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A model for continuous quality improvement in small scale practices
... In turn, proximal outcomes may mediate the effect of CQI process on more distal outcomes (e.g., structural changes to the process of care, and provider adherence to these changes). Our concept of CQI process focuses on the use of CQI methods most salient to primary care settings [51]. These methods are reflected in Weiner's operational definition of CQI 'use of cross-functional teams to identify and solve quality problems, use of scientific methods and statistical tools by these teams to monitor and analyse work processes, and use of processmanagement tools . . ...
... Organisation-wide use of CQI methods covers indicators of the use of CQI methods across an organisation [52,89]. The use of CQI methods by QI teams encompasses the main components of CQI depicted in our initial framework (e.g., setting aims, structured problem solving, data collection and analysis, use of QI tools) [51,[90][91][92]. ...
Background
Continuous quality improvement (CQI) methods are widely used in healthcare; however, the effectiveness of the methods is variable, and evidence about the extent to which contextual and other factors modify effects is limited. Investigating the relationship between these factors and CQI outcomes poses challenges for those evaluating CQI, among the most complex of which relate to the measurement of modifying factors. We aimed to provide guidance to support the selection of measurement instruments by systematically collating, categorising, and reviewing quantitative self-report instruments.
Methods
Data sources: We searched MEDLINE, PsycINFO, and Health and Psychosocial Instruments, reference lists of systematic reviews, and citations and references of the main report of instruments. Study selection: The scope of the review was determined by a conceptual framework developed to capture factors relevant to evaluating CQI in primary care (the InQuIRe framework). Papers reporting development or use of an instrument measuring a construct encompassed by the framework were included. Data extracted included instrument purpose; theoretical basis, constructs measured and definitions; development methods and assessment of measurement properties. Analysis and synthesis: We used qualitative analysis of instrument content and our initial framework to develop a taxonomy for summarising and comparing instruments. Instrument content was categorised using the taxonomy, illustrating coverage of the InQuIRe framework. Methods of development and evidence of measurement properties were reviewed for instruments with potential for use in primary care.
Results
We identified 186 potentially relevant instruments, 152 of which were analysed to develop the taxonomy. Eighty-four instruments measured constructs relevant to primary care, with content measuring CQI implementation and use (19 instruments), organizational context (51 instruments), and individual factors (21 instruments). Forty-one instruments were included for full review. Development methods were often pragmatic, rather than systematic and theory-based, and evidence supporting measurement properties was limited.
Conclusions
Many instruments are available for evaluating CQI, but most require further use and testing to establish their measurement properties. Further development and use of these measures in evaluations should increase the contribution made by individual studies to our understanding of CQI and enhance our ability to synthesise evidence for informing policy and practice.
... While each has its place in healthcare, none has been completely successful in bringing about significant changes in the delivery of care and controlling costs. These process improvements achieved limited success and did not address operational issues within the healthcare organization (Geboers et al., 1999;Hoque, 2003;Schneiderman, 1999). The immediate relief seen in an organization's bottom line stopped the organization from pursuing sustainable improvements. ...
... In the past 20 years, healthcare organizations utilized various business process improvements to decrease inconsistencies in the delivery of care. Researchers have examined both the advantages and disadvantages of such improvements, with little proof to show that any have been completely successful in their implementation, mostly due to their lack of employee involvement (Geboers et al., 1999;Hoque, 2003;Schneiderman, 1999). Thus, this case study is undertaken to understand the effectiveness of lean and kaizen as it is subjectively experienced by participants (i.e., employees), who are the subject matter experts, at a private hospital in a northwest state. ...
... Of these, 2080 were for depression counselling and that translated to monitoring, and continuous (re) alignment of the interests of all involved stakeholders 35 if the implementation is to succeed. As researchers, we had to balance being flexible and responsive to the implementation environment, maintaining diplomacy whilst also insisting on fidelity of the intervention. ...
Introduction
The treatment gap for mental health disorders persists in low‐ and middle‐income countries despite overwhelming evidence of the efficacy of task‐sharing mental health interventions. Key barriers in the uptake of these innovations include the absence of policy to support implementation and diverting of staff from usual routines in health systems that are already overstretched. South Africa enjoys a conducive policy environment; however, strategies for operationalizing the policy ideals are lacking. This paper describes the Mental health INTegration Programme (MhINT), which adopted a health system strengthening approach to embed an evidence‐based task‐sharing care package for depression to integrate mental health care into chronic care at primary health care (PHC).
Methods
The MhINT care package consisting of psycho‐education talks, nurse‐led mental health assessment, and a structured psychosocial counselling intervention provided by lay counsellors was implemented in Amajuba district in KwaZulu‐Natal over a 2‐year period. A learning health systems approach was adopted, using continuous quality improvement (CQI) strategies to facilitate embedding of the intervention.
MhINT was implemented along five phases: the project phase wherein teams to drive implementation were formed; the diagnostic phase where routinely collected data were used to identify system barriers to integrated mental health care; the intervention phase consisting of capacity building and using Plan‐Do‐Study‐Act cycles to address implementation barriers and the impact and sustaining improvement phases entailed assessing the impact of the program and initiation of system‐level interventions to sustain and institutionalize successful change ideas.
Results
Integrated planning and monitoring were enabled by including key mental health service indicators in weekly meetings designed to track the performance of noncommunicable diseases and human immunovirus clinical programmes. Lack of standardization in mental health screening prompted the validation of a mental health screening tool and testing feasibility of its use in centralized screening stations. A culture of collaborative problem‐solving was promoted through CQI data‐driven learning sessions. The province‐level screening rate increased by 10%, whilst the district screening rate increased by 7% and new patients initiated to mental health treatment increased by 16%.
