How to sustainably build capacity in quality improvement within a healthcare organisation: a deep-dive, focused qualitative analysis

Knowledge boundaries for implementation of quality improvement interventions; a qualitative study

Introduction

Implementation and adoption of quality improvement interventions have proved difficult, even in situations where all participants recognise the relevance and benefits of the intervention. One way to describe difficulties in implementing new quality improvement interventions is to explore different types of knowledge boundaries, more specifically the syntactic, semantic and pragmatic boundaries, influencing the implementation process. As such, this study aims to identify and understand knowledge boundaries for implementation processes in nursing homes and homecare services.

Methods

An exploratory qualitative methodology was used for this study. The empirical data, including individual interviews (n = 10) and focus group interviews (n = 10) with leaders and development nurses, stem from an externally driven leadership intervention and a supplementary tracer project entailing an internally driven intervention. Both implementations took place in Norwegian nursing homes and homecare services. The empirical data was inductively analysed in accordance with grounded theory.

Results

The findings showed that the syntactic boundary included boundaries like the lack of meeting arenas, and lack of knowledge transfer and continuity in learning. Furthermore, the syntactic boundary was mostly related to the dissemination and training of staff across the organisation. The semantic boundary consisted of boundaries such as ambiguity, lack of perceived impact for practice and lack of appropriate knowledge. This boundary mostly related to uncertainty of the facilitator role. The pragmatic boundary included boundaries related to a lack of ownership, resistance, feeling unsecure, workload, different perspectives and a lack of support and focus, reflecting a change of practices.

Discussion

This study provides potential solutions for traversing different knowledge boundaries and a framework for understanding knowledge boundaries related to the implementation of quality interventions.

The characteristics of leadership and their effectiveness in quality management in healthcare - A systematic literature review and a content analysis

Effective quality leadership is identified as a critical factor for organisational success. Leadership style has an important role in the implementation of quality management. This systematic review describes the characteristics of leadership in quality management in healthcare, and analyses their association with successful or unsuccessful quality management by using content analysis. Papers published in peer-reviewed journals between 2011 and June 2023 were selected by exploring the Abi/Inform, Business Source Complete, Cinahl, Pubmed and Web of Science electronic databases. Altogether 3014 records were found. PRISMA-protocol was used for selection of studies. 12 original and three review articles were included. Six leadership characteristics were identified that were linked to successful or unsuccessful implementation of quality management. The six categories were strategic, knowledge-oriented, value-based, supportive, participatory and communicative leadership. Supercategories and subcategories of successful and unsuccessful implementation are described. The results can be used to identify the leadership characteristics that promote successful quality management in healthcare organisations. In education for leaders and managers, attention should be in the characteristics and style of leadership and their impact on the effectiveness of quality management.

Catalyzing System Change: 100 Quality Improvement Projects in 1000 Days

BACKGROUND

Health system change requires quality improvement (QI) infrastructure that supports frontline staff implementing sustainable innovations. We created an 8-week rapid-cycle QI training program, Stanford Primary Care-Project Engagement Platform (PC-PEP), open to patient-facing primary care clinicians and staff.

OBJECTIVE

Examine the feasibility and outcomes of a scalable QI program for busy practicing providers and staff in an academic medical center.

DESIGN

Program evaluation.

PARTICIPANTS

A total of 172 PCPH team members: providers (n = 55), staff (n = 99), and medical learners (n = 18) in the Stanford Division of Primary Care and Population Health (PCPH) clinics, 2018-2021.

MAIN MEASURES

We categorized projects by the Institute for Healthcare Improvement's (IHI) Quintuple Aim (QA): better health, better patient experience, lower cost of care, better care team experience, and improved equity/inclusion. We assessed project progress with a modified version of The Ottawa Hospital Innovation Framework: step 1 (identified root causes), step 2 (designed/tested interventions), step 3 (assessed project outcome), step 4 (met project goal with target group), step 5A (intervention(s) spread within clinic), step 5B (intervention(s) spread to different setting). Participants rated post-participation QI self-efficacy.

