Implementing continuous quality improvement (CQI) in hospitals: lessons learned from the International Quality Study

A scoping review of continuous quality improvement in healthcare system: conceptualization, models and tools, barriers and facilitators, and impact

BACKGROUND

The growing adoption of continuous quality improvement (CQI) initiatives in healthcare has generated a surge in research interest to gain a deeper understanding of CQI. However, comprehensive evidence regarding the diverse facets of CQI in healthcare has been limited. Our review sought to comprehensively grasp the conceptualization and principles of CQI, explore existing models and tools, analyze barriers and facilitators, and investigate its overall impacts.

METHODS

This qualitative scoping review was conducted using Arksey and O'Malley's methodological framework. We searched articles in PubMed, Web of Science, Scopus, and EMBASE databases. In addition, we accessed articles from Google Scholar. We used mixed-method analysis, including qualitative content analysis and quantitative descriptive for quantitative findings to summarize findings and PRISMA extension for scoping reviews (PRISMA-ScR) framework to report the overall works.

RESULTS

A total of 87 articles, which covered 14 CQI models, were included in the review. While 19 tools were used for CQI models and initiatives, Plan-Do-Study/Check-Act cycle was the commonly employed model to understand the CQI implementation process. The main reported purposes of using CQI, as its positive impact, are to improve the structure of the health system (e.g., leadership, health workforce, health technology use, supplies, and costs), enhance healthcare delivery processes and outputs (e.g., care coordination and linkages, satisfaction, accessibility, continuity of care, safety, and efficiency), and improve treatment outcome (reduce morbidity and mortality). The implementation of CQI is not without challenges. There are cultural (i.e., resistance/reluctance to quality-focused culture and fear of blame or punishment), technical, structural (related to organizational structure, processes, and systems), and strategic (inadequate planning and inappropriate goals) related barriers that were commonly reported during the implementation of CQI.

CONCLUSIONS

Implementing CQI initiatives necessitates thoroughly comprehending key principles such as teamwork and timeline. To effectively address challenges, it's crucial to identify obstacles and implement optimal interventions proactively. Healthcare professionals and leaders need to be mentally equipped and cognizant of the significant role CQI initiatives play in achieving purposes for quality of care.

Continuous quality improvement in a Maltese hospital using logical framework analysis

Purpose

The purpose of this paper is to present the application of logical framework analysis (LFA) for implementing continuous quality improvement (CQI) across multiple settings in a tertiary care hospital.

Design/methodology/approach

This study adopts a multiple case study approach. LFA is implemented within three diverse settings, namely, intensive care unit, surgical ward, and acute in-patient psychiatric ward. First, problem trees are developed in order to determine the root causes of quality issues, specific to the three settings. Second, objective trees are formed suggesting solutions to the quality issues. Third, project plan template using logical framework (LOGFRAME) is created for each setting.

Findings

This study shows substantial improvement in quality across the three settings. LFA proved to be effective to analyse quality issues and suggest improvement measures objectively.

Research limitations/implications

This paper applies LFA in specific, albeit, diverse settings in one hospital. For validation purposes, it would be ideal to analyse in other settings within the same hospital, as well as in several hospitals. It also adopts a bottom-up approach when this can be triangulated with other sources of data.

Practical implications

LFA enables top management to obtain an integrated view of performance. It also provides a basis for further quantitative research on quality management through the identification of key performance indicators and facilitates the development of a business case for improvement.

Originality/value

LFA is a novel approach for the implementation of CQI programs. Although LFA has been used extensively for project development to source funds from development banks, its application in quality improvement within healthcare projects is scant.

Towards Strategic Quality Management of Health Care

This paper briefly explores the history of quality management principles and their application to health care. Defining some of the principles that have evolved in quality management, especially in health care management, the paper discusses the analysis of and means used to improve quality using structure, process and outcome variables, with special focus on examples of the use of these in developing countries' health care systems. Finally, the paper describes some of the measurement and implementation challenges for those interested in quality management in health care.

