Predicting the Sustainability of Quality Improvement Initiatives in Healthcare: A Data-Driven Study.

BackgroundContext shapes the effectiveness of knowledge implementation and influences health improvement. Successful healthcare quality improvement (QI) initiatives frequently fail to transfer to different settings, with local contextual factors often cited as the cause. Understanding and overcoming contextual barriers is therefore crucial to implementing effective improvement; yet context is still poorly understood. There is a paucity of information on the mechanisms underlying how and why QI projects succeed or fail in given settings. A realist review of empirical studies of healthcare QI initiatives will be undertaken to examine the influence and impact of contextual factors on quality improvement in healthcare settings and explore whether QI initiatives can work in all contexts.MethodsThe review will explore which contextual factors are important, and how, why, when and for whom they are important, within varied settings. The dynamic nature of context and change over time will be explored by examining which aspects of context impact at key points in the improvement trajectory. The review will also consider the influence of context on improvement outcomes (provider- and patient-level), spread and sustainability. The review process will follow five iterative steps: (1) clarify scope, (2) search for evidence, (3) appraise primary studies and extract data, (4) synthesise evidence and draw conclusions and (5) disseminate findings. The reviewers will consult with experts and stakeholders in the early stages to focus the review and develop a programme theory consisting of explanatory ‘context–mechanism–outcome’ configurations. Searches for primary evidence will be conducted iteratively. Data will be extracted and tested against the programme theory. A review advisory group will oversee the review process. Review findings will follow RAMESES guidelines and will be disseminated via a report, presentations and peer-reviewed publications.DiscussionThe review will update and consolidate evidence on the contextual conditions for effective improvement and distil new knowledge to inform the design and development of context-sensitive QI initiatives. This review ties in with the study of improvement programmes as vehicles of change and the development of an evidence base around healthcare improvement by addressing whether QI initiatives can work in all contexts.Systematic review registrationPROSPERO CRD42017062135

Quality Improvement is a Professional Responsibility in Diabetes Care

Editors’ Note and Prologue

National Quality Improvement in Radiation Therapy: A Look at the Past, Present, and Future

In 1999, an Institute of Medicine report spurred health care organizations to implement systems-based quality improve ment efforts and tackle patient safety. Simultaneously, the Accreditation Council for Graduate Medical Education asked residency programs to address Practice-Based Learning and Systems-Based Practice competencies. Medical educators now advocate incorporation of these competencies in undergraduate medical education.The authors examine the success of these efforts both from the health care delivery and systems perspective as well as from the perspective of educators as they aspire to engage medical students and residents in these domains. The authors argue that the missing element that prevents health care systems from the full realization of the promise of quality improvement is bidirectional alignment. Included are examples from the literature to demonstrate how medical educators are moving toward alignment of learners with health system quality improvement and safety needs. Finally, the authors explore business and information technology governance literature in support of the hypothesis that bidirectional alignment should be the next step in moving from reactive to proactive systems of care.

Introduction Poor quality health care is a significant cause of preventable deaths, especially in low- and middle-income countries (LMICs). Quality improvement is multifaceted and includes strategies such as standard setting, quality assurance and clinic audits. In order to move quality improvement in health care into every day practice it is essential to fully engage the frontline where health care is delivered. The objective of this scoping review is to investigate front line health care worker line led quality improvement in Sub Saharan Africa (SSA). Methods We conducted a scoping review to identify, map and synthesize evidence on health care worker led quality improvement initiatives in Sub Sahara Africa using electronic databases PubMed, Cochrane, Embase, CINAHL, Scopus and Psychinfo to identify peer-reviewed literature published between January 2000 and January 2021. To identify grey literature, we used the same search terms in google search to a maximum of 10 pages or when there was no new information. All evidence was scored based on the 6 criteria described by Backhouse et al., which clearly distinguish quality improvement from clinical audit and research. Inclusion criteria were studies that involved frontline health care workers to test “change ideas” and used data systems to measure improvement in service delivery. Results A total of 75 records were identified and including 52 from the peer review search and 23 records from the grey literature search. Only 15 of 47 countries had publications (peer-review or grey literature) describing QI initiatives. Most quality improvement (QI) initiatives were multicomponent and included knowledge transfer, skills building, mentorship and learning visits. Most publications reported QI initiatives aimed at reproductive, maternal, neonatal and child health (n=23) and HIV (n=14) service delivery. Only 6 had experimental designs. No publications were identified prior to 2012 and a rapid escalation of published quality improvement initiatives from 2012 to 2020 was seen. Conclusion QI is in the very nascent stage in SSA. Most large-scale public health QI initiatives are sector specific, siloed, and donor driven. QI initiatives within sector specific programs have not moved horizontally and have had limited ability to change the broader system. Energy must be exerted to change the status quo. Making health care safer and more effective is not spontaneous.

