Tutorial: quality improvement project models

Quality improvement teams function best when all team members agree to a unifying model to guide their effort. Unfortunately, there are many quality improvement project models to choose from in the literature. And while it seems that they are quite different, all effective models are built on the same conceptual base. In this tutorial, we will explain these basic concepts and then show how to use them to examine and enhance our understanding of some widely used models. We will also discuss the need for these models, describe how teams can learn from projects that followed different models, and provide guidance to organizations that are choosing one.     

Organizationwide quality improvement in health care

Organizationwide quality improvement has offered many organizations in many different industries a new approach to work and leadership. The lessons learned can be applied to the health care setting. QA professionals can play an important role in this change by leading through example--first in their own departments and the work they currently perform and then throughout the entire organization.     

Knowledge systems,health care teams,and clinical practice: a study of successful change

Clinical teams are of growing importance to healthcare delivery, but little is known about how teams learn and change their clinical practice. We examined how teams in three US hospitals succeeded in making significant practice improvements in the area of antimicrobial resistance. This was a qualitative cross-case study employing Soft Knowledge Systems as a conceptual framework. The purpose was to describe how teams produced, obtained, and used knowledge and information to bring about successful change. A purposeful sampling strategy was used to maximize variation between cases. Data were collected through interviews, archival document review, and direct observation. Individual case data were analyzed through a two-phase coding process followed by the cross-case analysis. Project teams varied in size and were multidisciplinary. Each project had more than one champion, only some of whom were physicians. Team members obtained relevant knowledge and information from multiple sources including the scientific literature, experts, external organizations, and their own experience. The success of these projects hinged on the teams' ability to blend scientific evidence, practical knowledge, and clinical data. Practice change was a longitudinal, iterative learning process during which teams continued to acquire, produce, and synthesize relevant knowledge and information and test different strategies until they found a workable solution to their problem. This study adds to our understanding of how teams learn and change, showing that innovation can take the form of an iterative, ongoing process in which bits of K&I are assembled from multiple sources into potential solutions that are then tested. It suggests that existing approaches to assessing the impact of continuing education activities may overlook significant contributions and more attention should be given to the role that practical knowledge plays in the change process in addition to scientific knowledge.     

Quality improvement as an investment

Health care organizations are experiencing increasing internal and external pressures to improve the quality of care that they provide. However, there is not a framework that can be used to help understand the value of quality improvement projects and to prioritize competing projects. By understanding the current processes, costs and outcomes of care, enumerating the costs and benefits of change, anticipating the timing of the costs and benefits, and performing a financial analysis, quality improvement efforts can be evaluated as investments. Only by understanding and adapting to the financial environments in which health care organizations operate can continuous quality improvement in health care succeed.     

Sustainability of healthcare improvement: what can we learn from learning theory?

ABSTRACT: BACKGROUND: Changes that improve the quality of health care should be sustained. Falling back to old, unsatisfactory ways of working is a waste of resources and can in the worst case increase resistance to later initiatives to improve care. Quality improvement relies on changing the clinical system yet factors that influence the sustainability of quality improvements are poorly understood. Theoretical frameworks can guide further research on the sustainability of quality improvements. Theories of organizational learning have contributed to a better understanding of organizational change in other contexts. To identify factors contributing to sustainability of improvements, we use learning theory to explore a case that had displayed sustained improvement. METHODS: Forde Hospital redesigned the pathway for elective surgery and achieved sustained reduction of cancellation rates. We used a qualitative case study design informed by theory to explore factors that contributed to sustain the improvements at Forde Hospital. The model Evidence in the Learning Organization describes how organizational learning contributes to change in healthcare institutions. This model constituted the framework for data collection and analysis. We interviewed a strategic sample of 20 employees. The in-depth interviews covered themes identified through our theoretical framework. Through a process of coding and condensing, we identified common themes that were interpreted in relation to our theoretical framework. RESULTS: Clinicians and leaders shared information about their everyday work and related this knowledge to how the entire clinical pathway could be improved. In this way they developed a revised and deeper understanding of their clinical system and its interdependencies. They became increasingly aware of how different elements needed to interact to enhance the performance and how their own efforts could contribute. CONCLUSIONS: The improved understanding of the clinical system represented a change in mental models of employees that influenced how the organization changed its performance. By applying the framework of organizational learning, we learned that changes originating from a new mental model represent double-loop learning. In double-loop learning, deeper system properties are changed, and consequently changes are more likely to be sustained.     

