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PubMed1994

Enhancing faculty participation and interest in quality improvement in academic centers.

Continuous quality improvement (CQI) is necessary in maintaining and improving the quality of medical care delivered. However, quality assurance (QA) in the past was performed superficially to meet requirements of the Joint Commission on Accreditation of Health Care Organizations and other regulatory agencies. Academic faculty participation in QA activity was also limited. Faculty often assume that meaningful quality process demands excessive efforts and time unrewarded with career advancement, promotion, or monetary compensation. In addition, unstructured QA leads to duplication of data and loss of educational opportunity. We reorganized the QA process in internal medicine using the CQI concept to: (a) improve academic faculty participation, (b) incorporate educational concepts, (c) stimulate interest in outcome research and CQI, and (d) integrate cost containment. A reorganized CQI format has stimulated enthusiastic participation of faculty and residents, and has generated conferences and grand rounds pertinent to medical care, outcome research, and cost containment. We conclude that academic faculty should play leadership roles in the CQI process and include teaching models. Improved and increased academic faculty participation could be realized, when educational values, research activities, and cost analysis are incorporated into the CQI process.

Academic Medical Centers↗

PubMed2003

Methods for evaluation of small scale quality improvement projects.

Evaluation is an integral component of quality improvement and there is much to be learned from the evaluation of small scale quality improvement initiatives at a local level. This type of evaluation is useful for a number of different reasons including monitoring the impact of local projects, identifying and dealing with issues as they arise within a project, comparing local projects to draw lessons, and collecting more detailed information as part of a bigger evaluation project. Focused audits and developmental studies can be used for evaluation within projects, while methods such as multiple case studies and process evaluations can be used to draw generalised lessons from local experiences and to provide examples of successful projects. Evaluations of small scale quality improvement projects help those involved in improvement initiatives to optimise their choice of interventions and use of resources. Important information to add to the knowledge base of quality improvement in health care can be derived by undertaking formal evaluation of local projects, particularly in relation to building theory around the processes of implementation and increasing understanding of the complex change processes involved.

Family Practice↗

PubMed2000

What are Medicare managed care plans doing to measure and improve quality of care?

To explore managed care plans' efforts to assess and improve quality of care for Medicare beneficiaries, the authors surveyed managed care plans with risk contracts for Medicare beneficiaries in 20 large metropolitan areas in January 1998. The survey inquired about: (1) the health plans' efforts to assess and improve quality of care for specific underuse, overuse, and misuse problems; (2) how the health plans assessed functional status of enrollees, and (3) the quality improvement program they believed had the greatest impact on the health of enrollees. The managed care plans reported a heterogeneous mix of quality improvement activities ranging from poorly developed to very sophisticated. The vast majority of the more sophisticated programs addressed problems with underuse of services rather than overuse or misuse.

Aged↗

PubMed2004

When does quality improvement count as research? Human subject protection and theories of knowledge.

The publication of insights from a quality improvement project recently precipitated a ruling by the lead federal regulatory agency that regulations providing protection for human subjects of research should apply. The required research review process did not match the rapid changes, small samples, limited documentation, clinician management, and type of information commonly used in quality improvement. Yet quality improvement can risk harm to patients, so some review might be in order. The boundaries and processes are not clear. Efforts have been made to determine what constitutes "research", but this has proved difficult and often yields irrational guidance with regard to protection of patients. Society needs a workable way to separate activities that will improve care, on the one hand, and those that constitute research, on the other. Practitioners who lead both quality improvement and research projects claim that those which rapidly give feedback to the care system that generated the data, aiming to change practices within that system, are "quality improvement" no matter whether the findings are published, whether the project is grant funded, and whether contemporaneous controls do not have the intervention. This criterion has not previously been proposed as a possible demarcation. The quandaries of which projects to put through research review and how to ensure ethical implementation of quality improvement need to be resolved.

Human Experimentation↗

PubMedDate not supplied

Using quality improvement to enhance research readiness in palliative care.

Quality improvement is an essential feature of the ongoing development of palliative care programs. Little has been written, however, about using quality improvement as a strategy to introduce research concepts to staff and administrators for the purpose of enhancing research readiness in healthcare settings. This article describes such an endeavor. The authors discuss two quality improvement initiatives undertaken by a palliative care program in Canada. These two examples demonstrate how the quality improvement process acted as a catalyst to enhance research readiness.

British Columbia↗

PubMed2001

Enhancing causal interpretations of quality improvement interventions.