Improving the quality of health care is a national priority. Nonetheless, no systematic effort has assessed the status of quality improvement (QI) initiatives for children or reviewed past research in child health care QI. This assessment is necessary to establish priorities for QI programs and research. To assess the status of QI initiatives and research, we reviewed the literature and interviewed experts experienced in QI for child health services. We defined QI as activities intended to close the gap between desired processes and outcomes of care and what is actually delivered. We classified reports published between 1985 and 1997 by publication characteristics, study design, clinical problem addressed, site of intervention, the QI method(s) used, and explicit association with a continuous quality improvement program. We reviewed 68 reports meeting our definition of QI. More than half (48) were published after 1994. The reviewed reports included controlled evaluations in 36% of all identified interventions, and 3% of the reports were associated with continuous quality improvement. QI methods demonstrating some effectiveness included reminder systems for office-based preventive services and inpatient pathways for complex care. Reportedly successful QI initiatives more commonly described improvement in administrative measures such as rate of hospitalization or length of stay rather than functional status or quality of life. Interviews found that barriers to QI for children were similar to those for adults, but were compounded by difficulties in measuring child health outcomes, limited resources among public organizations and small provider groups, and relative lack of competition for pediatric tertiary care providers. Research and dissemination of QI for children were seen as less well developed than for adults. Attempts to improve the quality of child health services have been increasing, and the evidence we reviewed suggests that it is possible to improve the quality of care for children. Nonetheless, numerous gaps remain in the understanding of QI for children, and widespread improvement in the quality of health services for children faces significant barriers.

Data Management for Quality Improvement: How to Collect and Manage Data.

Quality improvement (QI) is a health care concept that ensures patients receive high-quality (safe, timely, effective, efficient, equitable, patient-centered) and affordable care. Despite its importance, the application of QI in athletic health care has been limited. To describe the need for and define QI in health care, to describe how to measure quality in health care, and to present a QI case in athletic training. As the athletic training profession continues to grow, a widespread engagement in QI efforts is necessary to establish the value of athletic training services for the patients that we serve. A review of the importance of QI in health care, historical perspectives of QI, tools to drive QI efforts, and examples of common QI initiatives is presented to assist clinicians in better understanding the value of QI for advancing athletic health care and the profession. Clinical and Research Advantages: By engaging clinicians in strategies to measure outcomes and improve their patient care services, QI practice can help athletic trainers provide high-quality and affordable care to patients.

Quality improvement (QI) initiatives in healthcare are crucial for enhancing service quality and healthcare outcomes. The success of these initiatives depends on the active engagement of healthcare professionals, which can be influenced by several factors within the healthcare system. This systematic review synthesized the factors influencing healthcare professionals' engagement in QI projects, focusing on identifying both barriers and facilitators. A mixed methods systematic review (MMSR) was conducted using the JBI methodology for MMSR. Databases such as MEDLINE, CINAHL, Scopus, and Embase were searched for studies that explored barriers and facilitators to QI engagement of health professionals in the clinical setting. Methodological quality was assessed using the Mixed-Methods Appraisal Tool (MMAT). The extracted data were synthesized using the JBI convergent integrated approach to MMSR. Eighteen studies (seven qualitative, nine quantitative, and two mixed-methods) published between 2007 and 2023 were included in the review. The analysis revealed barriers and facilitators to engagement in QI initiatives at different levels of the health system. At the QI program level, the engagement of health professionals to QI was influenced by the approach to QI, evidence underpinning the QI initiative, QI knowledge and training, and access to QI specialists. At the health professional level, barriers and facilitators were related to their organizational role, motivation, perceptions about QI, and collaborations with individuals and groups. At the organizational level, factors related to culture and climate, leadership, available resources (including human resource and workload, infrastructure, and incentives), and institutional priorities influenced health professionals' participation in QI. This review highlights the complex interplay of organizational, individual, and QI program level factors that influence the engagement of healthcare professionals in QI. Overcoming these complex barriers and leveraging facilitators is crucial for enhancing participation in QI efforts. The findings underscore the need for a multi-level strategy that focuses on creating a conducive organizational culture, providing robust leadership, and ensuring adequate resources and training for healthcare professionals. Such strategies hold the potential to enhance the effectiveness and sustainability of QI initiatives in healthcare settings.

