873) met the inclusion criteria. We observed an increase in KPI target achievements after MPR-CQI policy implementation. Mediation analysis demonstrated a significant reduction in mortality due to indirect effect of MPR-CQI implementation through improvement in KPI target achievement occurring in the post-implementation era (OR: 0.70; 95%CI: 0.65-0.76; p < 0.0001).

CONCLUSIONS

Our study suggests that MPR-CQI achieved by standardized clinical practice and periodical, structured, medical patient review may improve patients' survival through improvement in medical KPIs.

Continuous quality improvement as a tool to implement evidence-informed problem solving: experiences from the district and health facility level in Uganda

Background

Continuous quality improvement processes in health care were developed for use at health facility level, and that is where they have been used the most, often addressing defined care processes. However, in different settings different factors have been important to support institutionalization. This study explores how continuous quality improvement processes were institutionalized at the district level and at the health facility level in Uganda.

Methods

This qualitative study was carried out in seven districts in Uganda. Semi-structured interviews with key informants from the district health management teams and document review were conducted. Thematic analysis was used to analyze the data.

Results

All districts that participated in the study formed Continuous Quality Improvement (CQI) teams both at the district level and at the health facilities. The district CQI teams comprised of members from different departments within the district health office. District level CQI teams were mandated to take the lead in addressing management gaps and follow up CQI activities at the health facility level. Acceptability of quality improvement processes by the district leadership was identified across districts as supporting the successful implementation of CQI. However, high turnover of staff at health facility level was also reported as a detrimental to the successful implementation of quality improvement processes. Also the district health management teams did not engage much in addressing their own roles using continuous quality improvement.

Conclusion

The leadership and management provided by the district health management team was an important factor for the use of Continuous Quality Improvement principles within the district. The key roles of the district health team revolved around the institutionalisation of CQI at different levels of the health system, monitoring results of continuous quality improvement implementation, mobilising resources and health care delivery hence promoting the culture of quality, direct implementation of CQI, and creating an enabling environment for the lower-level health facilities to engage in CQI. High turnover of staff at health facility level was also reported as one of the challenges to the successful implementation of continuous quality improvement. The DHT did not engage much in addressing gaps in their own roles using continuous quality improvement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06061-8.

The micropolitics of implementation; a qualitative study exploring the impact of power, authority, and influence when implementing change in healthcare teams

Background

Healthcare organisations are complex social entities, comprising of multiple stakeholders with differing priorities, roles, and expectations about how care should be delivered. To reach agreement among these diverse interest groups and achieve safe, cost-effective patient care, healthcare staff must navigate the micropolitical context of the health service. Micropolitics in this study refers to the use of power, authority, and influence to affect team goals, vision, and decision-making processes. Although these concepts are influential when cultivating change, there is a dearth of literature examining the mechanisms through which micropolitics influences implementation processes among teams. This paper addresses this gap by exploring the role of power, authority, and influence when implementing a collective leadership intervention in two multidisciplinary healthcare teams.

Methods

The multiple case study design adopted employed a triangulation of qualitative research methods. Over thirty hours of observations (Case A = 16, Case B = 15) and twenty-five interviews (Case A = 13, Case B = 12) were completed. An in-depth thematic analysis of the data using an inductive coding approach was completed to understand the mechanisms through which contextual factors influenced implementation success. A context coding framework was also employed throughout implementation to succinctly collate the data into a visual display and to provide a high-level overview of implementation effect (i.e. the positive, neutral, or negative impact of contextual determinants on implementation).

Results

The findings emphasised that implementing change in healthcare teams is an inherently political process influenced by prevailing power structures. Two key themes were generated which revealed the dynamic role of these concepts throughout implementation: 1) Exerting hierarchical influence for implementation; and 2) Traditional power structures constraining implementation. Gaining support across multiple levels of leadership was influential to implementation success as the influence exercised by these individuals persuaded follower engagement. However, the historical dynamics of each team determined how this influence was exerted and perceived, which negatively impacted some participants’ experiences of the implementation process.

Conclusion

To date, micropolitics has received scant attention in implementation science literature. This study introduces the micropolitical concepts of power, authority and influence as essential contextual determinants and outlines the mechanisms through which these concepts influence implementation processes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05905-z.

Patient feedback to improve quality of patient-centred care in public hospitals: a systematic review of the evidence

Background

To review systematically the published literature relating to interventions informed by patient feedback for improvement to quality of care in hospital settings.

Methods

A systematic search was performed in the CINAHL, EMBASE, PsyInfo, MEDLINE, Cochrane Libraries, SCOPUS and Web of Science databases for English-language publications from January 2008 till October 2018 using a combination of MeSH-terms and keywords related to patient feedback, quality of health care, patient-centred care, program evaluation and public hospitals. The quality appraisal of the studies was conducted with the MMAT and the review protocol was published on PROSPERO. Narrative synthesis was used for evaluation of the effectiveness of the interventions on patient-centred quality of care.

Results

Twenty papers reporting 20 studies met the inclusion criteria, of these, there was one cluster RCT, three before and after studies, four cross-sectional studies and 12 organisational case studies. In the quality appraisal, 11 studies were rated low, five medium and only two of high methodological quality. Two studies could not be appraised because insufficient information was provided. The papers reported on interventions to improve communication with patients, professional practices in continuity of care and care transitions, responsiveness to patients, patient education, the physical hospital environment, use of patient feedback by staff and on quality improvement projects. However, quantitative outcomes were only provided for interventions in the areas of communication, professional practices in continuity of care and care transitions and responsiveness to patients. Multi-component interventions which targeted both individual and organisational levels were more effective than single interventions. Outcome measures reported in the studies were patient experiences across various diverse dimensions including, communication, responsiveness, coordination of and access to care, or patient satisfaction with waiting times, physical environment and staff courtesy.

Conclusion

Overall, it was found that there is limited evidence on the effectiveness of interventions, because few have been tested in well-designed trials, very few papers described the theoretical basis on which the intervention had been developed. Further research is needed to understand the choice and mechanism of action of the interventions used to improve patient experience.

Assessment of facility performance during mass treatment of chronic hepatitis C in Egypt: Enablers and obstacles

BACKGROUND

The national committee for control of viral hepatitis (NCCVH) in Egypt, settled by the Ministry of health, treated over one million patients in around 60 centers with chronological changes in drug combinations. This research aims to study the health care facilities and services provided by NCCVH treatment centers in Egypt and explore hinders faced.