KEY RESULTS

Within 1000 days, 172 unique participants completed 104 PC-PEP projects. Most projects aimed to improve patient health (55%) or care team experience (23%). Among projects, 9% reached step 1, 8% step 2, 16% step 3, 26% step 4, 21% step 5A, and 20% step 5B. Learner involvement increased likelihood of scholarly products (47% vs 10%). Forty-six of 47 (98%) survey respondents reported improved QI self-efficacy. Medical assistants, more so than physicians, reported feeling acknowledged by the health system for their QI efforts (100% vs 61%).

CONCLUSIONS

With appropriate QI infrastructure, scalable QI training models like Stanford PC-PEP can empower frontline workers to create meaningful changes across the IHI QA.

Motivational drivers for health professionals in a large quality improvement collaborative project in Brazil: a qualitative study

BACKGROUND

The success of collaborative quality improvement (QI) projects in healthcare depends on the context and engagement of health teams; however, the factors that modulate teams' motivation to participate in these projects are still unclear. The objective of the current study was to explore the barriers to and facilitators of motivation; the perspective was health professionals in a large project aiming to implement evidence-based infection prevention practices in intensive care units of Brazilian hospitals.

METHODS

This qualitative study was based on content analysis of semistructured in-depth interviews held with health professionals who participated in a collaborative QI project named "Improving patient safety on a large scale in Brazil". In accordance with the principle of saturation, we selected a final sample of 12 hospitals located throughout the five regions of Brazil that have implemented QI; then, we conducted videoconference interviews with 28 health professionals from those hospitals. We encoded the interview data with NVivo software, and the interrelations among the data were assessed with the COM-B model.

RESULTS

The key barriers identified were belief that improvement increases workload, lack of knowledge about quality improvement, resistance to change, minimal involvement of physicians, lack of supplies, lack support from senior managers and work overload. The primary driver of motivation was tangible outcomes, as evidenced by a decrease in infections. Additionally, factors such as the active participation of senior managers, teamwork, learning in practice and understanding the reason for changes played significant roles in fostering motivation.

CONCLUSION

The motivation of health professionals to participate in collaborative QI projects is driven by a variety of barriers and facilitators. The interactions between the senior manager, quality improvement teams, and healthcare professionals generate attitudes that modulate motivation. Thus, these aspects should be considered during the implementation of such projects. Future research could explore the cost-effectiveness of motivational approaches.

Built to last? Barriers and facilitators of healthcare program sustainability: a systematic integrative review

OBJECTIVE

To identify barriers and facilitators associated with the sustainability of implemented and evaluated improvement programs in healthcare delivery systems.

DATA SOURCES AND STUDY SETTING

Six academic databases were searched to identify relevant peer-reviewed journal articles published in English between July 2011 and June 2022. Studies were included if they reported on healthcare program sustainability and explicitly identified barriers to, and facilitators of, sustainability.

STUDY DESIGN

A systematic integrative review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Study quality was appraised using Hawker's Quality Assessment Tool.

DATA COLLECTION/EXTRACTION METHODS

A team of reviewers screened eligible studies against the inclusion criteria and extracted the data independently using a purpose-designed Excel spreadsheet. Barriers and facilitators were extracted and mapped to the Integrated Sustainability Framework (ISF). Frequency counts of reported barriers/facilitators were performed across the included studies.

