Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress

Understanding and improving patient experience: a national survey of training courses provided by higher education providers and healthcare organizations in England

BACKGROUND

Understanding and improving 'patient experience' is essential to delivering high quality healthcare. However, little is known about the provision of education and training to healthcare staff in this increasingly important area.

OBJECTIVES

This study aims to ascertain the extent and nature of such provision in England and to identify how it might be developed in the future.

METHODS

An on-line survey was designed to explore training provision relating to patient experiences. To ensure that respondents thought about patient experience in the same way we defined patient experience training as that which aims to teach staff: 'How to measure or monitor the experience, preferences and priorities of patients and use that knowledge to improve their experience'. Survey questions (n=15) were devised to cover nine consistently reported key aspects of patient experience; identified from the research literature and recommendations put forward by professional bodies. The survey was administered to (i) all 180 providers of Higher Education (HE) to student/qualified doctors, nurses and allied health professionals, and (ii) all 390 National Health Service (NHS) trusts in England. In addition, we added a single question to the NHS 2010 Staff Survey (n=306,000) relating to the training staff had received to deliver a good patient experience.

RESULTS

Two hundred and sixty-five individuals responded to the on-line survey representing a total of 159 different organizations from the HE and healthcare sectors. Respondents most commonly identified 'relationships' as an 'essential' aspect of patient experience education and training. The biggest perceived gaps in current provision related to the 'physical' and 'measurement' aspects of our conceptualization of patient experience. Of the 148,657 staff who responded to the Staff Survey 41% said they had not received patient experience training and 22% said it was not applicable to them.

CONCLUSIONS

While some relevant education courses are in place in England, the results suggest that specific training with regard to the physical needs and comfort of patients, and how patient experiences can be measured and used to improve services, should be introduced. Future developments should also focus, firstly, on involving a wider range of patients in planning and delivering courses and, secondly, evaluating whether courses impact on the attitudes and behaviors of different professional groups and might therefore contribute to improved patient experiences.

Cluster randomized adaptive implementation trial comparing a standard versus enhanced implementation intervention to improve uptake of an effective re-engagement program for patients with serious mental illness

Background

Persons with serious mental illness (SMI) are disproportionately burdened by premature mortality. This disparity is exacerbated by poor continuity of care with the health system. The Veterans Health Administration (VA) developed Re-Engage, an effective population-based outreach program to identify veterans with SMI lost to care and to reconnect them with VA services. However, such programs often encounter barriers getting implemented into routine care. Adaptive designs are needed when the implementation intervention requires augmentation within sites that do not initially respond to an initial implementation intervention. This protocol describes the methods used in an adaptive implementation design study that aims to compare the effectiveness of a standard implementation strategy (Replicating Effective Programs, or REP) with REP enhanced with External Facilitation (enhanced REP) to promote the uptake of Re-Engage.

Methods/Design

This study employs a four-phase, two-arm, longitudinal, clustered randomized trial design. VA sites (n = 158) across the United States with a designated Re-Engage provider, at least one Veteran with SMI lost to care, and who received standard REP during a six-month run-in phase. Subsequently, 88 sites with inadequate uptake were stratified at the cluster level by geographic region (n = 4) and VA regional service network (n = 20) and randomized to REP (n = 49) vs. enhanced REP (n = 39) in phase two. The primary outcome was the percentage of veterans on each facility outreach list documented on an electronic web registry. The intervention was at the site and network level and consisted of standard REP versus REP enhanced by external phone facilitation consults. At 12 months, enhanced REP sites returned to standard REP and 36 sites with inadequate participation received enhanced REP for six months in phase three. Secondary implementation outcomes included the percentage of veterans contacted directly by site providers and the percentage re-engaged in VA health services.

Discussion

Adaptive implementation designs consisting of a sequence of decision rules that are tailored based on a site’s uptake of an effective program may produce more relevant, rapid, and generalizable results by more quickly validating or rejecting new implementation strategies, thus enhancing the efficiency and sustainability of implementation research and potentially leading to the rollout of more cost-efficient implementation strategies.

Trial registration

Current Controlled Trials ISRCTN21059161.

Challenges to quality assurance and improvement efforts in behavioral health organizations: a qualitative assessment

Behavioral health organizations have been increasingly required to implement plans to monitor and improve service quality. This qualitative study explores challenges that quality assurance and improvement (QA/I) personnel experience in performing their job in those practice settings. Sixteen QA/I personnel from different agencies in St. Louis, Missouri, U.S.A., were interviewed face-to-face using a semi-structured instrument to capture challenges and a questionnaire to capture participant and agency characteristics. Data analysis followed a grounded theory approach. Challenges involved agency resources, agency buy-in, personnel training, competing demands, shifting standards, authority, and research capacity. Further research is needed to assess these challenges given expected outcomes.

Public service quality improvements: a case for exemption from IRB review of public administration research

Should the exemption from Institutional Review Board (IRB) evaluations currently in place for quality improvements research be extended to public administration research that addresses questions of improving the quality of public service delivery? As a means to both reduce the level of disdain held by a group of social science researchers for IRBs and to reduce the cost of review for minimal risk studies, I argue here that much of the current public administration research should also be exempted from normal processes of review by IRBs on the basis of their similarity to Quality Improvements (QI) research, a category of studies already granted exemption. This argument dovetails provisions currently in place for studies of public service and public benefit, but reframes these exemptions in the language of "quality improvements," which may be a more comfortable language for IRBs concerned to demonstrate compliance for review of all fields. To expedite this argument into the practices of IRBs, I included a checklist that researchers could use to self-identify their studies as QI, not research as such.