METHODS

A cross-sectional operational research study. Multistage random sampling technique was applied for Egyptian governorates. From each stratum one governorate was chosen from which one center was randomly selected. Quality of recorded data for each center in the central server (Data-oriented parameter), newly designed score to assess the overall performance of the centers was retrieved from computer based recording system. A self-administered questionnaire was completed by the centers head.

RESULTS

This study included 24 treatment centers from urban, rural areas, Upper and Lower Egypt. The Upper centers showed the best completeness of follow-up records and the least compliance rates. None of the centers had 100% completeness of follow-up data. Proportion of SVR is minimally less than proportion of patient with known outcome in all treatment centers. A novel indicator standardizing the comparisons of performance of different facilities was introduced: Total number of physicians/total number of SVR patients with completed records. The highest response rate: Monfiya Governorate (Lower Egypt), Aswan (Upper Egypt), Completeness of follow-up records: Kalyoubia (Lower Egypt), Sohag governorate (Upper Egypt). The average administrative score was 64%.

CONCLUSION

Challenges of NCCVH program: overcrowdings, resistant sociocultural background among rural patients, limited accessibility for internal migrants and incompleteness of data entry are system lacking points. Strengths include, clear patient pathway, well-established database online application, well-trained physicians and treatment availability.

Can quality improvement improve the quality of care? A systematic review of reported effects and methodological rigor in plan-do-study-act projects

Background

The Plan-Do-Study-Act (PDSA) method is widely used in quality improvement (QI) strategies. However, previous studies have indicated that methodological problems are frequent in PDSA-based QI projects. Furthermore, it has been difficult to establish an association between the use of PDSA and improvements in clinical practices and patient outcomes. The aim of this systematic review was to examine whether recently published PDSA-based QI projects show self-reported effects and are conducted according to key features of the method.

Methods

A systematic literature search was performed in the PubMed, Embase and CINAHL databases. QI projects using PDSA published in peer-reviewed journals in 2015 and 2016 were included. Projects were assessed to determine the reported effects and the use of the following key methodological features; iterative cyclic method, continuous data collection, small-scale testing and use of a theoretical rationale.

Results

Of the 120 QI projects included, almost all reported improvement (98%). However, only 32 (27%) described a specific, quantitative aim and reached it. A total of 72 projects (60%) documented PDSA cycles sufficiently for inclusion in a full analysis of key features. Of these only three (4%) adhered to all four key methodological features.

Conclusion

Even though a majority of the QI projects reported improvements, the widespread challenges with low adherence to key methodological features in the individual projects pose a challenge for the legitimacy of PDSA-based QI. This review indicates that there is a continued need for improvement in quality improvement methodology.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4482-6) contains supplementary material, which is available to authorized users.

Improving laboratory test utilisation at the multihospital Yale New Haven Health System

Background

Waste persists in healthcare and negatively impacts patients. Clinicians have direct control over test ordering and ongoing international efforts to improve test utilisation have identified multifaceted approaches as critical to the success of interventions. Prior to 2015, Yale New Haven Health lacked a coherent strategy for laboratory test utilisation management.

Methods

In 2015, a system-wide laboratory formulary committee was formed at Yale New Haven Health to manage multiple interventions designed to improve test utilisation. We report here on specific interventions conducted between 2015 and 2017 including reduction of (1) obsolete or misused testing, (2) duplicate orders, and (3) daily routine lab testing. These interventions were driven by a combination of modifications to computerised physician order entry, test utilisation dashboards and physician education. Measurements included test order volume, blood savings and cost savings.

Results

Testing for a number of obsolete/misused analytes was eliminated or significantly decreased depending on alert rule at order entry. Hard stops significantly decreased duplicate testing and educational sessions significantly decreased daily orders of routine labs and increased blood savings but the impact waned over time for select groups. In total, we realised approximately $100 000 of cost savings during the study period.

Conclusion

Through a multifaceted approach to utilisation management, we show significant reductions in low-value clinical testing that have led to modest but significant savings in both costs and patients’ blood.

Adaptation and Implementation of a Family Caregiver Skills Training Program: From Single Site RCT to Multisite Pragmatic Intervention

PURPOSE

We describe an approach to rapidly adapt and implement an education and skills improvement intervention to address the needs of family caregivers of functionally impaired veterans-Helping Invested Families Improve Veterans' Experience Study (HI-FIVES).

DESIGN

Prior to implementation in eight sites, a multidisciplinary study team made systematic adaptations to the curriculum content and delivery process using input from the original randomized controlled trial (RCT); a stakeholder advisory board comprised of national experts in caregiver education, nursing, and implementation; and a veteran/caregiver engagement panel. To address site-specific implementation barriers in diverse settings, we applied the Replicating Effective Programs implementation framework.

FINDINGS

Adaptations to HI-FIVES content and delivery included identifying core/noncore curriculum components, reducing instruction time, and simplifying caregiver recruitment for clinical settings. To enhance curriculum flexibility and potential uptake, site personnel were able to choose which staff would deliver the intervention and whether to offer class sessions in person or remotely. Curriculum materials were standardized and packaged to reduce the time required for implementation and to promote fidelity to the intervention.

CONCLUSIONS

The emphasis on flexible intervention delivery and standardized materials has been identified as strengths of the adaptation process. Two key challenges have been identifying feasible impact measures and reaching eligible caregivers for intervention recruitment.

CLINICAL RELEVANCE

This systematic implementation process can be used to rapidly adapt an intervention to diverse clinical sites and contexts. Nursing professionals play a significant role in educating and supporting caregivers and care recipients and can take a leading role to implement interventions that address skills and unmet needs for caregivers.

The challenges of implementation of clinical governance in Iran: a meta-synthesis of qualitative studies

Background

Policy- and decision-makers seek to improve the quality of care in the health sector and therefore aim to improve quality through appropriate policies. Higher quality of care will satisfy service providers and the public, reduce costs, increase productivity, and lead to better organisational performance. Clinical governance is a method through which management can be improved and made more accountable, and leads to the provision of better quality of care. In November 2009, the Iranian Ministry of Health and Medical Education implemented new clinical guidelines to standardise and improve clinical services as well as to increase efficiency and reduce costs. The purpose of this study was to assess the challenges of implementing clinical governance through a meta-synthesis of qualitative studies published in Iran.

Methods

Ten databases, including ISI/Web of Sciences, PubMed/MEDLINE, Embase, PsycINFO, the Cochrane Library, CINAHL, Scopus, Barakatns, MagIran and the Scientific Information Database, were searched between January 2009 and May 2018. The quality of the included studies was assessed using the Critical Appraisal Skills Programme tool. This study was reported according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research guidelines. Thematic synthesis was used to analyse the data.

