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

Hospital quality improvement in Ethiopia: a partnership-mentoring model

BACKGROUND AND OBJECTIVE

Quality improvement efforts are increasingly common in the United States; however, their use in developing countries is limited. We sought to evaluate the impact of a large-scale intervention on several key management indicators through hospital quality improvement efforts.

DESIGN

Pre-post-descriptive study of 14 hospitals in Ethiopia.

SETTING

Six regions and two city administrations in Ethiopia.

PARTICIPANTS

Hospital leaders and management mentors in participating hospitals.

INTERVENTION

In collaboration with the Ministry of Health and the Clinton HIV/AIDS Initiative, we implemented a countrywide quality improvement initiative in which 24 mentors with hospital administration experience were placed for 1 year in Ethiopia to work side-by-side with hospital management teams. We also provided a professional development course to enhance quality improvement skills.

MAIN OUTCOME MEASURE

s) Presence of 75 key management indicators; reported management skills of hospital leaders by the mentors.

RESULTS

In pre-post analysis, we found improvement in 45 of the 75 (60%) key management indicators between August 2006 and May 2007. The changes reflected a total of 105 management indicators improved across the 14 hospitals, which equates to a per-hospital mean of 7.5 (standard deviation 5.9) improvements. Reported management skills of hospital leaders improved in several management domains, although their reported confidence in these skills remained largely unchanged.

CONCLUSIONS

Our findings indicate that quality improvement efforts can be effective in improving hospital management in developing countries. Longer follow-up is required to assess the sustainability of the hospital improvements accomplished.

Relationship between nurses and physicians in terms of organizational culture: who is responsible for subordination of nurses?

AIM

To investigate how nurses and physicians perceive organizational culture, their integration into the organizational processes, and relations within a health care team.

METHODS

We performed a cross-sectional study that included 106 physicians and 558 nurses from 14 Slovenian hospitals in December 2005. The hospitals were randomly selected. We distributed the questionnaires on the same day to physicians and nurses during a morning shift. The total number of distributed questionnaires represented a 20% of each personnel category at each hospital. The following variables were studied: organizational culture, integration of nurses and physicians in hospital processes, and subordination of nurses to physicians.

RESULTS

Physicians and nurses favored a culture of internal focus, stability, and control. Both groups estimated that they had a low level of personal involvement in their organizations and indicated insufficient involvement in work teams, while nurses also felt that they were subordinated (mean+/-standard deviation, 3.6+/-0.9 on a scale from 1 to 5) to physicians (2.7+/-1.0; P<0.001). Control orientation correlated positively with the subordination of nurses (PP<0.005) and negatively with personal integration in an organization (PP<0.005).

CONCLUSION

We found out that subordination of nurses can be explained by market culture, level of personal involvement, and the level of education. Our research showed that the professional growth of nurses was mainly threatened by organizational factors such as hierarchy, control orientation, a lack of cooperation and team building between physicians and nurses, as well as insufficient inclusion of both physicians and nurses into change implementation activities.

The effectiveness of nurse-led telemonitoring of asthma: results of a randomized controlled trial

RATIONALE, AIMS AND OBJECTIVES

The aim of the study was to evaluate the effects on, and the relationship between, asthma symptoms, asthma-specific quality of life and medical consumption of a nurse-led telemonitoring intervention compared with regular care in asthma in the Netherlands.

METHODS

One hundred and nine asthmatic outpatients (56 children; 53 adults) were randomly assigned to the treatment arms (12-month follow-up). The control group received regular outpatient care, while the intervention group used an asthma monitor with modem at home with an asthma nurse as the main caregiver. Clinical asthma symptoms and medical consumption were measured by using diaries. Asthma-specific quality of life was measured by the (Paediatric) Asthma Quality of Life Questionnaire.

RESULTS

The study population generally represented mild to moderate asthmatics. The results show improvement in follow-up, but no statistically significant difference between the groups was observed. Moderate to high correlations were found within the outcome parameters, but the most remarkable was the low and statistically significant correlation between asthma-specific quality of life (daily functioning) and the self-reported beta-2 agonists.

CONCLUSION

Overall, the telemonitoring programme evaluated in this study did not significantly decrease asthma symptoms or medical consumption, or improve asthma-specific quality of life. The results showed that a telemonitoring programme on its own is not a guarantee of success. The patients' perception of asthma-specific quality of life (daily functioning) should be a key element in asthma telemonitoring programmes.

Publication of quality report cards and trends in reported quality measures in nursing homes

OBJECTIVE

To examine associations between nursing homes' quality and publication of the Nursing Home Compare quality report card.

DATA SOURCES/STUDY SETTINGS

Primary and secondary data for 2001-2003: 701 survey responses of a random sample of nursing homes; the Minimum Data Set (MDS) with information about all residents in these facilities, and the Nursing Home Compare published quality measure (QM) scores.

STUDY DESIGN

Survey responses provided information on 20 specific actions taken by nursing homes in response to publication of the report card. MDS data were used to calculate five QMs for each quarter, covering a period before and following publication of the report. Statistical regression techniques were used to determine if trends in these QMs have changed following publication of the report card in relation to actions undertaken by nursing homes.

PRINCIPAL FINDINGS

Two of the five QMs show improvement following publication. Several specific actions were associated with these improvements.

CONCLUSIONS

Publication of the Nursing Home Compare report card was associated with improvement in some but not all reported dimensions of quality. This suggests that report cards may motivate providers to improve quality, but it also raises questions as to why it was not effective across the board.

An approach to measure compliance to clinical guidelines in psychiatric care

BACKGROUND

The aim of this study was to measure six months compliance to Swedish clinical guidelines in psychiatric care after an active supported implementation process, using structured measures derived from the guidelines.