Regional implementation of a pediatric cardiology chest pain guideline using SCAMPs methodology

BACKGROUND AND OBJECTIVES

Chest pain is a complaint for which children are frequently evaluated. Cardiac causes are rarely found despite expenditure of considerable time and resources. We describe validation throughout New England of a clinical guideline for cost-effective evaluation of pediatric patients first seen by a cardiologist for chest pain using a unique methodology termed the Standardized Clinical Assessment and Management Plans (SCAMPs).

METHODS

A total of 1016 ambulatory patients, ages 7 to 21 years initially seen for chest pain at Boston Children's Hospital (BCH) or the New England Congenital Cardiology Association (NECCA) practices, were evaluated by using a SCAMPs chest pain guideline. Findings were analyzed for diagnostic elements, patterns of care, and compliance with the guideline. Results from the NECCA practices were compared with those of Boston Children's Hospital, a regional core academic center.

RESULTS

Two patients had chest pain due to a cardiac etiology, 1 with pericarditis and 1 with an anomalous coronary artery origin. Testing performed outside of guideline recommendations demonstrated only incidental findings. Patients returning for persistent symptoms did not have cardiac disease. The pattern of care for the NECCA practices and BCH differed minimally.

CONCLUSIONS

By using SCAMPs methodology, we have demonstrated that chest pain in children is rarely caused by heart disease and can be evaluated in the ambulatory setting efficiently and effectively using minimal resources. The methodology can be implemented regionally across a wide range of clinical practice settings and its approach can overcome a number of barriers that often limit clinical practice guideline implementation.

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.

Reenvisioning assessment for the Academy and the Accreditation Council for Pharmacy Education's standards revision process

Assessment has become a major aspect of accreditation processes across all of higher education. As the Accreditation Council for Pharmacy Education (ACPE) plans a major revision to the standards for doctor of pharmacy (PharmD) education, an in-depth, scholarly review of the approaches and strategies for assessment in the PharmD program accreditation process is warranted. This paper provides 3 goals and 7 recommendations to strengthen assessment in accreditation standards. The goals include: (1) simplified standards with a focus on accountability and improvement, (2) institutionalization of assessment efforts; and (3) innovation in assessment. Evolving and shaping assessment practices is not the sole responsibility of the accreditation standards. Assessment requires commitment and dedication from individual faculty members, colleges and schools, and organizations supporting the college and schools, such as the American Association of Colleges of Pharmacy. Therefore, this paper also challenges the academy and its members to optimize assessment practices.

The impact of organizational culture on the outcome of hospital care: after the implementation of person-centred care

AIMS

To measure the effect of organizational culture on health outcomes of patients 3 months after discharge.

METHODS

a quantitative study using Organizational Values Questionnaire (OVQ) and a health-related quality of life instrument (EQ-5D). A total of 117 nurses, 69% response rate, and 220 patients answered the OVQ and EQ-5D, respectively.

RESULTS

The regression analysis showed that; 16% (R(2) = 0.02) of a decreased health status, 22% (R(2) = 0.05) of pain/discomfort and 13% (R(2) = 0.02) of mobility problems could be attributed to the combination of open system (OS) and Human Relations (HR) cultural dimensions, i.e., an organizational culture being dominated by flexibility.

CONCLUSIONS

The results from the present study tentatively indicated an association between an organizational culture and patients' health related quality of life 3 months after discharge. Even if the current understanding of organizational culture, which is dominated by flexibility, is considered favourable when implementing a new health care model, our results showed that it could be hindering instead of helping the new health care model in achieving its objectives.

Incentivizing primary care providers to innovate: building medical homes in the post-Katrina New Orleans safety net

OBJECTIVE

To evaluate safety-net clinics' responses to a novel community-wide Patient-Centered Medical Home (PCMH) financial incentive program in post-Katrina New Orleans.

DATA SOURCES/STUDY SETTING

Between June 2008 and June 2010, we studied 50 primary care clinics in New Orleans receiving federal funds to expand services and improve care delivery.

STUDY DESIGN

Multiwave, longitudinal, observational study of a local safety-net primary care system.

DATA COLLECTION

Clinic-level data from a semiannual survey of clinic leaders (89.3 percent response rate), augmented by administrative records.

PRINCIPAL FINDINGS

Overall, 62 percent of the clinics responded to financial incentives by achieving PCMH recognition from the National Committee on Quality Assurance (NCQA). Higher patient volume, higher baseline PCMH scores, and type of ownership were significant predictors of achieving NCQA recognition. The steepest increase in adoption of PCMH processes occurred among clinics achieving the highest, Level 3, NCQA recognition. Following NCQA recognition, 88.9 percent stabilized or increased their use of PCMH processes, although several specific PCMH processes had very low rates of adoption overall.

CONCLUSIONS

Findings demonstrate that widespread PCMH implementation is possible in a safety-net environment when external financial incentives are aligned with the goal of practice innovation.

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.

Using the Delphi technique to improve clinical outcomes through the development of quality indicators in renal cell carcinoma

PURPOSE

Optimal quality of care is needed for ideal outcomes. In renal cell carcinoma (RCC), there is a lack of information defining optimal care. This is particularly important in RCC, with increased complexity of care and a need for coordination among providers. The goal of this study was to identify quality indicators (QIs) and measures of quality care across the RCC disease spectrum.