Results

Ten studies were selected and included based on the inclusion/exclusion criteria. In the first stage, 75 items emerged and were coded, and, following comparison and combination of the codes, 32 codes and 8 themes were finally extracted. These themes included health system structure, management, person-power, cultural factors, information and data, resources, education and evaluation.

Conclusion

The findings of the study showed that there exist a variety of challenges for the implementation of clinical governance in Iran. To successfully implement a health policy, its infrastructure needs to be created. Using the views and support of stakeholders can ensure that a policy is well implemented.

Trial registration

CRD42017079077. Dated October 10, 2017.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0399-5) contains supplementary material, which is available to authorized users.

The Adoption of Surgical Innovations at Academic Versus Nonacademic Health Centers

PURPOSE

The value of the health care services provided by academic health centers (AHCs) in the United States increasingly is being questioned. AHCs play a prominent role in developing new surgical innovations, including new minimally invasive techniques, which are costly up front but can lead to significant benefits like decreased morbidity and lengths of stays. This study explored the role of AHCs in the adoption of these surgical innovations as a novel measure of their value.

METHOD

The authors combined data from the American Hospital Association and the State Inpatient Databases from California, Florida, Washington State, and New York. They compared the number and percentage of patients who received four new, innovative surgical procedures (vs. those who received the traditional procedures) at Council of Teaching Hospitals (COTH) hospitals to those at non-COTH hospitals from 2009 to 2011.

RESULTS

Overall, 61.1% (27,175) of the procedures performed at COTH hospitals used new techniques, compared with 47.2% (41,680) at non-COTH hospitals, across all years (P < .0001). The number and percentage of procedures using the new techniques increased in all years and for all procedures.

CONCLUSIONS

Not only do AHCs play a role in developing surgical innovations but they also adopt these new techniques more quickly than other hospitals, and thereby they provide additional benefits to patients. These findings provide an important and understudied perspective on the value of AHCs.

Domains associated with successful quality improvement in healthcare - a nationwide case study

Background

There is a distinct difference between what we know and what we do in healthcare: a gap that is impairing the quality of the care and increasing the costs. Quality improvement efforts have been made worldwide by learning collaboratives, based on recognized continual improvement theory with limited scientific evidence. The present study of 132 quality improvement projects in Norway explores the conditions for improvement from the perspectives of the frontline healthcare professionals, and evaluates the effectiveness of the continual improvement method.

Methods

An instrument with 25 questions was developed on prior focus group interviews with improvement project members who identified features that may promote or inhibit improvement. The questionnaire was sent to 189 improvement projects initiated by the Norwegian Medical Association, and responded by 70% (132) of the improvement teams. A sub study of their final reports by a validated instrument, made us able to identify the successful projects and compare their assessments with the assessments of the other projects. A factor analysis with Varimax rotation of the 25 questions identified five domains. A multivariate regression analysis was used to evaluate the association with successful quality improvements.

Results

Two of the five domains were associated with success: Measurement and Guidance (p = 0.011), and Professional environment (p = 0.015). The organizational leadership domain was not associated with successful quality improvements (p = 0.26).

Conclusion

Our findings suggest that quality improvement projects with good guidance and focus on measurement for improvement have increased likelihood of success. The variables in these two domains are aligned with improvement theory and confirm the effectiveness of the continual improvement method provided by the learning collaborative. High performing professional environments successfully engaged in patient-centered quality improvement if they had access to: (a) knowledge of best practice provided by professional subject matter experts, (b) knowledge of current practice provided by simple measurement methods, assisted by (c) improvement knowledge experts who provided useful guidance on measurement, and made the team able to organize the improvement efforts well in spite of the difficult resource situation (time and personnel). Our findings may be used by healthcare organizations to develop effective infrastructure to support improvement and to create the conditions for making quality and safety improvement a part of everyone’s job.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2454-2) contains supplementary material, which is available to authorized users.

Staffs' and managers' perceptions of how and when discrete event simulation modelling can be used as a decision support in quality improvement: a focus group discussion study at two hospital settings in Sweden

OBJECTIVE

To explore healthcare staffs' and managers' perceptions of how and when discrete event simulation modelling can be used as a decision support in improvement efforts.

DESIGN

Two focus group discussions were performed.

SETTING

Two settings were included: a rheumatology department and an orthopaedic section both situated in Sweden.

PARTICIPANTS

Healthcare staff and managers (n=13) from the two settings.

INTERVENTIONS

Two workshops were performed, one at each setting. Workshops were initiated by a short introduction to simulation modelling. Results from the respective simulation model were then presented and discussed in the following focus group discussion.

RESULTS

Categories from the content analysis are presented according to the following research questions: how and when simulation modelling can assist healthcare improvement? Regarding how, the participants mentioned that simulation modelling could act as a tool for support and a way to visualise problems, potential solutions and their effects. Regarding when, simulation modelling could be used both locally and by management, as well as a pedagogical tool to develop and test innovative ideas and to involve everyone in the improvement work.

CONCLUSIONS

Its potential as an information and communication tool and as an instrument for pedagogic work within healthcare improvement render a broader application and value of simulation modelling than previously reported.

How changing quality management influenced PGME accreditation: a focus on decentralization and quality improvement

BACKGROUND

Evaluating the quality of postgraduate medical education (PGME) programs through accreditation is common practice worldwide. Accreditation is shaped by educational quality and quality management. An appropriate accreditation design is important, as it may drive improvements in training. Moreover, accreditors determine whether a PGME program passes the assessment, which may have major consequences, such as starting, continuing or discontinuing PGME. However, there is limited evidence for the benefits of different choices in accreditation design. Therefore, this study aims to explain how changing views on educational quality and quality management have impacted the design of the PGME accreditation system in the Netherlands.

METHODS

To determine the historical development of the Dutch PGME accreditation system, we conducted a document analysis of accreditation documents spanning the past 50 years and a vision document outlining the future system. A template analysis technique was used to identify the main elements of the system.

RESULTS

Four themes in the Dutch PGME accreditation system were identified: (1) objectives of accreditation, (2) PGME quality domains, (3) quality management approaches and (4) actors' responsibilities. Major shifts have taken place regarding decentralization, residency performance and physician practice outcomes, and quality improvement. Decentralization of the responsibilities of the accreditor was absent in 1966, but this has been slowly changing since 1999. In the future system, there will be nearly a maximum degree of decentralization. A focus on outcomes and quality improvement has been introduced in the current system. The number of formal documents striving for quality assurance has increased enormously over the past 50 years, which has led to increased bureaucracy. The future system needs to decrease the number of standards to focus on measurable outcomes and to strive for quality improvement.