METHODS

In this observational study four psychiatric clinics each participated in active implementation of the clinical guidelines for the assessment and treatment of depression and guidelines for assessment and treatment of patients with suicidal behaviours developed by The Stockholm Medical Advisory Board for Psychiatry. The implementation programme included seminars, local implementation teams, regular feedback and academic visits. Additionally two clinics only received the guidelines and served as controls. Compliance to guidelines was measured using indicators, which operationalised requirements of preferred clinical practice. 725 patient records were included, 365 before the implementation and 360 six months after.

RESULTS

Analyses of indicators registered showed that the actively implementing clinics significantly improved their compliance to the guidelines. The total score differed significantly between implementation clinics and control clinics for management of depression (mean scores 9.5 (1.3) versus 5.0 (1.5), p < 0.001) as well as for the management of suicide (mean scores 8.1 (2.3) versus 4.5 (1.9), p < 0.001). No changes were found in the control clinics and only one of the OR was significant.

CONCLUSION

Compliance to clinical guidelines measured by process indicators of required clinical practice was enhanced by an active implementation.

Organizational resiliency: how top-performing hospitals respond to setbacks in improving quality of cardiac care

Despite substantial improvement in recent years in hospital performance in many quality measures for acute myocardial infarction (AMI), national performance lags in a key publicly reported quality indicator for AMI--door-to-balloon time, the period from patient (with ST-segment elevation myocardial infarction or STEMI) arrival to provision of percutaneous coronary intervention or balloon angioplasty. Previous research has elucidated distinguishing features of hospitals that routinely achieved recommended door-to-balloon times for patients with STEMI. However, what has not been fully explored is how top-performing hospitals handle setbacks during the improvement process. In this study, we used qualitative methods to characterize the range of setbacks in door-to-balloon improvement efforts and the strategies used to address these barriers among hospitals that were ultimately successful in reducing door-to-balloon time to meet clinical guidelines. Setbacks included (1) failure to anticipate and address implications of initial changes in door-to-balloon processes for the system as a whole; (2) tension between and within departments and disciplines, which needed to gain consensus about how to reduce door-to-balloon time; and (3) waning attention to door-to-balloon performance as a top priority after the perceived goal of reducing treatment times had been reached. Our findings demonstrate key aspects of technical capacity, organizational culture, and environmental conditions that were factors in maintaining improvement efforts despite setbacks and hence may be critical to sustaining top performance. Understanding how top-performing hospitals recognize and respond to setbacks can help senior management promote organizational resiliency, leading to an environment in which learning, growth, and quality improvement can be sustained.

Implementation of the resident assessment instrument/minimum data set in the nursing home as organization: implications for quality improvement in RN clinical assessment

The Resident Assessment Instrument/Minimum Data Set (RAI/MDS) used in nursing homes (NHs) participating in the Federal Medicare and Medicaid programs is a state-of-the-art, computerized clinical assessment instrument. RAI/MDS-derived data are essential, used for NH reimbursement, quality measurement, regulatory quality monitoring activities, and clinical care planning. Completing or coordinating the RAI/MDS, which may be conceived of as implementation, is a federally mandated responsibility of the RN involving clinical assessment, a core professional competency of any RN. How the RAI/MDS is implemented in each NH provides evidence of how each NH as an organization understands both the RAI/MDS process and its organizational level responsibility for promotion of RN competence in clinical assessment. Research literature related to RAI/MDS development, testing, and accuracy is used to identify what is known about organizational level implementation of the RAI/MDS. Evidence-based suggestions to enhance RN competence in RAI/MDS clinical assessments, given existing organizational barriers, are provided.

Review: Conceptualization and Measurement of Organizational Readiness for Change

Health care practitioners and change experts contend that organizational readiness for change is a critical precursor to successful change implementation. This article assesses how organizational readiness for change has been defined and measured in health services research and other fields. Analysis of 106 peer-reviewed articles reveals conceptual ambiguities and disagreements in current thinking and writing about organizational readiness for change. Inspection of 43 instruments for measuring organizational readiness for change reveals limited evidence of reliability or validity for most publicly available measures. Several conceptual and methodological issues that need to be addressed to generate knowledge useful for practice are identified and discussed.

Does quality improvement work? Evaluation of the Organ Donation Breakthrough Collaborative

OBJECTIVE

The Organ Donation Breakthrough Collaborative is a quality improvement initiative to encourage adoption of "best practices" for identifying potential donors and obtaining consent for deceased organ donation. We evaluate the impact of the first phase on organ donation rates.

SETTING

We study donation rates in the 95 hospitals that participated in the first phase and a control group of 125 hospitals.

DESIGN

We use a controlled pre/post design. The preperiod is the year before the start of the Collaborative (September 2002 to August 2003), the postperiod is the final 6 months of the first phase (March 2004 to August 2004).

DATA

We use administrative data from the Organ Procurement and Transplantation Network to compute the conversion rate in each hospital group and time period. The conversion rate is the proportion of eligible donors who became actual donors.

PRINCIPAL FINDINGS

Preperiod conversion rates in Collaborative and control hospitals were similar: 52 and 51 percent, respectively. In the postperiod, the conversion rate increased to 60 percent among Collaborative hospitals and remained at 51 percent among control hospitals. The relative change was 8 percentage points (95 percent confidence interval: 2-13: p<.001).

CONCLUSIONS

Our findings suggest that the Breakthrough Collaborative led to an increase in donation rates at participating hospitals.

Implementing academic detailing for breast cancer screening in underserved communities

BACKGROUND

African American and Hispanic women, such as those living in the northern Manhattan and the South Bronx neighborhoods of New York City, are generally underserved with regard to breast cancer prevention and screening practices, even though they are more likely to die of breast cancer than are other women. Primary care physicians (PCPs) are critical for the recommendation of breast cancer screening to their patients. Academic detailing is a promising strategy for improving PCP performance in recommending breast cancer screening, yet little is known about the effects of academic detailing on breast cancer screening among physicians who practice in medically underserved areas. We assessed the effectiveness of an enhanced, multi-component academic detailing intervention in increasing recommendations for breast cancer screening within a sample of community-based urban physicians.