RESULTS

Of the 124 studies included in this review, almost half utilised qualitative designs (n = 52; 41.9%) and roughly one third were conducted in the USA (n = 43; 34.7%). Few studies (n = 29; 23.4%) reported on program sustainability beyond 5 years of program implementation and only 16 of them (55.2%) defined sustainability. Factors related to the ISF categories of inner setting (n = 99; 79.8%), process (n = 99; 79.8%) and intervention characteristics (n = 72; 58.1%) were most frequently reported. Leadership/support (n = 61; 49.2%), training/support/supervision (n = 54; 43.5%) and staffing/turnover (n = 50; 40.3%) were commonly identified barriers or facilitators of sustainability across included studies. Forty-six (37.1%) studies reported on the outer setting category: funding (n = 26; 56.5%), external leadership by stakeholders (n = 16; 34.8%), and socio-political context (n = 14; 30.4%). Eight studies (6.5%) reported on discontinued programs, with factors including funding and resourcing, poor fit, limited planning, and intervention complexity contributing to discontinuation.

CONCLUSIONS

This review highlights the importance of taking into consideration the inner setting, processes, intervention characteristics and outer setting factors when sustaining healthcare programs, and the need for long-term program evaluations. There is a need to apply consistent definitions and implementation frameworks across studies to strengthen evidence in this area.

TRIAL REGISTRATION

https://bmjopen.bmj.com/content/7/11/e018568 .

Unsafe care in residential settings for older adults: a content analysis of accreditation reports

Residents of aged care services can experience safety incidents resulting in preventable serious harm. Accreditation is a commonly used strategy to improve the quality of care; however, narrative information within accreditation reports is not generally analysed as a source of safety information to inform learning. In Australia, the Aged Care Quality and Safety Commission (ACQSC), the sector regulator, undertakes over 500 accreditation assessments of residential aged care services against eight national standards every year. From these assessments, the Aged Care Quality and Safety Commission generates detailed Site Audit Reports. In over one-third (37%) of Site Audit Reports, standards relating to Personal and Clinical Care (Standard 3) are not being met. The aim of this study was to identify the types of resident Safety Risks that relate to Personal and Clinical Care Standards not being met during accreditation or re-accreditation. These data could inform priority setting at policy, regulatory, and service levels. An analytical framework was developed based on the World Health Organization's International Classification for Patient Safety and other fields including Clinical Issue (the issue related to the incident impacting the resident, e.g. wound/skin or pain). Information relating to safety incidents in the Site Audit Reports was extracted, and a content analysis undertaken using the analytical framework. Clinical Issue and the International Classification for Patient Safety-based classification were combined to describe a clinically intuitive category ('Safety Risks') to describe ways in which residents could experience unsafe care, e.g. diagnosis/assessment of pain. The resulting data were descriptively analysed. The analysis included 65 Site Audit Reports that were undertaken between September 2020 and March 2021. There were 2267 incidents identified and classified into 274 types of resident Safety Risks. The 12 most frequently occurring Safety Risks account for only 32.3% of all incidents. Relatively frequently occurring Safety Risks were organisation management of infection control; diagnosis/assessment of pain, restraint, resident behaviours, and falls; and multiple stages of wounds/skin management, e.g. diagnosis/assessment, documentation, treatment, and deterioration. The analysis has shown that accreditation reports contain valuable data that may inform prioritization of resident Safety Risks in the Australian residential aged care sector. A large number of low-frequency resident Safety Risks were detected in the accreditation reports. To address these, organizations may use implementation science approaches to facilitate evidence-based strategies to improve the quality of care delivered to residents. Improving the aged care workforces' clinical skills base may address some of the Safety Risks associated with diagnosis/assessment and wound management.

Enhancing Strategic Learning Through the Implementation of Robust Process Improvement in a Specialized Tertiary Care Hospital

Introduction

Performance improvement (PI) in healthcare is essential to improve health, patient experience, and reduce costs. PI projects became low, inconsistent and weakly-sustained in our hospital. The low number and low sustainability were scarcely in alignment with our strategic goal to become a high reliability organization (HRO). This was due to lack of standardized knowledge and ability to initiate and sustain PI projects. Therefore, a structured framework was developed, followed by the building of capacity and capability in the use of robust process improvement (RPI) amidst the COVID-19 pandemic.