MATERIALS AND METHODS

A modified Delphi technique was used to select QIs that are relevant and practical to RCC care. This technique involved an expert panel of 13 urologic and medical oncologists who participated in two e-mail questionnaires and an in-person meeting to review and prioritize potential QIs. These potential QIs were identified from a systematic literature review or were suggested by panel members.

RESULTS

From 233 literature citations, 34 possible QIs were identified; 24 additional potential QIs were suggested. A final set of 23 QIs was established. These are distributed across the RCC disease spectrum as follows (number of QIs in parentheses): screening (n=1), diagnosis/prognosis (n=3), surgical for localized disease (n=6), surgery for advanced disease (n=3), systemic therapy (n=6), and follow-up (n=2). In addition, two QIs related to survival outcomes (overall and progression-free survival) were selected.

CONCLUSION

A systematic, consensus-based approach was used to determine relevant QIs in RCC care. These 23 QIs will provide a means of evaluating the quality of RCC care in an effort to improve outcomes in patients. The next step will be to establish a means of measuring each QI based on defined or yet-to-be-defined benchmarks.

Systematic review of quality improvement interventions directed at cancer specialists

PURPOSE

Summary evidence on the effectiveness of quality improvement interventions (QIIs) directed at cancer specialists is needed for two reasons. First, there are some innovations over which only cancer specialists have control (eg, surgical technique or chemotherapy regimen). Second, implementation of QIIs has opportunity costs; the time and money spent on an ineffective QII might be better spent on direct patient care.

METHODS

Medical Subject Headings and text words for "quality improvement" were combined with those for "neoplasm" to search MEDLINE, PsycINFO, CINAHL, and EMBASE from January 1990 to August 2012 for studies of QIIs directed at cancer specialists (eg, medical/radiation oncologist, surgeon). All study designs were included.

RESULTS

Five thousand seven hundred eighty-one articles were screened, but only 12 met the inclusion criteria, including three cluster randomized controlled trials (cRCTs), seven uncontrolled before-and-after comparisons, and two cross-sectional studies. All 12 studies were conducted in response to concerns about quality of care. No cRCT showed a benefit of the QIIs tested. Some uncontrolled before-and-after and cross-sectional studies reported a benefit from the QII, but these studies are difficult to interpret because of concerns about uncontrolled confounding. Interventions in all studies were multifaceted, but descriptions of different components were limited, and only one study examined their separate impact.

CONCLUSION

The published evidence about how to facilitate timely and consistent adoption of new clinical knowledge by cancer specialists into everyday clinical practice is thin. More investment is needed in research about the solution (QIIs) to match the investment in research about the problem (inconsistent/slow adoption of innovative cancer treatments).

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.

Improving referral of patients for consideration of adjuvant chemotherapy after surgical resection of lung cancer

BACKGROUND

Clinical trials demonstrate improved survival for patients with completely resected non-small-cell lung cancer (nsclc) who receive adjuvant chemotherapy. Concerns have been raised about the implementation of those data. The present study measured rates of referral for adjuvant chemotherapy and barriers to referral, and it also evaluated a knowledge translation strategy to change practice.

METHODS

An audit and feedback approach was used. Using a retrospective cohort of patients undergoing thoracotomy at St. Joseph's Hospital in Hamilton, Ontario, during January-December 2008, anonymized data were presented to a group of thoracic surgeons for evaluation and feedback.

RESULTS

Among 150 thoracotomies performed, 55 patients with nsclc were potentially eligible for adjuvant chemotherapy, but only 27 (49%) were referred for it. Significant variability in referral between surgeons (19%-100%) was observed. Reasons for non-referral were poorly documented in the medical record, but appeared to be primarily the surgeon's decision. The feedback session with surgeons produced a number of constructive suggestions to implement change in practice.

CONCLUSIONS

Our findings suggest that surgeon choice was the most significant barrier to implementation of adjuvant chemotherapy for nsclc. Audit and feedback was a useful knowledge translation strategy. However, longer follow-up is needed to document change in practice.

A model for maternal depression

With the awareness of maternal depression as a prevalent public health issue and its important link to child physical and mental health, attention has turned to how healthcare providers can respond effectively. Intimate partner violence (IPV) and the use of alcohol, tobacco, and other drugs are strongly related to depression, particularly for low-income women. The American College of Obstetricians and Gynecologists (ACOG) recommends psychosocial screening of pregnant women at least once per trimester, yet screening is uncommonly done. Research suggests that a collaborative care approach improves identification, outcomes, and cost-effectiveness of care. This article presents The Perinatal Mental Health Model, a community-based model that developed screening and referral partnerships for use in community obstetric settings in order to specifically address the psychosocial needs of culturally diverse, low-income mothers.

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.

The influence of teams to sustain quality improvement in nursing homes that "need improvement"

OBJECTIVES

Qualitatively describe the use of team and group processes in intervention facilities participating in a study targeted to improve quality of care in nursing homes "in need of improvement."

DESIGN/SETTING/PARTICIPANTS

A randomized, two-group, repeated-measures design was used to test a 2-year intervention for improving quality of care and resident outcomes. Intervention group (n = 29) received an experimental multilevel intervention designed to help them: (1) use quality improvement methods, (2) use team and group process for direct-care decision-making, (3) focus on accomplishing the basics of care, and (4) maintain more consistent nursing and administrative leadership committed to communication and active participation of staff in decision-making.

