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Quality improvement

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For other uses, see QI (disambiguation).

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].

Methods[edit | edit source]

Lean Sigma[edit | edit source]

Lean sigma combines approaches[3].

Positive deviance[edit | edit source]

Main article: 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[edit | edit source]

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[edit | edit source]

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[edit | edit source]

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

Audit and feedback[edit | edit source]

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[edit | edit source]

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[edit | edit source]

Workforce redesign may help[27].

Financial pressure[edit | edit source]

Per-for-performance[edit | edit source]

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

Prior authorization[edit | edit source]

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].

Why quality improvement efforts succeed and fail[edit | edit source]

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:

“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].

Work culture and quality improvement[edit | edit source]

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]

References[edit | edit source]

  1. ↑ Anonymous (2025), Quality improvement (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ Harrison R, Manias E, Mears S, Heslop D, Hinchcliff R, Hay L (2018). "Addressing unwarranted clinical variation: A rapid review of current evidence". J Eval Clin Pract. doi:10.1111/jep.12930. PMID 29766616.
  3. ↑ Danese, P., Manfè, V. and Romano, P. (2017), A Systematic Literature Review on Recent Lean Research: State-of-the-art and Future Directions. International Journal of Management Reviews. doi:10.1111/ijmr.12156
  4. ↑ 4.0 4.1 Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M (2004). "The power of positive deviance". BMJ. 329 (7475): 1177–9. doi:10.1136/bmj.329.7475.1177. PMC 527707. PMID 15539680.
  5. ↑ Bock, L. (2015). The Two Tails. In: Work rules!: Insights from inside Google that will transform how you live and lead. Twelve. ISBN 1455554790
  6. ↑ Baxter R, Taylor N, Kellar I, Lawton R (2016). "What methods are used to apply positive deviance within healthcare organisations? A systematic review". BMJ Qual Saf. 25 (3): 190–201. doi:10.1136/bmjqs-2015-004386. PMC 4789698. PMID 26590198.
  7. ↑ Belrhiti Z, Nebot Giralt A, Marchal B (2018). "Complex Leadership in Healthcare: A Scoping Review". Int J Health Policy Manag. 7 (12): 1073–1084. doi:10.15171/ijhpm.2018.75. PMC 6358662. PMID 30709082.
  8. ↑ Lindberg, Curt; Clancy, Thomas R. (2010). "Positive Deviance". JONA: The Journal of Nursing Administration. 40 (4): 150–153. doi:10.1097/NNA.0b013e3181d40e39. ISSN 0002-0443.
  9. ↑ Lindberg, Curt; Schneider, Marguerite (2013). "Combating infections at Maine Medical Center: Insights into complexity-informed leadership from positive deviance". Leadership. 9 (2): 229–253. doi:10.1177/1742715012468784. ISSN 1742-7150.
  10. ↑ Cooperrider, David L., and Suresh Srivastva. "APPRECIATIVE INQUIRY IN ORGANIZATIONAL LIFE." (1987).
  11. ↑ Stroebel CK, McDaniel RR, Crabtree BF, Miller WL, Nutting PA, Stange KC (2005). "How complexity science can inform a reflective process for improvement in primary care practices". Jt Comm J Qual Patient Saf. 31 (8): 438–46. doi:10.1016/s1553-7250(05)31057-9. PMID 16156191.
  12. ↑ 12.0 12.1 12.2 12.3 Ruhe MC, Bobiak SN, Litaker D, Carter CA, Wu L, Schroeder C; et al. (2011). "Appreciative Inquiry for quality improvement in primary care practices". Qual Manag Health Care. 20 (1): 37–48. doi:10.1097/QMH.0b013e31820311be. PMC 4222905. PMID 21192206.
