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Resources found: Medical literature = 50, Web resources = 4, Documents = 8.
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Medical literature
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Alexander, JA and Hearld LR.
Review: What Can We Learn From Quality Improvement Research?: A Critical Review of Research Methods.
Medical Care Research Review
2009;
66:
235-271.
Abstract
This article presents a systematic review of the research methods used to study quality
improvement (QI) effectiveness in health care organizations. The review relied on
existing literature as well as emergent themes to identify types of QI programs (e.g.,
data/feedback, information technology, staff education) and quality outcomes (e.g.,
mortality, morbidity, unnecessary variation). Studies were separated into four categories
according to the type of organization in which the QI program was introduced:
(a) hospital, (b) nursing home, (c) physician group, and (d) other health care organization.
Results of the review indicate that most QI effectiveness research is conducted in
hospital settings, is focused on multiple QI interventions, and utilizes process measures
as outcomes. The review also yielded substantial variation with respect to the study
designs used to examine QI effectiveness. The article concludes with a critique of these
designs and suggestions for ways future research could address these shortcomings.
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Alexander, JA et al.
Increasing the relevance of research to health care managers: Hospital CEO imperatives for improving quality and lowering costs.
Health Care Management Review
2007;
32:
150-159.
Abstract
Background: Evidence-based management assumes that available research
evidence is consistent with the problems and decision-making conditions faced by
those who will utilize this evidence in practice.
Purpose: This article attempts to identify how hospital leaders view key
determinants of hospital quality and costs, as well as the fundamental ways these
leaders ‘‘think’’ about solutions to quality and cost issues in their organizations.
The objective of this analysis is to better inform the research agenda and
approaches pursued by health services research so that this research reflects the
‘‘realities’’ of practice in hospitals.
Methods: We conducted a series of semistructured interviews with a
convenience sample of eight hospital and three health system leaders.
Questions focused on current and future challenges facing hospitals as they
relate to hospital quality, costs, and efficiency, and potential solutions to
those challenges.
Findings: Nine major organizational and managerial factors emerged from the
interviews, including staffing, evidence-based practice, information
technology, data availability and benchmarking, and leadership. Hospital leaders
tend to think about these factors systemically and consider process-related
factors as the important drivers of cost and quality.
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Auerbach AD, Landefeld S, Shojania KG.
The Tension between Needing to Improve Care and Knowing How to Do It.
N Engl J Med
2007;
357:
608 - 613.
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Berwick, D.
The Science of Improvement.
Journal of American Medical Association
2008;
299:
1182-1184.
Abstract
Commentary
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Blumenthal D.
Employer-Sponsored Insurance — Riding the Health Care Tiger.
N Engl J Med
2006;
355:
195-202.
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Bowman, Sobo, Asch, Gifford.
Measuring persistence of implementation: QUERI Series.
Implementation Science
2008;
3:
Abstract
As more quality improvement programs are implemented to achieve gains in performance, the
need to evaluate their lasting effects has become increasingly evident. However, such long-term
follow-up evaluations are scarce in healthcare implementation science, being largely relegated to
the "need for further research" section of most project write-ups. This article explores the variety
of conceptualizations of implementation sustainability, as well as behavioral and organizational
factors that influence the maintenance of gains. It highlights the finer points of design considerations
and draws on our own experiences with measuring sustainability, framed within the rich theoretical
and empirical contributions of others. In addition, recommendations are made for designing
sustainability analyses.
This article is one in a Series of articles documenting implementation science frameworks and
approaches developed by the U.S. Department of Veterans Affairs Quality Enhancement Research
Initiative (QUERI).
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Cable, G.
Enhancing causal interpretations of quality improvement interventions.
Quality in Health Care
2001;
10:
179-186.
Abstract
In an era of chronic resource scarcity it is
critical that quality improvement professionals
have confidence that their project
activities cause measured change. A commonly
used research design, the single
group pre-test/post-test design, provides
little insight into whether quality improvement
interventions cause measured
outcomes. A re-evaluation of a quality
improvement programme designed to reduce
the percentage of bilateral cardiac
catheterisations for the period from January
1991 to October 1996 in three catheterisation
laboratories in a north eastern
state in the USA was performed using an
interrupted time series design with
switching replications. The accuracy and
causal interpretability of the findings were
considerably improved compared with the
original evaluation design. Moreover, the
re-evaluation provided tangible evidence
in support of the suggestion that more
rigorous designs can and should be more
widely employed to improve the causal
interpretability of quality improvement
eVorts. Evaluation designs for quality
improvement projects should be constructed
to provide a reasonable opportunity,
given available time and resources,
for causal interpretation of the results.