METHODS

Two medically underserved communities were matched and randomized to intervention and control arms. Ninety-four primary care community (i.e., not hospital based) physicians in northern Manhattan were compared to 74 physicians in the South Bronx neighborhoods of the New York City metropolitan area. Intervention participants received enhanced physician-directed academic detailing, using the American Cancer Society guidelines for the early detection of breast cancer. Control group physicians received no intervention. We conducted interviews to measure primary care physicians' self-reported recommendation of mammography and Clinical Breast Examination (CBE), and whether PCPs taught women how to perform breast self examination (BSE).

RESULTS

Using multivariate analyses, we found a statistically significant intervention effect on the recommendation of CBE to women patients age 40 and over; mammography and breast self examination reports increased across both arms from baseline to follow-up, according to physician self-report. At post-test, physician involvement in additional educational programs, enhanced self-efficacy in counseling for prevention, the routine use of chart reminders, computer- rather than paper-based prompting and tracking approaches, printed patient education materials, performance targets for mammography, and increased involvement of nursing and other office staff were associated with increased screening.

CONCLUSION

We found some evidence of improvement in breast cancer screening practices due to enhanced academic detailing among primary care physicians practicing in urban underserved communities.

A comparative study of quality outcomes in freestanding ambulatory surgery centers and hospital-based outpatient departments: 1997-2004

RESEARCH OBJECTIVE

To compare quality outcomes from surgical procedures performed at freestanding ambulatory surgery centers (ASCs) and hospital-based outpatient departments (HOPDs).

DATA SOURCES

Patient-level ambulatory surgery (1997-2004), hospital discharge (1997-2004), and vital statistics data (1997-2004) for the state of Florida were assembled and analyzed.

STUDY DESIGN

We used a pooled, cross-sectional design. Logistic regressions with time fixed-effects were estimated separately for the 12 most common ambulatory surgical procedures. Our quality outcomes were risk-adjusted 7-day and 30-day mortality and 7-day and 30-day unexpected hospitalizations. Risk-adjustment for patient demographic characteristics and severity of illness were calculated using the DCG/HCC methodology adjusting for primary diagnosis only and separately for all available diagnoses.

PRINCIPAL FINDINGS

Although neither ASCs nor HOPDs performed better overall, we found some difference by procedure that varied based on the risk-adjustment approach used.

CONCLUSIONS

There appear to be important variations in quality outcomes for certain procedures, which may be related to differences in organizational structure, processes, and strategies between ASCs and HOPDs. The study also confirms the importance of risk-adjustment for comorbidities when using administrative data, particularly for procedures that are sensitive to differences in severity.

Defining a high performance healthcare organisation

Composite measures of performance are insufficient on their own

Process evaluation in an intervention designed to improve rates of colorectal cancer screening in a VA medical center

Colorectal cancer (CRC) is the third most common cancer in the United States. Although CRC screening is recommended for individuals 50 years and older, screening completion rates are low. This can be attributed to provider and patient barriers. We developed an intervention to improve provider recommendation and patient screening among noncompliant male veterans in a 2-year randomized controlled trial and examined the relationship between participation and study outcomes among patients and providers. Overall, providers who attended intervention sessions recommended CRC screening during 64% of patient visits and providers who did not attend any intervention sessions recommended screening during 54% of visits (p < .01). Patients of providers who attended intervention sessions also were more likely to be screened (42% versus 29%, p < .05). The patient intervention did not have the desired impact. The subgroup of patients in the patient intervention was not more likely to complete CRC screening.

Does quality improvement implementation affect hospital quality of care?

The authors examined how the association between quality improvement (QI) implementation in hospitals and hospital clinical quality is moderated by hospital organizational and environmental context. The authors used Ordinary Least Squares regression analysis of 1,784 community hospitals to model seven quality indicators as a function of four measures of QI implementation and a variety of control variables. They found that forces that are external and internal to the hospital condition the impact of particular QI activities on quality indicators: specifically data use, statistical tool use, and organizational emphasis on Continuous Quality Improvement (CQI). Results supported the proposition that QI implementation is unlikely to improve quality of care in hospital settings without a commensurate fit with the financial, strategic, and market imperatives faced by the hospital.

Effectiveness of a practice-based, multimodal quality improvement intervention for gastroenteritis within a Medicaid managed care network

OBJECTIVE

Acute gastroenteritis results in 220,000 hospitalizations yearly in the United States. The substantial geographic variation in gastroenteritis care, coupled with the evidence of effective treatment of dehydration in nonhospital settings, suggests that the majority of these hospitalizations are avoidable. We sought to decrease hospitalizations for gastroenteritis by using practice-based, multimodal quality improvement methods that target multiple care processes to make them consistent with evidence-based guidelines.

METHODS

We used a controlled before/after study design to evaluate a quality improvement intervention in a 20-practice Medicaid network. All 20 practices participated in continuing education sessions; received free oral rehydration solution, patient education materials, and performance feedback; and participated in a follow-up conference call. Three practices were chosen to develop and pilot office-process changes. These practices formed interdisciplinary teams to develop and test changes and collaborated with project faculty and each other. They shared their learning with the other 17 practices via a conference call and toolkit. We compared before/after gastroenteritis hospital admissions for children <5 years old covered by Medicaid in the intervention practices with all other Medicaid recipients in North Carolina using claims data from 2000-2002.

