The influence of context on quality improvement success in health care: a systematic review of the literature

Context: The mixed results of success among QI initiatives may be due to differences in the context of these initiatives. Methods: The business and health care literature was systematically reviewed to identify contextual factors that might influence QI success; to categorize, summarize, and synthesize these factors; and to understand the current stage of development of this research field. Findings: Forty‐seven articles were included in the final review. Consistent with current theories of implementation and organization change, leadership from top management, organizational culture, data infrastructure and information systems, and years involved in QI were suggested as important to QI success. Other potentially important factors identified in this review included: physician involvement in QI, microsystem motivation to change, resources for QI, and QI team leadership. Key limitations in the existing literature were the lack of a practical conceptual model, the lack of clear definitions of contextual factors, and the lack of well‐specified measures. Conclusions: Several contextual factors were shown to be important to QI success, although the current body of literature lacks adequate definitions and is characterized by considerable variability in how contextual factors are measured across studies. Future research should focus on identifying and developing measures of context tied to a conceptual model that examines context across all levels of the health care system and explores the relationships among various aspects of context.     

Exciting but exhausting: experiences with participatory research with chronically ill adolescents

Background  Adolescents with chronic conditions are major users of paediatric hospitals, but seldom participate in the evaluation of services or in research. Little is known about the usefulness of the participatory approach in adolescent health research.
Objective  To evaluate the feasibility, benefits and limitations of a participatory research (PR) project involving chronically ill adolescents as co-researchers.
Design, setting and participants  Nine adolescents, aged 15–17 years, acted as co-researchers in a hospital-based PR project. They co-developed an interview protocol and during a disco party held for this purpose interviewed each other and 25 fellow patients (12–19 years). They provided advice on the draft report and participated in the dissemination of the results, but were not involved in the design of the project or analysis of results.
Results  Involving adolescents in participatory health research was feasible and appreciated by researchers and youth alike, but had its drawbacks too. The peer-research attracted few participants, the interviews lacked depth and did not yield substantial new insights. Maintaining a high level of participation of the chronically ill co-researchers also proved difficult.
Conclusions  Adolescents with chronic conditions like to have a say in the design and evaluation of hospital services. But their participation as co-researchers demands ample resources from all parties involved without automatically improving research quality. PR does not seem the most effective and efficient way to make services more responsive. We therefore recommend further exploration of other creative and sustainable ways for involving youth in health-care service development and innovation.     

Integrated dementia care in The Netherlands: a multiple case study of case management programmes

The number of dementia patients is growing, and they require a variety of services, making integrated care essential for the ability to continue living in the community. Many healthcare systems in developed countries are exploring new approaches for delivering health and social care. The purpose of this study was to describe and analyse a new approach in extensive case management programmes concerned with long‐term dementia care in The Netherlands. The focus is on the characteristics, and success and failure factors of these programmes. A multiple case study was conducted in eight regional dementia care provider networks in The Netherlands. Based on a literature study, a questionnaire was developed for the responsible managers and case managers of the eight case management programmes. During 16 semistructured face‐to‐face interviews with both respondent groups, a deeper insight into the dementia care programmes was provided. Project documentation for all the cases was studied. The eight programmes were developed independently to improve the quality and continuity of long‐term dementia care. The programmes show overlap in terms of their vision, tasks of case managers, case management process and the participating partners in the local dementia care networks. Differences concern the targeted dementia patient groups as well as the background of the case managers and their position in the local dementia care provider network. Factors for success concern the expert knowledge of case managers, investment in a strong provider network and coherent conditions for effective inter‐organizational cooperation to deliver integrated care. When explored, caregiver and patient satisfaction was high. Further research into the effects on client outcomes, service use and costs is recommended in order to further analyse the impact of this approach in long‐term care. To facilitate implementation, with a focus on joint responsibilities of the involved care providers, policy recommendations are to develop incentives for collaborative financial contracts between insurers and providers.     