Evaluators of quality improvement initiatives
may infrequently have access to randomised
designs. Nonetheless, as shown
here, other very rigorous research designs
are available for improving causal interpretability.
Unilateral methodological
surrender need not be the only alternative
to randomised experiments.
(Quality in Health Care 2001;10:179–186)
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Crofts JF, Ellis D, Draycott TJ, Winter C, Hunt LP, Akande VA..
Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomized controlled trial of local hospital, simulation centre and teamwork training.
BJOG
2007;
114:
1534-1541.
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Damschroder, LJ et al.
Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science.
Implementation Science
2009;
4:
1-15.
Abstract
Background: Many interventions found to be effective in health services research studies fail to translate into meaningful
patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative
outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs
sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help
promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a
comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology
and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research
(CFIR) that offers an overarching typology to promote implementation theory development and verification about what works
where and why across multiple contexts.
Methods: We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based
on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our
own findings, and potential for measurement. We combined constructs across published theories that had different labels but
were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts.
Results: The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics
of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g.,
evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12
constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related
to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present
explicit definitions for each construct.
Conclusion: The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of
constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories.
It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.
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Davidoff, F and Batalden, P.
Toward stronger evidence on quality improvement. Draft publication guidelines: the beginning of a consensus project.
Qual. Saf. Health Care
2005;
14:
319-325.
Abstract
In contrast with the primary goals of science, which are
to discover and disseminate new knowledge, the primary
goal of improvement is to change performance.
Unfortunately, scholarly accounts of the methods,
experiences, and results of most medical quality
improvement work are not published, either in print or
electronic form. In our view this failure to publish is a
serious deficiency: it limits the available evidence on
efficacy, prevents critical scrutiny, deprives staff of the
opportunity and incentive to clarify thinking, slows
dissemination of established improvements, inhibits
discovery of innovations, and compromises the ethical
obligation to return valuable information to the public.
The reasons for this failure are many: competing service
responsibilities of and lack of academic rewards for
improvement staff; editors’ and peer reviewers’
unfamiliarity with improvement goals and methods; and
lack of publication guidelines that are appropriate for
rigorous, scholarly improvement work. We propose here
a draft set of guidelines designed to help with writing,
reviewing, editing, interpreting, and using such reports.
We envisage this draft as the starting point for
collaborative development of more definitive guidelines.
We suggest that medical quality improvement will not
reach its full potential unless accurate and transparent
reports of improvement work are published frequently
and widely.
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Davidoff, F. et al.
Publication guidelines for quality improvement in health care: evolution of the SQUIRE project.
Quality and Safety in Health Care
2008;
17:
i3-i9.
Abstract
In 2005, draft guidelines were published for reporting
studies of quality improvement interventions as the initial
step in a consensus process for development of a more
definitive version. This article contains the full revised
version of the guidelines, which the authors refer to as
SQUIRE (Standards for QUality Improvement Reporting
Excellence). This paper also describes the consensus
process, which included informal feedback from authors,
editors and peer reviewers who used the guidelines;
formal written commentaries; input from a group of
publication guideline developers; ongoing review of the
literature on the epistemology of improvement and
methods for evaluating complex social programmes; a
two-day meeting of stakeholders for critical discussion
and debate of the guidelines’ content and wording; and
commentary on sequential versions of the guidelines from
an expert consultant group. Finally, the authors consider
the major differences between SQUIRE and the initial draft
guidelines; limitations of and unresolved questions about
SQUIRE; ancillary supporting documents and alternative
versions that are under development; and plans for
dissemination, testing and further development of
SQUIRE.
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Declan Devane, RM, RNT, PgDip(Stats), MSc, Cecily M. Begley, RM, MSc, PhD, FTCD, Mike Clarke, BA(Oxon), DPhil, Dell Horey, PhD,MMedSc(ClinEpi), BAppSc(Chem), and Colm OBoyle, RM, RNT, PhDipCHSE, MSc.
Evaluating Maternity Care: A Core Set of Outcome Measures.
Birth
2007;
34:
164-172.