RESULTS

The qualitative analysis revealed a subgroup of homes ("Full Adopters") likely to continue quality improvement activities that were able to effectively use teams. "Full Adopters" had either the nursing home administrator or director of nursing who supported and were actively involved in the quality improvement work of the team. "Full Adopters" also selected care topics for the focus of their quality improvement team, instead of "communication" topics of the "Partial Adopters" or "Non-Adopters" in the study who were identified as unlikely to continue to continue quality improvement activities after the intervention. "Full Adopters" had evidence of the key elements of complexity science: information flow, cognitive diversity, and positive relationships among staff; this evidence was lacking in other subgroups. All subgroups were able to recruit interdisciplinary teams, but only those that involved leaders were likely to be effective and sustain team efforts at quality improvement of care delivery systems.

CONCLUSIONS

Results of this qualitative analysis can help leaders and medical directors use the key elements and promote information flow among staff, residents, and families; be inclusive as discussions about care delivery, making sure diverse points of view are included; and help build positive relationships among all those living and working in the nursing home. Wide-spread adoption of the intervention in the randomized study is feasible and could be enabled by nursing home Medical Directors in collaborative practice with Advanced Practice Nurses.

Organizational culture and the implementation of person centered care: results from a change process in Swedish hospital care

Sweden has one of the oldest, most coherent and stable healthcare systems in the world. The culture has been described as conservative, mechanistic and increasingly standardized. In order to provide a care adjusted to the patient, person centered care (PCC) has been developed and implemented into some parts of the health care industry. The model has proven to decrease patient uncertainty. However, the impact of PCC has been limited in some clinics and hospital wards. An assumption is that organizational culture has an impact on desired outcomes of PCC, such as patient uncertainty. Therefore, in this study we identify the impact of organizational culture on patient uncertainty in five hospital wards during the implementation of PCC. Data from 220 hospitalized patients who completed the uncertainty cardiovascular population scale (UCPS) and 117 nurses who completed the organizational values questionnaire (OVQ) were investigated with regression analysis. The results seemed to indicate that in hospitals where the culture promotes stability, control and goal setting, patient uncertainty is reduced. In contrast to previous studies suggesting that a culture of flexibility, cohesion and trust is positive, a culture of stability can better sustain a desired outcome of reform or implementation of new care models such as person centered care. It is essential for health managers to be aware of what characterizes their organizational culture before attempting to implement any sort of new healthcare model. The organizational values questionnaire has the potential to be used as a tool to aid health managers in reaching that understanding.

Literature review to identify factors that support implementation of evidence-based practice in residential aged care

The aim was to undertake a review of the literature on change management, quality improvement, evidence-based practice and diffusion of innovations to identify key factors that might influence the uptake and continued use of evidence in residential aged care. The key factors will be used to shape and inform the evaluation of the Encouraging Best Practice in Residential Aged Care Program which commenced in Australia in 2007. MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews were searched using combinations of search terms. Searching focused on existing literature reviews, discussions of relevant conceptual and theoretical frameworks and primary studies that have examined the implementation of evidence-based practice in residential aged care. Keyword searching was supplemented with snowball searching (following up on the references cited in the papers identified by the search), searching by key authors in the field and hand searching of a small number of journals. In general, the period covered by the searches was from 2002 to 2008. The findings from the literature are often equivocal. Analysis and consolidation of factors derived from the literature that might influence the implementation of evidence-based practice resulted in the identification of eight factors: (i) a receptive context for change; (ii) having a model of change to guide implementation; (iii) adequate resources; (iv) staff with the necessary skills; (v) stakeholder engagement, participation and commitment; (vi) the nature of the change in practice; (vii) systems in place to support the use of evidence; and (viii) demonstrable benefits of the change. Most of the literature included in the review is from studies in healthcare and hence the generalisability to residential aged care is largely unknown. However, the focus of this research is on clinical care, within the context of residential aged care, hence the healthcare literature is relevant. The factors are relatively broad and cover the evidence itself, the process of implementation, the context within which evidence will be implemented and the systems and resources to support implementation. It is likely that the factors are not independent of each other. The set of factors will be refined over the course of the evaluation.

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.

Adherence behavior in the prevention and treatment of cardiovascular disease

Adherence is critical to the overall management of individuals at risk for and with cardiovascular disease. It forms an interplay between the patient, provider, and health care system and includes barriers that have been encountered within all 3 domains. Improving adherence to exercise, diet, and medication as well as focusing on addictive disorders such as smoking cessation requires patient, provider, and health care system approaches. The use of the cognitive/behavioral elements of health behavior change and communication strategies such as motivational interviewing and coaching serve to enhance overall adherence. Continuous quality improvement initiatives at the system level of change also increase the likelihood that teams will succeed in helping individuals change their behavior. Cardiac rehabilitation programs offer a unique opportunity for health care professionals to play a key role in supporting individuals through the health behavior change process.

Continuous Quality Improvement and Health Educators

Quality improvement is increasingly at the forefront of health care, creating a growing demand in clinical settings for health professionals adept at understanding and optimizing systems of health care delivery. Compared with clinicians, administrators, and health services researchers, health educators have to date played less of a role in quality improvement. However, as this article argues, the potential for health educators to contribute to such efforts is great because health education and quality improvement are more similar in their goals and approaches than is commonly recognized. Health educators bring important skills to quality improvement practice in areas such as needs assessment, participatory planning, and evaluation. To illustrate the mutual benefits that arise when these two practices intersect, the implementation of an electronic patient scheduling system led by quality improvement professionals in a large home care agency is described.

