Quality Improvement in Health Care: From Conceptual Frameworks and Definitions to Implementation

A Role for Government: An Observation on Federal Healthcare Efforts in Prevention

Reliability of the health care delivery system

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

Editors’ Note and Prologue

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.

AHALF DECADE HAS ELAPSED SINCE THE INSTITUTE OF Medicine released2 landmarkreportsonhealthcare safety and quality, To Err Is Human and Crossing the Quality Chasm. Those studies helped articulate a broad agenda for quality improvement in health care, and examples of success on a small scale are numerous. However, the collective impact of improvement work has been far below the potential envisioned by the Institute of Medicine. Health care can benefit now from a new sense of urgency, with levels of discipline and pace akin to those of a political campaign. Political campaigns cannot afford patience. Political campaign professionals often cite the rule: “Some is not a number; soon is not a time.” A campaign works with a firm target: 50% plus one: the number of votes needed to win— one less is not enough—and a firm deadline: election day. To quicken the pace of quality improvement in health care, the Institute for Healthcare Improvement (IHI) in December 2004 launched the 100 000 Lives Campaign—a national initiative with a goal of saving 100 000 lives among patients in hospitals through improvements in the safety and effectiveness of health care. For operational purposes in the campaign, a “life saved” is defined as a patient successfully discharged from a hospital who, absent the changes achieved during the campaign, would not have survived. Arbitrarily, IHI set a deadline of June 14, 2006, for achieving that goal, precisely 18 months after the announcement of the campaign at the IHI’s 16th Annual National Forum on Quality Improvement in Health Care. All of the nation’s 5759 hospitals have been invited to join through a simple enrollment process, explained on the IHI Web site (available at http://www.ihi.org), and they have been requested to acknowledge publicly their involvement, regularly sharing their progress in reducing mortality. How can US hospitals possibly save 100 000 lives by June 14, 2006? The campaign proposes that US hospitals implement as many as possible of 6 highly feasible interventions for which efficacy is documented in the peer-reviewed literature and is reflected in standards set by relevant specialty societies and government agencies. Campaign Interventions

Basics of Quality Improvement in Health Care

The Institute for Healthcare Improvement (IHI) formed the Interdisciplinary Professional Education Collaborative in 1994 with assistance from the Health Resources and Services Administration, Bureau of Health Professions, and Pew Health Professions Commission. The IHI-sponsored National Forum on Quality Improvement in Health Care is an annual international meeting designed to enhance professionals' learning about the use of continuous quality improvement in health care. Learners were taught to give and improve care in interdisciplinary teams. Participants were student and practicing nurses, physicians, social workers, and other health professionals. Building on its success in geriatrics, the Learning Team Model was used in another interdisciplinary team training demonstration project involving pediatric primary care settings, the Catalyst for Kids project. The Academy of Healthcare Improvement provides strategic direction for the field and offers a set of resources to support individuals across the world who are interested in advancing the field of quality improvement in health care.

Internationally, the implementation of diagnosis-related group systems has underlined the importance of quality assurance and improvement in health care systems. Support is expected by various concepts based on different theories and traditions. Published experience and knowledge of other countries with long-standing DRG systems and data in literature are studied to see whether there is an evidence-based impact of quality assurance and quality improvement on health care systems. Relevant data was searched for in the Cochrane-database, the INAHTA-databases DARE, NHSEED and HTA, in DIMDI and the Medline-database of the NIH as well as generally in the internet, addressing the different countries. Several tools of quality assurance and quality improvement like accreditation, evidence-based medicine and guidelines exist in most of the 18 countries studied. Some of them, such as registries and audits, have marked national characteristics. Similar problems in provision of health care are reported internationally. There is broad consensus as to the aspects to be addressed in quality improvement concepts. Though international consensus on effective organization and methods of external assessment is growing there is only limited evidence for efficiency and general applicability of the different tools. Their cost impact, too, has not undergone systematic evaluation. Procedures like feedback strategies and reflection have been identified as having the potenzial to change the practice of health care professionals on a local level, but evidence for system-related impact is missing. Above all, for all concepts of quality improvement there is no real evidence of clinical benefit in the sense of better patient outcomes. None of the various tools for quality improvement in health care proves superior so far. It remains unclear which tool suits best for which intended improvement and in which context. Although quality improvement as a strategy meets with wide approval and appears to be a correct health policy, it remains doubtful whether it really improves clinical outcome and patient-centred health care. Public health research should address these questions. New concepts (e. g. integrating different tools of quality assurance and improvement or DMP systems) need evaluation prior to their broad implementation. Social medicine is called upon to mediate between the consented health care aims of society and medicine.

McLaughlin and Kaluzny’s Continuous Quality Improvement in Health Care, 4th edition

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

Effective quality improvement is a key factor in optimizing the care of hospitalized patients. Unfortunately, the US health care system has a poor safety record when compared to other major industries. For example, at 250 000 per year, medical errors are the third leading cause of death in the United States. Safety barrier management, a widely used methodology in high-risk industries such as commercial airline transportation and oil drilling, has not been widely used in traditional quality improvement efforts in health care, which rely more on standard lean Six Sigma quality approaches. The authors describe a quality improvement project that uses safety barrier analysis to help inform solutions to improve venous thromboembolism prophylaxis in hospitalized patients. This study found that safety barrier analysis helped inform solutions to improve venous thromboembolism prophylaxis at the study institution and can be a useful adjunct to standard lean Six Sigma methodologies for quality improvement in health care.

There is no single best approach to quality improvement. Quality improvement has been adapted from its predominantly Japanese origins to form distinct, hybrid systems embedded in national cultures. These systems have seldom been studied despite their potential internationally to inform the local management of health care organizations. This article suggests six lessons from an 'ideal type' of one such system, New Zealand Māori quality improvement in health care. Mapped against 'mainstream' concepts of quality improvement, the lessons are to: emulate the character of leaders in health care; encourage 'cultural governance'; operate the health care organization as a 'family'; move forward with eyes on the past; foster spiritual health; and respect everything for itself. These lessons support a global struggle by indigenous peoples to have their national cultures reflected in programmes to improve their health care, and have potential relevance to mainstream services. By increasing cultural competence, responsiveness to indigenous health needs, and awareness of insights from another culture, the lessons reveal opportunities to improve quality by incorporating aspects of a Māori ideal type.

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.

While medical and technological advances continue to shape and advance health care, there has been growing emphasis on translating these advances into improvement in overall health care quality outcomes in the United States. Innovators such as Abraham Flexner and Ernest Codman engaged in rigorous reviews of systems and patient outcomes igniting wider spread interest in quality improvement in health care. Codman’s efforts even contributed to the founding of the American College of Surgeons. This society catalyzed a quality improvement initiative across the United States and the formation of the Joint Commission on Accreditation of Hospitals. Since that time, those such as Avedis Donabedian and the Institute of Medicine have worked to structure the process of improving both the quality and delivery of health care. Significant advances include the defining of minimum standards for hospital accreditation, 7 pillars of quality in medicine, and the process by which quality in medicine is evaluated. All of these factors have affected current practice more each day. In a field such as spinal surgery, cost and quality measures are continually emphasized and led to large outcome databases to better evaluate outcomes in complex, heterogeneous populations. Going forward, these databases will be instrumental in developing practice patterns and improving spinal surgery outcomes.