RESULTS

The 3 high-intensity practices all made numerous changes to care processes. Most of the 17 low-intensity practices reported changes in their gastroenteritis care processes. Gastroenteritis admission rates declined 45% in high-intensity practices and 44% in low-intensity practices during the study compared with 11% in the control practices.

CONCLUSIONS

A practice-based, multimodal quality improvement intervention that targets multiple care processes on the basis of evidence-based guidelines lowered rates of gastroenteritis hospitalization in a Medicaid network. This approach could lower costs attributable to gastroenteritis for Medicaid programs.

Consultants’ attitudes to clinical governance: Barriers and incentives to engagement

OBJECTIVE

To explore medical specialists' attitudes to clinical governance in acute hospitals and factors influencing these attitudes.

METHODS

A semi-structured interview study with a purposeful sample of 24 medical specialists from two contrasting hospitals. Hospital A had a low level of consultant involvement in quality improvement initiatives and Hospital B had higher levels of engagement.

RESULTS

Specialists from both hospitals acknowledged that quality improvement was a major part of their role. Among specialists from Hospital A, the lack of a commonly held focus on quality-improvement, poor inter-professional relationships and little clinical engagement in management were the main factors generating negative attitudes towards clinical governance. Effective communication of the hospital's goal of continuous quality improvement to all staff groups, a sense of being able to get issues affecting the quality of care heard by senior management, and a perception that there were clear structures and processes to support clinical governance, were factors that resulted in a more positive attitude to clinical governance among specialists in Hospital B. Specialists from both hospitals identified lack of time across all professional groups and availability of accurate data as barriers to involvement in clinical governance activities.

CONCLUSION

The cultural context, level of technical support available, ability to communicate clear goals and strategies and the presence of structures to support delivery, all contribute to shaping specialists' attitudes to clinical governance and in turn influence levels of engagement and ultimately the success of quality improvement initiatives.

Do clinical guidelines enhance safe practice in obstetrics and gynaecology?

Clinical guidelines are increasingly used to promote a more uniform standard of high-quality evidence-based health care. International agencies advocate guideline development methods founded on three principles: that recommendations are evidence-based, are explicitly linked to the type and quality of evidence, and are developed by multidisciplinary stakeholder groups. Numerous interventions have been described to support the implementation of guidelines. Systematic reviews suggest that most interventions produce modest to moderate improvements in care; multifaceted interventions appear to be no more effective than single interventions, and the lowest-cost implementation strategy (dissemination of printed materials) may improve care and be feasible in many settings. Given the considerable costs of developing valid guidelines de novo, we advocate local adaptation of existing guidelines if available. We suggest a pragmatic framework to assist policy-makers and clinicians in deciding how best to use the scarce resources available for quality-improvement activities.

Determinants of implementation effectiveness: adapting a framework for complex innovations

Many innovations in the health sector are complex, requiring coordinated use by multiple organizational members to achieve benefits. Often, complex innovations are adopted with great anticipation only to fail during implementation. The health services literature provides limited conceptual guidance to researchers and practitioners about implementation of complex innovations. In the present study, we adapt an organizational framework of innovation implementation developed and validated in a manufacturing setting and explore the extent to which it aptly characterizes implementation in health sector organizations. Through comparative case studies of four cancer clinical research networks, we illustrate how this conceptual framework captures key determinants of the implementation of new programs in cancer prevention and control (CP/C) research and helps explain observed differences in implementation effectiveness. Key determinants include management support and innovation-values fit, which contribute to an organizational "climate" for implementation. We explore the implications for researchers and managers.

How do teams in quality improvement collaboratives interact?

BACKGROUND

The multi-organizational collaborative is a popular model for quality improvement (QI) initiatives. It assumes organizations will share information and social support. However, there is no comprehensive documentation of the extent to which teams do interact. Considering QI collaboratives as networks, interactions among reams were documented, and the associations between network roles and performance were examined.

METHODS

A telephone survey of official team contact persons for 94 site teams in three QI collaborarives was conducted in 2002 and 2003. Four performance measures were used to assess the usefulness of ties to other teams and being considered a leader by peers.

RESULTS

Eighty percent of the teams said they would contact another team again if they felt the need. Teams made a change as a direct result of interaction in 86% of reported relationships. Teams typically exchanged tools such as software and interacted outside of planned activities. Having a large number of ties to other teams is strongly related to the number of mentions as a leader. Both of these variables are related to faculty-assessed performance, number of changes the ream made to improve care, and depth of those changes.

DISCUSSION

The Findings suggest that collaborative teams do indeed exchange important information, and the social dynamics of the collaborarives contribute to individual and collaborative success.

Current Pulse

One of the reasons for rising health care costs is medical errors, a majority of which result from faulty systems and processes. Health care in the past has used process-based initiatives such as Total Quality Management, Continuous Quality Improvement, and Six Sigma to reduce errors. These initiatives to redesign health care, reduce errors, and improve overall efficiency and customer satisfaction have had moderate success. Current trend is to apply the successful Toyota Production System (TPS) to health care since its organizing principles have led to tremendous improvement in productivity and quality for Toyota and other businesses that have adapted them. This article presents insights on the effectiveness of TPS principles in health care and the challenges that lie ahead in successfully integrating this approach with other quality initiatives.

Monitoring the rate of re-exploration for excessive bleeding after cardiac surgery in adults

BACKGROUND

The monitoring of adverse events in clinical care can be an important part of quality assurance. There is little evidence on the monitoring of re-exploration after cardiac surgery.

OBJECTIVE

To apply statistical monitoring techniques to the rate of re-exploration for excessive bleeding in adult patients undergoing cardiac surgery procedures using cardiopulmonary bypass at Geelong Hospital, Victoria, Australia, between 1997 and 2003.

METHODS

Shewhart charts, moving average plots and cumulative sum (CUSUM) charts were used to demonstrate changes in the rate of re-exploration over time.