Primary care practice-based care management for chronically ill patients (PraCMan) in German healthcare: Outcome of a propensity-score matched cohort study

BackgroundGrowing prevalence of chronic diseases is a rising challenge for healthcare systems. The Primary Care Practice-Based Care Management (PraCMan) programme is a comprehensive disease management intervention in primary care in Germany aiming to improve medical care and to reduce potentially avoidable hospitalisations for chronically ill patients.ObjectivesThis study aimed to assess the effect of PraCMan on hospitalisation rate and related costs.MethodsA retrospective propensity-score matched cohort study was performed. Reimbursement data related to patients treated in general practices between 1st July 2013 and 31st December 2017 were supplied by a statutory health insurance company (AOK Baden-Wuerttemberg, Germany) to compare hospitalisation rate and direct healthcare costs between patients participating in the PraCMan intervention and propensity-score matched controls following usual care. Outcomes were determined for the one-year-periods before and 12 months after beginning of participation in the intervention.ResultsIn total, 6148 patients participated in the PraCMan intervention during the observation period and were compared to a propensity-score matched control group of 6148 patients from a pool of 63,446 eligible patients. In the one-year period after the intervention, the per-patient hospitalisation rate was 8.3% lower in the intervention group compared to control (p = 0.0004). Per-patient hospitalisation costs were 9.4% lower in favour of the intervention group (p = 0.0002).ConclusionThis study showed that the PraCMan intervention may be associated with a lower rate of hospital admissions and hospitalisation costs than usual care. Further studies may assess long-term effects of PraCMan and its efficacy in preventing known complications of chronic diseases.     

Applying the principles of adaptive leadership to person‐centred care for people with complex care needs: Considerations for care providers,patients, caregivers and organizations

BackgroundHealth systems in many countries see person‐centred care as a critical component of high‐quality care but many struggle to operationalize it in practice. We argue that models such as adaptive leadership can be a critical lever to support person‐centred care, particularly for people who have multiple complex care needs.ObjectiveTo reflect on two concepts: person‐centred care and adaptive leadership and share how adaptive leadership can advance person‐centred care at the front‐line care delivery level and the organizational level.FindingsThe defining feature of adaptive leadership is the separation of technical solutions (ie applying existing knowledge and techniques to problems) from adaptive solutions (ie requiring shifts in how people work together, not just what they do). Addressing adaptive challenges requires identifying key assumptions that may limit motivations for change and the behaviours influenced by these assumptions. Thus, effective care for patients, particularly those with multiple complex care needs, often entails helping care providers and patients to examine their relationships and behaviours not just identifying technical solutions. Addressing adaptive challenges also requires a supportive and enabling organizational context. We provide illustrative examples of how adaptive leadership principles can be applied at both the front line of care and the organization level in advancing person‐centred care delivery.ConclusionsAdvancing person‐centred care at both the clinical and organizational levels requires a growth mindset, a willingness to try (and fail) and try again, comfort in being uncomfortable and a commitment to figure things out, in partnership, in iterative ways. Patients, caregivers, care providers and organizational leaders all need to be adaptive leaders in this endeavour.     

Gaps in the evidence on improving social care outcomes: findings from a meta‐review of systematic reviews

Adult social care continues to be a central policy concern in the UK. The Adult Social Care Outcomes Framework (ASCOF) is a range of measures nationally available to drive forward improvement on outcomes and quality in local councils. While there is an emphasis on improving transparency, quality and outcomes, drawing on research evidence to achieve these aims is often difficult because the evidence is not easily identifiable, is disparate or of variable quality. We conducted a meta‐review to analyse and summarise systematic review‐level evidence on the impact of interventions on the four outcomes set out in the ASCOF: quality of life, delaying and reducing the need for services, satisfaction with services and safeguarding of vulnerable adults. This paper focuses on the availability of review‐level evidence and the presence of significant gaps in this evidence base. A range of health and social care databases were searched, including MEDLINE, ASSIA and The Cochrane Library in January and February 2012. All systematic reviews evaluating the efficacy of social care interventions for improving ASCOF outcomes for older people, people with long‐term conditions, mental health problems or physical and/or learning disabilities were eligible. Two reviewers independently screened systematic reviews for quality and relevance and extracted data; 43 systematic reviews were included, the majority of which examined the impact of interventions on quality of life (n = 34) and delaying and reducing the need for support (n = 25). Limited systematic review‐level evidence was found regarding satisfaction with services and safeguarding. There were also significant gaps in relation to key social care interventions and population groups. Research priorities include addressing these gaps and the collation of data on interventions, outcomes and populations more closely related to social care. Overall, a more relevant, comprehensive and robust evidence base is required to support improvement of outcomes for recipients of adult social care.     