Improvement science has supported the methodological foundations for the application of quality improvement (QI) in healthcare. However, concerns persist regarding the rigour of QI evaluation. Theories, Models and Frameworks (TMFs) from implementation science support the uptake of evidence-based practices but their use to guide the evaluation of QI initiatives remains insufficiently characterised. To identify which implementation science TMFs have been used to evaluate QI initiatives in healthcare, assess how these TMFs were applied in the evaluation, and compare the TMFs' intrinsic methodological attributes. We conducted a scoping review following Arksey and O'Malley's framework. Eligible studies were published between 2010 and 2025 and evaluated a QI initiative using at least one TMF. Peer-reviewed literature was searched in PubMed, Scopus and Web of Science. Grey literature was retrieved through targeted Google searches. TMFs were evaluated at the article level according to their application in each study and at the TMF level according to their intrinsic methodological attributes. Out of 1824 records screened, 80 studies were included. 23 unique TMFs were identified. Of these, the most frequently used were the Reach, Effectiveness, Adoption, Implementation and Maintenance framework (27%) and the Consolidated Framework for Implementation Research (20%). Although 94% of studies used TMFs to guide data collection or analysis, only 43% explicitly tested construct relationships or causal pathways. TMFs demonstrated high conceptual clarity and structure but limited equity and sociocultural responsiveness. Application of TMFs in the evaluation of QI initiatives was heterogeneous. No single TMF captured the full range of evaluative functions. More rigorous evaluation requires an integrative approach that combines complementary TMFs to examine context, mechanisms of improvement and outcomes. Prospective operationalisation of TMF constructs, particularly equity, within study design and evaluation is essential to strengthen reproducibility and improve the transferability of findings across settings.