RESULTS

A CUSUM chart was used retrospectively at a time of perceived deteriorating clinical outcomes in patients of the cardiac surgery service. At this time, an intervention aimed at reducing the re-exploration rate was performed, and subsequent CUSUM charts indicated an improvement in this rate. The CUSUM chart has become an important part of the quality feedback of clinical care outcomes within the Anaesthesia & Pain Management unit of Geelong Hospital.

CONCLUSION

Statistical monitoring techniques for quality assurance can identify important changes in clinical performance, and their adoption by clinicians is recommended.

The impact of a quality improvement program on systems, processes, and structures in medical clinics

OBJECTIVE

We sought to assess whether participation in a quality-improvement collaborative changed care processes, systems, and organization of outpatient human immunodeficiency virus (HIV) clinics.

METHODS

We surveyed clinicians, medical directors, and HIV program administrators before and after an 18-month quality improvement collaborative at 54 intervention and 37 control clinics providing HIV care. Surveys assessed clinic structures, processes, systems, and culture. During the collaborative, a clinician-administrator team from each intervention clinic attended 4 2-day sessions on quality improvement techniques. Conference calls, a website, and an e-mail list provided support and facilitated communication among collaborative participants.

RESULTS

Survey response rates were 85% or greater. Six of 54 organizational measures differed significantly between baseline and follow-up. Intervention clinicians reported greater computer availability (82% vs. 67%, P = 0.03) and use (3.13 vs. 2.68, P = 0.02; 4-point scale), attended more local (14.2 vs. 8.6, P < 0.01) and national (4.1 vs. 2.9, P = 0.01) conferences, and rated leaders' ability to implement quality improvement higher (3.8 vs. 3.4, P = 0.01; 5-point scale). Intervention directors were more likely to compare quality data to other clinics (79% vs. 54%, P = 0.04). For the set of 54 measures, intervention clinics were more likely to have higher post-intervention scores than controls (sign test, mean = 14.5, P < 0.0001).

CONCLUSIONS

A quality-improvement collaborative for HIV clinics resulted in modest organizational changes. Achieving greater change may require more focused and/or intensive interventions, greater resources for participating clinics, and better developed information technology.

Measuring organizational attributes of primary care practices: development of a new instrument

OBJECTIVE

To develop an instrument to measure organizational attributes relevant for family practices using the perspectives of clinicians, nurses, and staff.

DATA SOURCES/STUDY SETTING

Clinicians, nurses, and office staff (n=640) from 51 community family medicine practices.

DESIGN

A survey, designed to measure a practices' internal resources for change, for use in family medicine practices was created by a multidisciplinary panel of experts in primary care research and health care organizational performance. This survey was administered in a cross-sectional study to a sample of diverse practices participating in an intervention trial. A factor analysis identified groups of questions relating to latent constructs of practices' internal resources for capacity to change. ANOVA methods were used to confirm that the factors differentiated practices.

DATA COLLECTION

The survey was administered to all staff from 51 practices.

PRINCIPAL FINDINGS

The factor analysis resulted in four stable and internally consistent factors. Three of these factors, "communication,""decision-making," and "stress/chaos," describe resources for change in primary care practices. One factor, labeled "history of change," may be useful in assessing the success of interventions.

CONCLUSIONS

A 21-item questionnaire can reliably measure four important organizational attributes relevant to family practices. These attributes can be used both as outcome measures as well as important features for targeting system interventions.

Indigenous health: effective and sustainable health services through continuous quality improvement

The Australian government's Healthy for Life program is supporting capacity development in Indigenous primary care using continuous quality improvement (CQI) techniques. An important influence on the Healthy for Life program has been the ABCD research project. The key features contributing to the success of the project are described. The ABCD research project: uses a CQI approach, with an ongoing cycle of gathering data on how well organisational systems are functioning, and developing and then implementing improvements; is guided by widely accepted principles of community-based research, which emphasise participation; and adheres to the principles and values of Indigenous health research and service delivery. The potential for improving health outcomes in Aboriginal and Torres Strait Islander communities using a CQI approach should be strengthened by clear clinical and managerial leadership, supporting service organisations at the community level, and applying participatory-action principles.

Aligning measurement-based quality improvement with implementation of evidence-based practices

Two models for improving quality of care have been adopted by segments of the US mental healthcare system. Measurement-based quality improvement (MBQI) is routinely conducted by many provider organizations (including practices, hospitals and health plans), either at their own initiative or at the behest of payers and oversight organizations. Systematic implementation of evidence-based practices (EBPs) is being undertaken by several state mental health authorities and by other systems of care, working in collaboration with services researchers and stakeholders. Although they are distinct approaches, MBQI and EBP implementation (EBPI) overlap in their objectives and means. This article explores the degree to which these two approaches are aligned and whether further coordination between them could yield greater effectiveness or efficiency.

Quality Improvement in Public Health Emergency Preparedness

Quality improvement (QI) methods have been used in many industries to improve performance and outcomes. This chapter reviews key QI concepts and their application to public health emergency preparedness (PHEP). We conclude that for QI to flourish and become standard practice, changes to the status quo are necessary. In particular, public health should build its capabilities in QI, enhance implementation, and align incentives to facilitate use of QI.

