Quality improvement in large healthcare organizations

Organizational attributes that contribute to the learning & improvement capabilities of healthcare organizations: a scoping review

BACKGROUND

This study aims to explore and identify the organizational attributes that contribute to learning and improvement capabilities (L&IC) in healthcare organizations. The authors define learning as a structured update of system properties based on new information, and improvement as a closer correspondence between actual and desired standards. They highlight the importance of learning and improvement capabilities in maintaining high-quality care, and emphasize the need for empirical research on organizational attributes that contribute to these capabilities. The study has implications for healthcare organizations, professionals, and regulators in understanding how to assess and enhance learning and improvement capabilities.

METHODS

A systematic search of peer-reviewed articles published between January 2010 and April 2020 was carried out in the PubMed, Embase, CINAHL, and APA PsycINFO databases. Two reviewers independently screened the titles and abstracts and conducted a full-text review of potentially relevant articles, eventually adding five more studies identified through reference scanning. Finally, a total of 32 articles were included in this review. We extracted the data about organizational attributes that contribute to learning and improvement, categorized them and grouped the findings step-by-step into higher, more general-level categories using an interpretive approach until categories emerged that were sufficiently different from each other while also being internally consistent. This synthesis has been discussed by the authors.

RESULTS

We identified five attributes that contribute to the L&IC of healthcare organizations: perceived leadership commitment, open culture, room for team development, initiating and monitoring change, and strategic client focus, each consisting of multiple facilitating aspects. We also found some hindering aspects.

CONCLUSIONS

We have identified five attributes that contribute to L&IC, mainly related to organizational software elements. Only a few are identified as organizational hardware elements. The use of qualitative methods seems most appropriate to understand or assess these organizational attributes. We feel it is also important for healthcare organisations to look more closely at how clients can be involved in L&IC.

TRIAL REGISTRATION

Not applicable.

Use and exchange of knowledge in the introduction of hospital-based home rehabilitation after a stroke: barriers and facilitators in change management

Background

The purpose of the study was to contribute to research and practice on how the use and exchange of knowledge can facilitate change in health care, specifically methods supporting managers. The study also aimed to investigate barriers related to governance principles that may affect organizational ability to improve quality of care. To achieve the purpose, the study followed a project of hospital-based home rehabilitation after a stroke at a hospital in Norrbotten County, Sweden.

Methods

Seven individual interviews were performed to obtain information from the project members and the managers involved in the project. A group interview with the team and their immediate manager were conducted after the project ended. A thematic analysis was performed to identify and present patterns that formed the results of the study.

Results

The study shows how knowledge was identified, gathered, used, and disseminated in the project. The analysis pointed out how knowledge played an important role from two perspectives: in evidence-based practice in rehabilitation work and for change management. Knowledge exchange and learning across organizational boundaries increased the pace, efficiency, and effectiveness, but collaboration on knowledge, in the sense of joint activities based on a common purpose, only took place within the rehabilitation work. Furthermore, there were indications that governance principles, such as the distribution of financial responsibility and the requirements for official recommendations, influenced the pace of change.

Conclusions

It was shown that the exchange of knowledge and collaboration can facilitate change in health care, but that communication needs to be planned and prioritised. Readiness for change was the basis for the success of the project and for ensuring commitment among those involved. There is also a need for the management to understand how governance principles may affect the efficiency of change work.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07618-x.

Supporting the provision of pharmacy medication reviews to marginalised (medically underserved) groups: a before/after questionnaire study investigating the impact of a patient-professional co-produced digital educational intervention

OBJECTIVES

People who are marginalised (medically underserved) experience significant health disparities and their voices are often 'seldom heard'. Interventions to improve professional awareness and engagement with these groups are urgently needed. This study uses a co-production approach to develop an online digital educational intervention in order to improve pharmacy staffs' intention to offer a community pharmacy medication review service to medically underserved groups.

DESIGN

Before/after (3 months) self-completion online questionnaire.

SETTING

Community pharmacies in the Nottinghamshire (England) geographical area.

PARTICIPANTS

Community pharmacy staff.

INTERVENTION

Online digital educational intervention.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was 'behaviour change intention' using a validated 12-item survey measure. The secondary outcome measure was pharmacist self-reported recruitment of underserved groups to the medication review service.