CONCLUSION

The challenge for accreditors is to find the right balance between trusting and controlling medical professionals. Their choices will be reflected in the accreditation design. The four themes could enhance international comparisons and encourage better choices in the design of accreditation systems.

Does Provider Self-Reporting of Etiquette Behaviors Improve Patient Experience? A Randomized Controlled Trial

BACKGROUND

There is a glaring lack of published evidence-based strategies to improve the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience scores on the physician domain. Strategies that have been used are resource intensive and difficult to sustain.

OBJECTIVE

We hypothesized that prompting providers to assess their own etiquette-based practices every 2 weeks over the course of 1 year would improve patient experience on the physician domain.

DESIGN

Randomized controlled trial.

SETTING

4 acute care hospitals.

PARTICIPANTS

Hospitalists.

INTERVENTION

Hospitalists were randomized to the study or the control arm. The study arm was prompted every 2 weeks for 12 months to report how frequently they engaged in 7 best-practice bedside etiquette behaviors. Control arm participants received similarly worded questions on quality improvement behaviors.

MEASUREMENT

Provider experience scores were calculated from the physician HCAHPS and Press Ganey survey provider items.

RESULTS

Physicians reported high rates of etiquette-based behavior at baseline, and this changed modestly over the study period. Self-reported etiquette behaviors were not associated with experience scores. The difference in difference analysis of the baseline and postintervention physician experience scores between the intervention arm and the control arm was not statistically significant (P = 0.71).

CONCLUSION

In this 12-month study, biweekly reflection and reporting of best-practice bedside etiquette behaviors did not result in significant improvement on physician domain experience scores. It is likely that hospitalists' self-assessment of their bedside etiquette may not reflect patient perception of these behaviors. Furthermore, hospitalists may be resistant to improvement in this area since they rate themselves highly at baseline. Journal of Hospital Medicine 2017;12:402-406.

What allows a health care system to become a learning health care system: Results from interviews with health system leaders

INTRODUCTION

The US health care system faces pressure to improve quality while managing complexity, curbing costs, and reducing inefficiency. These shortcomings have sparked interest in the Learning Health Care System (LHCS) as an alternate approach to organizing research and clinical care. Although diverse stakeholders have expressed support for moving toward an LHCS model, limited guidance exists for institutions considering such a transition.

METHODS

Interviews were conducted with institutional leaders from 25 health care systems considered to be at the forefront of LHCS. Interviews focused on the process of transitioning toward an LHCS, including motivations for change, key components, challenges encountered, and strategies for success, and on ethics and regulatory issues encountered. Qualitative analysis identified key themes across institutions.

RESULTS

Respondents described 5 themes related to the origin of their LHCS transformation: (1) visionary leadership or influence of a key individual, (2) adaptation to a changing health care landscape, (3) external funding, (4) regulatory or legislative influence, and (5) mergers or expansions. They described 6 challenges: (1) organizational culture, (2) data systems and data sharing, (3) funding learning activities, (4) limited supply of skilled individuals, (5) managing competing priorities, and (6) regulatory challenges. Finally, they suggested 8 strategies to support transformation: (1) strong leadership, (2) setting a limited number of organizational priorities, (3) building on existing strengths, (4) training programs, (5) "purposeful" design of data systems, (6) internal transparency of quality metrics, (7) payer/provider integration, and, within academic medical centers, (8) academic/clinical integration.

CONCLUSIONS

Even institutions at the forefront of LHCS described the transition as difficult. Their experiences provide insight into other institutions considering similar transitions, including elements essential for success and likely challenges.

Improving the efficiency and effectiveness of ward rounds

Purpose

Ward rounds in hospitals are crucial for decision-making in the context of patient treatment processes. However, these tasks are not systematically managed and are often extended due to missing information or equipment or staff unavailability. This research aims to assess whether ward rounds can be structured more efficiently and effectively from the perspective of patients and staff.

Design/methodology/approach

This mixed-method approach examines the ward rounds conducted in three units within a haematology department of a major Danish hospital. Baseline measures were collected to capture the value of the ward round described by patients and staff. The information on patient and equipment flows associated with a typical ward round was mapped with recommendations for improvement.

Findings

Staff aspired to deliver a good-quality ward round, but what this meant was never articulated and there were no established standards. The duration of the ward round was unpredictable and could take 6 hours to complete. Improvements identified by the team allow the ward rounds to be completed by mid-day with much more certainty.

Research limitations/implications

This research provides an insight as to how ward rounds are conducted within a Danish haematology department.

Practical implications

The research has implications for those involved in ward rounds to reduce the time taken whilst maintaining quality and safety of patient care.

Social implications

This research has implications for patients and their families who wish to spend time with consultants.

Originality/value

Previous research has focused on the interactions between doctors and nurses. This research focuses on the operational process of the ward round and presents a structured approach to support multi-disciplinary teams with a focus on value from the patient’s perspective.

Insurance, racial/ethnic, SES-related disparities in quality of care among US adults with diabetes

Diabetes-related quality improvement initiatives are typically aimed at improving outcomes and reducing complications. Studies have found that disparities in quality persist for certain racial/ethnic and socioeconomically disadvantaged groups; however, results are mixed with regard to insurance-based differences. The purpose of this study is to investigate the independent associations between type of health insurance coverage, race/ethnicity, and socioeconomic status (SES), and quality of care, as measured by benchmark indicators of diabetes-related primary care. This study used the Diabetes Care Survey of the 2010 Medical Expenditure Panel Survey. Bivariate and multivariate logistic regressions were used to examine the association between quality of diabetes care and type of insurance coverage, race/ethnicity, and SES. Multivariate analyses also controlled for additional demographic and health status characteristics. Respondents with insurance coverage (particularly those with private insurance or with Medicare and Medicaid coverage) were more likely to receive quality diabetes care than uninsured individuals. Few significant disparities based on race/ethnicity or SES persisted in subsequent multivariate analyses. Findings suggest that insurance coverage may make the greatest impact in ensuring equitable distribution of quality diabetes care, regardless of race/ethnicity or socioeconomic status. With the implementation of Affordable Care Act under which more people could potentially gain access to insurance, policymakers should next track insurance-based diabetes care disparities.

Lean Participative Process Improvement: Outcomes and Obstacles in Trauma Orthopaedics

Objectives

To examine the effectiveness of a “systems” approach using Lean methodology to improve surgical care, as part of a programme of studies investigating possible synergy between improvement approaches.

