Quality improvement

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 combines approaches^[3].

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 (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].

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.

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

Simple audient and feedback with peer comparison may be toxic by creating zero-sum, competitive mindsets^[17][18] andt may dcrease physician well-being^[19].

Audit and feedback may be more effective if "providing specific suggestions for improvement, written, and more frequent feedback strengthened this effect," according to a meta-analysis^[20]. A more recent meta-analysis concluded that audit and feedback is more successful when^[21]:

• "delivered by a supervisor or respected colleague
• "presented frequently"
• "featuring both specific goals and action-plans"
• "aiming to decrease the targeted behavior
• "baseline performance is lower"
• "recipients are non-physicians"

Physicians may be less receptive to audit and feedback^[21]. This may be in part due to a perception by physicians that metrics do not fully descibe the value of the physician.

Practice facilitation may help based on the experience of the American Academy of Family Physicians' (AAFP) National Demonstration Project (NDP)^[22][23].

The Heart Health NOW Study found uncertain evidence from organizational leadership and Adaptive Reserve^[24].

The VA's PACT used in-person^[25] and online^[26] collaborative methods.

The NHS...

Workforce redesign may help^[27].

Per-for-performance may not work optimally.^[28]

In carefully selected settings, prior authorization may be helpful for controlling unessessary costs.^[29][30]

Suggestions have been made to reform the prior authorization process^[31].

Various organizational characteristics, some based on complexity science^[32][33][34], may predict why quality improvement projects succeed^[35][36][37] and fail^[12][38][39]. Causes include:

• Lack of clinical champion^{[12][40][41][42]}, especially a physician^[41][42]
• No internal efforts for self-measurement^[40][43]

“when I see workers measuring themselves, I see quality.” Attributed to W. Edwards Deming^[43]

• Large numbers of healthcare providers and patients to coordinate at a clinic.^[44]
• "practices' ability to respond to change and to adapt team roles in workflow, influenced by both local leadership and stable staffing"^[45]

Studies using appreciative inquiry have been done.^[12][46]

Different approaches may be needed depending on the level of certainty in the clinical science behind a quality improvement project.^[47]

Recommendations for QI projects to implement guidelines may not include tactics to foster a positive workplace culture^[48][48].

A systematic review found an association with workplace culture and clinical outcomes^[49]. 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^[50]:

• '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^[51]:

• '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" ^[52].
• "Slight enhancements in clinical outcomes, while hospital financial and efficiency measures all showed overwhelmingly positive operating results"^[53]

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