Abstract
Background: Comparing the relative effectiveness of interventions on specific
outcomes across trials can be problematic due to differences in the choice and definitions of outcome
measures used by researchers. We sought to identify a minimum set of outcome measures for
evaluating models of maternity care from the perspective of key stakeholders. Methods: A 3-round,
electronic Delphi survey design was used. Setting was multinational, comprising a range of key
stakeholders. Participants consisted of a single heterogeneous panel of maternity service users,
midwives, obstetricians, pediatricians/neonatologists, family physicians/general practitioners, policymakers,
service practitioners, and researchers of maternity care. Members of the panel self-assessed
their expertise in evaluating models of maternity care. Results: A total of 320 people from 28
countries expressed willingness to take part in this survey. Round 1 was completed by 218 (68.1%)
participants, of whom 173 (79.4%) completed round 2 and 152 (87.9%) of these completed round 3.
Fifty outcomes were identified, with both a mean value greater than the overall group mean for all
outcomes combined (x= 4.18) and rated 4 or more on a 5-point Likert-type scale for importance of
inclusion in a minimum data set of outcome measures by at least 70 percent of respondents. Three
outcomes were collapsed into a single outcome so that the final minimum set includes 48 outcomes.
Conclusions: Given the inconsistencies in the choice of outcome measures routinely collected and
reported in randomized evaluations of maternity care, it is hoped that use of the data set will increase
the potential for national and international comparisons of models for maternity care. Although not
intended to be prescriptive or to inhibit the collection of other outcomes, we hope that the core set will
make it easier to assess the care of women and their babies during pregnancy and childbirth. (BIRTH
34:2 June 2007)
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Diaz M, Neuhauser D.
Pasteur and Parachutes: When Statistical Process Control is Better than a Randomized Controlled Trial.
Qual Saf Health Care
2005;
14:
140-143.
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Dückers, Michel LA, Cordula Wagner and Peter P Groenewegen.
Developing and testing an instrument to measure the presence of conditions for successful implementation of quality improvement collaboratives.
BMC Health Services Research
2008;
8:
Abstract
Background: In quality improvement collaboratives (QICs) teams of practitioners from different
health care organizations are brought together to systematically improve an aspect of patient care.
Teams take part in a series of meetings to learn about relevant best practices, quality methods and
change ideas, and share experiences in making changes in their own local setting. The purpose of
this study was to develop an instrument for measuring team organization, external change agent
support and support from the team's home institution in a Dutch national improvement and
dissemination programme for hospitals based on several QICs.
Methods: The exploratory methodological design included two phases: a) content development
and assessment, resulting in an instrument with 15 items, and b) field testing (N = 165). Internal
consistency reliability was tested via Cronbach's alpha coefficient. Principal component analyses
were used to identify underlying constructs. Tests of scaling assumptions according to the multi
trait/multi-item matrix, were used to confirm the component structure.
Results: Three components were revealed, explaining 65% of the variability. The components
were labelled 'organizational support', 'team organization' and 'external change agent support'. One
item not meeting item-scale criteria was removed. This resulted in a 14 item instrument. Scale
reliability ranged from 0.77 to 0.91. Internal item consistency and divergent validity were
satisfactory.
Conclusion: On the whole, the instrument appears to be a promising tool for assessing team
organization and internal and external support during QIC implementation. The psychometric
properties were good and warrant application of the instrument for the evaluation of the national
programme and similar improvement programmes.
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Dückers, Michel LA; Peter Spreeuwenberg, Cordula Wagner and Peter P Groenewegen.
Exploring the black box of quality improvement collaboratives: modelling relations between conditions, applied changes and outcomes.
Implementation Science
2009;
4:
Abstract
Introduction: Despite the popularity of quality improvement collaboratives (QICs) in different
healthcare settings, relatively little is known about the implementation process. The objective of
the current study is to learn more about relations between relevant conditions for successful
implementation of QICs, applied changes, perceived successes, and actual outcomes.
Methods: Twenty-four Dutch hospitals participated in a dissemination programme based on
QICs. A questionnaire was sent to 237 leaders of teams who joined 18 different QICs to measure
changes in working methods and activities, overall perceived success, team organisation, and
supportive conditions. Actual outcomes were extracted from a database with team performance
indicator data. Multi-level analyses were conducted to test a number of hypothesised relations
within the cross-classified hierarchical structure in which teams are nested within QICs and
hospitals.