Facilitators and barriers to the implementation of patient flow improvement strategies

Patient flow improvement strategies have been effective in reducing emergency department (ED) crowding, but little guidance is available on the implementation process. By using a qualitative research design, our objective was to identify common facilitators and barriers to the implementation of patient flow improvement strategies and successful approaches for mitigating barriers. Six hospitals participated in an 18-month Urgent Matters learning network launched in October 2008. The hospitals selected strategies to improve patient flow that could be implemented within 3 months with measurable impact. Across 6 hospitals, 8 strategies were implemented. We conducted 2 rounds of key informant interviews with improvement teams, for a total of 129 interviews. Interviews were recorded, transcribed, and coded by using a grounded theory approach to identify common themes. Factors facilitating implementation included participation in the learning network and strategic selection of team members. Common challenges included staff resistance and entrenched organizational culture. Some of the challenges were mitigated through approaches such as staff education and department leaders' constant reinforcement. Our findings indicate that several facilitators and barriers are common to the implementation of different strategies. Leveraging facilitators and developing a strategy to address common barriers may leave hospital and ED leaders better prepared to implement patient flow improvement strategies.     

Evaluating the use of a modified CAHPS® survey to support improvements in patient-centred care: lessons from a quality improvement collaborative

Objectives To evaluate the use of a modified Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey to support quality improvement in a collaborative focused on patient‐centred care, assess subsequent changes in patient experiences, and identify factors that promoted or impeded data use. Background Healthcare systems are increasingly using surveys to assess patients’ experiences of care but little is established about how to use these data in quality improvement. Design Process evaluation of a quality improvement collaborative. Setting and participants The CAHPS team from Harvard Medical School and the Institute for Clinical Systems Improvement organized a learning collaborative including eight medical groups in Minnesota. Intervention Samples of patients recently visiting each group completed a modified CAHPS® survey before, after and continuously over a 12‐month project. Teams were encouraged to set goals for improvement using baseline data and supported as they made interventions with bi‐monthly collaborative meetings, an online tool reporting the monthly data, a resource manual called The CAHPS® Improvement Guide, and conference calls. Main outcome measures Changes in patient experiences. Interviews with team leaders assessed the usefulness of the collaborative resources, lessons and barriers to using data. Results Seven teams set goals and six made interventions. Small improvements in patient experience were observed in some groups, but in others changes were mixed and not consistently related to the team actions. Two successful groups appeared to have strong quality improvement structures and had focussed on relatively simple interventions. Team leaders reported that frequent survey reports were a powerful stimulus to improvement, but that they needed more time and support to engage staff and clinicians in changing their behaviour. Conclusions Small measurable improvements in patient experience may be achieved over short projects. Sustaining more substantial change is likely to require organizational strategies, engaged leadership, cultural change, regular measurement and performance feedback and experience of interpreting and using survey data.     

Introduction of a quality improvement program in a children's hospital in Tehran: design, implementation, evaluation and lessons learned.

BACKGROUND AND OBJECTIVE: Reports addressing continuous quality improvement (CQI) methods in developing countries are scant and there are questions about the applicability of quality improvement methods in such settings. The structure and output of a formal quality improvement program implemented in a teaching hospital affiliated with the Tehran University of Medical Sciences is presented. OBJECTIVE METHOD: During a nine-month period, a multi-stage quality improvement program was implemented. It comprised: (i) training workshops; (ii) a steering committee; (iii) weekly consultation and facilitation of improvement projects; and (iv) a day-long demonstration and recognition meeting. Four cycles of workshops were held in which 132 employees were trained in the basics of CQI. RESULTS: Thirty improvement projects were initiated. Twenty-five of the projects were completed. In an evaluation survey more than 70% of respondents assessed a 'positive impact' on organizational culture, work efficiency and quality of services. More than 90% believed that the changes were sustained, and more than 60% reported that they have implemented additional improvement projects. CONCLUSION: Our quality improvement package supported rapid implementation of multiple projects. The underlying 'change structure' comprised the improvement teams, top management and the university's quality improvement office; it integrated project management, support and facilitation functions by the respective participant. Organization-wide change was more limited than anticipated. To institutionalize the program and ensure sustainability, a local structure for change should be organized, management coaching should be sustained, local facilitators should be developed, incentives should be established and physician involvement should be emphasized.     