Monitoring quality in Israeli primary care: The primary care physicians' perspective

BACKGROUND

Since 2000, Israel has had a national program for ongoing monitoring of the quality of the primary care services provided by the country's four competing non-profit health plans. Previous research has demonstrated that quality of care has improved substantially since the program's inception and that the program enjoys wide support among health plan managers. However, prior to this study there were anecdotal and journalistic reports of opposition to the program among primary care physicians engaged in direct service delivery; these raised serious questions about the extent of support among physicians nationally.

GOALS

To assess how Israeli primary care physicians experience and rate health plan efforts to track and improve the quality of care.

METHOD

The study population consisted of primary care physicians employed by the health plans who have responsibility for the quality of care of a panel of adult patients. The study team randomly sampled 250 primary-care physicians from each of the four health plans. Of the 1,000 physicians sampled, 884 met the study criteria. Every physician could choose whether to participate in the survey by mail, e-mail, or telephone. The anonymous questionnaire was completed by 605 physicians - 69% of those eligible. The data were weighted to reflect differences in sampling and response rates across health plans.

MAIN FINDINGS

The vast majority of respondents (87%) felt that the monitoring of quality was important and two-thirds (66%) felt that the feedback and subsequent remedial interventions improved medical care to a great extent. Almost three-quarters (71%) supported continuation of the program in an unqualified manner. The physicians with the most positive attitudes to the program were over age 44, independent contract physicians, and either board-certified in internal medicine or without any board-certification (i.e., residents or general practitioners). At the same time, support for the program was widespread even among physicians who are young, board-certified in family medicine, and salaried.Many physicians also reported that various problems had emerged to a great or very great extent: a heavier workload (65%), over-competitiveness (60%), excessive managerial pressure (48%), and distraction from other clinical issues (35%). In addition, there was some criticism of the quality of the measures themselves. Respondents also identified approaches to addressing these problems.

CONCLUSIONS

The findings provide perspective on the anecdotal reports of physician opposition to the monitoring program; they may well accurately reflect the views of the small number of physicians directly involved, but they do not reflect the views of primary care physicians as a whole, who are generally quite supportive of the program. At the same time, the study confirms the existence of several perceived problems. Some of these problems, such as excess managerial pressure, can probably best be addressed by the health plans themselves; while others, such as the need to refine the quality indicators, are probably best addressed at the national level. Cooperation between primary care physicians and health plan managers, which has been an essential component of the program's success thus far, can also play an important role in addressing the problems identified.

Revising acute care systems and processes to improve breastfeeding and maternal postnatal health: a pre and post intervention study in one English maternity unit

BACKGROUND

Most women in the UK give birth in a hospital labour ward, following which they are transferred to a postnatal ward and discharged home within 24 to 48 hours of the birth. Despite policy and guideline recommendations to support planned, effective postnatal care, national surveys of women's views of maternity care have consistently found in-patient postnatal care, including support for breastfeeding, is poorly rated.

METHODS

Using a Continuous Quality Improvement approach, routine antenatal, intrapartum and postnatal care systems and processes were revised to support implementation of evidence based postnatal practice. To identify if implementation of a multi-faceted QI intervention impacted on outcomes, data on breastfeeding initiation and duration, maternal health and women's views of care, were collected in a pre and post intervention longitudinal survey. Primary outcomes included initiation, overall duration and duration of exclusive breastfeeding. Secondary outcomes included maternal morbidity, experiences and satisfaction with care. As most outcomes of interest were measured on a nominal scale, these were compared pre and post intervention using logistic regression.

RESULTS

Data were obtained on 741/1160 (64%) women at 10 days post-birth and 616 (54%) at 3 months post-birth pre-intervention, and 725/1153 (63%) and 575 (50%) respectively post-intervention. Post intervention there were statistically significant differences in the initiation (p = 0.050), duration of any breastfeeding (p = 0.020) and duration of exclusive breastfeeding to 10 days (p = 0.038) and duration of any breastfeeding to three months (p = 0.016). Post intervention, women were less likely to report physical morbidity within the first 10 days of birth, and were more positive about their in-patient care.

CONCLUSIONS

It is possible to improve outcomes of routine in-patient care within current resources through continuous quality improvement.

Using quality indicators in anaesthesia: feeding back data to improve care

After recent UK policy developments, considerable attention has been focused upon how clinical specialties measure and report on the quality of care delivered to patients. Defining the right indicators alone is insufficient to close the feedback loop. This narrative review aims to describe and synthesize a diverse body of research relevant to the question of how information from quality indicators can be fed back and used effectively to improve care. Anaesthesia poses certain challenges in the identification of valid outcome indicators sensitive to variations in anaesthetic care. Metrics collected during the immediate post-anaesthetic recovery period, such as patient temperature, patient-reported quality of recovery, and pain and nausea, provide potentially useful information for the anaesthetist, yet this information is not routinely fed back. Reviews of the effects of feeding back performance data to healthcare providers suggest that this may result in small to moderate positive effects upon outcomes and professional practice, with stronger effects where feedback is integrated within a broader quality improvement strategy. The dominant model for use of data within quality improvement is based upon the industrial process control approach, in which care processes are monitored continuously for process changes which are rapidly detectable for corrective action. From this review and experience of implementing these principles in practice, effective feedback from quality indicators is timely, credible, confidential, tailored to the recipient, and continuous. Considerable further work is needed to understand how information from quality indicators can be fed back in an effective way to clinicians and clinical units, in order to support revalidation and continuous improvement.