This section includes detailed findings from the second set of visits (2015–2017) of the Clinical Learning Environment Review (CLER) Program. The findings in the 6 CLER Focus Areas1 are based on site visits to the major participating clinical sites (ie, hospitals and medical centers) for 287 Accreditation Council for Graduate Medical Education (ACGME)-accredited Sponsoring Institutions (SIs) with 3 or more core residency programs.23 These clinical sites serve as clinical learning environments (CLEs) for the SIs.Collectively, the 287 SIs oversee 9167 ACGME-accredited residency and fellowship programs, with a median of 20 programs per SI. These larger SIs account for 87.1% of all residents and fellows in ACGME-accredited programs—with a range of 17 to 2156 trainees per SI (median = 246).Approximately 28% of the CLEs were located in the Northeast region of the United States, 30.3% in the South, 26.5% in the Midwest, and 14.6% in the West. The sites ranged in size from 107 to 2654 acute care beds (median = 528). The majority (67.2%) were nongovernment, not-for-profit organizations; 23.3% were government, nonfederal; 5.9% were investor-owned, for-profit; and 3.5% were government, federal. Although the CLER teams spent the majority of their time at inpatient settings, they also sometimes visited affiliated ambulatory care practices in close proximity.In total, the CLER teams interviewed more than 1600 members of executive leadership (including chief executive officers), 9262 residents and fellows, 8164 core faculty members, and 6034 program directors of ACGME-accredited programs in group meetings. Additionally, the CLER teams interviewed the CLEs' leadership in patient safety and health care quality and thousands of residents, fellows, faculty members, nurses, pharmacists, social workers, and other health care professionals while on walking rounds in the clinical areas.As previously described in the CLER National Report of Findings 2016,4 these findings are based on a mixed methods approach to data gathering and analysis to improve the accuracy of the findings by combining quantitative, descriptive, and qualitative evidence in a complementary manner. As such, some of the findings are represented quantitatively while others are described qualitatively.The combination of methodologies and varied representation of findings should be considered when interpreting the results, making comparisons, or drawing conclusions. Both supporting and conflicting evidence may be presented to explain or qualify findings. For example, results from the group interviews may appear more positive than information gathered on walking rounds. Alternatively, practices reported during group interviews may have been verified on walking rounds.During the group interviews with residents and fellows, faculty members, and program directors, an electronic audience response system (ARS; Keypoint Interactive version 2.6.6, Innovision Inc, Commerce Township, MI) was used to collect anonymous responses to closed-ended questions. The results from the ARS were analyzed at both the individual (eg, residents and fellows) and the CLE levels.At the individual level of analysis, results are presented as percentages of the total number of individuals surveyed. For example:At the CLE level of analysis, individual responses were aggregated at the CLE level and results are presented as median and interquartile range (IQR) percentages. For example:Statistically significant differences (ie, P ≤ .05) in responses due to resident and fellow characteristics (eg, residency year) and CLE characteristics (eg, bed size) are also reported. Of note, statistical significance does not always imply practical significance. For example, differences in responses by residency year may be statistically significant but the differences may not be meaningful or large enough to have practical relevance or implications.As described in the Methodology section,5 this report contains a specific set of descriptive terms that summarize quantitative results from both the ARS and specific findings that were quantified from the site visit reports. These terms and their corresponding quantitative ranges are as follows:Besides the quantitative data, this report contains qualitative data from a number of open-ended questions that CLER Site Visitors asked during group interviews and walking rounds. This information, by design, was not intended to be enumerated. For these questions, the site visit teams made an assessment of the relative magnitude of observations at each individual site. To prevent confusion, these results are presented in the report using a set of descriptive terms different from the previously described terms used for quantitative data. The qualitative descriptive terms, which are intended to approximate the quantitative terms above, are as follows:Finally, this section follows approximately the same structure as the individual CLER Site Visit reports received by participating institutions. This structure is intended to facilitate easy comparison between data from an individual site and that of this report, which aggregates results from all 287 SIs. Those who seek additional detail may consult the Appendices (p. 81–124). Appendix A contains additional information on the SIs, sites visited, and groups interviewed, Appendix B contains selected aggregated quantitative results from the group interviews with residents and fellows, and Appendix C contains qualitative information from the group interviews and walking rounds.The CLER Program explored several aspects of resident and fellow engagement in patient safety with emphasis on 5 major topics: culture of safety, use of the patient safety event reporting system, knowledge of patient safety principles and methods, inclusion in patient safety event investigations, and disclosure of patient safety events. Generally across CLEs, members of the executive leadership team identified