In an era of chronic resource scarcity it is critical that quality improvement professionals have confidence that their project activities cause measured change. A commonly used research design, the single group pre-test/post-test design, provides little insight into whether quality improvement interventions cause measured outcomes. A re-evaluation of a quality improvement programme designed to reduce the percentage of bilateral cardiac catheterisations for the period from January 1991 to October 1996 in three catheterisation laboratories in a north eastern state in the USA was performed using an interrupted time series design with switching replications. The accuracy and causal interpretability of the findings were considerably improved compared with the original evaluation design. Moreover, the re-evaluation provided tangible evidence in support of the suggestion that more rigorous designs can and should be more widely employed to improve the causal interpretability of quality improvement efforts. Evaluation designs for quality improvement projects should be constructed to provide a reasonable opportunity, given available time and resources, for causal interpretation of the results. Evaluators of quality improvement initiatives may infrequently have access to randomised designs. Nonetheless, as shown here, other very rigorous research designs are available for improving causal interpretability. Unilateral methodological surrender need not be the only alternative to randomised experiments.

Cardiac Catheterization↗

PubMedDate not supplied

Lessons learned while implementing service quality improvement.

The successful implementation of quality improvement (QI) in an organization requires the organization's executives to visibly and consistently demonstrate an understanding of and commitment to QI principles. One means of developing this understanding is to give executives firsthand experience with QI tools and skills. This article details the lessons learned by personnel at a large medical center during the implementation of QI initiatives and highlights some aspects of the role hospital executives must play in achieving QI. Whatever approach an organization chooses for the implementation of QI, the exercise of discipline to do what is right inevitably will lead to the improvement of quality.

Academic Medical Centers↗

PubMed2006

Case management saves hospital system dollar 23.9M, improves quality.

Case management saves hospital system dollar 23.9M, improves quality. As managed care organizations and government payers ask for quality improvements in exchange for increased reimbursement, hospitals nationwide are looking for ways to cut utilization and costs by using a combination of hospitalists and case management services.

Case Management↗

PubMed2006

Assessment of the Medicare quality improvement organization program.

BACKGROUND: Studies have shown improvement in quality of health care in the United States. However, the factors responsible for this improvement are largely unknown. OBJECTIVE: To evaluate the effect of the Medicare Quality Improvement Organization (QIO) Program in 4 clinical settings by using performance data for 41 quality measures during the 7th Scope of Work. DESIGN: Observational study in which differences in quality measures were compared between baseline and remeasurement periods for providers that received different levels of QIO interventions. SETTING: Nursing homes, home health agencies, hospitals, and physician offices in the 50 U.S. states, the District of Columbia, and 2 U.S. territories. PARTICIPANTS: Providers receiving focused QIO assistance related to quality measures and providers receiving general informational assistance from QIOs. MEASUREMENTS: 5 nursing home quality measures, 11 home health measures, 21 hospital measures, and 4 physician office measures. RESULTS: For nursing home, home health, and physician office measures, providers recruited specifically by QIOs for receipt of assistance showed greater improvement in performance on 18 of 20 measures than did providers who were not recruited; similar improvement was seen on the other 2 measures. Nursing homes and home health agencies improved more in all measures on which they chose to work with the QIO than in other measures. Nineteen of 21 hospital measures showed improvement; in this setting, QIOs were contracted for improvement initiatives solely at the statewide level. Overall, improvement was seen in 34 of 41 measures from baseline to remeasurement in the 7th Scope of Work. LIMITATIONS: As in any observational study, selection bias, regression to the mean, and secular trends may have influenced the results. CONCLUSIONS: These findings are consistent with an impact of the QIO Program and QIO technical assistance on the observed improvement. Future evaluations of the QIO Program will attempt to better address the limitations of the design of this study.

Emergency Medical Services↗

PubMedDate not supplied

From quality assurance to quality improvement: the Joint Commission and the new quality paradigm.

Frank Appel, NAQAP's representative on the Joint Commission's QI Task Force, describes the ongoing Agenda for Change as progressively defining a new vision of effectiveness in healthcare organizations. This vision, first articulated in 1989 in the Principles of Organization and Management Effectiveness in Healthcare Organizations, is based on the fundamental concepts of total quality management (TQM), the new paradigm in healthcare. The first direct outcome of these principles is a new set of leadership standards that will appear in the 1992 Accreditation Manual for Hospitals (AMH). The Joint Commission is using the mechanism of standards' revision to lead healthcare organizations into a transition to continuous quality improvement (CQI). The 1992 AMH contains a revision of the current QA standards in the direction of quality assessment and improvement standards. The transition to CQI standards will be complete by 1994, when the data-driven process of CQI will also be incorporated into information management. Major CQI revisions also will occur in other parts of the management. Major CQI revisions also will occur in other parts of the AMH. "Second generation" clinical indicators presently under development reflect the process and cross-functional orientation of CQI. TQM is seen by the Joint Commission as the next step in a logical progression in QI methods, while CQI offers answers to the weaknesses of current QA programs. Mr. Appel concludes with an outline of these weaknesses, and a strong message of encouragement to the quality professional to meet the challenge of leadership during this transition.