Results: Organisational and external change agent support is related positively to the number of
changed working methods and activities that, if increased, lead to higher perceived success and
indicator outcomes scores. Direct and indirect positive relations between conditions and
perceived success could be confirmed. Relations between conditions and actual outcomes are
weak. Multi-level analyses reveal significant differences in organisational support between hospitals.
The relation between perceived successes and actual outcomes is present at QIC level but not at
team level.
Discussion: Several of the expected relations between conditions, applied changes and outcomes,
and perceived successes could be verified. However, because QICs vary in topic, approach,
complexity, and promised advantages, further research is required: first, to understand why some
QIC innovations fit better within the context of the units where they are implemented; second, to
assess the influence of perceived success and actual outcomes on the further dissemination of
projects over new patient groups.
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Fung CH, Lim YW, Mattke S, Damberg C, Shekelle PG.
Systematic review: the evidence that publishing patient care performance data improves quality of care.
Ann Intern Med
2008;
148:
111-123.
Abstract
BACKGROUND: Previous reviews have shown inconsistent effects of publicly reported performance data on quality of care, but many new studies have become available in the 7 years since the last systematic review. PURPOSE: To synthesize the evidence for using publicly reported performance data to improve quality. DATA SOURCES: Web of Science, MEDLINE, EconLit, and Wilson Business Periodicals (1999-2006) and independent review of articles (1986-1999) identified in a previous systematic review. Only sources published in English were included. STUDY SELECTION: Peer-reviewed articles assessing the effects of public release of performance data on selection of providers, quality improvement activity, clinical outcomes (effectiveness, patient safety, and patient-centeredness), and unintended consequences. DATA EXTRACTION: Data on study participants, reporting system or level, study design, selection of providers, quality improvement activity, outcomes, and unintended consequences were extracted. DATA SYNTHESIS: Forty-five articles published since 1986 (27 of which were published since 1999) evaluated the impact of public reporting on quality. Many focus on a select few reporting systems. Synthesis of data from 8 health plan-level studies suggests modest association between public reporting and plan selection. Synthesis of 11 studies, all hospital-level, suggests stimulation of quality improvement activity. Review of 9 hospital-level and 7 individual provider-level studies shows inconsistent association between public reporting and selection of hospitals and individual providers. Synthesis of 11 studies, primarily hospital-level, indicates inconsistent association between public reporting and improved effectiveness. Evidence on the impact of public reporting on patient safety and patient-centeredness is scant. LIMITATIONS: Heterogeneity made comparisons across studies challenging. Only peer-reviewed, English-language articles were included. CONCLUSION: Evidence is scant, particularly about individual providers and practices. Rigorous evaluation of many major public reporting systems is lacking. Evidence suggests that publicly releasing performance data stimulates quality improvement activity at the hospital level. The effect of public reporting on effectiveness, safety, and patient-centeredness remains uncertain.
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Gawande A.
Annals of Medicine: The Checklist.
The New Yorker
2007;
Abstract
Download
This is an essay on the use of checklists in medical quality improvement and profiles Peter Pronovost's translational research in their use in ICUs. Atul Gawande's writing style works wonderfully for both lay and professional audiences.
This is a great tool to use when introducing a checklist into a new medical service.
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Glasgow RE, Magid DJ, Beck A, Ritzwoller D, Estabrooks PA. .
Practical clinical trials for translating research to practice.
Medical Care
2005;
43:
551-557.
Abstract
Rationale: There is a pressing need for practical clinical trials
(PCTs) that are more relevant to clinicians and decision-makers, but
many are unaware of these trials. Furthermore, such trials can be
challenging to conduct and to report.
Objective: The objective of this study was to build on the seminal
paper by Tunis et al (Practical clinical trials. Increasing the value of
clinical research for decision making in clinical and health policy.
JAMA. 2003;290:1624 –1632.) and to provide recommendations and
examples of how practical clinical trials can be conducted and the
results reported to enhance external validity without sacrificing
internal validity.
Key Issues: We discuss evaluating practical intervention options,
alternative research designs, representativeness of samples participating
at both the patient and the setting/clinician level, and the need
for multiple outcomes to address clinical and policy implications.
Conclusions: We provide a set of specific recommendations for
issues to be reported in PCTs to increase their relevance to clinicians
and policymakers, and to help reduce the gap between research and
practice.
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Greenhalgh T, Robert G, Macfarlane F, Bate P, Kriakidou O.
Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations.
The Milbank Quarterly
2004;
82:
581 - 629.
Abstract
This article summarizes an extensive literature review addressing the question, How can we spread and sustain innovations in health service delivery and organization? It considers both content (defining and measuring the diffusion of innovation in organizations) and process (reviewing the literature in a systematic and reproducible way). This article discusses (1) a parsimonious and evidence-based model for considering the diffusion of innovations in health service organizations, (2) clear knowledge gaps where further research should be focused, and (3) a robust and transferable methodology for systematically reviewing health service policy and management. Both the model and the method should be tested more widely in a range of contexts.
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Herbert C, Neuhauser D.
Improving Hypertension Care with Patient-generated Run Charts: Physician, Patient, and Management Perspectives.
Q Manage Health Care
2004;
13:
174-177.
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Ibarra V, Titler MG, Reiter RC.
Issues in the development and implementation of clinical pathways.
AACN Clin Issues
1996;
7:
436-47.
Abstract
Issues related to the development and implementation of clinical pathways require thoughtful planning, collaborative teamwork, and an understanding of the evolutionary nature of this work. Creating an understanding of the purpose behind the development of these guidelines often is only the first issue to be considered. Other common issues include physician involvement, documentation, pathway development, variance data analysis and feedback, and integration with outcomes management activities. Successfully addressing these issues is an ongoing component of a clinical pathway program.
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Jamtvedt G, Young JM, Kristoffersen DT, O'Brien MA, Oxman AD.
Audit and Feedback: Effects on Professional Practice and Health Care Outcomes.
Cochrane Database of Systematic Reviews
2006;
1:
Abstract
Download
Background: Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not consistently been found to be effective.
Objectives: To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes.
Search strategy: We searched the Cochrane Effective Practice and Organisation of Care Group's register and pending file up to January 2004.
Selection criteria: Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes.
Data collection and analysis: Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken. For each comparison we calculated the risk difference (RD) and risk ratio (RR), adjusted for baseline compliance when possible, for dichotomous outcomes and the percentage and the percent change relative to the control group average after the intervention, adjusted for baseline performance when possible, for continuous outcomes. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: the type of intervention (audit and feedback alone, audit and feedback with educational meetings, or multifaceted interventions that included audit and feedback), the intensity of the audit and feedback, the complexity of the targeted behaviour, the seriousness of the outcome, baseline compliance and study quality.
Main results: Thirty new studies were added to this update, and a total of 118 studies are included. In the primary analysis 88 comparisons from 72 studies were included that compared any intervention in which audit and feedback is a component compared to no intervention. For dichotomous outcomes the adjusted risk difference of compliance with desired practice varied from - 0.16 (a 16 % absolute decrease in compliance) to 0.70 (a 70% increase in compliance) (median = 0.05, inter-quartile range = 0.03 to 0.11) and the adjusted risk ratio varied from 0.71 to 18.3 (median = 1.08, inter-quartile range = 0.99 to 1.30). For continuous outcomes the adjusted percent change relative to control varied from -0.10 (a 10 % absolute decrease in compliance) to 0.68 (a 68% increase in compliance) (median = 0.16, inter-quartile range = 0.05 to 0.37). Low baseline compliance with recommended practice and higher intensity of audit and feedback were associated with larger adjusted risk ratios (greater effectiveness) across studies.
Authors' conclusions: Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The relative effectiveness of audit and feedback is likely to be greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively.
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Kinsman L, James E, Ham J.
An interdisciplinary, evidence-based process of clinical pathway implementation increases pathway usage.
Lippincotts Case Manag
2004;
9:
184-96.
Abstract
Clinical pathways have been implemented in many healthcare settings as a link between evidence and practice. Most published research concludes that when clinical pathways are implemented and used by health professionals, there is a positive impact on health outcomes. However, some research also suggests that utilization of clinical pathways by health professionals is low and that implementation strategies for linking evidence with clinical practice often prove to be weak or ineffective. This paper describes a before and after study to determine whether an interdisciplinary, genuinely collaborative, and evidence-based process of clinical pathway implementation resulted in increased documented use of an acute myocardial infarction (AMI) clinical pathway by health professionals in a regional Australian hospital. Underpinning the design and implementation process was the belief that true team involvement would lead to ownership, acceptance, and, ultimately, to increased usage of the pathway. Documented clinical pathway usage was measured in two ways: (1) the presence of the AMI clinical pathway in the medical records of patients diagnosed with an AMI and (2) the proportion of the AMI clinical pathway completed when it was present in the medical record. A total of 195 medical records of those diagnosed with an AMI were audited before (n = 124) and after (n = 71) the implementation process. The interdisciplinary, truly collaborative, and evidence-based implementation process resulted in a statistically significant increase in documented usage of the AMI pathway (22.6% vs. 57.7%; p <.000). Results indicate that involvement of key users in the design and implementation of a clinical pathway significantly increases staff utilization of the document.