  13. ↑ Laws MB, Michaud J, Shield R, McQuade W, Wilson IB (2018). "Comparison of Electronic Health Record-Based and Claims-Based Diabetes Care Quality Measures: Causes of Discrepancies". Health Serv Res. 53 Suppl 1: 2988–3006. doi:10.1111/1475-6773.12819. PMC 6056571. PMID 29282723.
  14. ↑ LaBonte CT, Payne P, Rollow W, Smith MW, Nissar A, Holtz P; et al. (2019). "Performance on Electronic Clinical Quality Measures in the Comprehensive Primary Care Initiative". Am J Med Qual. 34 (2): 119–126. doi:10.1177/1062860618794868. PMID 30132334.
  15. ↑ Garman AN, McAlearney AS, Harrison MI, Song PH, McHugh M (2011). "High-performance work systems in health care management, part 1: development of an evidence-informed model". Health Care Manage Rev. 36 (3): 201–13. doi:10.1097/HMR.0b013e318201d1bf. PMID 21646880.
  16. ↑ Appendix 1. Definitions of High-Performance Work Practices. Content last reviewed August 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/cusp/clabsi-hpwpreport/clabsi-hpwpap.html
  17. ↑ Chun, Jinseok S.; Sherf, Elad N.; Slepian, Michael L. (2023). "In it to win it? Comparative evaluation increases zero-sum beliefs". Motivation Science. American Psychological Association (APA). 9 (1): 31–41. doi:10.1037/mot0000287. ISSN 2333-8121.
  18. ↑ Kakkar, Hemant; Sivanathan, Niro (2022). "The impact of leader dominance on employees' zero-sum mindset and helping behavior". Journal of Applied Psychology. American Psychological Association (APA). 107 (10): 1706–1724. doi:10.1037/apl0000980. ISSN 1939-1854.
  19. ↑ Reiff JS, Zhang JC, Gallus J, Dai H, Pedley NM, Vangala S; et al. (2022). "When peer comparison information harms physician well-being". Proc Natl Acad Sci U S A. 119 (29): e2121730119. doi:10.1073/pnas.2121730119. PMC 9303988 Check |pmc= value (help). PMID 35858307 Check |pmid= value (help).
  20. ↑ Hysong SJ (2009). "Meta-analysis: audit and feedback features impact effectiveness on care quality". Med Care. 47 (3): 356–63. doi:10.1097/MLR.0b013e3181893f6b. PMC 4170834. PMID 19194332.
  21. ↑ 21.0 21.1 Ivers NM, Grimshaw JM, Jamtvedt G, Flottorp S, O'Brien MA, French SD; et al. (2014). "Growing literature, stagnant science? Systematic review, meta-regression and cumulative analysis of audit and feedback interventions in health care". J Gen Intern Med. 29 (11): 1534–41. doi:10.1007/s11606-014-2913-y. PMC 4238192. PMID 24965281.
  22. ↑ Wang A, Pollack T, Kadziel LA, Ross SM, McHugh M, Jordan N; et al. (2018). "Impact of Practice Facilitation in Primary Care on Chronic Disease Care Processes and Outcomes: a Systematic Review". J Gen Intern Med. doi:10.1007/s11606-018-4581-9. PMID 30066117.
  23. ↑ Chase SM, Crabtree BF, Stewart EE, Nutting PA, Miller WL, Stange KC; et al. (2015). "Coaching strategies for enhancing practice transformation". Fam Pract. 32 (1): 75–81. doi:10.1093/fampra/cmu062. PMID DOI: 10.1093/fampra/cmu062[Indexed for ME 25281823 DOI: 10.1093/fampra/cmu062[Indexed for ME Check |pmid= value (help).
  24. ↑ Henderson KH, DeWalt DA, Halladay J, Weiner BJ, Kim JI, Fine J; et al. (2018). "Organizational Leadership and Adaptive Reserve in Blood Pressure Control: The Heart Health NOW Study". Ann Fam Med. 16 (Suppl 1): S29–S34. doi:10.1370/afm.2210. PMC 5891311. PMID 29632223.
  25. ↑ Bidassie B, Davies ML, Stark R, Boushon B (2014). "VA experience in implementing Patient-Centered Medical Home using a breakthrough series collaborative". J Gen Intern Med. 29 Suppl 2: S563–71. doi:10.1007/s11606-014-2773-5. PMC 4070243. PMID 24715402.
  26. ↑ Luck J, Bowman C, York L, Midboe A, Taylor T, Gale R; et al. (2014). "Multimethod evaluation of the VA's peer-to-peer Toolkit for patient-centered medical home implementation". J Gen Intern Med. 29 Suppl 2: S572–8. doi:10.1007/s11606-013-2738-0. PMC 4070245. PMID 24715401.