Setting

A controlled before-after study using the orthopaedic trauma theatre of a UK Trust hospital as the active site and an elective orthopaedic theatre in the same Trust as control.

Participants

All staff involved in surgical procedures in both theatres.

Interventions

A one-day “lean” training course delivered by an experienced specialist team was followed by support and assistance in developing a 6 month improvement project. Clinical staff selected the subjects for improvement and designed the improvements.

Outcome Measures

We compared technical and non-technical team performance in theatre using WHO checklist compliance evaluation, “glitch count” and Oxford NOTECHS II in a sample of directly observed operations, and patient outcome (length of stay, complications and readmissions) for all patients. We collected observational data for 3 months and clinical data for 6 months before and after the intervention period. We compared changes in measures using 2-way analysis of variance.

Results

We studied 576 cases before and 465 after intervention, observing the operation in 38 and 41 cases respectively. We found no significant changes in team performance or patient outcome measures. The intervention theatre staff focused their efforts on improving first patient arrival time, which improved by 20 minutes after intervention.

Conclusions

This version of “lean” system improvement did not improve measured safety processes or outcomes. The study highlighted an important tension between promoting staff ownership and providing direction, which needs to be managed in “lean” projects. Space and time for staff to conduct improvement activities are important for success.

Inertia in health care organizations: A case study of peritoneal dialysis services

BACKGROUND

Change is difficult for health care organizations where adoption of new practices is notoriously slow. Inertial behavior may reflect organizations' rational, strategic nonresponse to its environment or latent, institutionalizing preservation of dominant organizational routines and norms. Such strategic and selective influences of organizational inertia have different implications on the efficacy of policy to induce intended change.

PURPOSE

The aim of this study was to examine whether strategic and selective factors were associated with the provision of peritoneal dialysis (PD) services in outpatient dialysis facilities in the United States between 1995 and 2003.

APPROACH

We conducted a longitudinal retrospective study of all outpatient end-stage renal disease dialysis facilities, using 1995-2003 administrative data from the U.S. Renal Data System.

FINDINGS

Less than half of U.S. dialysis facilities offered PD, and this pattern was stable despite substantial growth of dialysis facilities entering the market. We found little support for strategic influences and some evidence that selective factors were predictive of dialysis facilities' PD provision.

PRACTICE IMPLICATIONS

Although the design of many policy and health care reform efforts widely accepts the strategic perspective of altering incentives and the environment to induce change, the presence of selective inertial influences raises concerns about the efficacy of policy intervention in the face of institutionalized organizational behavior that may be less amenable to policy intervention. Incentives recently introduced by Medicare to increase facility provision of PD may be less effective than might be expected.

Effect of HCAHPS reporting on patient satisfaction with physician communication

INTRODUCTION

Prior studies, using limited data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, reported that public reporting increases satisfaction scores in all domains except physician communication. Our objective was to examine changes in patient satisfaction with physician communication using all available data.

METHODS

We used publicly accessible datasets: HCAHPS (2007-2013), socioeconomic datasets from the US Census Bureau, and hospital service area (HSA) dataset from the Dartmouth Atlas of Health Care. Satisfaction scores were determined by the percentage of responses to "doctors always communicated well." Hospitals were grouped into quartiles based on 2007 scores. We used multilevel models to account for correlation between within-hospital observations.

RESULTS

HCAHPS data were reported by 2273 hospitals in 2007. During the 7-year period, overall satisfaction scores with physician communication increased by 2.8% (P < 0.001). The lowest quartile hospitals had significant increase in satisfaction scores, whereas the highest quartile scores decreased (0.87% per year vs -0.23% per year; P < 0.001). These differences remained significant after adjusting for hospital and local population characteristics. Survey response rate and the number of acute-care beds and physicians in the HSA were positively associated, whereas HSA population size and being a teaching hospital were negatively associated with patient satisfaction scores (all P < 0.005).

CONCLUSIONS

Although there has been an improvement in patient satisfaction with physicians during the past 7 years, this improvement was not seen in all hospitals. The overall gap between hospitals has narrowed, which can be further improved through sharing best practices.

Accounting for quality: on the relationship between accounting and quality improvement in healthcare

BACKGROUND

Accounting-that is, standardized measurement, public reporting, performance evaluation and managerial control-is commonly seen to provide the core infrastructure for quality improvement in healthcare. Yet, accounting successfully for quality has been a problematic endeavor, often producing dysfunctional effects. This has raised questions about the appropriate role for accounting in achieving quality improvement. This paper contributes to this debate by contrasting the specific way in which accounting is understood and operationalized for quality improvement in the UK National Health Service (NHS) with findings from the broadly defined 'social studies of accounting' literature and illustrative examples.

DISCUSSION

This paper highlights three significant differences between the way that accounting is understood to operate in the dominant health policy discourse and recent healthcare reforms, and in the social studies of accounting literature. It shows that accounting does not just find things out, but makes them up. It shows that accounting is not simply a matter of substance, but of style. And it shows that accounting does not just facilitate, but displaces, control. The illumination of these differences in the way that accounting is conceptualized helps to diagnose why accounting interventions often fail to produce the quality improvements that were envisioned. This paper concludes that accounting is not necessarily incompatible with the ambition of quality improvement, but that it would need to be understood and operationalized in new ways in order to contribute to this end. Proposals for this new way of advancing accounting are discussed. They include the cultivation of overlapping and even conflicting measures of quality, the evaluation of accounting regimes in terms of what they do to practice, and the development of distinctively skeptical calculative cultures.

Implementation and evaluation of a multicomponent quality improvement intervention to improve efficiency of hepatitis C screening and diagnosis

BACKGROUND

Given recent advances in hepatitis C virus (HCV) treatment, health systems must ensure that patients with a positive HCV antibody receive timely determination of their HCV status through viral testing. At the Louis Stokes Cleveland Department of Veterans Affairs Medical Center, viral testing was completed within six months of the first instance of a positive HCV antibody test for only 45% of patients. Beginning in 2008, three sequential improvements were implemented to close this care gap.

METHODS

The three sequential improvements phases were as follows: (1) improving patient-centeredness of screening process in ambulatory patients, (2) local implementation of the Department of Veterans Affairs national HCV reflex testing policy, and (3) local evaluation of the efficiency and effectiveness of local implementation of reflex testing.

RESULTS

From 2005 through 2013, 40 to 150 unique patients/quarter required viral testing following a positive antibody test. The firsts and second-phase improvements resulted in a 68% and 96% completion rate for timely viral testing during respective improvement phases. In the third improvement phase, remaining process problems related to the reflex testing process were identified using a locally developed electronic HCV population management application, resulting in a sustained rate of 100% completion of timely viral testing. Interrupted time series analysis revealed that the implementation of HCV reflex testing had the largest impact on the ability to complete timely viral testing.