Navigation roles support chronically ill older adults through healthcare transitions: a systematic review of the literature

Transitions between various healthcare services are potential points for fragmented care and can be confusing and complicated for patients, formal and informal caregivers. These challenges are compounded for older adults with chronic disease, as they receive care from many providers in multiple care settings. System navigation has been suggested as an innovative strategy to address these challenges. While a number of navigation models have been developed, there is a lack of consensus on the desired characteristics and effectiveness of this role. We conducted a systematic literature review to describe existing navigator models relevant to chronic disease management for older adults and to investigate the potential impact of each model. Relevant literature was identified using five electronic databases - Medline, CINAHL, the Cochrane database, Embase and PsycINFO between January 1999 and April 2011. Following a recommended process for health services research literature reviews, exclusion and inclusion criteria were applied to retrieved articles; 15 articles documenting nine discrete studies were selected. This review suggests that the role of a navigator for the chronically ill older person is a relatively new one. It provides some evidence that integrated and coordinated care guided by a navigator, using a variety of interventions such as care plans and treatment goals, is beneficial for chronically ill older adults transitioning across care settings. There is a need to further clarify and standardise the definition of navigation, as well as a need for additional research to assess the effectiveness and cost of different approaches to the health system.     

Quality of primary health care in Saudi Arabia: a comprehensive review.

OBJECTIVES: Little is known about the quality of primary care in Saudi Arabia, despite the central role of primary care centers in Saudi health strategy. This study presents an overview of quality of primary care in Saudi Arabia, and identifies factors impeding the achievement of quality, with the aim of determining how the quality of Saudi primary care could be improved. METHOD: Using a systematic search strategy, data were extracted from the published literature on quality of care in Saudi primary care services, and on barriers to achieving high-quality care. RESULTS: Of the 128 studies initially identified, 31 met the inclusion criteria for the review. Studies identified were diverse in methodology and focus. Components of quality were reviewed in terms of access and effectiveness of both clinical and interpersonal care. Good access and effective care were reported for certain services including: immunization, maternal health care, and control of epidemic diseases. Poor access and effectiveness were reported for chronic disease management programs, prescribing patterns, health education, referral patterns, and some aspects of interpersonal care including those caused by language barriers. Several factors were identified as determining whether high-quality care was delivered. These included management and organizational factors, implementation of evidence-based practice, professional development, use of referrals to secondary care, and organizational culture. CONCLUSION: There is substantial variation in the quality of Saudi primary care services. In order to improve quality, there is a need to improve the management and organization of primary care services. Professional development strategies are also needed to improve the knowledge and skills of staff.     

Economic evaluation of care for the chronically ill: A literature review

Financial problems of governments and the consequent urge toset limits on health care growth have increased the importanceof economic rationalization. A systematic review of the presentbody of knowledge might facilitate the need to set prioritiesin health care policies and research in an ageing society withgrowing numbers of the elderly and chronically ill. After explainingthe purpose and methods of full economic evaluation, we reviewthe literature on 3 major chronic diseases, diabetes mellitus(20 publications), rheumatoid arthritis (15) and chronic obstructivepulmonary disease (COPD) and asthma (8). This review serves2 objectives: to review the existing literature and to assessits quality. The review reveals a lack of full economic evaluationin this sector of health care. The total number of referencesto the specified chronic diseases covers 5% of all economicliterature and 44% of all references under Index Medicus' heading‘economics’, while the burden of illness is substantial,resulting in high indirect costs to the patients themselvesand to society. The dominant approach is cost-effectivenessanalysis (71%), followed by cost-benefit analysis (20%). Cost-utilityanalysis is rare (9%), partly because it is still in the phaseof development. However, this approach can deal better withthe objectives of many interventions in chronic care, i.e. increasingthe quality rather than the quantity of life. We make a pleafor full economic evaluation of chronic care programmes andfor the development of quality of life measures which coverthe broad domain of well-being of the chronically ill.     

Community-based integrated care: myth or must?