  27. ↑ Laurant M, van der Biezen M, Wijers N, Watananirun K, Kontopantelis E, van Vught AJ (2018). "Nurses as substitutes for doctors in primary care". Cochrane Database Syst Rev. 7: CD001271. doi:10.1002/14651858.CD001271.pub3. PMID 30011347.
  28. ↑ Bond AM, Schpero WL, Casalino LP, Zhang M, Khullar D (2022). "Association Between Individual Primary Care Physician Merit-based Incentive Payment System Score and Measures of Process and Patient Outcomes". JAMA. 328 (21): 2136–2146. doi:10.1001/jama.2022.20619. PMID 36472595 Check |pmid= value (help).
  29. ↑ Smalley WE, Griffin MR, Fought RL, Sullivan L, Ray WA (1995). "Effect of a prior-authorization requirement on the use of nonsteroidal antiinflammatory drugs by Medicaid patients". N Engl J Med. 332 (24): 1612–7. doi:10.1056/NEJM199506153322406. PMID 7753141.
  30. ↑ Fischer MA, Schneeweiss S, Avorn J, Solomon DH (2004). "Medicaid prior-authorization programs and the use of cyclooxygenase-2 inhibitors". N Engl J Med. 351 (21): 2187–94. doi:10.1056/NEJMsa042770. PMID 15548779.
  31. ↑ Resneck JS (2020). "Refocusing Medication Prior Authorization on Its Intended Purpose". JAMA. 323 (8): 703–704. doi:10.1001/jama.2019.21428. PMID 32011641 Check |pmid= value (help).
  32. ↑ Bruening, Rebecca A.; Sperber, Nina; Wang, Virginia; Mahanna, Elizabeth; Choate, Ashley; Tucker, Matthew; Zullig, Leah L.; Van Houtven, Courtney Harold; Allen, Kelli D.; Hastings, Susan N. (22 March 2022). "Self-Organization of Interprofessional Staff to Improve Mobility of Hospitalized Patients with STRIDE: a Complexity Science-Informed Qualitative Study". Journal of General Internal Medicine. 37 (16): 4216–4222. doi:10.1007/s11606-022-07482-9. eISSN 1525-1497. ISSN 0884-8734. PMID 35319083 Check |pmid= value (help).
  33. ↑ Massoud MR, Barry D, Murphy A, Albrecht Y, Sax S, Parchman M (2016). "How do we learn about improving health care: a call for a new epistemological paradigm". Int J Qual Health Care. 28 (3): 420–4. doi:10.1093/intqhc/mzw039. PMC 4931911. PMID 27118664.
  34. ↑ Jordon M, Lanham HJ, Anderson RA, McDaniel RR (2010). "Implications of complex adaptive systems theory for interpreting research about health care organizations". J Eval Clin Pract. 16 (1): 228–31. doi:10.1111/j.1365-2753.2009.01359.x. PMC 3667707. PMID 20367840.
  35. ↑ Leykum LK, Pugh J, Lawrence V, Parchman M, Noël PH, Cornell J; et al. (2007). "Organizational interventions employing principles of complexity science have improved outcomes for patients with Type II diabetes". Implement Sci. 2: 28. doi:10.1186/1748-5908-2-28. PMC 2018702. PMID 17725834.
  36. ↑ Leykum LK, Parchman M, Pugh J, Lawrence V, Noël PH, McDaniel RR (2010). "The importance of organizational characteristics for improving outcomes in patients with chronic disease: a systematic review of congestive heart failure". Implement Sci. 5: 66. doi:10.1186/1748-5908-5-66. PMC 2936445. PMID 20735859.
  37. ↑ Lanham HJ, Leykum LK, Taylor BS, McCannon CJ, Lindberg C, Lester RT (2013). "How complexity science can inform scale-up and spread in health care: understanding the role of self-organization in variation across local contexts". Soc Sci Med. 93: 194–202. doi:10.1016/j.socscimed.2012.05.040. PMID 22819737.
  38. ↑ Arar NH, Noel PH, Leykum L, Zeber JE, Romero R, Parchman ML (2011). "Implementing quality improvement in small, autonomous primary care practices: implications for the patient-centred medical home". Qual Prim Care. 19 (5): 289–300. PMC 3313551. PMID 22186171.
  39. ↑ Michel, P., et al. "What are the Barriers and Facilitators to the Implementation and/or Success of Quality Improvement and Risk Management in Hospitals: A Systematic Literature Review." J Epidemiol Public Health Rev 1.4 (2016).
