Quality improvement

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For other uses, see QI (disambiguation).

Quality improvement is "the attainment or process of attaining a new level of performance or qualit."[1].

The Malcolm Baldrige Health Care version of the Criteria for Performance Excellence (HCPE) award has been created to foster a culture of quality improvement across an organization. Two studies of the impact of the award have found:

  • "No significant difference in process of care results or outcomes between Baldrige recipients and their competitors, there was a significant difference in patient experience results" [2].
  • "Slight enhancements in clinical outcomes, while hospital financial and efficiency measures all showed overwhelmingly positive operating results"[3]

Wennberg's classification framework can categorize causes of unwarranted variation[4].

Lean Sigma

Lean sigma combines approaches[5].

Measuring quality

Quality measures and their benchmarks are available form several organizations including:

  • CQI Resource Center (coordinated by the Centers for Medicare & Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC); U.S. Department of Health and Human Services)

Tactics for improvement

Workforce redesign may help[6].

Practice facilitation may help[7].

Why quality improvement efforts succeed and fail

Various organizational characteristics, some based on complexity science[8][9], may predict why quality improvement projects succeed[10][11][12] and fail[13][14].ref>Michel, P., et al. "What are the Barriers and Facilitators to the Implementation and/or Success of Quality Improvement and Risk Management in Hospitals: A Systematic Literature Review." J Epidemiol Public Health Rev 1.4 (2016).</ref>. Causes include:

Studies using appreciative inquiry have been done.[13][18]

Different approaches may be needed depending on the level of certainty in the clinical science behind a quality improvement project.[19]

Recommendations for QI projects to implement guidelines may not include tactics to foster a positive workplace culture[20][20].

Work culture and quality improvement

A systematic review found an association with workplace culture and clinical outcomes[21]. However, this review did not provide details of attributes of positive culture. This review did not find any randomized trials.

A cross-sectional study of 537 American hospitals found that clinical improvement was associated with the following, ranked in descending order of impact[22]:

  • 'having physician and nurse champions rather than nurse champions alone'
  • 'fostering an organizational environment in which clinicians are encouraged to solve problems creatively'
  • 'holding monthly meetings to review AMI cases between hospital clinicians and staff who transported patients to the hospital'

A cohort of 10 American hospitals found[23]:

  • 'effective inclusion of staff from different disciplines and levels in the organisational hierarchy in the team guiding improvement efforts (referred to as the ‘guiding coalition’ in each hospital)'
  • 'authentic participation in the work of the guiding coalition'
  • 'distinct patterns of managing conflict'