Conclusions
The CQI approach holds promise in facilitating the attainment of integrated mental health care in resource‐scarce contexts. A collaborative relationship between researchers and health system stakeholders is an important strategy for facilitating the uptake of evidence‐based innovations. However, the lack of interventions to address healthcare workers' own mental health poses a threat to integrated mental health care at PHC.
... Audit and feedback have been recognized as important facilitators when implementing CQI, with increased intensity of support more effective in helping to incorporate improvements into practice [28,30,76]. The impact of collaboration and active communication may help to explain the apparent benefits from the use of CQI in primary care, where team structures reflect those used in operationalizing CQI methods [77,78] and such initiatives are incentivized through other mechanisms (e.g., Quality and Outcomes Framework) [79]. Despite several different approaches to CQI, we identified that PDSA and MoI were the models most frequently used, showing benefit on clinical process and patient outcomes in a third of trials respectively. ...
Background:
Efforts to improve the quality, safety, and efficiency of health care provision have often focused on changing approaches to the way services are organized and delivered. Continuous quality improvement (CQI), an approach used extensively in industrial and manufacturing sectors, has been used in the health sector. Despite the attention given to CQI, uncertainties remain as to its effectiveness given the complex and diverse nature of health systems. This review assesses the effectiveness of CQI across different health care settings, investigating the importance of different components of the approach.
Methods:
We searched 11 electronic databases: MEDLINE, CINAHL, EMBASE, AMED, Academic Search Complete, HMIC, Web of Science, PsycINFO, Cochrane Central Register of Controlled Trials, LISTA, and NHS EED to February 2019. Also, we searched reference lists of included studies and systematic reviews, as well as checking published protocols for linked papers. We selected randomized controlled trials (RCTs) within health care settings involving teams of health professionals, evaluating the effectiveness of CQI. Comparators included current usual practice or different strategies to manage organizational change. Outcomes were health care professional performance or patient outcomes. Studies were published in English.
Results:
Twenty-eight RCTs assessed the effectiveness of different approaches to CQI with a non-CQI comparator in various settings, with interventions differing in terms of the approaches used, their duration, meetings held, people involved, and training provided. All RCTs were considered at risk of bias, undermining their results. Findings suggested that the benefits of CQI compared to a non-CQI comparator on clinical process, patient, and other outcomes were limited, with less than half of RCTs showing any effect. Where benefits were evident, it was usually on clinical process measures, with the model used (i.e., Plan-Do-Study-Act, Model of Improvement), the meeting type (i.e., involving leaders discussing implementation) and their frequency (i.e., weekly) having an effect. None considered socio-economic health inequalities.
Conclusions:
Current evidence suggests the benefits of CQI in improving health care are uncertain, reflecting both the poor quality of evaluations and the complexities of health services themselves. Further mixed-methods evaluations are needed to understand how the health service can use this proven approach.
Trial registration:
Protocol registered on PROSPERO (CRD42018088309).
... Malah Goetsch dan Davis (2013) turut menyokong bahawa usaha penambahbaikan kualiti haruslah sentiasa dijalankan secara berterusan dengan menitikberatkan budaya kualiti organisasi yang mapan. Justeru amalan peningkatan kualiti secara berterusan dan konsisten pada hakikatnya merupakan suatu cabaran yang perlu ditangani secara sistematik dan strategik (Geboers, Grol, Bosch, Hoogen, Mokkink, Montfort & Oltheten, 1999;Hunter, Ober, Paddock, Hunt & Levan, 2014;Rashidah, Nurul Huda & Safura Adeela, 2012). ...
In line with Malaysia's aspiration to be a center of educational excellence in the region, the National Education System has implemented an education reform program as a platform to meet the continuing quality improvement needs at all levels of educational institutions. Hence, this study aims to examine the continuous quality improvement practices in religious schools that have gained public attention lately. Cross-sectional survey method was applied in the data collection process. The instrument used consists of two parts, namely Demographic Section and Continuous Quality Improvement Climate questionnaires. A total of 478 respondents comprising senior religious teachers in Kelantan were involved in the study. Stratified random sampling methods were used in the sample selection process. The findings show that religious schools adopt high-quality continuous improvements in all dimensions. However, there are significant differences based on demographic and dimension aspects. Therefore, school development factors and elements in continuous quality improvement practices should be properly addressed by stakeholders in every level of educational management.
... Healthcare organizations have utilized everything from Total Quality Management (TQM), Continuous Quality Improvement and Balanced Score Card approaches (Lifvergren, Chakhunsahvili, & Bergman) to Six Sigma, Lean and Lean Sigma (Inozu, Chauncey, Kamataris, & Mount, 2012). Unfortunately, with the possible exception of current efforts to implement Lean in many organizations, a number of these process improvements have achieved limited success and did not address key operational issues (Geboers, Grol, Van Den Bosch, Hoogen, Mokkink, Montfort, & Oltheten, 1999, Hoque, 2003, Schneiderman, 1999. Why is it that these approaches have not yielded the desired wide-spread impact on healthcare? ...
Many engineers are working to create process improvements in healthcare. Despite this focus, the current results have often disappointed. One reason may be that the sheer complexity of the healthcare system does not lend itself to the creation of transformational changes through the layering of multiple incremental improvements. If this is true, we must move beyond simply attempting to integrate engineering methods into healthcare and look to a more systems thinking approach. In order for a systems level approach to be successful, leadership at all levels of the organization must do more than believe in the value of the change. They must exhibit the behaviors necessary to drive successful change. This paper presents a meta-analysis of the literature as it relates to change management and leadership within healthcare. The impact leadership practices have on change efforts and other organizational outcomes are identified and avenues for future research are outlined.