Balancing participation and expertise: a comparison of locally and centrally managed health care quality improvement within primary care practices

In a longitudinal qualitative study, the authors evaluated two health care quality improvement (QI) methods that emphasized either participation (local approach) or expertise (central approach). They followed teams using these approaches to develop depression care QI programs for primary care practices over several years, observing their processes and outcomes and learning about participants' perceptions, beliefs, and experiences. Concordant with the literature, most participants preferred the local approach, but some were willing to relinquish some decision making to experts. Participants identified unique advantages of both the local (e.g., maximizes buy-in and local fit) and central (e.g., maximizes efficiency, reduces burden) approaches. The authors propose a hybrid model in which experts make strategic decisions about what practices to adopt and local site personal make tactical decisions about implementation. They believe that balancing participation and expertise provides the best formula for producing lasting QI for health care organizations across a wide variety of circumstances.     

How team-based reflection affects quality improvement implementation: a qualitative study

Quality improvement (QI) interventions in health care organizations have produced mixed results with significant questions remaining about how QI interventions are implemented. Team-based reflection may be an important element for understanding QI implementation. Extensive research has focused on individual benefits of reflection including links between reflection, learning, and change. There are currently no published studies that explore how team-based reflection impact QI interventions. We selected 4 primary care practices participating in a QI trial that used a facilitated, team-based approach to improve colorectal cancer screening rates. Trained facilitators met with a team of practice members for up to eleven 1-hour meetings. Data include audio-recorded team meetings and associated fieldnotes. We used a template approach to code transcribed data and an immersion/crystallization technique to identify patterns and themes. Three types of team-based reflection and how each mattered for QI implementation were identified: organizational reflection promoted buy-in, motivation, and feelings of inspiration; process reflection enhanced team problem solving and change management; and relational reflection enhanced discussions of relational dynamics necessary to implement desired QI changes. If QI interventions seek to make changes where collaboration and coordination of care is required, then deliberately integrating team-based reflection into interventions can provide opportunities to facilitate change processes.     

Filmmakers/Educators/Facilitators? Understanding the Role of Adult Intermediaries in Youth Media Production in the UK and the USA

The possibilities that making “their own” media might contain for engaging young people in learning has been celebrated in recent years, while the role of adult intermediaries in guiding these projects remains too often obscured. Here, I draw on several years of ethnographic research conducted in the UK and the USA to distinguish among three different types of facilitators: guides who privilege processes over outputs; collaborators who position themselves within an egalitarian team; and mentors, who draw on specialist knowledge to encourage young people to make “high quality” films. I assess the impact of these different modes on the central claims made for youth media as a means of developing skills, critical media literac(ies), and encouraging youth “voice.” Although youth media organizations struggling with sustainability often conflate these practices, these approaches lend themselves to achieving diverse aims and thus differences could be better delineated by facilitators and by funders in order to realize the ambitions proposed by youth media projects.     

Department deployment: integrating quality improvement into day-to-day management

Despite the time and resources that The George Washington University Medical Center (GWUMC) put into training and forming QI teams, QI staff found that CQI was not being used to carry out critical day-to-day departmental functions. In other words, CQI didn't affect the way staff did "real work." In response, the medical center developed an approach that integrates CQI with departmental leadership, structure, culture, and work routine. With the help of a coach, willing departments at GWUMC choose from a series of 155 activities that they complete at their own pace (eg, setting departmental CQI goals, developing a departmental mission). The department deployment process moves staff through three levels of increasing sophistication and maturity with CQI methods: awareness, understanding, and bonding. It is intended to make quality a habit for staff, or a part of the organizational mind set, rather than an isolated "project." This article will describe how the department deployment approach was developed, its philosophical underpinnings, and its methodology and tools. Then, an example will illustrate how one hospital department--social work and utilization case management--successfully used this approach.     

Getting going together: can clinical teams and managers collaborate to identify problems and initiate improvement?

A clear aim is key for the success of improvement projects, yet many fail already at this stage. We studied how clinical teams and managers at a university hospital in Sweden identified problems and defined aims as they initiated 24 process improvement projects. Categorizing and comparing problems at 3 stages of problem definition, we found that the majority of problems fell into 1 of 3 categories: information issues, poor procedures, and waiting times. Going through these stages, managers and clinical teams prioritized waiting-time problems. We show how managers can ask such teams to quickly identify problems suited for improvement projects through this step-wise, facts-based approach. We conclude that they can add their management perspective when giving specific assignments, to harness the combined benefits of both a bottom-up and a top-down approach to improvement.     