Hospital Administration↗

PubMed1991

A quality improvement management model for renal care.

The purpose of this article is to explore the potential for applying the theory and tools of quality improvement (total quality management) in the renal care setting. We believe that the coupling of the statistical techniques used in the Deming method of quality improvement, with modern approaches to outcome and process analysis, will provide the renal care community with powerful tools, not only for improved quality (i.e., reduced morbidity and mortality), but also for technology evaluation and resource allocation.

Humans↗

PubMed2003

Institutionalizing pain management: the Post-Operative Pain Management Quality Improvement Project.

Clinical practice and quality improvement (QI) guidelines for acute postoperative pain management have been developed to address the well-documented problem of undertreatment of postoperative pain. The Post-Operative Pain Management Quality Improvement Project (the POP Project) was initiated to determine whether an intervention designed to support hospitals in the development of QI efforts would lead to improvements in structures, processes, and outcomes consistent with recommended guidelines. A nationwide sample of 233 hospitals joined the project. The intervention consisted of written resource materials accompanied by support services that included an e-mail list server, a resource Web page, and assistance from POP Project staff via telephone. Data regarding critical structures, processes (practice patterns), and patient outcomes were collected at baseline before the intervention began and at follow-up 12 to 18 months later. Results showed a statistically significant increase from baseline (45%) to follow-up (72%) in the presence of structural elements that are critical to improving pain management. There were statistically significant improvements in practices including documented use of pain rating scales, decreased use of intramuscular opioids, and increased use of nonpharmacologic strategies. Patient survey data showed no change in pain outcomes. Evaluation data showed that 70% of hospitals were very or extremely satisfied with their participation in the POP Project and 90% of them planned to continue efforts to improve pain management after the POP Project ended. Further research is needed to determine how to translate the excellent results obtained for structure and process into meaningful outcomes for patients.

Data Collection↗

PubMed1993

The quality march. Part two of a national survey of quality improvement activities.

Overall, the findings suggest that CQI/TQM hospitals report a greater level of satisfaction with their quality improvement efforts; take more board actions to improve quality; perceive a more positive impact on human resource development issues and on financial outcomes; are generally more likely to report statistically significant improvements in selected patient outcomes; and are more likely to report cost savings than hospitals not involved in CQI/TQM activities. The final article in the series will discuss CQI/TQM areas of assistance in furthering quality improvement efforts, particularly in regard to clinical applications and physician involvement.

Consumer Behavior↗

PubMed2005

Narrative methods in quality improvement research.

This paper reviews and critiques the different approaches to the use of narrative in quality improvement research. The defining characteristics of narrative are chronology (unfolding over time); emplotment (the literary juxtaposing of actions and events in an implicitly causal sequence); trouble (that is, harm or the risk of harm); and embeddedness (the personal story nests within a particular social, historical and organisational context). Stories are about purposeful action unfolding in the face of trouble and, as such, have much to offer quality improvement researchers. But the quality improvement report (a story about efforts to implement change), which is common, must be distinguished carefully from narrative based quality improvement research (focused systematic enquiry that uses narrative methods to generate new knowledge), which is currently none. We distinguish four approaches to the use of narrative in quality improvement research--narrative interview; naturalistic story gathering; organisational case study; and collective sense-making--and offer a rationale, describe how data can be collected and analysed, and discuss the strengths and limitations of each using examples from the quality improvement literature. Narrative research raises epistemological questions about the nature of narrative truth (characterised by sense-making and emotional impact rather than scientific objectivity), which has implications for how rigour should be defined (and how it might be achieved) in this type of research. We offer some provisional guidance for distinguishing high quality narrative research in a quality improvement setting from other forms of narrative account such as report, anecdote, and journalism.

Health Services Research↗

PubMed2000

Obstacles to collaborative quality improvement: the case of ambulatory general medical care.

OBJECTIVE: To assess the effectiveness of inter-site collaboration and report-card style feedback of quality measures on quality improvement in the outpatient setting and to identify major barriers to improvement. DESIGN: A collaborative quality improvement effort consisting of a large cross-sectional data collection effort (chart reviews and patient surveys), feedback of comparative quality of care data to improvement teams, and collaboration between sites. SETTING: Eleven primary care sites in the Boston area. STUDY PARTICIPANTS: Quality improvement teams at each site with physician leaders. INTERVENTION: Education about techniques of rapid-cycle quality improvement, coaching of on-site teams, and report-card style feedback of comparative site-specific quality of care data. RESULTS: Multiple quality improvement projects were undertaken through this collaboration. However, though we were careful to educate teams on methods of continuous quality improvement and to name specific clinical leaders, the degree of collaboration and quality improvement fell short of expectations. Major impediments to improvement included lack of team members' time and resources, lack of incentives, and unempowered team leadership. The primary obstacle to collaboration was the diversity of sites and inability of teams to create interventions that were relevant to other sites. CONCLUSION: Despite ample quality of care data, quality improvement education, and a structured collaborative process, achieving quality improvement in the ambulatory setting is still a difficult challenge. Organizations need to find ways of overcoming the obstacles faced by improvement teams in order to maximize quality improvement.