RESULTS

All pharmacies in the Nottinghamshire area (n=237) were approached in June 2017 and responses were received from 149 staff (from 122 pharmacies). At 3 months (after completing the baseline questionnaire), 96 participants (from 80 pharmacies) completed a follow-up questionnaire, of which two-thirds (n=62) reported completing the e-learning. A before/after comparison analysis found an improving trend in all the five constructs of behaviour change intention (intention, social influence, beliefs about capabilities, moral norms and beliefs about consequences), with a significant increase in mean score of participants' 'beliefs about capabilities' (0.44; 95% CI 0.11 to 0.76, p=0.009). In the short-term, no significant change was detected in the number of patients being offered and the patient completing a medication review.

CONCLUSIONS

Although increases in the numbers of patients being offered a medication review was not detected, the intervention has the potential to significantly improve pharmacy professionals' 'beliefs about capabilities' in the short-term. Wider organisational and policy barriers to engagement with marginasied groups may need to be addressed. Future research should focus on the interplay between digital learning and practice to better identify and understand effective practice change pathways.

Quality indicators and their regular use in clinical practice: results from a survey among users of two cardiovascular National Registries in Sweden

Objective

To examine the regular use of quality indicators from Swedish cardiovascular National Quality Registries (NQRs) by clinical staff; particularly differences in use between the two NQRs and between nurses and physicians.

Design

Cross-sectional online survey study.

Setting

Two Swedish cardiovascular NQRs: (a) Swedish Heart Failure Registry and (b) Swedeheart.

Participants

Clinicians (n =185; 70% nurses, 26% physicians) via the NQRs' email networks.

Main Outcome Measures

Frequency of NQR use for (a) producing healthcare activity statistics; (b) comparing results between similar departments; (c) sharing results with colleagues; (d) identifying areas for quality improvement (QI); (e) surveilling the impact of QI efforts; (f) monitoring effects of implementation of new treatment methods; (g) doing research and (h) educating and informing healthcare professionals and patients.

Results

Median use of NQRs was 10 times a year (25th and 75th percentiles range: 3-23 times/year). Quality indicators from the NQRs were used mainly for producing healthcare activity statistics. Median use of Swedeheart was six times greater than Swedish Heart Failure Registry (SwedeHF; P < 0.000). Physicians used the NQRs more than twice as often as nurses (18 vs. 7.5 times/year; P < 0.000) and perceived NQR work more often as meaningful. Around twice as many Swedeheart users had the role to participate in data analysis and in QI efforts compared to SwedeHF users.

Conclusions

Most respondents used quality indicators from the two cardiovascular NQRs infrequently (<3 times/year). The results indicate that linking registration of quality indicators to using them for QI activities increases their routine use and makes them meaningful tools for professionals.

Data and knowledge standards for learning health: A population management example using chronic kidney disease

The widespread creation of learning health care systems (LHSs) will depend upon the use of standards for data and knowledge representation. Standards can facilitate the reuse of approaches for the identification of patient cohorts and the implementation of interventions. Standards also support rapid evaluation and dissemination across organizations. Building upon widely-used models for process improvement, we identify specific LHS activities that will require data and knowledge standards. Using chronic kidney disease (CKD) as an example, we highlight the specific data and knowledge requirements for a disease-specific LHS cycle, and subsequently identify areas where standards specifications, clarification, and tools are needed. The current data standards for CKD population management recommendations were found to be partially ambiguous, leading to barriers in phenotyping, risk identification, patient-centered clinical decision support, patient education needs, and care planning. Robust tools are needed to effectively identify patient health care needs and preferences and to measure outcomes that accurately depict the multiple facets of CKD. This example presents an approach for defining the specific data and knowledge representation standards required to implement condition-specific population health management programs. These standards specifications can be promoted by disease advocacy and professional societies to enable the widespread design, implementation, and evaluation of evidence-based health interventions, and the subsequent dissemination of experience in different settings and populations.

Enhancing policy implementation to improve healthcare practices: The role and strategies of hybrid national-local support structures

BACKGROUND

In this study, we followed a national initiative to enhance the use of quality indicators gathered in national quality registries (NQRs) for improvement of clinical practices in Swedish healthcare, more specifically by investigating the support strategies of regional support centers with national and local missions. The aim was to increase knowledge on the role, challenges, and strategies of support structures with mixed and complex missions in the healthcare system.