patient safety as their highest priority area for improvement.The patient safety and quality leaders in many CLEs indicated that they periodically conduct a culture of safety survey that includes residents, fellows, and faculty members. Overall, 97.7% of the residents and fellows in the group interviews reported that their CLE provides a safe and nonpunitive environment for reporting errors.Across CLEs, physicians and other staff members also reported use of the patient safety event reporting system to report on individual behaviors. This use included reporting on behaviors in a retaliatory fashion or in a manner that could be perceived as punitive.Given this and based on the collective findings from the site visits, it is unclear as to whether residents, fellows, and other staff members perceived a safe and nonpunitive culture for reporting patient safety events.Overall, CLEs had 1 or more mechanisms for reporting patient safety events, including an online or paper-based patient safety event reporting system, a chain-of-command system that allowed events to be reported to an immediate supervisor (eg, a more senior resident or faculty member), and a mechanism to verbally report events to the patient safety staff (eg, hotline).In general, residents and fellows appeared to be aware of their CLE's process for reporting patient safety events such as adverse events, near misses/close calls, and unsafe conditions. During walking rounds, the CLER Site Visit teams also asked nurses about their CLE's patient safety event reporting system. Across nearly all CLEs (97.2%), nurses appeared to be familiar with their CLE's system for reporting patient safety events.Approximately 78% of CLEs were able to provide information on the number of patient safety event reports submitted by residents and fellows (see Appendix C1), and 70.7% were able to provide the number of patient safety event reports submitted by attending physicians. The remaining CLEs indicated that their system did not track such information. Whereas CLEs occasionally provided the Graduate Medical Education Committee and their governing body with information on the number or percentage of patient safety event reports submitted by residents and fellows, it was less common for them to routinely report the number or percentage of patient safety event reports submitted by faculty members to these same groups.Generally across CLEs, the residents and fellows interviewed on walking rounds appeared to lack understanding and awareness of the range of reportable patient safety events, including what defines a near miss/close call. In most CLEs (83.6%), nurses' understanding of reportable patient safety events also varied (see Appendix C2).Across CLEs, residents, fellows, and nurses appeared to focus on reporting sentinel events, medication errors, patient falls, and other events with harm; they did not appear to recognize near misses/close calls, unsafe conditions, events without harm, unexpected deteriorations, or known procedural complications as reportable patient safety events. Residents, fellows, and nurses appeared to have little awareness of the importance of reporting these events and how such reporting can provide valuable information for identifying system failures, addressing vulnerabilities in the system, reducing risks, and improving patient safety.Overall, 72.7% of the residents and fellows in the group interviews indicated that they had experienced an adverse event, near miss/close call, or unsafe condition while at their CLE. This experience varied by gender, year of training, and specialty grouping (see Appendix B1).Of the residents and fellows who reported that they had experienced an adverse event, near miss/close call, or unsafe condition, 49.8% indicated that they had personally reported the patient safety event using the CLE's patient safety event reporting system. Responses varied by gender, year of training, and specialty grouping. Across CLEs, the median (IQR) finding was 50.0% (37.5%–66.7%) and varied by region, CLE bed size, and type of ownership (see Appendix B2). For those who did not personally enter the patient safety event into the system, 13.6% indicated that they relied on a nurse to submit the patient safety event report, 24.4% indicated that they relied on a physician supervisor, and 12.1% indicated that they cared for the patient and chose not to submit a report.When faculty members and program directors in the group interviews were asked what process residents and fellows most frequently followed when reporting a patient safety event, 57.9% of the faculty members and 53.7% of the program directors indicated that they believed residents and fellows most often reported the event themselves using the CLE's patient safety event reporting system.In a separate query, 23.6% of the residents and fellows in the group interviews indicated that they had reported a near miss/close call event while at the CLE; responses varied by gender, year of training, and specialty grouping (FIGURE 1). Across CLEs, this finding ranged from 0% to 100%, with a median (IQR) of 23.1% (15.2%–33.3%); responses varied by region and type of ownership (see Appendix B3).On walking rounds, residents and fellows in many CLEs mentioned that they often report patient safety events locally or through their chain of command while also indicating familiarity with the patient safety event reporting system and its use. When they delegated or relied on others to report, it was unclear if these reports were formally captured in the CLE's centralized patient safety event reporting system. Residents and fellows mentioned the cumbersome process of submitting a report, the time needed to enter a report, fears of repercussion, and the uncertainty of receiving feedback as reasons for not reporting. The collective information from the site visits indicated that in 70.6% of the CLEs, resident and fellow reporting of patient