Ambulatory Care↗

PubMed1998

The impact of mammography quality improvement legislation in Michigan: implications for the National Mammography Quality Standards Act.

OBJECTIVES: This study examined the impact of state legislation on mammography quality and access in Michigan. METHODS: The impact of state legislation was analyzed with respect to utilization, numbers of machines and facilities, and image quality. RESULTS: The legislation had a positive effect on image quality improvement, had no impact on utilization by women aged 50 years and above, and resulted in few facility closures. CONCLUSIONS: Michigan's legislative intervention appears to have had a positive effect on efforts to improve mammography quality assurance with implications for other federal and state efforts to achieve quality assurance in health care delivery.

Aged↗

PubMed2004

Effects of a quality improvement collaborative on the outcome of care of patients with HIV infection: the EQHIV study.

BACKGROUND: Multi-institution collaborative quality improvement programs are a well-established and broadly applicable quality improvement strategy, but there is little systematic assessment their effectiveness. OBJECTIVE: To evaluate the effectiveness of a quality improvement collaborative in improving the quality of care for HIV-infected patients. DESIGN: Controlled pre- and postintervention study. SETTING: Clinics receiving funding from the Ryan White Comprehensive AIDS Resources Emergency Act. PARTICIPANTS: 44 intervention clinics and 25 control clinics matched by location (urban or rural), region, size, and clinic type. MEASUREMENTS: Changes in quality-of-care measures abstracted from medical records of pre- and postintervention samples of patients at each study clinic. Measures examined included use and effectiveness of antiretroviral therapy, screening and prophylaxis, and access to care. INTERVENTION: A multi-institutional quality improvement collaborative (the "Breakthrough Series"). RESULTS: 9986 patients were studied. Clinical and sociodemographic characteristics of the intervention and control patients were similar (P > 0.05). Differences in changes in the quality of care were not statistically significant. The proportion of patients with a suppressed viral load increased by 11 percentage points (from 40.1% to 51.1%) in the intervention group compared with 5.3 percentage points (from 43.6% to 48.8%) in the control group, but this difference was not statistically significant (P = 0.18). In addition, rates of appropriate screening tests and prophylaxis did not differ between intervention and control sites. LIMITATIONS: It was not possible to perform a pure randomized trial of the intervention or to assess other measures of quality, such as adherence and satisfaction. CONCLUSIONS: This prospective, matched study of almost 10 000 patients found that a quality improvement collaborative did not significantly affect the quality of care. Additional research is needed to improve methods of teaching and implementing quality improvement programs to achieve better results.

AIDS-Related Opportunistic Infections↗

PubMed2007

Quality improvement: the divergent views of managers and clinicians.

AIM: The aim of this study was to identify and explore nurse managers' and clinical nurses' perceptions of quality improvement as related to their practice. BACKGROUND: The quality improvement process has become an integral component of health care service delivery. The pivotal role that nurse managers and clinical nurses play in the success of quality improvement initiatives is consistently reported throughout the literature. Published evidence has primarily focused on nurses' perceptions of "quality" and the importance of the nurse's role. However, the literature fails to provide evidence that nurse managers and clinical nurses agree with this. METHOD: Research was conducted at one large regional hospital in Australia in the year 2000 and used a descriptive qualitative research methodology. Data were collected using semistructured interviews with six nurse managers and six clinical nurses on two consecutive occasions and analysed using constant comparative analysis. RESULTS: Nurse managers' and clinical nurses' understanding of the concept of quality improvement and how it applies to the practice of nursing differed. Each group identified that quality improvement can be beneficial to nursing practice, but blamed each other for potential benefits not being realized. Both nurse managers and clinical nurses offered similar solutions with varied emphasis on how quality improvement could improve nursing practice and patient outcomes. CONCLUSION: The quality improvement process requires review. Nurse managers and clinical nurses offered divergent views of the identified deficiencies in the way quality improvement is implemented that reduce its clinical impact. Integral to the success of any quality improvement process is the inclusion of views of both nurse managers and clinical nurses.

Attitude of Health Personnel↗