METHODS

Documents and 25 semistructured interviews with staff at 6 regional support centers, ie, quality registry centers, formed this multiple case study. Data were analyzed using conventional content analysis.

RESULTS

The centers' strategies varied from developing the NQRs to become more suitable for improvement to supporting healthcare's use of NQRs, from the use of task to process-oriented support strategies, and from taking on national responsibilities to responding to local initiatives. All quality registry centers engaged in initiatives inspired by the Breakthrough Series approach. Some used preexisting change concepts or collaborated with local development units. A main challenge was to overcome a lack of formal mandate to act in the healthcare organizations they served.

CONCLUSIONS

Support functions with mixed and complex missions have to use a variation of strategies to reach relevant actors and achieve changes. This study provides valuable input for policy and decision-makers on the support strategies used and challenges of support functions with complex missions situated in-between national and local levels of the healthcare system, here denoted hybrid national-local support structures.

Exploring the potential of a multi-level approach to improve capability for continuous organizational improvement and learning in a Swedish healthcare region

BACKGROUND

Eldercare and care of people with functional impairments is organized by the municipalities in Sweden. Improving care in these areas is complex, with multiple stakeholders and organizations. Appropriate strategies to develop capability for continuing organizational improvement and learning (COIL) are needed. The purpose of our study was to develop and pilot-test a flexible, multilevel approach for COIL capability building and to identify what it takes to achieve changes in key actors' approaches to COIL. The approach, named "Sustainable Improvement and Development through Strategic and Systematic Approaches" (SIDSSA), was applied through an action-research and action-learning intervention.

METHODS

The SIDSSA approach was tested in a regional research and development (R&D) unit, and in two municipalities handling care of the elderly and people with functional impairments. Our approach included a multilevel strategy, development loops of five flexible phases, and an action-learning loop. The approach was designed to support systems understanding, strategic focus, methodological practices, and change process knowledge - all of which required double-loop learning. Multiple qualitative methods, i.e., repeated interviews, process diaries, and documents, provided data for conventional content analyses.

RESULTS

The new approach was successfully tested on all cases and adopted and sustained by the R&D unit. Participants reported new insights and skills. The development loop facilitated a sense of coherence and control during uncertainty, improved planning and problem analysis, enhanced mapping of context and conditions, and supported problem-solving at both the individual and unit levels. The systems-level view and structured approach helped participants to explain, motivate, and implement change initiatives, especially after working more systematically with mapping, analyses, and goal setting.

CONCLUSIONS

An easily understood and generalizable model internalized by key organizational actors is an important step before more complex development models can be implemented. SIDSSA facilitated individual and group learning through action-learning and supported systems-level views and structured approaches across multiple organizational levels. Active involvement of diverse organizational functions and levels in the learning process was facilitated. However, the time frame was too short to fully test all aspects of the approach, specifically in reaching beyond the involved managers to front-line staff and patients.

Facilitating system-wide organizational change in health care

Purpose

– The purpose of this paper was to investigate the role of an intra-organizational change facilitating function (CFF) in relation to a multi-level development initiative in a health care organization. Involved actors’ views on factors in need of attention and how the CFF related to these factors were studied.

Design/methodology/approach

– A longitudinal case study design was used, combining data from questionnaires, process diaries and interviews with employees at the CFF, managers and clinic staff.

Findings

– Factors on micro, meso and macro levels, crucial to attend to, were highlighted by respondents at staff and managerial levels. The CFF related to some of these factors by acting upon them, or by developing plans to handle them, while other factors were unattended to. The CFF activities also had indirect influence on other factors. The CFF role and responsibilities were not clearly defined beforehand, and a need to clarify a division of roles and responsibilities is highlighted.

Research limitations/implications

– Our study contributes to current knowledge on facilitation of change by relating it to an organizational dimension of implementation.

Practical implications

– The description of important factors to handle during a large organizational change process and issues a CFF can encounter may aid others involved in designing and managing large organizational development initiatives.

Originality/value

– The study elaborates on less studied functions and roles of an intra-organizational CFF in relation to factors of vital importance for organizational change and development in health-care organizations.