... 16 Research on the effectiveness of local collaboratives has repeatedly shown positive results. 17 Another quality improvement strategy relies on peer visits to practices by trained providers, such as nurses and physicians. The providers offer training, feedback, materials, and other support to ensure that guidelines are implemented and care is improved. ...
The Dutch health care system's recent experiences with reform hold lessons for U.S. legislators and policymakers. In 2003, the Netherlands spent 9.8 percent of its gross domestic product on health care, below the spending levels in Germany, France, and Canada and more than one-third less than the United States. Even under the constraints of this budget, the Netherlands has implemented a number of health sector reforms that have led to important quality improvements. This report discusses several of these initiatives, including the central focus on primary care; reorganization of after-hours and emergency care; utilization of clinical guidelines, performance indicators, diagnostic treatment combinations; local collaboratives; and introduction of more stringent accreditation and evaluation procedures.
... Wie auch in den Spitälern sind die Praxen als organisatorische Einheiten gefordert, für sich ein Programm zur laufenden Qualitätsverbesserung zu implementieren [51]. ...
Ausländische Studien haben ergeben, dass Hunderte von Patientinnen und Patienten jährlich durch vermeidbare medizinische Fehler geschädigt oder gar getötet werden. Entsprechende Hochrechnungen für die Schweiz haben für grosses Echo in den Medien gesorgt. Bislang gibt es weder in der Schweiz noch in Europa eine umfassende Statistik über medizinische Behandlungsfehler. Studien aus den USA zeigen, dass jährlich etwa 120 000 Patienten an Behand- lungsfehlern sterben. Der ärztliche Kunstfehler wird als fünftwichtigste Todes- ursache in den Vereinigten Staaten angesehen (1). Fehlervorwürfe betreffen vor allem die operativen Disziplinen und hierbei im besonderen die Spitalärzte. Allerdings ist davon auszugehen, dass dies kein getreues Abbild der Realität ist, sondern eher ein Wahrnehmungseffekt. Denn sieht man von fachspezifischen Problemen ab, werden vorrangig folgende drei Gründe für die Entstehung von medizinischen Behandlungsfehlern deutlich: organisatorische Defizite mit Kommunikationsmängeln, Dokumentationsdefizite und die Behandlung von Patientinnen und Patienten in nicht optimal geeigneten Einrichtungen (2). Präventionsansätze beinhalten die Einführung von Qualitätssicherungs- und Managementinstrumenten in Krankenhäusern sowie ärztlichen Praxen. Dazu kommen themenbezogene Analysen zusammengefasster Fehlermeldun- gen sowie die Entwicklung von Leitlinien. Wünschenswert wäre ein nationa- les Projekt zur Analyse von ausreichend grossen Zahlen vermuteter Behand- lungsfehler mit Ableitung entsprechender Vermeidungsstrategien. Nur so kann aus dem ursprünglich geschützten Privatbereich einer Klinik eine Aufgabe von hohem gesamtgesellschaftlichem Interesse entstehen.
... Furthermore, several authors suggests that CQI programs that are introduced in a somewhat prescriptive, mechanis-tic fashion and without regard to the particularities of the organization in which they are applied, are more likely to encounter resistance, and ultimately fail to institutionalize (Blumenthal & Kilo, 1998;Cox, Wilcock, & Young, 1999). Geboers et al. (1999), for example, emphasize that in the case of smaller size practice settings, simultaneous implementation of an all encompassing CQI package may not be appropriate, and facilitation by experts from the outside may oftentimes be required. ...
Background:
Overseeing the quality of community-based, home-care services is a subject of concern in most jurisdictions confronted with population aging and the rise of chronic conditions. Although various quality management strategies have been used in different health care settings, continuous quality improvement (CQI) is still in the early stages of development among home-care service providers. What is more, some authors have raised questions as to whether CQI is suitable to the unique character of home-care and can be adequately applied to a diverse and varied range of agencies, each featuring a unique organizational culture, professional mix, and mode of operation.
Purposes:
The article reports on how differing organizational cultures--as found in a set of public and private home-care providers--appear to affect agency receptivity to CQI during program implementation.
Methodology/approach:
The research methodology is characterized by a qualitative, multiple case study approach. Data were gathered from a purposive sample of four home-care agencies in Quebec, Canada, belonging to the public, private for-profit, and not-for-profit sectors.
Findings and practice implications:
It is concluded that a core set of cultural attributes play a decisive role in determining agency receptivity to CQI, even when its effect is mediated by several contingent variables. Further, some of the levers and barriers to implementation identified in previous research seem less relevant to home-care agencies. A number of policy/management implications are discussed, which may enhance receptivity to CQI by home-care agencies and prevent implementation failure.
... These statements reflect the four culture types. Commitment to quality improvement is measured by an overall average score on quality improvement questions by the European foundation for quality management scale adapted for primary care [13, 20]. Response categories range from 1 (strongly disagree) to 5 (strongly agree). ...
The aim of this exploratory study was to investigate to what extent primary care professionals are able to change their systems for delivering care to chronic obstructive pulmonary disease (COPD) patients and what professional and organizational factors are associated with the degree of process implementation.
Quasi-experimental design with 1 year follow-up after intervention.
Three regional COPD management programmes in the Netherlands, in which general practices cooperated with regional hospitals.
All participating primary care professionals (n = 52).
COPD management programme.
Professional commitment, organizational context and degree of process implementation.
Professionals significantly changed their systems for delivering care to COPD patients, namely self-management support, decision support, delivery system design and clinical information systems. Associations were found between organizational factors, professional commitment and changes in processes of care. Group culture and professional commitment appeared to be, to a moderate degree, predictors of process implementation.