safety events into the CLE's patient safety event reporting system was varied or infrequent (see Appendix C3).In the group interviews, the CLER teams also explored faculty members' and program directors' use of the CLE's patient safety event reporting system. Approximately 36% of the faculty members reported that they had personally reported an adverse event, near miss/close call, or unsafe condition in the past year (median [IQR], 35.7% [26.0%–46.6%] across CLEs). Among the program directors, 35.9% reported that they had personally reported an adverse event, near miss/close call, or unsafe condition in the past year (5.5% had no clinical responsibilities at the site). Across CLEs, the median (IQR) finding was 36.0% (27.3%–50.0%). In both groups, responses varied by CLE bed size and type of ownership.In the group interviews, the CLER teams asked residents and fellows whether they received feedback on patient safety event reports. Of those who had experienced an adverse event, near miss/close call, or unsafe condition and who had personally submitted a patient safety event report or relied on a nurse or supervisor to submit the report, 46.1% reported that they received feedback on the outcome of the report. Responses varied by gender, specialty grouping, and year of training (FIGURE 2; see also Appendix B4).Residents and fellows often mentioned receiving an e-mail acknowledging receipt of the patient safety event report. They also noted receiving requests for additional information as part of a formal patient safety event investigation. It was uncommon for residents to mention receiving information on the outcome of the investigation, including recommended actions to address vulnerabilities in the system and to improve patient safety. Across CLEs, residents, fellows, nurses, and other clinical staff expressed a strong desire to receive feedback in response to submitting a patient safety event report.Overall, CLEs varied in their processes for reviewing and prioritizing patient safety events. Residents and fellows also varied in their knowledge of these processes and often used the term "black box," indicating that these processes were unclear. Many residents and fellows appeared to be unaware of how their CLEs use the reporting of adverse events, near misses/close calls, or unsafe conditions to improve care both broadly and at the individual departmental level. Residents and fellows were rarely involved in their CLE's process for reviewing and prioritizing patient safety events that required further investigation.On walking rounds, the CLER teams explored resident and fellow participation in the time-out process as part of patient safety practices (eg, ambulatory and bedside procedures). Across many CLEs, residents, fellows, nurses, and other health care professionals interviewed on walking rounds indicated that residents and fellows do not consistently conduct standardized time-outs before performing bedside procedures.Across most CLEs (91.6%), residents and fellows appeared to have limited knowledge of fundamental patient safety principles and methods (eg, Swiss cheese model of system failure, root cause analysis, fishbone diagrams; see Appendix C4).When asked to identify their skills in applying patient safety principles, the majority of the faculty members indicated that they were either proficient or expert (62.7% and 25.1%, respectively) in applying these skills. Similarly, most of the program directors reported themselves as proficient or expert (63.6% and 21.9%, respectively).Of the residents and fellows in the group interviews, 36.3% reported that they had participated in a structured interprofessional simulation activity related to patient safety. Responses varied by gender, year of training, and specialty grouping. Across CLEs, the median (IQR) finding was 37.1% (26.3%–50.0%), with responses varying by region and type of ownership.In many CLEs, the patient safety and quality leaders indicated that they did not track resident and fellow participation in patient safety event investigations (eg, root cause analysis). A limited number of CLEs provided the Graduate Medical Education Committee and the governing body with information regarding the number of residents and fellows who had participated in formal patient safety event investigations.The CLER teams also asked the program directors in the group interviews if they measured resident and fellow participation in patient safety event investigations. Approximately 42% of the program directors reported tracking resident and fellow involvement (median [IQR], 44.4% [30.0%–66.7%] across CLEs). Responses varied by region, CLE bed size, and type of ownership.In the group interviews, 37.6% of the residents and fellows who were postgraduate year 3 (PGY-3) and higher indicated that they had participated in an interprofessional investigation of a patient safety event that included components such as analysis of system issues, development and implementation of an action plan, and monitoring for continuous improvement. Reponses varied by specialty grouping (FIGURE 3). Across CLEs, the median (IQR) finding was 37.6% (28.6%–50.0%), with responses varying by region, CLE bed size, and type of ownership (see Appendix B5).The CLER teams also asked faculty members about their involvement in interprofessional patient safety event investigations. Approximately 64% of the faculty members in the group interviews reported that they had participated in an investigation of a patient safety event that involved physicians, nurses, administrators, and other health care professionals (median [IQR], 63.3% [53.0%–73.2%] across CLEs).Overall, the format and process of investigating patient safety events varied both across and within CLEs. It was uncommon for residents and fellows to describe involvement in comprehensive systems-based approaches to patient safety event investigations aimed at preventing future adverse events and