Integrating palliative and critical care: description of an intervention

A large proportion of deaths in the United States occur in the intensive care unit (ICU) or after a stay in the ICU, and there is evidence of problems in the quality of care these patients and their families receive. In an effort to respond to this problem, we developed a multifaceted, nurse-focused, quality improvement intervention that is based on self-efficacy theory applied to changing clinician behavior. We have called the intervention "Integrating Palliative and Critical Care." This five-component intervention includes: 1) critical care clinician education to increase knowledge and awareness of the principles and practice of palliative care in the ICU, 2) critical care clinician local champions to provide role modeling and promote attitudinal change concerning end-of-life care, 3) academic detailing of nurse and physician ICU directors to identify and address local barriers to improving end-of-life care in each ICU, 4) feedback of local quality improvement data, and 5) system supports including implementation of palliative care order forms, family information pamphlets, and other system supports for providing palliative care in the ICU. The goal of this report is to describe the conceptual model that led to the development of the intervention, and for each of the five components, we describe the theoretical and empirical support for each component, the content of the component, and the lessons we have learned in implementing the component. Future reports will need to examine the ability of the interventions to improve outcomes of palliative care in the ICU.

Evidence-based strategies for reducing cesarean section rates: a meta-analysis

BACKGROUND

Canada's cesarean section rate reached an all-time high of 22.5 percent of in-hospital deliveries in 2002 and was associated with potential maternal and neonatal complications. Clinical practice guidelines represent an appropriate mean for reducing cesarean section rates. The challenge now lies in implementing these guidelines. Objectives of this meta-analysis were to assess the effectiveness of interventions for reducing the cesarean section rate and to assess the impact of this reduction on maternal and perinatal mortality and morbidity.

METHODS

The Cochrane Library, EMBASE, and MEDLINE were consulted from January 1990 to June 2005. Additional studies were identified by screening reference lists from identified studies and expert suggestions. Studies involving rigorous evaluation of a strategy for reducing overall cesarean section rates were identified. Randomized controlled trials, controlled before-and-after studies, and interrupted time series studies were evaluated according to Effective Practice and Organisation of Care Group criteria.

RESULTS

Among the 10 included studies, a significant reduction of cesarean section rate was found by random meta-analysis (pooled RR = 0.81 [0.75, 0.87]). No evidence of publication bias was identified. Audit and feedback (pooled RR = 0.87 [0.81, 0.93]), quality improvement (pooled RR = 0.74 [0.70, 0.77]), and multifaceted strategies (pooled RR=0.73 [0.68, 0.79]) were effective for reducing the cesarean section rate. However, quality improvement based on active management of labor showed mixed effects. Design of studies showed a higher effect for noncontrolled studies than for controlled studies (pooled RR = 0.76 [0.72, 0.81] vs 0.92 [0.88, 0.96]). Studies including an identification of barriers to change were more effective than other interventions for reducing the cesarean section rate (pooled RR = 0.74 [0.71, 0.78] vs 0.88 [0.82, 0.94]). Among included studies, no significant differences were found for perinatal and neonatal mortality and perinatal and maternal morbidity with respect to the mode of delivery. Only 1 study showed a significant reduction of neonatal and perinatal mortality (p < 0.001).

CONCLUSIONS

The cesarean section rate can be safely reduced by interventions that involve health workers in analyzing and modifying their practice. Our results suggest that multifaceted strategies, based on audit and detailed feedback, are advised to improve clinical practice and effectively reduce cesarean section rates. Moreover, these findings support the assumption that identification of barriers to change is a major key to success.

Performance improvement based on integrated quality management models: what evidence do we have? A systematic literature review

PURPOSE

Health care organizations have to improve their performance for multiple stakeholders and organize integrated care. To facilitate this, various integrated quality management models can be used. This article reviews the literature on the Malcolm Baldrige Quality Award (MBQA) criteria, the European Foundation Quality Management (EFQM) Excellence model (Excellence award models) and the Chronic Care Model. The focus is on the empirical evidence for improved performance by the implementation of interventions based on these models.

DATA SOURCES

A systematic literature review from 1995 to May 2006 in the Pubmed, Cochrane, and ABI- databases was conducted.

STUDY SELECTION

After selection, 37 studies were included, 16 in the Excellence award model search and 21 in the Chronic Care Model search. DATA EXTRACTION AND RESULTS OF ANALYSIS: Data were retrieved about the main intervention elements, study design, evidence level, setting and context factors, data collection and analysis, principal results and performance dimensions. No Excellence Award model studies with controlled designs were found. For the Chronic Care Model, one systematic review, one meta analysis and six controlled studies were included. Seventeen studies (2 in Excellence award model, 15 in Chronic Care Model) reported one or more significant results.

CONCLUSION

There is some evidence that implementing interventions based on the 'evidence-based developed' Chronic Care Model may improve process or outcome performances. The evidence for performance improvement by interventions based on the 'expert-based developed' MBQA criteria and the EFQM Excellence model is more limited. Only a few studies include balanced measures on multiple performance dimensions. Considering the need for integrated care and chronic care improvement, the further development of these models for guiding improvements in integrated care settings and their specific context factors is suggested.

Planning and studying improvement in patient care: the use of theoretical perspectives

A consistent finding in articles on quality improvement in health care is that change is difficult to achieve. According to the research literature, the majority of interventions are targeted at health care professionals. But success in achieving change may be influenced by factors other than those relating to individual professionals, and theories may help explain whether change is possible. This article argues for a more systematic use of theories in planning and evaluating quality-improvement interventions in clinical practice. It demonstrates how different theories can be used to generate testable hypotheses regarding factors that influence the implementation of change, and it shows how different theoretical assumptions lead to different quality-improvement strategies.

A Review of Organizational Culture Instruments for Nurse Executives

Nurse executives are aware of the complexities of organizational culture. It impacts the nursing work environment and patient care safety and quality. The authors describe several widely available tools that nurse leaders can use to assess organizational culture in the work environment. The psychometric and conceptual strengths and weaknesses of the measures are described and recommendations for use in nursing and patient care administration are provided.

Improving the use of research evidence in guideline development: 16. Evaluation

BACKGROUND

The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the last of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this.

