Quality improvement

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Quality improvement is "the attainment or process of attaining a new level of performance or quality."[1].

Wennberg's classification framework can categorize causes of unwarranted variation[2].


Lean Sigma

Lean sigma combines approaches[3].

Positive deviance

A positive deviance approach has been recommended to identify and disseminate best organizational practices[4][5] [6]Early description of this method was[4]:

  • "Develop case definitions"
  • "Identify four to six people who have achieved an unexpected good outcome despite high risk"
  • "Interview and observe these people to discover uncommon behaviours or enabling factors that could explain the good outcome"
  • "Analyse the findings to confirm that the behaviours are uncommon and accessible to those who need to adopt them"
  • "Design behaviour change activities to encourage community adoption of the new behaviours"
  • "Monitor implementation and evaluate the results"

Positive deviance is consistent with complexity leadership[7][8][9].

Appreciative inquiry

Appreciative inquiry (AI) was developed in 1987 by Cooperrider and Srivastva[10] Appreciative inquiry is consistent with complexity science[11].

AI may encourage receptivity to improvement, but without actual improvement[12].

Measuring quality

Quality measures and their benchmarks are available from several organizations including:

  • CQI Resource Center (coordinated by the Centers for Medicare & Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC); U.S. Department of Health and Human Services)

For reporting of quality measures:

  • eCQMs may be better than claims-based reporting[13] of quality. eCQMs could also be used for billing[14].

Goodhart's law is when measures become organizational goals, problems may ensue.

Tactics for improvement

A conceptual model has been developed[15] and recommended by the AHRQ[16].

Practice facilitation

Practice facilitation may help based on the experience of the American Academy of Family Physicians' (AAFP) National Demonstration Project (NDP)[17][18].

The Heart Health NOW Study found uncertain evidence from organizational leadership and Adaptive Reserve[19].

The VA's PACT used in-person[20] and online[21] collaborative methods.

The NHS...

Workforce redesign

Workforce redesign may help[22].


Per-for-performance may not work optimally.[23]

Why quality improvement efforts succeed and fail

Various organizational characteristics, some based on complexity science[24][25][26], may predict why quality improvement projects succeed[27][28][29] and fail[12][30][31]. Causes include:

“when I see workers measuring themselves, I see quality.” Attributed to W. Edwards Deming[35]

  • Large numbers of healthcare providers and patients to coordinate at a clinic.[36]
  • "practices' ability to respond to change and to adapt team roles in workflow, influenced by both local leadership and stable staffing"[37]

Studies using appreciative inquiry have been done.[12][38]

Different approaches may be needed depending on the level of certainty in the clinical science behind a quality improvement project.[39]

Recommendations for QI projects to implement guidelines may not include tactics to foster a positive workplace culture[40][40].

Work culture and quality improvement

A systematic review found an association with workplace culture and clinical outcomes[41]. However, this review did not provide details of attributes of positive culture. This review did not find any randomized trials.

A cross-sectional study of 537 American hospitals found that clinical improvement was associated with the following, ranked in descending order of impact[42]:

  • 'having physician and nurse champions rather than nurse champions alone'
  • 'fostering an organizational environment in which clinicians are encouraged to solve problems creatively'
  • 'holding monthly meetings to review AMI cases between hospital clinicians and staff who transported patients to the hospital'

A cohort of 10 American hospitals found[43]:

  • 'effective inclusion of staff from different disciplines and levels in the organisational hierarchy in the team guiding improvement efforts (referred to as the ‘guiding coalition’ in each hospital)'
  • 'authentic participation in the work of the guiding coalition'
  • 'distinct patterns of managing conflict'

The Malcolm Baldrige Health Care version of the Criteria for Performance Excellence (HCPE) award has been created to foster a culture of quality improvement across an organization. Two studies of the impact of the award have found:

  • "No significant difference in process of care results or outcomes between Baldrige recipients and their competitors, there was a significant difference in patient experience results" [44].
  • "Slight enhancements in clinical outcomes, while hospital financial and efficiency measures all showed overwhelmingly positive operating results"[45]


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