sustaining improvements in patient safety. In general, residents and fellows described experiences that lacked the attributes of a formal patient safety event investigation with very little or no interprofessional or interdisciplinary engagement. Residents and fellows varied widely in their perceptions of what constituted a formal investigation of a patient safety event. Across many CLEs, case conferences, morbidity and mortality conferences, and grand rounds continued to be the major approach to patient safety event investigations.Faculty members and program directors indicated that departmental mortality conferences, case conferences, and online modules were other informal approaches to model elements of a patient safety event investigation.In the group interviews, 66.0% of the residents and fellows indicated that they had received training on disclosing medical errors to patients and/or families (4.5% reported that such training was not applicable). Responses varied by year of training. Across CLEs, the median (IQR) finding was 68.2% (57.1%–79.3%), with responses varying by region and CLE bed size. Of those who received training, 10.1% indicated that the training was primarily simulation based; 69.8%, didactic and/or online; 15.1%, informal; and 5.0%, other.Approximately 82% of the residents and fellows in the group interviews indicated that they knew of CLE resources to assist them in coping with a major patient safety event that resulted in a patient death (median [IQR], 85.8% [74.7%–93.0%] across CLEs; see Appendix B6 for information on variability). Of those familiar with the resources, most indicated that they would be somewhat (39.8%) or very comfortable (44.7%) in using these resources.The CLER Program explored resident and fellow engagement in improving health care quality within the context of 6 major areas: involvement in developing and implementing the CLE's strategies for health care quality, awareness of the CLE's health care quality priorities, knowledge of health care quality terminology and methods, engagement in quality improvement (QI) projects, access to quality metrics data, and engagement in CLE efforts to address health care disparities.As part of understanding the CLE's approach to improving health care quality, the CLER Site Visit teams reviewed the organization's strategic plan for quality and interviewed both executive and patient safety and quality leaders. Overall, a limited number of CLEs appeared to integrate QI within the organization as part of a system-wide, comprehensive approach to promote experiential learning and to improve quality and safety across the organization.Across CLEs, resident and fellow involvement in strategic planning for QI was uncommon. Residents and fellows often served as implementers of CLE-wide QI activities (eg, hand hygiene, reducing hospital-acquired infections, reducing 30-day readmissions).A limited number of CLEs had instituted resident and fellow committees aimed at increasing resident and fellow engagement in QI; few of these committees were integrated into the CLE's formal QI processes. In many CLEs, resident and fellow participation in institutional QI committees was uncommon; often, roles and expectations for participation were undefined or unclear. The clinical sites also appeared to have insufficient structure to allow residents and fellows to attend committee meetings regularly and to participate in meaningful ways. Additionally, residents and fellows in many CLEs were not included in the governing body's patient safety and quality committees.In general, priorities for improving health care quality varied across CLEs. However, some common themes included alignment with broad national priorities such as Centers for Medicare & Medicaid Services value-based purchasing, Core Measures, or publicly reported performance measures. Many were also highly focused on meeting specific criteria such as reducing 30-day readmissions or improving performance on metrics related to pneumonia, chronic heart failure, and surgical care improvement project measures.In the group interviews, 78.8% of the residents and fellows (PGY-2 and above) reported knowing their CLE's priorities for improving health care quality (see Appendix B7 for additional information on variability). When asked the same question, 84.4% of the faculty members and 86.7% of the program directors reported knowing the priorities. Often, the physician groups focused on departmental activities and did not describe priorities that aligned with those identified by the CLE's executive leadership or the patient safety and quality leaders. When the physicians identified priorities aligned with those of executive leadership, they were most commonly around nationally recognized measures, especially those related to programs with financial incentives such as measures from the Centers for Medicare & Medicaid Services.In 55.1% of the CLEs, the residents and fellows appeared to have limited knowledge or understanding of basic QI terminology and methods such as Lean, Plan-Do-Study-Act, and Six Sigma (FIGURE 4, see also Appendix C5). A limited number of residents and fellows could articulate the QI approach employed by their CLE in designing and implementing QI activities to improve patient care.In general, the approach to educating residents and fellows about health care QI varied both within and between CLEs. Although some type of education was common as part of new resident and fellow orientation, a limited number of CLEs aimed to provide ongoing training for all residents and in health care QI appeared to primarily within or medical education programs, and the methods, and appeared to of the CLEs, the patient safety and quality leaders indicated that they resident and fellow QI the group interviews with residents and fellows (PGY-2 and reported they had participated in a QI project of their design, or by their program or Of this reported