Perceptions of changes in practice following peer review in the National Chronic Obstructive Pulmonary Disease Resources and Outcomes Project

PURPOSE

The purpose of this paper is to examine perceptions of local service change and concepts of change amongst participants in a UK nationwide randomised controlled trial of informal, structured, reciprocated, multidisciplinary peer review with feedback to promote quality improvement: the National Chronic Obstructive Pulmonary Disease Resources and Outcomes Project (NCROP).

DESIGN/METHODOLOGY/APPROACH

The paper takes the form of a qualitative study, involving semi-structured interviews with 43 hospital respiratory consultants, nurses and general managers at 24 intervention and 11 control NCROP sites. Thematic analysis resulted in adoption of Joss and Kogan's quality indicators as an analytic framework.

FINDINGS

The paper finds that peer review was associated with positive changes, which may lead to sustained service improvement. Differences existed in perceptions of change among clinicians and between clinicians and managers. "Generic changes" (e.g. changes in interpersonal relations or cultural changes), were often not perceived as change.

RESEARCH LIMITATIONS/IMPLICATIONS

The study highlights the significance of generic change in evaluations of change processes. Most participants were clinicians limiting inter-professional comparisons. Some clinical staff failed to recognise changes they accomplished or their significance, perceiving change differently to others within their professional group. These findings have implications for policy and research. They should be considered when developing frameworks for assessing quality improvements and staff engagement with change.

ORIGINALITY/VALUE

This is the first qualitative study exploring participants' experience of peer review for quality improvement in healthcare. The study adds to previous research into UK health service improvement, which has had a more restricted focus on inter-professional differences.

Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant literature

Background

Formal evaluations of programmes are an important source of learning about the challenges faced in improving quality in healthcare and how they can be addressed. The authors aimed to integrate lessons from evaluations of the Health Foundation's improvement programmes with relevant literature.

Methods

The authors analysed evaluation reports relating to five Health Foundation improvement programmes using a form of ‘best fit’ synthesis, where a pre-existing framework was used for initial coding and then updated in response to the emerging analysis. A rapid narrative review of relevant literature was also undertaken.

Results

The authors identified ten key challenges: convincing people that there is a problem that is relevant to them; convincing them that the solution chosen is the right one; getting data collection and monitoring systems right; excess ambitions and ‘projectness’; organisational cultures, capacities and contexts; tribalism and lack of staff engagement; leadership; incentivising participation and ‘hard edges’; securing sustainability; and risk of unintended consequences. The authors identified a range of tactics that may be used to respond to these challenges.

Discussion

Securing improvement may be hard and slow and faces many challenges. Formal evaluations assist in recognising the nature of these challenges and help in addressing them.

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.

Quality improvement in cancer symptom assessment and control: the Provincial Palliative Care Integration Project (PPCIP)

CONTEXT

The Provincial Palliative Care Integration Project (PPCIP) was implemented in Ontario, Canada, to enhance the quality of palliative care delivery. The PPCIP promoted collaboration and integration across service sectors to improve screening and assessment, palliative care processes, as well as clinician practice and outcomes for cancer patients.

OBJECTIVES

The project involved 1) implementation of the Edmonton Symptom Assessment System (ESAS) for symptom screening, 2) use of "rapid-cycle change" quality improvement processes to improve screening and symptom management, and 3) improvements in integration and access to palliative care services.

METHODS

Symptom scores were collected and made accessible to the care team through a web-based tool and kiosk technology, which helped patients enter their ESAS scores at each visit to the regional cancer center or at home with their nurse. Symptom response data were gathered through clinical chart audits.

RESULTS

Within one year of implementation, regional cancer centers saw improvements in symptom screening (54% of lung cancer patients), symptom control (69% of patients with pain scores and 31% of patients with dyspnea scores seven or more were reduced to six or less within 72 hours), and functional assessment (23% of all patients and 64% of palliative care clinic patients). ESAS screening rates reached 29%, and functional assessment reached 26% of targeted home care patients.

CONCLUSION

The PPCIP demonstrated that significant strides in symptom screening and response can be achieved within a year using rapid-cycle change and collaborative approaches. It showed that both short- and long-term improvement require ongoing facilitation to embed the changes in system design and change the culture of clinical practice.

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.

More black box to explore: how quality improvement collaboratives shape practice change

BACKGROUND

Quality improvement collaboratives (QICs) are used extensively to promote quality improvement in health care. Evidence of their effectiveness is limited, prompting calls to "open up the black box" to better understand how and why such collaboratives work.

METHODS

We selected a cohort of 5 primary care practices that participated in a 6-month intervention study aimed at improving colorectal cancer screening rates. Using an immersion/crystallization technique, we analyzed qualitative data that included audio recordings and field notes of QICs and practice-based team meetings.

RESULTS

Three themes emerged from our analysis: (1) practice staff became empowered through and drew on the QICs to advance change efforts in the face of leader/physician resistance; (2) a mix of content and media in the QIC program was important for reaching all participants; (3) resources offered at the QIC did little to spur practice change efforts.