COPD management was effective; all processes improved significantly. Moreover, theoretically expected associations between organizational context and professional factors with the implementation of COPD management were indeed confirmed to some extent. Group culture and professional commitment are important facilitators.
... Geboers et al report in this issue of the journal a study that begins to address some of these questions and takes the issue of quality improvement for primary healthcare teams a step further. 9 10 They have developed a clearly defined model of continuous quality improvement suitable for the types of practices common in the Netherlands, including single handed practices. The core elements of their model are appropriate management of the team, factual data for guiding and monitoring quality improvement, a systematic approach for quality improvement methods, and collaboration among team members. ...
The integrated aviation training curriculum has been implemented to ensure high-quality aviation personnel training in Malaysia. However, the implementation process seemed to be at a slow pace which requires serious attention to strategic leadership and continuous quality improvement practices, especially in aviation training establishments. Therefore, this paper basically aims to discuss the level of strategic leadership and continuous quality improvement through the implementation of an integrated aviation training curriculum among local aviation academies. Additionally, the relationship between strategic leadership and continuous quality improvement practices will also be highlighted. The research utilized a quantitative approach with a survey design to address the research objectives. The respondents were 60 employees chosen from selected flying training academies using stratified random distribution. Descriptive data were collected through the adapted version of the “Strategic Leadership Questionnaires” and the “Continuous Quality Improvement Climate Survey”. Findings indicated that the levels of studied variables were high. Inferential statistics showed that there was a significant positive relationship between strategic leadership and continuous quality improvement practices. Based on the above findings, this paper provides important evidence for the aviation academy management board, national aviation authority, and the aviation community at large with regards to the primary role of strategic leadership and continuous quality improvement practices through the implementation of an integrated aviation training curriculum.
This chapter discusses how the generic implementation model can be used in practice, as suggested by experience and some research. To carry out the implementation activities effectively, a team is usually required to steer, coordinate, and communicate the activities, and, where necessary, provide support. The composition of such a team for improvement, innovation, or change depends largely on the scale of the implementation project, the type of innovation, and the budgetary possibilities. It is generally preferable to include different kinds of expertise and backgrounds in such a group: leadership; coordination expertise; technical expertise and administrative expertise. The chapter describes a study of organizational culture in healthcare organizations. It discusses the involvement of certain representatives or key individuals from the target group. Involvement of directors and key figures in institutions and professional groups in the implementation of improvements is seen as critical when introducing changes in care, stressing the importance of having the "board on board."
Samenvatting
Een goede planning van de implementatieactiviteiten (wanneer, waar en hoe gebeurt wat door wie?) is van groot belang voor een succesvolle en solide introductie van nieuwe werkwijzen in de praktijk.
Daarin zijn in elk geval nodig:
- een gemotiveerd team met daarin alle relevante expertise;
- creëren van een context die gunstig is voor verandering;
- betrekken van de doelgroep in het plan;
- zorg dragen voor betrokkenheid van leiders en sleutelfiguren;
- goede planning in de tijd;
- voldoende middelen en ondersteuning;
Adequate planning and preparation of implementation activities are often preconditions for successful introduction of new procedures and changes in the practice of healthcare. This chapter discusses a smaller, discrete number of aspects of organizational culture that could be connected with an effective implementation of new procedures. While some individuals consider culture as a characteristic of organizations, others consider it as the essential nature of an organization. In the latter sense, culture not only concerns observable characteristics but also the implicit knowledge and attitudes of the healthcare professionals. At the very least, the last characteristic makes it difficult to quantify and measure ?culture?. The chapter outlines key competencies in the area of medical leadership, emphasizing its influence on improvement processes.
Tables summarising the characteristics of instruments included for review of measurement properties (Tables S7-S9).
Background. The aim of the study was to explore the impact of feedback to general practitioners regarding patient evaluation of the quality of services rendered. Material and methods. 1,614 patients in 41 general practices assessed the quality of care they had received during the last 12 months. The results for each practice were compared to the mean quality level of all the practices, and returned to the practice. This report was followed by a questionnaire to the OPs asking for their opinion of such feedback. Six of the GPs were also interviewed by telephone. Results. The GPs welcomed patient quality evaluations and comparisons. However, they doubted that the feedback would lead to any action taken, as they had neither the time nor the energy to make changes in clinical performance or organisational structure. They questioned quality assessment by patients being an objective measure of quality. The GPs were willing to discuss the results in peer groups, but were reluctant to share the information with staff or patients. Interpretation. The present study does not indicate that feedback given in the form of reports; at practice level regarding patient assessed quality is an effective method for quality improvement.
These are standards of professional practice and not standards prepared or endorsed by Standards Australia. These are not legally binding.
Background: The analysis of the papers on the primary care quality assessment in Korea was performed to summarize existing papers, estimate the level of primary care quality, and suggest the directions and areas of the future research. Methods: Primary care quality-related papers were selected via internet web search engines which were Korean Journal of Family Medicine homepage, KMbase, and KoreaMed. Further papers were added after consultation to primary care quality assessment specialists in Korea. Results: The number of related papers was 29. Data collection was done mostly via mail or telephone questionnaire to suppliers, primary care physicians. Papers on resource capacity area were 11, on services delivery 4, on outcome by service 2, and on clinical performance 12. The total primary care score was low. The themes of clinical performance studies were common diseases in Korea. Conclusion: Research volume on primary care quality assessment was poor, especially on outcome area. Data collection methods and quality indicators are needed to diverse. Future researches using OECD health care quality indicators are needed to make international comparison possible, which finally contributes to primary care quality improvement in Korea.
To evaluate the feasibility of a model for continuous quality improvement in small scale general practice and the improvement projects that practices ran after the introduction of continuous quality improvement.