OBJECTIVES

We reviewed the literature on evaluating guidelines and recommendations, including their quality, whether they are likely to be up-to-date, and their implementation. We also considered the role of guideline developers in undertaking evaluations that are needed to inform recommendations.

METHODS

We searched PubMed and three databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct systematic reviews ourselves. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments.

KEY QUESTIONS AND ANSWERS

Our answers to these questions were informed by a review of instruments for evaluating guidelines, several studies of the need for updating guidelines, discussions of the pros and cons of different research designs for evaluating the implementation of guidelines, and consideration of the use of uncertainties identified in systematic reviews to set research priorities. How should the quality of guidelines or recommendations be appraised? WHO should put into place processes to ensure that both internal and external review of guidelines is undertaken routinely. A checklist, such as the AGREE instrument, should be used. The checklist should be adapted and tested to ensure that it is suitable to the broad range of recommendations that WHO produces, including public health and health policy recommendations, and that it includes questions about equity and other items that are particularly important for WHO guidelines. When should guidelines or recommendations be updated? Processes should be put into place to ensure that guidelines are monitored routinely to determine if they are in need of updating. People who are familiar with the topic, such as Cochrane review groups, should do focused, routine searches for new research that would require revision of the guideline. Periodic review of guidelines by experts not involved in developing the guidelines should also be considered. Consideration should be given to establishing guideline panels that are ongoing, to facilitate routine updating, with members serving fixed periods with a rotating membership. How should the impact of guidelines or recommendations be evaluated? WHO headquarters and regional offices should support member states and those responsible for policy decisions and implementation to evaluate the impact of their decisions and actions by providing advice regarding impact assessment, practical support and coordination of efforts. Before-after evaluations should be used cautiously and when there are important uncertainties regarding the effects of a policy or its implementation, randomised evaluations should be used when possible. What responsibility should WHO take for ensuring that important uncertainties are addressed by future research when the evidence needed to inform recommendations is lacking? Guideline panels should routinely identify important uncertainties and research priorities. This source of potential priorities for research should be used systematically to inform priority-setting processes for global research.

Evidence-Based Strategies for Implementing Guidelines in Obstetrics

OBJECTIVE

To estimate effective strategies for implementing clinical practice guidelines in obstetric care and to identify specific barriers to behavior change and facilitators in obstetrics.

DATA SOURCES

The Cochrane Library, EMBASE, and MEDLINE were consulted from January 1990 to June 2005. Additional studies were identified by screening reference lists from identified studies and experts' suggestions.

METHODS OF STUDY SELECTION

Studies of clinical practice guidelines implementation strategies in obstetric care and reviews of such studies were selected. Randomized controlled trials, controlled before-after studies, and interrupted time series studies were evaluated according to Effective Practice and Organization of Care criteria standards.

TABULATION, INTEGRATION, AND RESULTS

Studies were reviewed by two investigators to assess the quality and the efficacy of each strategy. Discordances between the two reviewers were resolved by consensus. In obstetrics, educational strategies with medical providers are generally ineffective; educational strategies with paramedical providers, opinion leaders, qualitative improvement, and academic detailing have mixed effects; audit and feedback, reminders, and multifaceted strategies are generally effective. These findings differ from data on the efficacy of clinical practice guidelines implementation strategies in other medical specialties. Specific barriers to behavior change in obstetrics and methods to overcome these barriers could explain these differences. The proportion of effective strategies is significantly higher among the interventions that include a prospective identification of barriers to change compared with standardized interventions.

CONCLUSION

Prospective identification of efficient strategies and barriers to change is necessary to achieve a better adaptation of intervention and to improve clinical practice guidelines implementation. In the field of obstetric care, multifaceted strategy based on audit and feedback and facilitated by local opinion leaders is recommended to effectively change behaviors.

Survey of the Use of Quality Indicators in Academic Radiology Departments

OBJECTIVE

Our purpose was to determine whether quality in academic radiology departments in the United States is systematically measured through indicators and evaluated by preset standards.

MATERIALS AND METHODS

We performed a cross-sectional study using a validated survey sent to Society of Chairmen of Academic Radiology Departments (SCARD) members and studied type, frequency of monitoring, and use of preset standards for evaluation of quality indicators. Statistical methods were descriptive summary statistics, chi-square test, analysis of variance, and Spearman's rank correlation test.

RESULTS

The response rate was 42% (55/132). Most responding hospitals were from the Northeast (20/55, 36.4%) and Midwest (18/55, 32.7%). About 58% (32/55) of the responding hospitals had more than 500 beds in operation; 50.9% (28/55) of the radiology departments performed 200,000-400,000 examinations per year. Among the 80% of departments (44/55) that monitored patient satisfaction, only 49.1% and 45.5% assessed referring physician and employee satisfaction, respectively. The most frequently monitored customer satisfaction indicator, patient satisfaction, was monitored quarterly or less frequently by 70.5% (31/44) of departments; about 45.5% (20/44) had preset standards for this indicator. MRI and CT were monitored for patient appointment access by 80% (44/55) and 72.7% (40/55) of departments, respectively; 59.1% (26/44) and 62.5% (25/40) of departments applied preset standards to these indicators, respectively. The reporting-time indicator monitored most frequently was report turnaround time (45/55, 81.8%). None of the differences in mean numbers and monitoring frequencies of the indicators and the use of preset standards to evaluate them by region and size of departments were significant (p >0.05).

CONCLUSION

Use of quality management indicators, particularly customer satisfaction indicators, is not a fully standardized and established process for academic radiology departments in the United States.

Impacts of evidence-based quality improvement on depression in primary care: a randomized experiment

CONTEXT

Previous studies testing continuous quality improvement (CQI) for depression showed no effects. Methods for practices to self-improve depression care performance are needed. We assessed the impacts of evidence-based quality improvement (EBQI), a modification of CQI, as carried out by 2 different health care systems, and collected qualitative data on the design and implementation process.