CONCLUSIONS

A continuous quality improvement approach, supported by an HCV population management application, achieved the complete closure of an important HCV care gap. Reflex testing should be initiated at facilities that have yet to adopt this approach.

Regulatory Authority Approaches to Deploying Quality Improvement Standards to Community Pharmacies

Background:

Continuous quality improvement (CQI) programs provide an effective means to improve the safety and quality of community pharmacy practice. The role of formal support processes in ensuring the success of these CQI programs is explored in this research using the SafetyNET-Rx project.

Objective:

The primary objectives of this research were to determine how knowledge of, and confidence in, mandated CQI standards differs among pharmacies with access to formal support mechanisms and those without and the challenges faced by both.

Methods:

A survey questionnaire was mailed to 179 community pharmacies in Nova Scotia, Canada, in spring 2011. Quantitative results were analyzed using the Mann-Whitney U test for nonparametric data. Qualitative open-ended responses were analyzed using content analysis.

Results:

Performing the Mann-Whitney U test indicated that a number of differences exist between the 2 groups with respect to: (1) staff knowledge of reporting quality-related events (QREs) to an anonymous database; (2) conducting annual pharmacy safety self-assessments; (3) confidence in meeting these 2 elements; and (4) documenting changes to address QREs. A number of challenges were identified by respondents through the open-ended questions.

Conclusions:

This research highlights the value of the active provision of formal support when developing standards related to quality improvement.

Dissemination of performance information and continuous improvement: A narrative systematic review

PURPOSE

Developing a performance measure and reporting the results to support decision making at an individual level has yielded poor results in many health systems. The purpose of this paper is to highlight the factors associated with the dissemination of performance information that generate and support continuous improvement in health organizations.

DESIGN/METHODOLOGY/APPROACH

A systematic data collection strategy that includes empirical and theoretical research published from 1980 to 2010, both qualitative and quantitative, was performed on Web of Science, Current Contents, EMBASE and MEDLINE. A narrative synthesis method was used to iteratively detail explicative processes that underlie the intervention. A classification and synthesis framework was developed, drawing on knowledge transfer and exchange (KTE) literature. The sample consisted of 114 articles, including seven systematic or exhaustive reviews.

FINDINGS

Results showed that dissemination in itself is not enough to produce improvement initiatives. Successful dissemination depends on various factors, which influence the way collective actors react to performance information such as the clarity of objectives, the relationships between stakeholders, the system's governance and the available incentives.

RESEARCH LIMITATIONS/IMPLICATIONS

This review was limited to the process of knowledge dissemination in health systems and its utilization by users at the health organization level. Issues related to improvement initiatives deserve more attention.

PRACTICAL IMPLICATIONS

Knowledge dissemination goes beyond better communication and should be considered as carefully as the measurement of performance. Choices pertaining to intervention should be continuously prompted by the concern to support organizational action.

ORIGINALITY/VALUE

While considerable attention was paid to the public reporting of performance information, this review sheds some light on a more promising avenue for changes and improvements, notably in public health systems.

Effects of auditing patient safety in hospital care: design of a mixed-method evaluation

BACKGROUND

Auditing of patient safety aims at early detection of risks of adverse events and is intended to encourage the continuous improvement of patient safety. The auditing should be an independent, objective assurance and consulting system. Auditing helps an organisation accomplish its objectives by bringing a systematic, disciplined approach to evaluating and improving the effectiveness of risk management, control, and governance. Audits are broadly conducted in hospitals, but little is known about their effects on the behaviour of healthcare professionals and patient safety outcomes. This study was initiated to evaluate the effects of patient safety auditing in hospital care and to explore the processes and mechanisms underlying these effects.

METHODS AND DESIGN

Our study aims to evaluate an audit system to monitor and improve patient safety in a hospital setting. We are using a mixed-method evaluation with a before-and-after study design in eight departments of one university hospital in the period October 2011-July 2014. We measure several outcomes 3 months before the audit and 15 months after the audit. The primary outcomes are adverse events and complications. The secondary outcomes are experiences of patients, the standardised mortality ratio, prolonged hospital stay, patient safety culture, and team climate. We use medical record reviews, questionnaires, hospital administrative data, and observations to assess the outcomes. A process evaluation will be used to find out which components of internal auditing determine the effects.

DISCUSSION

We report a study protocol of an effect and process evaluation to determine whether auditing improves patient safety in hospital care. Because auditing is a complex intervention targeted on several levels, we are using a combination of methods to collect qualitative and quantitative data about patient safety at the patient, professional, and department levels. This study is relevant for hospitals that want to early detect unsafe care and improve patient safety continuously.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR3343.

Facilitators of transforming primary care: a look under the hood at practice leadership

PURPOSE

This study examined how characteristics of practice leadership affect the change process in a statewide initiative to improve the quality of diabetes and asthma care.

METHODS

We used a mixed methods approach, involving analyses of existing quality improvement data on 76 practices with at least 1 year of participation and focus groups with clinicians and staff in a 12-practice subsample. Existing data included monthly diabetes or asthma measures (clinical measures) and monthly practice implementation, leadership, and practice engagement scores rated by an external practice coach.

RESULTS

Of the 76 practices, 51 focused on diabetes and 25 on asthma. In aggregate, 50% to 78% made improvements within in each clinical measure in the first year. The odds of making practice changes were greater for practices with higher leadership scores (odds ratios = 2.41-4.20). Among practices focused on diabetes, those with higher leadership scores had higher odds of performing nephropathy screening (odds ratio = 1.37, 95% CI, 1.08-1.74); no significant associations were seen for the intermediate outcome measures of hemoglobin A1c, blood pressure, and cholesterol. Focus groups revealed the importance of a leader, typically a physician, who believed in the transformation work (ie, a visionary leader) and promoted practice engagement through education and cross-training. Practices with greater change implementation also mentioned the importance of a midlevel operational leader who helped to create and sustain practice changes. This person communicated and interacted well with, and was respected by both clinicians and staff.

CONCLUSIONS

In the presence of a vision for transformation, operational leaders within practices can facilitate practice changes that are associated with clinical improvement.