A descriptive study.
Twenty general practices in the Netherlands tested the model in an intervention period of 18 months.
A model for continuous quality improvement adapted for general practice was introduced into the practices using a structured strategy. Practices were supported by trained facilitators.
Acceptance at introduction and continued application of the model; the topics of improvement projects that were set up in the practices; whether the improvement projects had been completed; whether they had met the criteria (the use of the "quality cycle" and the Oxford audit score); and whether the self set objectives had been met.
The model was introduced and accepted in all participating practices. Practices started 51 improvement projects. At the end of the study period 33 improvement projects had been completed. Practices chose a wide variety of objectives for these projects; most of them concerned medical or organisational topics. Practices started projects mainly because the topic was felt to be a problem or was causing a bottleneck in the organisation. The quality cycle was used in all projects, but practices did not always collect data and evaluate the outcomes. Fourteen projects could be discerned as "full audit". No differences existed in the quality of improvement projects among the various types of practice or between the topics addressed. At the end of the study period half of the practices continued applying the model.
This study showed that the model was feasible for small scale general practice. However, application of the model tended to disintegrate after the facilitator had left the practice. Practices succeeded reasonably well in running improvement projects. Introduction of continuous quality improvement should particularly focus on this. It is suggested that intensive support is necessary to implement and maintain continuous quality improvement in small scale practices.
Physicians today are confronted with increasing demand to ensure and improve care of their patients. A variety of approaches claim to provide solutions to the problems of health care delivery. These approaches represent different perspectives on optimal care and the best method for improving care. By summarizing recent reviews and debates in this field, this article critically reflects on the value of some of the approaches that have gained popularity during the last decades: evidence-based medicine and clinical practice guidelines, professional development, assessment and accountability, patient empowerment, and total quality management. Evidence regarding the impact and feasibility of the various approaches is mixed or simply lacking. In particular, the health care community lacks an understanding of which approaches are most appropriate for what types of improvement in what settings and of the determinants of successful performance change. Given the complexity of improvement and change in patient care, it is not realistic to expect that one approach can solve all the problems in health care delivery. None of the popular models for improving clinical performance appear to be superior. Therefore, bridges must be built and models must be integrated to be truly effective.
To provide (1) an overview of the purpose of practice improvement methods and a conceptual base for the relationship between the various practice improvement methods; (2) an evidence-based review of the range of practice improvement methods; and (3) practice-based recommendations.
Secondary research design using electronic literature search of PsycINFO database was carried out on eight practice improvement methods (PIMs) and the evidence for effectiveness presented.
There is evidence of effectiveness in changing practice for each of the PIMs reviewed, and for some, there is also evidence of effects on patient outcomes. Each has strengths and weaknesses. However, the stronger conclusion from reviews is that use of multiple PIMs is more likely to impact clinical practice and patient outcomes than use of a single PIM.
The development of PIMs should concentrate on combination and integration between methods to maximize their effectiveness.
Implementing systems for measuring and improving quality is seen as one of the most important challenges in general practice/family medicine (GP/FM) today. This includes activities such as setting and implementing guidelines and criteria, collecting and assessing data on the quality of care, improving and changing practice when needed, developing laws and policies for quality improvement, and providing training for care providers on quality improvement concepts and methods. These activities should be well planned and organised and the structures and conditions should be available to support the implementation of quality improvement.
We seem to lack a well-defined, comprehensive, and shared understanding of what is required for the continual improvement of health care--at the organizational and the industry levels. This article presents a framework that defines the new body of knowledge which, when joined with the professional knowledge of health care workers, can make continual improvement possible; and gives requirements for building and applying this knowledge to bring about improvement in health care organizations.
Studies of total quality management as a means of improving health care quality to date have relied on case studies of individual teams or hospitals. The Total Quality Improvement Registry Project surveyed quality coordinators (n = 36) and quality improvement team leaders (n = 228) to collect both site-level and team-level data on quality improvement in Veterans Health Administration hospitals. Usable responses were received from 100% of quality coordinators and 73.7% (168) of team leaders. Site-level data include hospital structural characteristics and measures of training and commitment, as well as features and activities of the hospital quality councils. Team-level data include size, membership, task, age, activities, and a proxy measure of quality improvement. The authors report on the relations between levels of commitment to total quality management principles, training levels, activities of quality councils, and team formation and success. These data provide support for a model of commitment to quality improvement that involves four realms of influence within the medical centers: (1) management, (2) physician leadership, (3) physician staff and middle management, and (4) nurses and employees. The authors also report on the activities of quality councils and the relation of their activities to commitment and perceived improvement. Using bivariate correlation and multiple regression, the authors found that the age of the quality council, overall facility commitment to total quality management philosophy, and physician commitment are the most critical variables in explaining numbers of teams, training intensity, and total perceived improvement at this sample of medical centers. Specifically, we find that commitment to total quality management philosophy and the number of active teams explains 41% of the observed variation in quality improvement. In future articles, the authors will report details of team activities and the development of teams over time.
There is now a wide variety of methods available to general practitioners who want to engage in quality assessment, quality assurance, or quality improvement activities in their practices. These methods require some kind of performance review, or at least the collection of some performance-related data. As in traditional research, the choice of methods depends on what research questions one wants to address. This paper elaborates on some key concepts related to the choice of methods, making a distinction between whether any method actually covers performance (what a doctor does in daily practice) or competence (what a doctor is capable of doing) as well as a distinction between whether a method is direct (patient-doctor contact is observable) or is indirect.
An overview frame will be presented of the methods most commonly used for data collection within quality assessment. These methods are discussed on their validity, reliability, feasibility and acceptability. Direct methods aimed at recording performance are assumed to hold the highest validity, but practical, economic and logistic factors may favour less ambitious methods for audit or quality improvement activities.