ISSUE: In spite of the many efforts that have been made to rationalize and improve the functioning and the quality of health care delivery in industrialized countries, too limited a degree of success has been achieved so far. This paper argues that this limited success originates from a lack of coherence among the various strategies and instruments developed to rationalize and improve the delivery of health care. ADDRESSING THE ISSUE: This fact can be shown by reducing the complexity of today's health care into three levels of decision making: the primary process of patient care, the organizational context, and the financing and policy context of health care systems. Distinct rationales exist on each of these three levels of decision making as actors have their own perspectives, cultures, disciplines, and traditions concerning the delivery of health care. These differences can often result in ambiguity of goals, conflicting interests between decision makers, bureaucracy, poor information transfer, and limited use of the available scientific knowledge on all three levels. In such a context, rationalization and quality-improvement efforts are frustrated and will have limited effectiveness. Therefore, the various rationalization strategies and instruments on all three levels of decision making should be embedded in our health care systems in a synergistic way. DEMONSTRATING THE PROPOSED SOLUTION: Community-based integrated care is a promising approach to addressing this issue successfully. How this concept might function as a unifying concept for quality improvement will be illustrated by relevant developments in the Academic Medical Center, University of Amsterdam in The Netherlands.     

A quality management model for integrated care: results of a Delphi and Concept Mapping study

Objective. The objective of this study is to identify the elements andclusters of a quality management model for integrated care. Design. In order to develop the model a combination of three methodswere applied. A literature study was conducted to identify elementsof integrated care. In a Delphi study experts commented andprioritized 175 elements in three rounds. During a half-a-daysession with the expert panel, Concept Mapping was used to clusterthe elements, position them on a map and analyse their content.Multi-dimensional statistical analyses were applied to designthe model. Participants. Thirty-one experts, with an average of 8.9 years of experienceworking in research, managing improvement projects or runningintegrated care programmes. Results. The literature study resulted in 101 elements of integratedcare. Based on criteria for inclusion and exclusion, 89 uniqueelements were determined after the three Delphi rounds. By usingConcept Mapping the 89 elements were grouped into nine clusters.The clusters were labelled as: ‘Quality care’, ‘Performancemanagement’, ‘Interprofessional teamwork’,‘Delivery system’, ‘Roles and tasks’,‘Patient-centeredness’, ‘Commitment’,‘Transparent entrepreneurship’ and ‘Result-focusedlearning’. Conclusion. The identified elements and clusters provide a basis for a comprehensivequality management model for integrated care. This model differsfrom other quality management models with respect to its generalapproach to multiple patient categories, its broad definitionof integrated care and its specification into nine differentclusters. The model furthermore accentuates conditions for effectivecollaboration such as commitment, clear roles and tasks andentrepreneurship. The model could serve evaluation and improvementpurposes in integrated care practice. To improve external validity,replication of the study in other countries is recommended.     

The moderate success of quality of care improvement efforts: three observations on the situation.

Why is the health care system still unable to achieve a breakthrough in its quality performance? This commentary offers three observations on the problem of the moderate success of quality of care improvement efforts. We based our discussion on theoretical models from management theory and research. We conclude that health care organizations invest efforts in quality improvement initiatives; however, there is a potential in improving the fit between these efforts and the specific problems these organizations face.     

What patients want from primary care consultations: a discrete choice experiment to identify patients' priorities

PURPOSE The consultation is fundamental to the delivery of primary care, but different ways of organizing consultations may lead to different patient experiences in terms of access, continuity, technical quality of care, and communication. Patients’ priorities for these different issues need to be understood, but the optimal methods for assessing priorities are unclear. This study used a discrete choice experiment to assess patients’ priorities.METHODS We surveyed patients from 6 family practices in England. The patients chose between primary care consultations differing in attributes such as ease of access (wait for an appointment), choice (flexibility of appointment times), continuity (physician’s knowledge of the patient), technical quality (thoroughness of physical examination), and multiple aspects of patient-centered care (interest in patient’s ideas, inquiry about patient’s social and emotional well-being, and involvement of patient in decision making). We used probit models to assess the relative priority patients placed on different attributes and to estimate how much they were willing to pay for them.RESULTS Analyses were based on responses from 1,193 patients (a 53% response rate). Overall, patients were willing to pay the most for a thorough physical examination ($40.87). The next most valued attributes of care were seeing a physician who knew them well ($12.18), seeing a physician with a friendly manner ($8.50), having a reduction in waiting time of 1 day ($7.22), and having flexibility of appointment times ($6.71). Patients placed similar value on the different aspects of patient-centered care ($12.06–$14.82). Responses were influenced by the scenario in which the decision was made (minor physical problem vs urgent physical problem vs ambiguous physical or psychological problem) and by patients’ demographic characteristics.CONCLUSIONS Although patient-centered care is important to patients, they may place higher priority on the technical quality of care and continuity of care. Discrete choice experiments may be a useful method for assessing patients’ priorities in health care.     