A retrospective evaluation of the Perfecting Patient Care University training program for health care organizations

This study evaluated how the Perfecting Patient Care (PPC) University, a quality improvement (QI) training program for health care leaders and clinicians, affected the ability of organizations to improve the health care they provide. This training program teaches improvement methods based on Lean concepts and principles of the Toyota Production System and is offered in several formats. A retrospective evaluation was performed that gathered data on training, other process factors, and outcomes after staff completed the PPC training. A majority of respondents reported gaining QI competencies and cultural achievements from the training. Organizations had high average scores for the success measures of "outcomes improved" and "sustainable monitoring" but lower scores for diffusion of QI efforts. Total training dosage was significantly associated with the measures of QI success. This evaluation provides evidence that organizations gained the PPC competencies and cultural achievements and that training dosage is a driver of QI success.

Measuring team factors thought to influence the success of quality improvement in primary care: a systematic review of instruments

BACKGROUND

Measuring team factors in evaluations of Continuous Quality Improvement (CQI) may provide important information for enhancing CQI processes and outcomes; however, the large number of potentially relevant factors and associated measurement instruments makes inclusion of such measures challenging. This review aims to provide guidance on the selection of instruments for measuring team-level factors by systematically collating, categorizing, and reviewing quantitative self-report instruments.

METHODS

DATA SOURCES

We searched MEDLINE, PsycINFO, and Health and Psychosocial Instruments; reference lists of systematic reviews; and citations and references of the main report of instruments.

STUDY SELECTION

To determine the scope of the review, we developed and used a conceptual framework designed to capture factors relevant to evaluating CQI in primary care (the InQuIRe framework). We included papers reporting development or use of an instrument measuring factors relevant to teamwork. Data extracted included instrument purpose; theoretical basis, constructs measured and definitions; development methods and assessment of measurement properties. Analysis and synthesis: We used qualitative analysis of instrument content and our initial framework to develop a taxonomy for summarizing and comparing instruments. Instrument content was categorized using the taxonomy, illustrating coverage of the InQuIRe framework. Methods of development and evidence of measurement properties were reviewed for instruments with potential for use in primary care.

RESULTS

We identified 192 potentially relevant instruments, 170 of which were analyzed to develop the taxonomy. Eighty-one instruments measured constructs relevant to CQI teams in primary care, with content covering teamwork context (45 instruments measured enabling conditions or attitudes to teamwork), team process (57 instruments measured teamwork behaviors), and team outcomes (59 instruments measured perceptions of the team or its effectiveness). Forty instruments were included for full review, many with a strong theoretical basis. Evidence supporting measurement properties was limited.

CONCLUSIONS

Existing instruments cover many of the factors hypothesized to contribute to QI success. With further testing, use of these instruments measuring team factors in evaluations could aid our understanding of the influence of teamwork on CQI outcomes. Greater consistency in the factors measured and choice of measurement instruments is required to enable synthesis of findings for informing policy and practice.

Measuring organizational and individual factors thought to influence the success of quality improvement in primary care: a systematic review of instruments

Background

Continuous quality improvement (CQI) methods are widely used in healthcare; however, the effectiveness of the methods is variable, and evidence about the extent to which contextual and other factors modify effects is limited. Investigating the relationship between these factors and CQI outcomes poses challenges for those evaluating CQI, among the most complex of which relate to the measurement of modifying factors. We aimed to provide guidance to support the selection of measurement instruments by systematically collating, categorising, and reviewing quantitative self-report instruments.

Methods

Data sources: We searched MEDLINE, PsycINFO, and Health and Psychosocial Instruments, reference lists of systematic reviews, and citations and references of the main report of instruments. Study selection: The scope of the review was determined by a conceptual framework developed to capture factors relevant to evaluating CQI in primary care (the InQuIRe framework). Papers reporting development or use of an instrument measuring a construct encompassed by the framework were included. Data extracted included instrument purpose; theoretical basis, constructs measured and definitions; development methods and assessment of measurement properties. Analysis and synthesis: We used qualitative analysis of instrument content and our initial framework to develop a taxonomy for summarising and comparing instruments. Instrument content was categorised using the taxonomy, illustrating coverage of the InQuIRe framework. Methods of development and evidence of measurement properties were reviewed for instruments with potential for use in primary care.

Results

We identified 186 potentially relevant instruments, 152 of which were analysed to develop the taxonomy. Eighty-four instruments measured constructs relevant to primary care, with content measuring CQI implementation and use (19 instruments), organizational context (51 instruments), and individual factors (21 instruments). Forty-one instruments were included for full review. Development methods were often pragmatic, rather than systematic and theory-based, and evidence supporting measurement properties was limited.

Conclusions

Many instruments are available for evaluating CQI, but most require further use and testing to establish their measurement properties. Further development and use of these measures in evaluations should increase the contribution made by individual studies to our understanding of CQI and enhance our ability to synthesise evidence for informing policy and practice.

Improving the effectiveness of health care innovation implementation: middle managers as change agents

The rate of successful health care innovation implementation is dismal. Middle managers have a potentially important yet poorly understood role in health care innovation implementation. This study used self-administered surveys and interviews of middle managers in health centers that implemented an innovation to reduce health disparities to address the questions: Does middle managers' commitment to health care innovation implementation influence implementation effectiveness? If so, in what ways does their commitment influence implementation effectiveness? Although quantitative survey data analysis results suggest a weak relationship, qualitative interview data analysis results indicate that middle managers' commitment influences implementation effectiveness when middle managers are proactive. Scholars should account for middle managers' influence in implementation research, and health care executives may promote implementation effectiveness by hiring proactive middle managers and creating climates in which proactivity is rewarded, supported, and expected.

Patient safety and quality improvement: an overview of QI

It is important for pediatric providers to be involved in quality improvement (QI) activities to improve children’s health outcomes.• The Model for Improvement asks several key questions related to a process, then uses Plan-Do-Study-Act(PDSA) cycles to implement, test, and spread changes.• Lean and Six Sigma methodologies can improve quality by increasing workflow efficiency and decreasing variation.• Root cause analysis (RCA) is a retrospective quality tool that helps determine factors contributing to errors and adverse events, so that improvements can be implemented.• Failure modes and effects analysis (FMEA) isa prospective quality tool that anticipates system vulnerabilities and helps develop risk reduction strategies.• Evidence-based interventions, such as best-practice guidelines, promote standardization and reduce errors and adverse events, especially in high-risk health-care settings.• Team training can improve communication and situational awareness to create a safer health-care environment.

Context challenges the champion: improving hip fracture care in a Swedish university hospital

PURPOSE

The purpose of this paper is to describe and explain a clinician-led improvement of a hip fracture care process in a university hospital, and to assess the results and factors helping and hindering change implementation.