One crucial element in all methods is creating a set of empirical data, as a basis for comparisons, reflection, dialogue and discussions among colleagues.
The demand for quality control of medical care has increased dramatically in recent years. In response to higher public awareness and political trends, the implementation of audit has swept through general practice in the UK, fuelled by the appearance of improved data collection systems and the greater sophistication of primary care teamwork. This concise yet comprehensive guide to the theory and practice of medical audit in the primary health care setting is edited by two university lecturers who are also practising GP's. It includes contributions from a range of practitioners who have experience of audit in action, and an appreciation of the potential pitfalls involved. This theoretical and practical guide to the challenge of medical audit has proved to be and will continue to be of value to general practitioners, trainees, and all members of the primary health care team.
Studies of total quality management as a means of improving health care quality to date have relied on case studies of individual teams or hospitals. The Total Quality Improvement Registry Project surveyed quality coordinators (n = 36) and quality improvement team leaders (n = 228) to collect both site-level and team-level data on quality improvement in Veterans Health Administration hospitals. Usable responses were received from 100% of quality coordinators and 73.7% (168) of team leaders. Site-level data include hospital structural characteristics and measures of training and commitment, as well as features and activities of the hospital quality councils. Team-level data include size, membership, task, age, activities, and a proxy measure of quality improvement. The authors report on the relations between levels of commitment to total quality management principles, training levels, activities of quality councils, and team formation and success. These data provide support for a model of commitment to quality improvement that involves four realms of influence within the medical centers: (1) management, (2) physician leadership, (3) physician staff and middle management, and (4) nurses and employees. The authors also report on the activities of quality councils and the relation of their activities to commitment and perceived improvement. Using bivariate correlation and multiple regression, the authors found that the age of the quality council, overall facility commitment to total quality management philosophy, and physician commitment are the most critical variables in explaining numbers of teams, training intensity, and total perceived improvement at this sample of medical centers. Specifically, we find that commitment to total quality management philosophy and the number of active teams explains 41% of the observed variation in quality improvement. In future articles, the authors will report details of team activities and the development of teams over time.
This article describes how the H. Claude Hudson Comprehensive Health Center (Los Angeles) implemented a continuous quality improvement program to reduce the unacceptably high rate of nonrepresentative Papanicolaou (Pap) smears (those lacking endocervical component). A review of the literature and telephone surveys indicated that the optimal Pap smear technique includes the use of a cervical cytobrush. Several cytobrushes were evaluated and one was chosen to be used facilitywide. Clinicians were given in-services on the proper cervical sampling techniques using the cytobrush. The rate of nonrepresentative Pap smears decreased approximately 12% during a five-month period; this has been attributed to uniform implementation of the cytobrush technique in nonpregnant patients, in-service education, and cooperative teamwork.
The transportation of inpatients within the hospital is a critical component of the patient care process. A quality improvement (QI) team at Massachusetts General Hospital (Boston) convened to improve this process and to pilot the QI approach there. Pilot QI projects have the burden of intense scrutiny by senior management at a point when the fundamentals needed for a successful QI project are scarce or not yet available. The authors, who were participants in this project, describe the methodology and outcomes of this pilot QI process as well as the lessons learned. The results confirm that, although difficult, it is possible to succeed in pilot projects and gain the support needed to move on to the next step in the QI journey.
Assuring the full adoption and impact of total quality management (TQM) requires the understanding that TQM involves transitional challenges to managers, individuals, work groups, and the organization as a whole. This article presents some of these challenges and describes how they might be met over time to determine the ultimate success of TQM adoption in an organization.
Hospitals and other health care institutions have been slow to adopt some of the quality innovations developed in manufacturing. The growing literature on these methods includes few specifics on how to implement the process in health care institutions. This article describes a single community hospital's implementation of the Hospital Corporation of America's Hospitalwide Quality Improvement Process, a model developed from the Deming method of statistics-based continuous quality improvement. The article addresses common questions about implementation, citing both examples of success and areas of difficulty.
Until recently, health professionals lacked incentives to integrate internal management processes, depending instead on external quality assurance and regulatory standards. Competitive markets and increased regulatory pressures now encourage managers to reorient systems from a cost-driven reimbursement approach to the implementation of Total Quality Care as a management strategy.
Imagine two assembly lines, monitored by two foremen. Foreman 1 walks the line, watching carefully. "I can see you all," he warns. "I have the means to measure your work, and I will do so. I will find those among you who are unprepared or unwilling to do your jobs, and when I do there will be consequences. There are many workers available for these jobs, and you can be replaced." Foreman 2 walks a different line, and he too watches. "I am here to help you if I can," he says. "We are in this together for the long . . .
We asked health care professionals to identify and prioritize barriers to implementing TQM in their organizations. Lack of evidence of TQM success was a commonly listed barrier. In response, we drew from research in the innovation literature that identifies factors that distinguish successful from failed efforts to innovate and improve. Applied to TQM principles, innovation findings overwhelmingly support customer and quality mindedness. To a lesser degree other principles are upheld, suggesting future research in the area.
This study examines the relationships among organizational culture, quality improvement processes and selected outcomes for a sample of up to 61 U. S. hospitals.
Primary data were collected from 61 U. S. hospitals (located primarily in the midwest and the west) on measures related to continuous quality improvement/total quality management (CQI/TQM), organizational culture, implementation approaches, and degree of quality improvement implementation based on the Baldrige Award criteria. These data were combined with independently collected data on perceived impact and objective measures of clinical efficiency (i.e., charges and length of stay) for six clinical conditions.