References

  1. ↑ Anonymous (2024), Quality improvement (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ Schulingkamp, R. C., & Latham, J. R. (2015). Health Care Performance Excellence: A Comparison of Baldrige Award Recipients and Competitors.
  3. ↑ Unger, K. L. (2013). An investigation into the effects of winning the Malcolm Baldrige National Quality Award on the performance of hospitals/healthcare systems (Doctoral dissertation, Colorado State University).
  4. ↑ Harrison R, Manias E, Mears S, Heslop D, Hinchcliff R, Hay L (2018). "Addressing unwarranted clinical variation: A rapid review of current evidence". J Eval Clin Pract. doi:10.1111/jep.12930. PMID 29766616.
  5. ↑ Danese, P., Manfè, V. and Romano, P. (2017), A Systematic Literature Review on Recent Lean Research: State-of-the-art and Future Directions. International Journal of Management Reviews. doi:10.1111/ijmr.12156
  6. ↑ Laurant M, van der Biezen M, Wijers N, Watananirun K, Kontopantelis E, van Vught AJ (2018). "Nurses as substitutes for doctors in primary care". Cochrane Database Syst Rev. 7: CD001271. doi:10.1002/14651858.CD001271.pub3. PMID 30011347.
  7. ↑ Wang A, Pollack T, Kadziel LA, Ross SM, McHugh M, Jordan N; et al. (2018). "Impact of Practice Facilitation in Primary Care on Chronic Disease Care Processes and Outcomes: a Systematic Review". J Gen Intern Med. doi:10.1007/s11606-018-4581-9. PMID 30066117.
  8. ↑ Massoud MR, Barry D, Murphy A, Albrecht Y, Sax S, Parchman M (2016). "How do we learn about improving health care: a call for a new epistemological paradigm". Int J Qual Health Care. 28 (3): 420–4. doi:10.1093/intqhc/mzw039. PMC 4931911. PMID 27118664.
  9. ↑ Jordon M, Lanham HJ, Anderson RA, McDaniel RR (2010). "Implications of complex adaptive systems theory for interpreting research about health care organizations". J Eval Clin Pract. 16 (1): 228–31. doi:10.1111/j.1365-2753.2009.01359.x. PMC 3667707. PMID 20367840.
  10. ↑ Leykum LK, Pugh J, Lawrence V, Parchman M, Noël PH, Cornell J; et al. (2007). "Organizational interventions employing principles of complexity science have improved outcomes for patients with Type II diabetes". Implement Sci. 2: 28. doi:10.1186/1748-5908-2-28. PMC 2018702. PMID 17725834.
  11. ↑ Leykum LK, Parchman M, Pugh J, Lawrence V, Noël PH, McDaniel RR (2010). "The importance of organizational characteristics for improving outcomes in patients with chronic disease: a systematic review of congestive heart failure". Implement Sci. 5: 66. doi:10.1186/1748-5908-5-66. PMC 2936445. PMID 20735859.
  12. ↑ Lanham HJ, Leykum LK, Taylor BS, McCannon CJ, Lindberg C, Lester RT (2013). "How complexity science can inform scale-up and spread in health care: understanding the role of self-organization in variation across local contexts". Soc Sci Med. 93: 194–202. doi:10.1016/j.socscimed.2012.05.040. PMID 22819737.
  13. ↑ 13.0 13.1 Ruhe MC, Bobiak SN, Litaker D, Carter CA, Wu L, Schroeder C; et al. (2011). "Appreciative Inquiry for quality improvement in primary care practices". Qual Manag Health Care. 20 (1): 37–48. doi:10.1097/QMH.0b013e31820311be. PMC 4222905. PMID 21192206.
  14. ↑ Arar NH, Noel PH, Leykum L, Zeber JE, Romero R, Parchman ML (2011). "Implementing quality improvement in small, autonomous primary care practices: implications for the patient-centred medical home". Qual Prim Care. 19 (5): 289–300. PMC 3313551. PMID 22186171.
  15. ↑ Rose AJ, Petrakis BA, Callahan P, Mambourg S, Patel D, Hylek EM; et al. (2012). "Organizational characteristics of high- and low-performing anticoagulation clinics in the Veterans Health Administration". Health Serv Res. 47 (4): 1541–60. doi:10.1111/j.1475-6773.2011.01377.x. PMC 3401398. PMID 22299722.
  16. ↑ 16.0 16.1 Curry LA, Spatz E, Cherlin E, Thompson JW, Berg D, Ting HH; et al. (2011). "What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study". Ann Intern Med. 154 (6): 384–90. doi:10.7326/0003-4819-154-6-201103150-00003. PMC 4735872. PMID 21403074.
  17. ↑ 17.0 17.1 Gabbay RA, Friedberg MW, Miller-Day M, Cronholm PF, Adelman A, Schneider EC (2013). "A positive deviance approach to understanding key features to improving diabetes care in the medical home". Ann Fam Med. 11 Suppl 1: S99–107. doi:10.1370/afm.1473. PMC 3707253. PMID 23690393.
  18. ↑ Peelle, Henry E. (2006). "Appreciative Inquiry and Creative Problem Solving in Cross-Functional Teams". The Journal of Applied Behavioral Science. SAGE Publications. 42 (4): 447–467. doi:10.1177/0021886306292479. ISSN 0021-8863.
  19. ↑ Leykum LK, Lanham HJ, Pugh JA, Parchman M, Anderson RA, Crabtree BF; et al. (2014). "Manifestations and implications of uncertainty for improving healthcare systems: an analysis of observational and interventional studies grounded in complexity science". Implement Sci. 9: 165. doi:10.1186/s13012-014-0165-1. PMC 4239371. PMID 25407138.
  20. ↑ 20.0 20.1 Harrison MB, Légaré F, Graham ID, Fervers B (2010). "Adapting clinical practice guidelines to local context and assessing barriers to their use". CMAJ. 182 (2): E78–84. doi:10.1503/cmaj.081232. PMC 2817341. PMID 19969563.
  21. ↑ Braithwaite J, Herkes J, Ludlow K, Testa L, Lamprell G (2017). "Association between organisational and workplace cultures, and patient outcomes: systematic review". BMJ Open. 7 (11): e017708. doi:10.1136/bmjopen-2017-017708. PMC 5695304. PMID 29122796.
  22. ↑ Bradley EH, Curry LA, Spatz ES, Herrin J, Cherlin EJ, Curtis JP; et al. (2012). "Hospital strategies for reducing risk-standardized mortality rates in acute myocardial infarction". Ann Intern Med. 156 (9): 618–26. doi:10.7326/0003-4819-156-9-201205010-00003. PMC 3386642. PMID 22547471.
  23. ↑ Bradley EH, Brewster AL, McNatt Z, Linnander EL, Cherlin E, Fosburgh H; et al. (2018). "How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study". BMJ Qual Saf. 27 (3): 218–225. doi:10.1136/bmjqs-2017-006574. PMC 5867433. PMID 29101290.



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