OBJECTIVE

Evaluate impacts of EBQI on practice-wide depression care and outcomes.

DESIGN

Practice-level randomized experiment comparing EBQI with usual care.

SETTING

Six Kaiser Permanente of Northern California and 3 Veterans Administration primary care practices randomly assigned to EBQI teams (6 practices) or usual care (3 practices). Practices included 245 primary care clinicians and 250,000 patients.

INTERVENTION

Researchers assisted system senior leaders to identify priorities for EBQI teams; initiated the manual-based EBQI process; and provided references and tools. EVALUATION PARTICIPANTS: Five hundred and sixty-seven representative patients with major depression.

MAIN OUTCOME MEASURES

Appropriate treatment, depression, functional status, and satisfaction.

RESULTS

Depressed patients in EBQI practices showed a trend toward more appropriate treatment compared with those in usual care (46.0% vs 39.9% at 6 months, P = .07), but no significant improvement in 12-month depression symptom outcomes (27.0% vs 36.1% poor depression outcome, P = .18). Social functioning improved significantly (mean score 65.0 vs 56.8 at 12 months, P = .02); physical functioning did not.

CONCLUSION

Evidence-based quality improvement had perceptible, but modest, effects on practice performance for patients with depression. The modest improvements, along with qualitative data, identify potential future directions for improving CQI research and practice.

The effects of the ARC organizational intervention on caseworker turnover, climate, and culture in children's service systems

OBJECTIVE

This study examines the effects of the Availability, Responsiveness, and Continuity (ARC) organizational intervention strategy on caseworker turnover, climate, and culture in a child welfare and juvenile justice system.

METHOD

Using a pre-post, randomized blocks, true experimental design, 10 urban and 16 rural case management teams were randomly assigned to either the ARC organizational intervention condition or to a control condition. The culture and climate of each case management team were assessed at baseline and again after the one-year organizational intervention was completed. In addition, caseworker turnover was assessed by identifying caseworkers on the sampled teams who quit their jobs during the year.

RESULTS

Hierarchical Linear Models (HLM) analyses indicate that the ARC organizational intervention reduced the probability of caseworker turnover by two-thirds and improved organizational climate by reducing role conflict, role overload, emotional exhaustion, and depersonalization in both urban and rural case management teams.

CONCLUSIONS

Organizational intervention strategies can be used to reduce staff turnover and improve organizational climates in urban and rural child welfare and juvenile justice systems. This is important because child welfare and juvenile justice systems in the U.S.A. are plagued by high turnover rates, and there is evidence that high staff turnover and poor organizational climates negatively affect service quality and outcomes in these systems.

Quality improvement implementation and hospital performance on patient safety indicators

This study examines the association between scope of Quality Improvement (QI) implementation in hospitals and hospital performance on patient safety indicators. Secondary data sources included a 1997 survey of hospital QI practices, Medicare Inpatient Database, American Hospital Association's Annual Survey of Hospitals, the Bureau of Health Professions' Area Resource File, and two proprietary data sets. Using a sample of 1,784 community hospitals, the study employed two-stage instrumental variables estimation in which predicted values of four QI scope variables and control variables were used to estimate four patient safety indicators. Involvement by multiple hospital units in the QI effort is associated with worse values on all four patient safety indicators. Percentages of hospital staff and of senior managers participating in QI teams exhibited no statistically significant association with any patient safety indicator. Percentage of physicians participating in QI teams is associated with better values on two patient safety indicators.

Clinical governance in UK commercial occupational health providers

BACKGROUND

Clinical governance has been introduced into health care in the United Kingdom as a means to improve quality. At present there is no legal duty for commercial occupational providers to implement this model.

AIM

This preliminary study examined how commercial occupational health providers had implemented clinical governance.

METHODS

The senior clinical manager of commercial occupational health providers completed a questionnaire.

RESULTS

Fourteen of 17 organizations asked to participate completed the survey. Most of these had implemented some form of clinical governance. Patient and public involvement was attributed the least importance of potential components of clinical governance. Organizations were more likely to have systems to address poor clinical performance than encourage excellent performance.

CONCLUSIONS

Commercial occupational health providers have implemented clinical governance. Its focus appears to be avoidance of failures rather than clinical excellence and patients. However, further work is needed to explore this more fully.

Individualized performance feedback to increase prenatal domestic violence screening

OBJECTIVES

Universal domestic violence (DV) screening once per trimester of pregnancy is recommended but rarely accomplished. Clinical leaders in this setting sought to improve adherence with this protocol. This prospective study used medical record audit and individualized performance feedback with peer comparison (IPF) to improve DV screening among first and second year obstetrics and gynecology (ob/gyn) residents.

METHODS

The setting is a northeastern, urban, hospital-based, prenatal clinic serving low-income women. Most patients are Latina (75%); 11% are black and 9% are white. Few begin care in the first trimester (8.5%). We gave all residents DV training. Next we gave IPF-four reports at seven-week intervals. We reviewed medical record notes on patient visits corresponding to the first medical encounter and week 16 and week 28 of pregnancy. We used this data to compare screening immediately before IPF and following each IPF report.

RESULTS

Screening increased steadily over time, from 60% of appropriate visits before IPF to 91% after the fourth report (Chi Square 28.4, p<.001). Adjusting for key factors, the odds of screening after the last IPF report were seven and a half times greater than the odds of screening before IPF (Odds Ratio: 7.6; 95% Confidence Interval: 3.0, 19.0).

CONCLUSIONS

IPF was associated with increased DV screening among first and second year ob/gyn residents in this setting. Increased screening improved compliance with the clinic protocol and increased opportunities for patient disclosure, education, and treatment, critical public health objectives.