The study involved cross-sectional examination of the named relationships.
Reliable and valid scales for the organizational culture and quality improvement implementation measures were developed based on responses from over 7,000 individuals across the 61 hospitals with an overall completion rate of 72 percent. Independent data on perceived impact were collected from a national survey and independent data on clinical efficiency from a companion study of managed care.
A participative, flexible, risk-taking organizational culture was significantly related to quality improvement implementation. Quality improvement implementation, in turn, was positively associated with greater perceived patient outcomes and human resource development. Larger-size hospitals experienced lower clinical efficiency with regard to higher charges and higher length of stay, due in part to having more bureaucratic and hierarchical cultures that serve as a barrier to quality improvement implementation.
What really matters is whether or not a hospital has a culture that supports quality improvement work and an approach that encourages flexible implementation. Larger-size hospitals face more difficult challenges in this regard.
Increasing numbers of health care organizations are adopting Continuous Quality Improvement (CQI) principles. This study's objective was to evaluate the attitudes toward and acceptance of CQI by a family practice residency program's providers and staff after 3 years' experience with the process.
Our CQI project groups examine selected problems and develop system-based solutions. We surveyed staff, residents, and faculty to determine their awareness of the CQI projects, the perceived usefulness of the projects and results, how well they were informed of the results, and whether they believe CQI is a useful tool in our clinic.
Of 19 clinical and/or administrative projects we implemented, 75% of the faculty, 55% of the residents, and 71% of the staff perceived the projects to be useful. Eighty-eight percent of the faculty, 64% of the residents, and 82% of the staff believe CQI to be useful tool in our clinic. However, only 50% of faculty, 36% of residents, and 24% of staff felt they were well informed of the project results. The time involved in CQI and the need to improve communication among personnel on CQI processes were identified as important concerns about CQI.
Faculty, resident, and staff members accept the CQI process and perceive it to be a useful tool in clinical practice. CQI requires attention to the time involved and communication about CQI projects and results.
Implementing patient-centered care (PCC) requires a fundamental shift in thinking-from how to best provide a wide variety of independent services to how to effectively combine individual service components into an integrated health care experience that meets patient needs and preferences.
PCC attempts to improve patient care by organizationally and physically moving selected service functions such as basic laboratory, pharmacy, admitting/discharge, medical records, housekeeping, and material support services to patient care areas, thus effecting an organizational restructuring. PCC creates teams composed of multiskilled or cross-trained individuals capable of providing more of the services directly on the patient care unit. Extensive redesign of the basic work processes as proposed by PCC advocates may result in significant changes in employee job scope, task responsibilities, professional autonomy, and reporting relationships. From the employee's perspective such changes may be neither warranted nor welcomed. Therefore, critical PCC implementation issues include obtaining employee buy-in and establishing appropriate incentive structures to facilitate the desired changes. How does PCC fit in with the popular improvement philosophies of total quality management (TQM) and continuous quality improvement (CQI)? Inherent within TQM and CQI is the belief that it is wiser to maximize efforts to design a product or process to be right the first time and to minimize resources devoted to inspection and repair caused by poor processes. PCC builds upon previous TQM/CQI health care efforts by focusing on ways to reduce the white space handoff problem by examining what, if any, changes in underlying structures and processes may be required. In the PCC hospital, TQM/CQI can function as intended, as a methodology for examining and improving the process of care and patient-care outcomes, regardless of internal departmental or profession-based organizational boundaries.
For hospitals to remain competitive in today's rapidly changing environment, it is becoming necessary to reevaluate both how they are organized and how their work processes have been designed and controlled. The groundwork already laid by TQM/CQI initiatives will facilitate the more fundamental and long-lasting improvements derived from the redesign of the patient-care unit as prescribed by the goals of PCC.
This article describes efforts to understand and improve the daily work processes of primary care within the Henry Ford Health System, where continuous quality improvement (CQI) has been a key business strategy since 1988. We began a pilot project in 1990 that attempted to accelerate the implementation of continuous improvement in primary care. The clinical site was the general internal medicine (GIM) ambulatory clinic, which has 50,000 patient visits annually.
For four key elements--physicians as leaders, prevention and primary care, patient access, and innovation and team work--we planned and implemented continuous improvement based on three questions: What were we trying to accomplish? What can we change that would lead to an improvement? How would we know a change is an improvement? EXAMPLE: Prevention and Primary Care. In our primary care setting, an appropriate clinical process to improve would include preventive medicine, specifically Pap-smear performance. In our partnership with the department of obstetrics/gynecology, GIM physicians wanted to improve the rate of adequate Pap smears. To reduce variation in the rates with which physicians collected specimens that were adequate for cytologic examination, the team recommended use of a specific tool, a cervi-brush, which should be more effective in producing adequate specimens. As cervi-brush use increased, rates of inadequate Pap smears dropped from 20%-25% in 1989 to less than 10% for the first six months of 1991.
By focusing attention and resources on a limited number of improvement teams, our initial success built enthusiasm and commitment within GIM and accelerated changes that were incorporated into strategic planning for the Henry Ford Health System as a whole.
Background:
In the mid-1980s Beth Israel Hospital Boston began a participatory management approach that encourages all members of the organization to improve productivity, efficiency, and quality through interdepartmental and intradepartmental project teams. The CT [computerized tomography]-Nursing-Transport Team, the hospital's first quality improvement project Team, grew out of an organizational challenge to solve an interdepartmental problem. The goal of the project was to have inpatients arrive on time for their scheduled CT-Scan appointment. Prior to the project's inception, over 50% of all inpatients scheduled for CT-Scans arrived more than 20 minutes late.
