Do primary care quality improvement frameworks consider equity?

BACKGROUND

Quality improvement (QI) is used by healthcare organisations internationally to improve care. Unless QI explicitly addresses equity, projects that aim to improve care may exacerbate health and care inequalities for disadvantaged groups. There are several QI frameworks used in primary care, but we do not know the extent to which they consider equity. This work aimed to investigate whether primary care QI frameworks consider equity.

METHODS

We conducted a search of MEDLINE, EMBASE and key websites to compile a list of the QI frameworks used in primary care. This list was refined by an expert panel. Guidance documents for each of the QI frameworks were identified from national websites or QI organisations. We undertook a document analysis of the guidance using NVivo.

RESULTS

We analysed 15 guidance documents. We identified the following themes: (1) there was a limited discussion of equity or targeted QI for disadvantaged groups in the documents, (2) there were indirect considerations of inequalities via patient involvement or targeting QI to patient demographics and (3) there was a greater focus on efficiency than equity in the documents.

CONCLUSION

There is limited consideration of equity in QI frameworks used in primary care. Where equity is discussed, it is implicit and open to interpretation. This research demonstrates a need for frameworks to be revised with an explicit equity focus to ensure the distribution of benefits from QI is equitable.

INnovation, QUality Improvement, Research, and Evidence-Based Practice (INQUIRE): A Navigation Model for Change and Discovery

BACKGROUND

Despite scholarly articles and pathway models delineating quality improvement (QI), evidence-based practice (EBP), research, and innovation, guidance is lacking when determining the project method. A practical, step-by-step approach is needed to support project navigation.

PURPOSE

To describe development and evaluation of a decision-making pathway model.

METHODS

The INQUIRE Model was developed using an iterative approach and was evaluated with 23 national conference attendees. The evaluation included 4 Likert-type items ranging from 1 (strongly disagree) to 7 (strongly agree).

RESULTS

The model guides users through project planning steps based on an identified trigger (eg, problem, opportunity, and challenge) to ultimately select a project method that aligns with the project scope and availability of a solution. Model evaluation found identification of the project method improved by 14%, scanning for a solution by 8%, avoiding missed steps by 36%, and building a team by 10%.

CONCLUSION

Findings suggest INQUIRE can enhance project planning and method (eg, QI, EBP, research, and innovation) selection. Organizations should evaluate project planning current state to identify the potential benefit of model incorporation.

Development and Implementation of a Model for Research, Evidence-Based Practice, Quality Improvement, and Innovation

BACKGROUND

Our medical center nursing council evaluated its current evidence-based practice (EBP) model and decided to consider alternatives.

PROBLEM

No models were inclusive of major nursing activities, such as EBP and quality improvement (QI) projects and research studies.

APPROACH

A model was developed, meeting the criteria of accessibility, ease of use, and reflective of professional practice activities: EBP and QI projects, research studies, and innovation. In the new model, I Model for Advancing Quality Patient Centered Care, professional practice is represented by 3 "I's": Inquiry, Improvement, and Innovation.

OUTCOMES

The model provides an algorithm with steps and decision points for nurses to follow based on a question from a clinical issue or problem. The model was approved by nursing-shared governance and is used for guiding relevant projects.

CONCLUSION

The I Model guides the nurse in inquiry or improvement while supporting a culture of innovation in professional practice.

Context and implementation: A concept analysis towards conceptual maturity

Context and implementation of health interventions have received increasing attention over the past decade, in particular with respect to their influence on the effectiveness and reach of complex interventions. The underlying concepts are both considered partially mature, limiting their operationalization in research and practice. We conducted systematic literature searches and pragmatic utility (PU) concept analyses to provide a state-of-the-art assessment of the concepts of "context" and "implementation" in the health sciences to create a common understanding for their use within systematic reviews and HTA. We performed two separate searches, one for context (EMBASE, MEDLINE) and the other for implementation (Google Scholar) to identify relevant models, theories and frameworks. 17 publications on context and 35 articles on implementation met our inclusion criteria. PU concept analysis comprises three guiding principles: selection of the literature, organization and structuring of the literature, and asking analytic questions of the literature. Both concepts were analyzed according to four features of conceptual maturity, i.e., consensual definitions, clear characteristics, fully described preconditions and outcomes, and delineated boundaries. Context and implementation are highly intertwined, with both concepts influencing and interacting with each other. Context is defined as a set of characteristics and circumstances that surround the implementation effort. Implementation is conceptualized as a planned and deliberately initiated effort with the intention to put an intervention into practice. The concept of implementation presents largely consensual definitions and relatively well-defined boundaries, while distinguishing features, preconditions and outcomes are not yet fully articulated. In contrast, definitions of context vary widely, and boundaries with neighbouring concepts, such as setting and environment, are blurred; characteristics, preconditions and outcomes are ill-defined. Therefore, the maturity of both concepts should be further improved to facilitate operationalization in systematic reviews and HTAs.