DESIGN/METHODOLOGY/APPROACH

The paper has a mixed methods case study design. Data collection was guided by a framework directing attention to the content and process of the change, its context and outcomes.

FINDINGS

Using a multiprofessional project team, beneficial changes in the early parts of the care process were achieved, but inability to change surgical staff work practices meant that the original goal of operating patients within 24 hours was not reached. After three years, top management introduced a hospital-wide process improvement programme, which "took over" the responsibility for improving hip fracture care.

RESEARCH IMPLICATIONS/LIMITATIONS

A clear vision why change is needed and what needs to be done, which is well communicated by a respected clinical leader, can motivate personnel, but other influences are also needed to bring about change. Without a plan agreed and supported by top management, changes are likely to be limited to parts of the process and improvements to patient care may be minimal. These and other findings may be applicable to similar situations in other services.

ORIGINALITY/VALUE

This case study is an illustration of both the strengths and the weaknesses of a "bottom-up, clinician-champion-led improvement initiative" in a complex university hospital.

Uncovering middle managers' role in healthcare innovation implementation

BACKGROUND

Middle managers have received little attention in extant health services research, yet they may have a key role in healthcare innovation implementation. The gap between evidence of effective care and practice may be attributed in part to poor healthcare innovation implementation. Investigating middle managers' role in healthcare innovation implementation may reveal an opportunity for improvement. In this paper, we present a theory of middle managers' role in healthcare innovation implementation to fill the gap in the literature and to stimulate research that empirically examines middle managers' influence on innovation implementation in healthcare organizations.

DISCUSSION

Extant healthcare innovation implementation research has primarily focused on the roles of physicians and top managers. Largely overlooked is the role of middle managers. We suggest that middle managers influence healthcare innovation implementation by diffusing information, synthesizing information, mediating between strategy and day-to-day activities, and selling innovation implementation.

SUMMARY

Teamwork designs have become popular in healthcare organizations. Because middle managers oversee these team initiatives, their potential to influence innovation implementation has grown. Future research should investigate middle managers' role in healthcare innovation implementation. Findings may aid top managers in leveraging middle managers' influence to improve the effectiveness of healthcare innovation implementation.

A3 Process: A Pragmatic Problem-Solving Technique for Process Improvement in Health Care

Short-term approaches or patch working are the predominant modes of solving process-related problems in organizations. As a result, problems recur at regular intervals and inhibit their smooth functioning. Organizational leaders have adopted various quality initiatives to produce sustainable change, but the existing literature suggests that many of them have met with limited success. The ‘A3 Process’, adapted from Toyota Motor Corporation, has been proposed as a pragmatic problem-solving technique for creating sustainable organizational change. Observing, drawing iconic sketches, discussing with other stakeholders, and experimenting has helped each stakeholder gain a deeper, contextualized understanding of the problem. These activities influenced knowledge validation and/or knowledge creation, both instrumental in transforming the stakeholder’s passive mindset to a collaborative and active mindset. This article presents one of the many applications of the A3 Process that produced enduring change in a health care environment.

Continuous quality improvement of nursing care: case study of a clinical pathway revision for cardiac catheterization

BACKGROUND

: Taiwan's Bureau of National Health Insurance (BNHI) has been gradually introducing Taiwan diagnosis related groups (Tw-DRGs) for inpatient cases since 2010. Challenged to adapt to payment system changes, hospitals must implement necessary management control systems or measures to maintain both fiscal soundness and medical care quality.

PURPOSE

: This study investigated the outcome of management participation in work to revise cardiac catheterization clinical pathway operating procedures.

METHODS

: BNHI-qualified cases for Tw-DRGs 125 payment principles were recruited as study subjects to revise the cardiac catheterization clinical pathway. Researchers compared pre- and postrevision values in terms of mean medical care fees, patient volumes, healthcare quality, and length of hospital stay, as well as financial risk.

RESULTS

: Significant differences were observed in precardiac catheterization nursing care completion rates, mean lengths of hospital stay, diagnosis numbers, surgical treatment numbers, and numbers of complications or comorbidities. Medical utilization was also significantly lower (p < .05) after revision implementation.

CONCLUSIONS

: Clinical pathway revision involves organization, procedural flows, and performance management. The revision successfully improved hospital finances and promoted medical care quality.

Addressing diabetes racial and ethnic disparities: lessons learned from quality improvement collaboratives

A review of national data confirms that while the quality of healthcare in the USA is slowly improving, disparities in diabetes prevalence, processes of care and outcomes for racial/ethnic minorities are not. Many quality measures can be addressed through system level interventions, referred to as quality improvement (QI), and QI collaboratives have been found to effectively improve processes of care for chronic conditions, including diabetes. However, the impact of QI collaboratives on the reduction of health disparities has been mixed. Lessons learned from previous QI collaboratives including the complexity of impacting clinical outcomes, the need for expert support for skills outside of QI methodology, limiting impact of poor data, and the need to develop disparities quality measures, can be used to inform future QI collaborative approaches to reduce diabetes racial/ethnic minority health disparities.

Managing health care decisions and improvement through simulation modeling

Simulation modeling is a way to test changes in a computerized environment to give ideas for improvements before implementation. This article reviews research literature on simulation modeling as support for health care decision making. The aim is to investigate the experience and potential value of such decision support and quality of articles retrieved. A literature search was conducted, and the selection criteria yielded 59 articles derived from diverse applications and methods. Most met the stated research-quality criteria. This review identified how simulation can facilitate decision making and that it may induce learning. Furthermore, simulation offers immediate feedback about proposed changes, allows analysis of scenarios, and promotes communication on building a shared system view and understanding of how a complex system works. However, only 14 of the 59 articles reported on implementation experiences, including how decision making was supported. On the basis of these articles, we proposed steps essential for the success of simulation projects, not just in the computer, but also in clinical reality. We also presented a novel concept combining simulation modeling with the established plan-do-study-act cycle for improvement. Future scientific inquiries concerning implementation, impact, and the value for health care management are needed to realize the full potential of simulation modeling.

Care platforms: a basic building block for care delivery

Without significant operational reform within the nation's health care delivery organizations, new financing models, payment systems, or structures are unlikely to realize their promise. Adapting insights from high-performing companies in other high-risk, high-cost, science- and technology-based industries, we propose the "care platform" as an organizing framework for internal operations in diversified provider organizations to increase the quality, reliability, and efficiency of care delivery. A care platform organizes "care production" around similar work, rather than organs or specialties; integrates standard and custom care processes; and surrounds them with specifically configured information and business systems. Such organizational designs imply new roles for physicians.