CONCLUSION

QICs offer a potentially powerful way of disseminating health care innovations through enhanced strategies for learning and change. Creating collaborative environments in which diverse participants learn, listen, reflect, and share together can enable them to take back to their own organizations key messages and change strategies that benefit them the most.

Using information technology to improve adult immunization delivery in an integrated urban health system

BACKGROUND

Adult immunizations prevent morbidity and mortality yet coverage remains suboptimal, in part due to missed opportunities. Clinical decision support systems (CDSSs) can improve immunization rates when integrated into routine work flow, implemented wherever care is delivered, and used by staff who can act on the recommendation.

METHODS

An adult immunization improvement project was undertaken in a large integrated, safety-net health care system. A CDSS was developed to query patient records and identify patients eligible for pneumococcal, influenza, or tetanus immunization and then generate a statement that recommends immunization or indicates a previous refusal. A new agency policy authorized medical assistants and nurses in clinics, and nurses in the hospital, to use the CDSS as a standing order. Immunization delivery work flow was standardized, and staff received feedback on immunization rates.

RESULTS

The CDSS identified more patients than a typical paper standing order and can be easily modified to incorporate changes in vaccine indications. The intervention led to a 10% improvement in immunization rates in adults 65 years of age or older and in younger adults with diabetes or chronic obstructive pulmonary disease. Overall, the improvements were sustained beyond the project period. The CDSS was expanded to encompass additional vaccines.

CONCLUSIONS

Interdepartmental collaboration was critical to identify needs, challenges, and solutions. Implementing the standing order policy in clinics and the hospital usually allowed immunizations to be taken out of the hands of clinicians. As an on-demand tool, CDSS must be used at each patient encounter to avoid missed opportunities. Staff retraining accompanied by ongoing assessment of immunization rates, work flow, and missed opportunities to immunize patients are critical to sustain and enhance improvements.

Improving care after myocardial infarction using a 2-year internet-delivered intervention: the Department of Veterans Affairs myocardial infarction-plus cluster-randomized trial

BACKGROUND

Cardiovascular risk reduction in ambulatory patients who survive myocardial infarction (MI) is effective but underused. We sought to evaluate a provider-directed, Internet-delivered intervention to improve cardiovascular management for post-MI outpatients.

METHODS

The Department of Veterans Affairs (VA) MI-Plus study was a cluster-randomized trial involving 168 community-based primary care clinics and 847 providers in 26 states, the Virgin Islands, and Puerto Rico, from January 1, 2002, through December 31, 2008, with the clinic as the randomization unit. We collected administrative data for 15,847 post-MI patients and medical record data for 10,452 of these. A multicomponent, Internet-delivered intervention included quarterly educational modules, practice guidelines, monthly literature summaries, and automated e-mail reminders delivered to providers for 27 months. Main outcome measures included percentage of patients who achieved each of 7 clinical indicators, a composite score of the 7 clinical indicators, and mean low-density lipoprotein cholesterol and hemoglobin A(1c) levels.

RESULTS

Clinics had a median of 3 providers (interquartile range, 2-6), with a median of 50.0% of providers (33.3%-66.7%) participating in the study. Patients in intervention clinics had greater improvements (from 70.0% to 85.5%) in the percentages prescribed β-blockers than patients in control clinics (71.9% to 84.0%; adjusted improvement gain for intervention vs control, 2.6%; 95% CI, 0.1%-4.1%). We found nonsignificant differences in improvements favoring patients in intervention clinics for 5 of 6 remaining clinical indicators and levels of low-density lipoprotein cholesterol and hemoglobin A(1c).

CONCLUSION

A longitudinal, Internet-delivered intervention improved only 1 of 7 clinical indicators of cardiovascular management in ambulatory post-MI patients.

Implementing complex innovations: factors influencing middle manager support

BACKGROUND

Middle manager resistance is often described as a major challenge for upper-level administrators seeking to implement complex innovations such as evidence-based protocols or new skills training. However, factors influencing middle manager support for innovation implementation are currently understudied in the U.S. health care literature.

PURPOSE

This article examined the factors that influence middle managers' support for and participation in the implementation of work-based learning, a complex innovation adopted by health care organizations to improve the jobs, educational pathways, skills, and/or credentials of their frontline workers.

METHODS

We conducted semistructured interviews and focus groups with 92 middle managers in 17 health care organizations. Questions focused on understanding middle managers' support for work-based learning as a complex innovation, facilitators and barriers to the implementation process, and the systems changes needed to support the implementation of this innovation.

FINDINGS

Factors that emerged as influential to middle manager support were similar to those found in broader models of innovation implementation within the health care literature. However, our findings extend previous research by developing an understanding about how middle managers perceived these constructs and by identifying specific strategies for how to influence middle manager support for the innovation implementation process. These findings were generally consistent across different types of health care organizations.

PRACTICE IMPLICATIONS

Study findings suggest that middle manager support was highest when managers felt the innovation fit their workplace needs and priorities and when they had more discretion and control over how it was implemented. Leaders seeking to implement innovations should consider the interplay between middle managers' control and discretion, their narrow focus on the performance of their own departments or units, and the dedication of staff and other resources for empowering their managers to implement these complex innovations.

Employing continuous quality improvement in community-based substance abuse programs

PURPOSE

This article aims to describe continuous quality improvement (CQI) for substance abuse prevention and treatment programs in a community-based organization setting.