Methods

A team of healthcare quality professionals collaborated with Hospital Performance Improvement-Press Ganey for hospital-wide quality improvement project. The team received training on RPI from Press Ganey and created the framework to use . This framework is based on the Institute for Healthcare Improvement Model for Improvement, Lean, Six Sigma, and FOCUS-PDSA (Find-Organize-Clarify-Understand-Select-Plan-Do-Study-Act). Thereafter, the team of internal coaches organized an RPI training course that consisted of 6 sessions, for clinical and nonclinical staff , using classroom and virtual sessions during the pandemic. This course was increased to eight sessions to avoid information overload. Process measures were collected using a survey to obtain feedback, whereas outcome measures were from the number of completed projects and their effects related to costs, access to care, waiting time, number of harms, and compliance.

Results

Participation and submission improved after three PDSA (Plan-Do-Study-Act) cycles. This resulted in an increased number of completed and sustained projects from 50 in 2019 to 94 in 2020 and continued to rise to 109 in 2021. There were 140 and 122 certified RPI coaches in 2020 and 2021, respectively. Although there was a decrease in the number of certified coaches in 2021, the number of completed projects was higher than in 2020. The overall effect of these completed projects by the third quarter of 2021 showed improvement in access to care by 39%, compliance to standards of care by 48%, satisfaction by 8%, and reduction in costs by 47,010 SAR, in waiting time of 170 hours, and in the number of harms by 89.

Conclusion

This quality improvement project led to enhanced capacity of staff as seen in the increased number of certified RPI coaches, thereby increasing the submission and completion of projects in 1 year. Its sustainability during the 2 succeeding years continued to enhance project completion and maintenance, bringing quality improvement benefits to the organization and the patients.

Scholarship in anesthesiology: the role of critical appraisal, literature review, quality improvement, journal club, and presentation skills

If asked to describe the term "anesthesiologist scholar", one may receive a variety of definitions depending on the individual's area of practice, location in the world, and the generation in which they trained. In this article, we review the roles of five core elements that make an anesthesiologist a "scholar": skills in critical appraisal, literature review, quality improvement, journal club participation, and presentation delivery. Although this list of scholarly components is not comprehensive, review of each element's role in the everyday practice and training of physicians will offer insight into their evolution and may offer a glimpse into the future of anesthesiologist scholars. Overall, through the dissemination, recognition, and support of scholarship through these practices, we will continue to achieve meaningful outcomes for our patients and promote a culture of collaboration worldwide. We should ensure that these topic areas become a bedrock of medical education globally, and we must foster opportunities for those who have already completed training to develop and master these skills as a part of their clinical and academic practice.

Utilization of Improvement Methodologies by Healthcare Quality Professionals During the COVID-19 Pandemic

INTRODUCTION

This study describes the work of healthcare quality professionals during the COVID-19 pandemic, highlighting the successes and challenges they faced when applying their expertise in performance and process improvement (PPI) to help manage the crisis.

METHODS

The researchers performed a descriptive analysis of anonymous survey data collected from members of the National Association for Healthcare Quality professional community who were asked about their improvement work during the pandemic response.

RESULTS

Most survey respondents used improvement methods to a great or moderate extent to measure what was happening (83%), rapidly review processes and practice (81%), and decide where to focus effort (81%). Fewer respondents used PPI methods to engage with patients and families (58% to a great or moderate extent). Looking to the future, respondents indicated that embedding systematic approaches to improvement within healthcare organizations (59%) and working in a more integrated way across teams (48%) should be prioritized in the post-pandemic recovery.

CONCLUSIONS

The results from this study demonstrate why healthcare leaders should recognize the value that performance improvement approaches provide to everyday operations. They must empower PPI experts to lead this critical work and continue building workforce capacity in PPI methods to strengthen staff engagement and achieve better outcomes.