Methods:
The team learned the Juran quality improvement methodology, using just-in-time training. The methodology consists of four major steps: problem definition and organization, the diagnostic journey, the remedial journey, and holding the gains. The team used many quality improvement tools including flow-charting, checksheets, histograms, Pareto charts, run charts, and brainstorming to find the root causes of the problem and achieve results.
Results:
The team members collected data and flowcharted the complexity of the CT appointment and patient pick-up process to pinpoint the root causes of delays. They found that three floors accounted for a majority of the delays and that four reasons for delays explained two-thirds of the problem. Additionally, as nurses and CT technologists flowcharted the process, they found that they used a different definition of "on-call" and that misconceptions existed about the scan and the preparation for it. When transporters were included on the team, the team discovered that delays occurred in a pattern and that communication with central transport was poor and inconsistent. After the team made changes in break times, equipment, communication, planning, and timing, the late patient arrivals dropped dramatically--more than 80% of patients arrived within five minutes of a scheduled appointment. One year after the project team stopped meeting, close to 70% of patients continue to arrive within five minutes of their scheduled appointment time, despite increased volume and no additional scanners.
Conclusion:
The success of the project reinforced many well-known quality improvement conditions for success. These include (1) choosing a project that is "high pain, high drain," (2) having a committed project leader who can keep the team effort going, (3) using data to lead the team to the root cause of a problem by pointing out where, when, and why the problems occur, (4) utilizing flow-charting and shadowing to understand the process from a fresh perspective, and (5) holding well-facilitated meetings with a defined purpose, ground rules, and meaningful agenda.
Effective questions stimulate, guide, and empower employees to think critically about the improvement processes that they are involved in as team leaders or team members in their daily activities. Learn how questions must be carefully phrased in order to provide guidance and maintain the integrity of the team's ability to choose options and implement change.
The nurse called me urgently into the room. The child, she said, was in acute respiratory distress.
I had never met either Jimmy (the 6 year old boy) or his mother (an inner city single teenage parent) before. His asthma attack was severe, his peak expiratory flow rate only 35% of normal. Twenty years ago my next steps would have been to begin bronchodilator treatment, call an ambulance, and send the boy to hospital. That also would have been the story 10 years ago, or five, or two.
But today, when I entered the room, the mother handed me her up to date list of treatments, including nebuliser treatment with β2 agonists, that she had administered with equipment that had been installed in her home. It continued with her graph of Jimmy's slowly improving peak flow levels, which she had measured and charted at home, having been trained by the asthma outreach nurse. She then gave me the nurse's cellular telephone number, along with a specific recommendation on the next medication to try for her son, one that had worked in the past but was not yet available for her to use at home.
My reply was interrupted by a knock on my door. It was the chief of the allergy department in my health maintenance organisation. He worked one floor above me in the health centre and, having been phoned by the outreach nurse, had decided to “pop down” to see if he could help. He also handed me a phial of the same new medication that the mother had just mentioned, suggesting that we try it.
Two hours later Jimmy was not in a hospital bed; he was at home breathing comfortably. Just to be safe the allergy nurse would be paying him a visit later that afternoon. …
Assessment of the benefits and limitations of a quality improvement programme based on total quality management principles in general practice over a period of one year (October 1993-4).
Questionnaires to practice team members before any intervention and after one year. Three progress reports completed by facilitators at four month intervals. Semistructured interviews with a sample of staff from each practice towards the end of the year.
18 self selected practices from across the former Oxford Region. Three members of each practice received an initial residential course and three one day seminars during the year. Each practice was supported by a facilitator from their Medical Audit Advisory Group.
Extent of understanding and implementation of quality improvement methodology. Number, completeness, and evaluation of quality improvement projects. Practice team members' attitudes to and involvement in team working and quality improvement.
16 of the 18 practices succeeded in implementing the quality improvement methods. 48 initiatives were considered and staff involvement was broad. Practice members showed increased involvement in, and appreciation of, strategic planning and team working, and satisfaction from improved patients services. 11 of the practices intend to continue with the methodology. The commonest barrier expressed was time.
Quality improvement programmes based on total quality management principles produce beneficial changes in service delivery and team working in most general practices. It is incompatible with traditional doctor centred practice. The methodology needs to be adapted for primary care to avoid quality improvement being seen as separate from routine activity, and to save time.
To evaluate the feasibility of a model for continuous quality improvement in small scale general practice and the improvement projects that practices ran after the introduction of continuous quality improvement.
A descriptive study.
Twenty general practices in the Netherlands tested the model in an intervention period of 18 months.
A model for continuous quality improvement adapted for general practice was introduced into the practices using a structured strategy. Practices were supported by trained facilitators.
Acceptance at introduction and continued application of the model; the topics of improvement projects that were set up in the practices; whether the improvement projects had been completed; whether they had met the criteria (the use of the "quality cycle" and the Oxford audit score); and whether the self set objectives had been met.
The model was introduced and accepted in all participating practices. Practices started 51 improvement projects. At the end of the study period 33 improvement projects had been completed. Practices chose a wide variety of objectives for these projects; most of them concerned medical or organisational topics. Practices started projects mainly because the topic was felt to be a problem or was causing a bottleneck in the organisation. The quality cycle was used in all projects, but practices did not always collect data and evaluate the outcomes. Fourteen projects could be discerned as "full audit". No differences existed in the quality of improvement projects among the various types of practice or between the topics addressed. At the end of the study period half of the practices continued applying the model.
This study showed that the model was feasible for small scale general practice. However, application of the model tended to disintegrate after the facilitator had left the practice. Practices succeeded reasonably well in running improvement projects. Introduction of continuous quality improvement should particularly focus on this. It is suggested that intensive support is necessary to implement and maintain continuous quality improvement in small scale practices.
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