DESIGN/METHODOLOGY/APPROACH

CQI (e.g., plan-do-study-act cycles (PDSA)) applied in healthcare and industry was adapted for substance abuse prevention and treatment programs in a community setting. The authors assessed the resources needed, acceptability and CQI feasibility for ten programs by evaluating CQI training workshops with program staff and a series of three qualitative interviews over a nine-month implementation period with program participants. The CQI activities, PDSA cycle progress, effort, enthusiasm, benefits and challenges were examined.

FINDINGS

Results indicated that CQI was feasible and acceptable for community-based substance abuse prevention and treatment programs; however, some notable resource challenges remain. Future studies should examine CQI impact on service quality and intended program outcomes.

RESEARCH LIMITATIONS/IMPLICATIONS

The study was conducted on a small number of programs. It did not assess CQI impact on service quality and intended program outcomes. Practical implications- This project shows that it is feasible to adapt CQI techniques and processes for community-based programs substance abuse prevention and treatment programs. These techniques may help community-based program managers to improve service quality and achieve program outcomes.

ORIGINALITY/VALUE

This is one of the first studies to adapt traditional CQI techniques for community-based settings delivering substance abuse prevention and treatment programs.

Evaluation of organizational culture among different levels of healthcare staff participating in the Institute for Healthcare Improvement's 100,000 Lives Campaign

BACKGROUND

Little is known about how hospital organizational and cultural factors associated with implementation of quality initiatives such as the Institute for Healthcare Improvement's (IHI) 100,000 Lives Campaign differ among levels of healthcare staff.

DESIGN

Evaluation of a mixed qualitative and quantitative methodology ("trilogic evaluation model").

SETTING

Six hospitals that joined the campaign before June 2006.

PARTICIPANTS

Three strata of staff (executive leadership, midlevel, and frontline) at each hospital. RESULTS. Surveys were completed in 2008 by 135 hospital personnel (midlevel, 43.7%; frontline, 38.5%; executive, 17.8%) who also participated in 20 focus groups. Overall, 93% of participants were aware of the IHI campaign in their hospital and perceived that 58% (standard deviation, 22.7%) of improvements in quality at their hospital were a direct result of the campaign. There were significant differences between staff levels on the organizational culture (OC) items, with executive-level staff having higher scores than midlevel and frontline staff. All 20 focus groups perceived that the campaign interventions were sustainable and that data feedback, buy-in, hardwiring (into daily activities), and leadership support were essential to sustainability.

CONCLUSIONS

The trilogic model demonstrated that the 3 levels of staff had markedly different perceptions regarding the IHI campaign and OC. A framework in which frontline, midlevel, and leadership staff are simultaneously assessed may be a useful tool for future evaluations of OC and quality initiatives such as the IHI campaign.

Primary care practice transformation is hard work: insights from a 15-year developmental program of research

BACKGROUND

Serious shortcomings remain in clinical care in the United States despite widespread use of improvement strategies for enhancing clinical performance based on knowledge transfer approaches. Recent calls to transform primary care practice to a patient-centered medical home present even greater challenges and require more effective approaches.

METHODS

Our research team conducted a series of National Institutes of Health funded descriptive and intervention projects to understand organizational change in primary care practice settings, emphasizing a complexity science perspective. The result was a developmental research effort that enabled the identification of critical lessons relevant to enabling practice change.

RESULTS

A summary of findings from a 15-year program of research highlights the limitations of viewing primary care practices in the mechanistic terms that underlie current or traditional approaches to quality improvement. A theoretical perspective that views primary care practices as dynamic complex adaptive systems with "agents" who have the capacity to learn, and the freedom to act in unpredictable ways provides a better framework for grounding quality improvement strategies. This framework strongly emphasizes that quality improvement interventions should not only use a complexity systems perspective, but also there is a need for continual reflection, careful tailoring of interventions, and ongoing attention to the quality of interactions among agents in the practice.

CONCLUSIONS

It is unlikely that current strategies for quality improvement will be successful in transforming current primary care practice to a patient-centered medical home without a stronger guiding theoretical foundation. Our work suggests that a theoretical framework guided by complexity science can help in the development of quality improvement strategies that will more effectively facilitate practice change.

Management systems, patient quality improvement, resource availability, and substance abuse treatment quality

OBJECTIVE

To examine the relationships among general management systems, patient-focused quality management/continuous process improvement (TQM/CPI) processes, resource availability, and multiple dimensions of substance use disorder (SUD) treatment.

DATA SOURCES/STUDY SETTING

Data are from a nationally representative sample of 221 SUD treatment centers through the National Treatment Center Study (NTCS).

STUDY DESIGN

The design was a cross-sectional field study using latent variable structural equation models. The key variables are management practices, TQM/continuous quality improvement (CQI) practices, resource availability, and treatment center performance.

DATA COLLECTION

Interviews and questionnaires provided data from treatment center administrative directors and clinical directors in 2007-2008.

PRINCIPAL FINDINGS

Patient-focused TQM/CQI practices fully mediated the relationship between internal management practices and performance. The effects of TQM/CQI on performance are significantly larger for treatment centers with higher levels of staff per patient.

CONCLUSIONS

Internal management practices may create a setting that supports implementation of specific patient-focused practices and protocols inherent to TQM/CQI processes. However, the positive effects of internal management practices on treatment center performance occur through use of specific patient-focused TQM/CPI practices and have more impact when greater amounts of supporting resources are present.