Assessment of chronic illness care (ACIC): a practical tool to measure quality improvement

OBJECTIVE: To describe initial testing of the Assessment of Chronic Illness Care (ACIC), a practical quality-improvement tool to help organizations evaluate the strengths and weaknesses of their delivery of care for chronic illness in six areas: community linkages, self-management support, decision support, delivery system design, information systems, and organization of care. DATA SOURCES: (1) Pre-post, self-report ACIC data from organizational teams enrolled in 13-month quality-improvement collaboratives focused on care for chronic illness; (2) independent faculty ratings of team progress at the end of collaborative. STUDY DESIGN: Teams completed the ACIC at the beginning and end of the collaborative using a consensus format that produced average ratings of their system's approach to delivering care for the targeted chronic condition. Average ACIC subscale scores (ranging from 0 to 11, with 11 representing optimal care) for teams across all four collaboratives were obtained to indicate how teams rated their care for chronic illness before beginning improvement work. Paired t-tests were used to evaluate the sensitivity. of the ACIC to detect system improvements for teams in two (of four) collaboratives focused on care for diabetes and congestive heart failure (CHF). Pearson correlations between the ACIC subscale scores and a faculty rating of team performance were also obtained. RESULTS: Average baseline scores across all teams enrolled at the beginning of the collaboratives ranged from 4.36 (information systems) to 6.42 (organization of care), indicating basic to good care for chronic illness. All six ACIC subscale scores were responsive to system improvements diabetes and CHF teams made over the course of the collaboratives. The most substantial improvements were seen in decision support, delivery system design, and information systems. CHF teams had particularly high scores in self-management support at the completion of the collaborative. Pearson correlations between the ACIC subscales and the faculty rating ranged from .28 to .52. CONCLUSION: These results and feedback from teams suggest that the ACIC is responsive to health care quality-improvement efforts and may be a useful tool to guide quality improvement in chronic illness care and to track progress over time.     

Optimizing patient involvement in quality improvement

Introduction

Patient and public involvement in healthcare planning, service development and health‐related research has received significant attention. However, evidence about the role of patient involvement in quality improvement work is more limited. We aimed to characterize patient involvement in three improvement projects and to identify strengths and weaknesses of contrasting approaches.

Methods

Three case study quality improvement projects were purposively sampled from a broader programme. We used an ethnographic approach involving 126 in‐depth interviews, 12 weeks of non‐participant observations and documentary analysis. Data analysis was based on the constant comparative method.

Results

The three projects differed in the ways they involved patients in their quality improvement work, including their rationales for including patients. We characterized three very different models of patient involvement, which were each influenced by project context. Patients played distinctive roles across the three projects, acting in some cases as intermediaries between the wider patient community and clinicians, and sometimes undertaking persuasive work to convince clinicians of the need for change. We identified specific strategies that can be used to help ensure that patient involvement works most effectively and that the enthusiasm of patients to make a difference is not dissipated.

Conclusion

Patient involvement in quality improvement work needs careful management to realize its full potential.     

Strategic learning in healthcare organizations

There is no definitive blueprint for the healthcare organization involved in strategic learning. However, what distinguishes strategic learning institutions is their acknowledgment that they must discover their own paths and solutions rather than blindly follow a detailed strategic mandate from administration. Answers to their most critical implementation and adaptive questions will not flow down ready-made from above, but will be tailored to meet the requirements of their own particular situation. Strategic learning organizations have certain attributes in common in developing their own answers: They continuously experiment rather than seek final solutions. They favor improvisation over forecasts. They formulate new actions rather than defend past ones. They nurture change rather than permanence. They encourage creative conflict rather than tranquillity. They encourage questioning rather than compliance. They expose contradictions rather than hide them (Weick 1977). Most importantly, strategic learning organizations realize that successful strategic change is best undertaken as a process of learning (O'Sullivan 1999). Healthcare organizations can no longer afford the illusion of traditional strategic planning, with its emphasis on bureaucratic controls from the top to the bottom. They must embrace the fundamental truth that most change occurs through processes of learning that occur in many locations simultaneously throughout the organization. The initial step in discovering ways to improve the capability of healthcare organizations is to adapt continuously while fulfilling their mission. Healthcare leaders must create a shared vision of where an institution is heading rather than what the final destination will be, nurture a spirit of experimentation and discovery rather than close supervision and unbending control, and recognize that plans have to be continuously changed and adjusted. To learn means to face the unknown: to recognize that we do not possess all the answers; to concede that we do not always know what to do; to admit that past actions and solutions may no longer be appropriate, in fact may have been the incubators of today's problems; to question basic assumptions long held about running the institution; and to make ourselves vulnerable to the political dynamics prevalent in all organizations. Hospitals and other healthcare organizations must seek to develop and maintain a continuing state of readiness in which everyone in the organization, from front-line clinician to senior management, is poised to act in anticipation of and in response to unforeseen changes in the environment and to learn from their own experiences in confronting the future.     