  40. ↑ 40.0 40.1 Rose AJ, Petrakis BA, Callahan P, Mambourg S, Patel D, Hylek EM; et al. (2012). "Organizational characteristics of high- and low-performing anticoagulation clinics in the Veterans Health Administration". Health Serv Res. 47 (4): 1541–60. doi:10.1111/j.1475-6773.2011.01377.x. PMC 3401398. PMID 22299722.
  41. ↑ 41.0 41.1 Curry LA, Spatz E, Cherlin E, Thompson JW, Berg D, Ting HH; et al. (2011). "What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study". Ann Intern Med. 154 (6): 384–90. doi:10.7326/0003-4819-154-6-201103150-00003. PMC 4735872. PMID 21403074.
  42. ↑ 42.0 42.1 Gabbay RA, Friedberg MW, Miller-Day M, Cronholm PF, Adelman A, Schneider EC (2013). "A positive deviance approach to understanding key features to improving diabetes care in the medical home". Ann Fam Med. 11 Suppl 1: S99–107. doi:10.1370/afm.1473. PMC 3707253. PMID 23690393.
  43. ↑ 43.0 43.1 Schiff GD, Ruan EL (2018). "The Elusive and Illusive Quest for Diagnostic Safety Metrics". J Gen Intern Med. 33 (7): 983–985. doi:10.1007/s11606-018-4454-2. PMC 6025651. PMID 29713882.
  44. ↑ Kressin NR, Lasser KE, Paasche-Orlow M, Allison J, Ash AS, Adams WG; et al. (2015). "Clinical Operations Variables are Associated With Blood Pressure Outcomes". Med Care. 53 (6): 480–4. doi:10.1097/MLR.0000000000000349. PMC 4944756. PMID 25974844.
  45. ↑ Misra-Hebert AD, Perzynski A, Rothberg MB, Fox J, Mercer MB, Liu X; et al. (2018). "Implementing team-based primary care models: a mixed-methods comparative case study in a large, integrated health care system". J Gen Intern Med. 33 (11): 1928–1936. doi:10.1007/s11606-018-4611-7. PMC 6206362. PMID 30084018.
  46. ↑ Peelle, Henry E. (2006). "Appreciative Inquiry and Creative Problem Solving in Cross-Functional Teams". The Journal of Applied Behavioral Science. SAGE Publications. 42 (4): 447–467. doi:10.1177/0021886306292479. ISSN 0021-8863.
  47. ↑ Leykum LK, Lanham HJ, Pugh JA, Parchman M, Anderson RA, Crabtree BF; et al. (2014). "Manifestations and implications of uncertainty for improving healthcare systems: an analysis of observational and interventional studies grounded in complexity science". Implement Sci. 9: 165. doi:10.1186/s13012-014-0165-1. PMC 4239371. PMID 25407138.
  48. ↑ 48.0 48.1 Harrison MB, Légaré F, Graham ID, Fervers B (2010). "Adapting clinical practice guidelines to local context and assessing barriers to their use". CMAJ. 182 (2): E78–84. doi:10.1503/cmaj.081232. PMC 2817341. PMID 19969563.
  49. ↑ Braithwaite J, Herkes J, Ludlow K, Testa L, Lamprell G (2017). "Association between organisational and workplace cultures, and patient outcomes: systematic review". BMJ Open. 7 (11): e017708. doi:10.1136/bmjopen-2017-017708. PMC 5695304. PMID 29122796.
  50. ↑ Bradley EH, Curry LA, Spatz ES, Herrin J, Cherlin EJ, Curtis JP; et al. (2012). "Hospital strategies for reducing risk-standardized mortality rates in acute myocardial infarction". Ann Intern Med. 156 (9): 618–26. doi:10.7326/0003-4819-156-9-201205010-00003. PMC 3386642. PMID 22547471.
  51. ↑ Bradley EH, Brewster AL, McNatt Z, Linnander EL, Cherlin E, Fosburgh H; et al. (2018). "How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study". BMJ Qual Saf. 27 (3): 218–225. doi:10.1136/bmjqs-2017-006574. PMC 5867433. PMID 29101290.
  52. ↑ Schulingkamp, R. C., & Latham, J. R. (2015). Health Care Performance Excellence: A Comparison of Baldrige Award Recipients and Competitors.
  53. ↑ Unger, K. L. (2013). An investigation into the effects of winning the Malcolm Baldrige National Quality Award on the performance of hospitals/healthcare systems (Doctoral dissertation, Colorado State University).


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