that their QI project was to 1 or more of the CLE's 23.3% were Of those who reported their QI were to the CLE's reported their involved interprofessional Appendices and provide detailed information on the group interviews and on walking rounds, the CLER teams asked residents and fellows to describe their QI Overall, residents and fellows varied in their of these It was uncommon for residents and fellows to describe that aligned with their CLE's priorities. In most CLEs few described that included the components of a QI (ie, (FIGURE see also Appendix Often, resident and fellow participation was limited to planning and implementing a QI For many residents and fellows, their QI did not formally and designing actions to and ongoing QI was also uncommon for residents and fellows to describe involvement in interprofessional QI During the interviews on walking rounds, a limited number of nurses and other health care professionals indicated that they were involved in interprofessional QI that included residents and the CLER teams faculty members in the group interviews about their engagement in interprofessional QI projects, 72.7% reported that they had participated in a QI project with nurses, pharmacists, and other members of the health care team (median [IQR], across the group interviews, of the program directors reported that their residents and fellows have access to for and data for the of health clinical and or national quality were often reported as common of QI data. Residents and fellows often mentioned the (eg, in specific reports from these data Many faculty members noted that residents and fellows had limited for data When it was often a departmental The type and of to residents and fellows varied both within and across of the residents and fellows in the group interviews reported receiving aggregated or QI data on their Responses varied by gender, year of training, and specialty grouping. Across CLEs, the median (IQR) finding was with responses varying by region, CLE bed size, and type of ownership (FIGURE see also Appendix the patient safety and quality leaders indicated that residents and fellows receive QI data to the care of their patients with others served by their clinical many CLEs, executive leaders were aware of of health their Many described to improve access to care and or care and for the often by residents and fellows from a few core (eg, and A limited number of residents and fellows from other specialty and programs reported in these limited number of executive leaders to health care within their or medical Overall, less than of executive leaders described a specific set of strategies or a approach to and in the care provided to or the clinical of their patient at for health care In approximately of the CLEs, the executive faculty members, or program directors indicated that some were data or related to health care specific patient many of these efforts were reported as the group interviews, 55.1% of the residents and fellows reported that they knew their CLE's priorities in addressing in health responses varied by year of training and specialty grouping. Across CLEs, this finding ranged from to (median [IQR], Responses varied by region, CLE bed size, and type of ownership (see Appendix In of the faculty members and of the program directors reported that they knew their CLE's priorities with to health care residents, fellows, faculty members, and program directors interviewed in the group interviews were able to describe at for health care at their clinical the group interviews, of the residents and fellows reported that they had received training that was specific to at for health care at their clinical reported receiving training that was not specific to the CLE's patient reported receiving training that was primarily informal while clinical and indicated that they had not received training at their CLEs, a median (IQR) of of the residents and fellows indicated that they had received training that was specific to at for health care at their clinical site. Responses varied by region, CLE bed size, and type of ownership (FIGURE see also Appendix interviews on walking rounds, many residents and fellows described education and training in that was and not specific to the

Basics of Quality Improvement in Health Care

Despite taking advantage of established learning from other industries, quality improvement initiatives in healthcare may struggle to outperform secular trends. The reasons for this are rarely explored in detail, and...

Objective: Quality improvement in the healthcare industry has evolved over the past few decades. In recent years, an increased focus on coordination of care efforts and the introduction of health information technology has been of high importance in improving the quality of patient care.Methods: In this review, we present a history of quality improvement efforts, discuss quality improvement in the healthcare industry, and examine quality improvement strategies with a focus on patient-centered care and information technology applications via patient registries.Results: Evidence shows that the key to quality improvement efforts in the healthcare industry is the coordination of patient care efforts through better data evaluation processes. By utilizing patient registries that can be linked to electronic health records (EHRs) and the Patient-Centered Medical Home (PCMH) framework, the quality of care provided to patients can be improved.Conclusions: While many healthcare organizations have quality improvement departments or teams in place that may be able to handle these types of efforts, it is important for organizations to be familiar with processes and frameworks that employees at different levels of the organization can be involved in. In order to ensure successful outcomes from quality improvement initiatives, managers and clinicians should work together in identifying problems and developing solutions.