Quality improvement initiative in school-based health centers across new Mexico

BACKGROUND: Quality improvement principles have been applied extensively to health care organizations, but implementation of quality improvement methods in school‐based health centers (SBHCs) remains in a developmental stage with demonstration projects under way in individual states and nationally. Rural areas, such as New Mexico, benefit from the use of distance education techniques to reach providers throughout the state. METHODS: The Envision New Mexico (ENM) Quality Improvement Initiative involves training in quality improvement concepts and methods, identification of best practices for selected clinical services, and repeated use of data to measure changes leading to improvement. The ENM employs the Model for Improvement and the “Plan‐Do‐Study‐Act” tool, which enables providers to self‐evaluate, set goals, and assess results with their own data. RESULTS: Providers tend to overestimate their use of best practices. Contrasting these perceptions with findings from medical record reviews can provide impetus and focus for quality improvement through changes in specific clinical practices and management systems. Preliminary findings from New Mexico suggest that quality improvement interventions can be effective, with initial improvements over baseline reviews typically in the 20–40% range. CONCLUSION: Systematic efforts to enhance the quality of care can help improve both the effectiveness and efficiency of SBHCs, and provide evidence of the value of the care provided. Simple, efficient quality improvement techniques, with the use of distance learning technologies, can help achieve the full promise of expanded school‐based health care.     

Learning in organizations working with telemedicine

To investigate learning in telemedicine, qualitative interviews were conducted with 30 people working with telepsychiatry, teledermatology, a telepathology frozen-section service and tele-otolaryngology. More than 80% of the respondents said that they had learnt something new by using telemedicine. Most frequently the participants improved their knowledge of the specialty in which they were involved, but this was not the only way in which they learnt. The learning did not necessarily change behaviour, as two-thirds of the respondents felt that the learning had not permitted them to perform tasks for which they had previously needed assistance (although this varied somewhat with the type of telemedical work that respondents were engaged in). Two-thirds of respondents thought that something more could be done in telemedical work to promote their own learning, which shows the clear potential for learning by telemedicine. Learning could be promoted further by extending the use of the technology to other applications. To start working with telemedicine, initial instruction seems to be sufficient--a more extensive training programme appears unnecessary. In future, as many applications of telemedicine are implemented, health-care organizations may become important arenas for learning and leaders will have to focus on learning. The results of the present study clearly showed that working with telemedicine produces learning.     

'It teaches you what to expect in future . . . ': interprofessional learning on a training ward for medical, nursing, occupational therapy and physiotherapy students

AIM: This paper presents findings from a multimethod evaluation of an interprofessional training ward placement for medical, nursing, occupational therapy and physiotherapy students. CONTEXT: Unique in the UK, and following the pioneering work at Link?ping, the training ward allowed senior pre-qualification students, under the supervision of practitioners, to plan and deliver interprofessional care for a group of orthopaedic and rheumatology patients. This responsibility enabled students to develop profession-specific skills and competencies in dealing with patients. It also allowed them to enhance their teamworking skills in an interprofessional environment. Student teams were supported by facilitators who ensured medical care was optimal, led reflective sessions and facilitated students' problem solving. METHODS: Data were collected from all groups of participants involved in the ward: students, facilitators and patients. Methods included questionnaires, interviews and observations. RESULTS AND DISCUSSION: Findings are presented from each participating group, with a particular emphasis placed on the perspective of medicine. The study found that students valued highly the experiential learning they received on the ward and felt the ward prepared them more effectively for future practice. However, many encountered difficulties adopting an autonomous learning style during their placement. Despite enjoying their work on the ward, facilitators were concerned that the demands of their role could result in 'burn-out'. Patients enjoyed their ward experience and scored higher on a range of satisfaction indicators than a comparative group of patients. CONCLUSIONS: Participants were generally positive about the training ward. All considered that it was a worthwhile experience and felt the ward should recommence in the near future.