Seizing the opportunity: the emergence of shared leadership during the deployment of an integrated performance management system

Background

Performance management systems have been introduced in health and social services institutions to improve organizational performance, supporting the emergence of new management behaviors that are more rooted in collaborative management practices. This study aims to understand how different leadership styles emerge through the implementation of a performance management system and its related tools, and how these can foster distributed leadership.

Methods

Over two years, the implementation of an integrated performance management system supporting the integration of social services for children, youth, and families was studied at a recently merged Canadian healthcare organization. Qualitative analysis of data collected from 15 interviews, 3 focus groups, and over 350 h of non-participant observation was conducted.

Results

The results show that leadership evolved to adapt to the context of organizational integration and was no longer confined to a single manager. Transformational leadership was needed to encourage the emergence of a new integrated performance management system and new behaviors among middle managers and team members. Transactional leadership was legitimized through the use of a status sheet when the integration project did not deliver the expected results. Both transformational and transactional leadership paved the way to distributed leadership, which in turn promoted collaborative practices associated with activities in control rooms and dialogue stemming from the status sheets. Distributed leadership among team members made a difference in the outcome of the integration project, which became a driver of collaboration.

Conclusions

The integrated performance management system and the use of its tools can help renew leadership in health and social service organizations. The results lend credence to the importance of distributed leadership in promoting collaborative practices to improve services for children, youth, and families. The results also highlight how various leadership styles can contribute to the emergence of distributed leadership over time.

What Does a Systems Approach to Quality Improvement Look Like in Practice?

Universally improving healthcare systems is difficult to achieve in practice with organisations implementing a range of quality improvement (QI) approaches, in varying and changing contexts, and efforts ranging from project-based improvements to whole system change. This study aimed to identify how organisations overcome the challenges to improving the quality of the services they deliver. Drawing on the eight challenges from the ‘Quality and Safety in Europe by Research (QUASER) hospital guide, we assessed eight cases reported by the UK-based regulator Care Quality Commission as improving their performance. A thematic analysis of these secondary data established that all eight challenges had been addressed or considered in varying degrees. Education and physical and technological challenges seemed less prominent than developments made to address other challenges such as developing leadership, structure, and culture to support improving quality. This paper relies on the analysis of secondary case data and one framework to assess improvement efforts. Further research is required to consider other models and frameworks and to collate longitudinal data to capture the dynamics and increasing the maturity of improving healthcare systems in practice.

Surgical safety checklist audits may be misleading! Improving the implementation and adherence of the surgical safety checklist: a quality improvement project

Despite good quality evidence for benefits with its use, challenges have been encountered in the correct and consistent implementation of the surgical safety checklist (SSC). Previous studies of the SSC have reported a discrepancy between what is documented and what is observed in real time. A baseline observational audit at our institution demonstrated compliance of only 3.5% despite a documented compliance of 100%. This project used quality improvement principles of identifying the problem and designing strategies to improve staff compliance with the SSC. These included changing the SSC from paper-based to a reusable laminated form, a broad multidisciplinary education and marketing campaign, targeted coaching and modifying the implementation in response to ongoing staff feedback. Five direct observational audits were undertaken over four Plan–Do–Study–Act cycles to capture real-time information on staff compliance. Two staff surveys were also undertaken. Compliance with the SSC improved from 3.5% to 63% during this study. Staff reported they felt the new process improved patient safety and that the new SSC was easily incorporated into their workflow. Improving compliance with the SSC requires deep engagement with and cooperation of surgical, anaesthesia and nursing teams and understanding of their work practices and culture. The prospective observational audit highlighted an initial 3.5% compliance rate compared with 100% based on an audit of the patient notes. Relying solely on a retrospective paper-based model can lead to hospitals being unaware of significant safety and quality issues. While in-person prospective observations are more time-consuming and resource-consuming than retrospective audits, this study highlights their potential utility to gain a clear picture of actual events. The significant variation between documented and observed data may have considerable implications for other retrospective studies which rely on human-entered data for their results.