Building primary health care systems: a case study from Sweden.

Health policy planners have discussed for some years how to transform existing hospital-based health delivery systems into primary-care-driven systems. Although this policy goal has been adopted in a number of western European nations, the actual process of implementing such a major change has proven stubborn and complex. In particular, efforts to transfer existing resources out of the hospital sector for use in building primary care activities have proven difficult. This paper examines the effort to design and implement a primary health care strategy in Sweden. It is divided into two segments. The first section sketches the broad health system context within which the Swedish primary care effort is being conducted. The second section focuses directly on Sweden's primary care strategy, detailing both its conceptual foundation and the organizational obstacles that have impeded the policy's implementation. This discussion is punctuated with findings from a 1981 survey of county council administrators' attitudes toward this primary care strategy. The paper concludes with a short discussion of several alternative organizational approaches that might speed the development of a primary-care-driven health system.     

Primary care after psychiatric crisis: a qualitative analysis

PURPOSE Patients with serious psychiatric problems experience difficulty accessing primary care. The goals of this study were to assess whether care managers improved access and to understand patients’ experiences with health care after a psychiatric crisis.METHODS A total of 175 consecutive patients seeking care in a psychiatric emergency department were randomly assigned to an intervention group with care managers or a control group. Brief, semistructured interviews about health care encounters were conducted at baseline and 1 year later. Five raters, using the content-driven, immersion-crystallization approach, analyzed 112 baseline and year-end interviews from 28 participants in each group. The main outcomes were patients’ responses about their care experiences, connections with primary care, and integration of medical and mental health care. Scores for physical function and mental function were compared by analysis of variance (ANOVA).RESULTS At baseline, most participants described negative experiences in receiving care and emphasized the importance of listening, sensitivity, and respect. Fully 71% of patients in the intervention group said that having a care manager to assist them with primary care connections was beneficial. Patients in the intervention group had significantly better physical and mental function than their counterparts in the control group at 6 months (P = .03 for each) but not at 12 months. There was also a trend toward functional improvement over the course of the study in the intervention group.CONCLUSIONS This analysis suggests that care management is effective in helping patients access primary care after a psychiatric crisis. It provides evidence on and insight into how care may be delivered more effectively for this population. Future work should assess the sustainability of care connections and longer-term patient health outcomes.     

Non-attendance in general practice: a systematic review and its implications for access to primary health care

BACKGROUND: Non-attendance in general practice has received increasing attention over the past few years. Its relationship with access to health care has been recognized and is of particular relevance in light of the access targets set out in the NHS Plan. METHODS: The literature was searched for articles relating to non-attendance. Titles and abstracts were examined, and relevant articles obtained. Bibliographies were examined for further references. Articles that described interventions for reducing non-attendance that were comparative studies and that examined general appointments, as opposed to appointments for screening purposes for example, were of particular interest. RESULTS AND CONCLUSIONS: The epidemiology of non-attendance has been well described, but there is little work on the reasons for non-attendance. Evidence for effective interventions to improve attendance in primary care is lacking, and this may prove to be an area of research interest in the future. As well as specific interventions to reduce non-attendance, new approaches to health care access are required in order to tackle this issue.     

Evaluation of access,a primary care program for indigent patients: inpatient and emergency room utilization

We analyzed the impact of a program that provides indigent patients with free primary care on inpatient admissions, emergency room (ER) visits, and resulting charges in 91 patients before and after admittance into the program.There was a decrease in ER visits after enrolling in the program (1.89 versus 0.83 visits per year; p < 0.0001). This difference translated into mean ER charges of $1174 vs. $717 (p = 0.0007), and a decrease in charges of $41,587 per year. The charges for the program (outpatient visits and laboratory) were $23,141. Entry into the program had no effect on inpatient admissions, which averaged 0.07 admissions per year both before and after admission to the program.Indigent patients enrolled in a complimentary primary care program had significantly decreased per-year ER utilization rates and charges. The program had no effect on inpatient admissions. By conservative estimate, the program decreased ER charges by approximately $18,000 per year secondary to decreased ER utilization.