Embedding organisational quality improvement through middle manager ownership

PURPOSE

To strengthen the middle manager role in a hospital quality improvement (QI) program, with a view to increasing and sustaining organisational QI implementation.

DESIGN/METHODOLOGY/APPROACH

Case study based action research project, combining pre- and post-action quantitative and qualitative data collection, relating to a QI program intervention in an Australian metropolitan specialist teaching hospital. A model for enhancing the middle manager role in QI was developed and then implemented as the action over a 12-month period.

FINDINGS

Middle manager understanding and ownership of the QI program and organisational QI implementation significantly increased, although their perceived enjoyment of being involved in QI decreased.

RESEARCH LIMITATIONS/IMPLICATIONS

This case-study based action research project was limited to one organisation of a specific type - a large specialist metropolitan teaching hospital. The composition of the middle manager group, therefore, is necessarily limited to particular specialties. It is acknowledged that findings from case study and action research methodologies are limited in their generalisability, but assist in the development of knowledge and principles that can be adapted to different settings.

PRACTICAL IMPLICATIONS

This QI implementation model can increase levels of organisational QI implementation by effecting a positive change in middle manager attitude to and involvement in QI.

ORIGINALITY/VALUE

There are many theories regarding the importance of the middle manager role in QI, but little empirical research into exactly what this role may be and how it may be strengthened. This research adds to the knowledge base, and provides clear steps for achieving increased staff involvement and QI implementation.

Would it work for us? Learning from quality improvement in Europe and beyond

DEVELOPING QUALITY TRANSFER TECHNOLOGY AND TRANSFERABILITY ASSESSMENT: Transferring a method or an approach that works in one organization to another organization may not produce the same effect. The result in one setting is an effect of the method or approach working within that system, not just an effect of the method or approach alone.

THE CONTEXT FOR QUALITY IMPROVEMENT (QI)

To better understand QI activities in a particular country, five aspects of the QI context need to be considered--the health care system, social values, health reform, history of quality assurance, and the language and politics of quality. For example, differences in terminology, even within one region of a country, undermine transferability of quality approaches and methods. LEARNING FROM OTHERS' SOLUTIONS AND STRATEGIES: The methods used to learn from others can be improved by seeking out reports describing the context of the improvement, by carefully deciding which facilities to visit and which conferences and networking events to attend, and by developing skills in judging transferability and in adapting others' strategies.

CONCLUSION

Similar changes in health care in most countries are creating a climate more conducive to QI methods than in the past, and there is more experience with these methods and there are more examples of their successful application. Learning from others has more benefits than finding solutions to one's own quality problems. By examining others' approaches to QI one may become aware of issues that have been ignored or that are latent problems in one's own organization.

Patients' complaints as a management tool for continuous quality improvement

Continuous quality improvement focuses on the customer and, therefore, requires attention to customers' feedback as a vital input. Customers' feedback in general hospitals includes utilization statistics of various services, patient satisfaction surveys and patients' complaints. The role of complaint data as a management tool, and particularly as applied to quality improvement, has received little attention in the literature. As a quality control tool, complaints are investigated on the individual, unit and organizational levels. Repeated complaints about the same units, procedures or individuals, are especially important for quality review. The role of the hospital administration is to draw on the human, technological and procedural resources at its disposal, along a solution time interval (immediate, short and long term), in designing its policy for quality improvement. Presents three examples of policy changes. The aggregate of complaint data serves, in addition, for follow-up of the effect of changes introduced by policy decisions.

Informatics: essential infrastructure for quality assessment and improvement in nursing

In recent decades there have been major advances in the creation and implementation of information technologies and in the development of measures of health care quality. The premise of this article is that informatics provides essential infrastructure for quality assessment and improvement in nursing. In this context, the term quality assessment and improvement comprises both short-term processes such as continuous quality improvement (CQI) and long-term outcomes management. This premise is supported by 1) presentation of a historical perspective on quality assessment and improvement; 2) delineation of the types of data required for quality assessment and improvement; and 3) description of the current and potential uses of information technology in the acquisition, storage, transformation, and presentation of quality data, information, and knowledge.