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Kinsman L, James EL.
Evidence-based practice needs evidence-based implementation.
Lippincotts Case Manag
2001;
6:
208-16.
Abstract
Clinical pathways have been designed to provide an effective interface between evidence and practice in healthcare. Strong evidence supports the assertion that when clinical pathways are utilized they improve outcomes. However, published evidence measuring the uptake of clinical pathways by health professionals remains sparse. This article presents a study evaluating the degree of documented compliance with the clinical pathway chart used for patients diagnosed with an acute myocardial infarction (AMI) in a major Australian regional hospital. The relationships between compliance and demographic and illness were also examined. Data were collected from 124 records with the result that the level of documented compliance was 16.5%. Clients with private health insurance had significantly higher documented compliance with the clinical pathway than those with no private health insurance. There were also significant variations in documented compliance according to the type of AMI recorded. Recommendations to improve compliance with clinical pathways are included along with recommendations for future research.
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Lammers, JC; Cretin, S; Gilman, S; Calingo, E.
TQM in Hospitals: Contributions of Commitment, Quality Councils, Teams, Budgets, and Training to Perceived Improvement at Veteran's Health Administration Hospitals.
Medical Care
1996;
34:
463-478.
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Leape LL, Berwick DM.
Five Years After To Err Is Human, What Have We Learned?.
JAMA
2005;
293:
2384-2390.
Abstract
Five years ago, the Institute of Medicine (IOM) called for a national effort
to make health care safe. Although progress since then has been slow, the
IOM report truly “changed the conversation” to a focus on changing systems,
stimulated a broad array of stakeholders to engage in patient safety,
and motivated hospitals to adopt new safe practices. The pace of change is
likely to accelerate, particularly in implementation of electronic health records,
diffusion of safe practices, team training, and full disclosure to patients
following injury. If directed toward hospitals that actually achieve high
levels of safety, pay for performance could provide additional incentives. But
improvement of the magnitude envisioned by the IOM requires a national
commitment to strict, ambitious, quantitative, and well-tracked national goals.
The Agency for Healthcare Research and Quality should bring together all
stakeholders, including payers, to agree on a set of explicit and ambitious
goals for patient safety to be reached by 2010.
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Lozeau D, Langley A, Denis JL.
The Corruption of Managerial Techniques by Organizations.
Human Relations
2002;
55:
537 - 564.
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Marsteller, Jill A.; Shortell, Stephen M.; Lin, Michael; Mendel, Peter; Dell, Elizabeth; Wang, Stephanie; Cretin, Shan; Pearson, Marjorie L.; Wu, Shin-Yi; Rosen, Mayde.
How Do Teams in Quality Improvement Collaboratives Interact?.
Joint Commission Journal on Quality and Patient Safety
2007;
33:
267-276.
Abstract
Background: The multi-organizational collaborative is a popular model for quality improvement (QI) initiatives. It assumes organizations will share information and social support. However, there is no comprehensive documentation of the extent to which teams do interact. Considering QI collaboratives as networks, interactions among teams were documented, and the associations between network roles and performance were examined.
Methods: A telephone survey of official team contact persons for 94 site teams in three QI collaboratives was conducted in 2002 and 2003. Four performance measures
were used to assess the usefulness of ties to other teams and being considered a leader by peers.
Results: Eighty percent of the teams said they would contact another team again if they felt the need. Teams made a change as a direct result of interaction in 86% of reported relationships. Teams typically exchanged tools such as software and interacted outside of planned activities. Having a large number of ties to other teams is strongly related to the number of mentions as a leader. Both of these variables are related to faculty-assessed performance, number of changes the team made to improve care, and depth of those changes.
Discussion: The findings suggest that collaborative teams do indeed exchange important information, and the social dynamics of the collaboratives contribute to individual and collaborative success.
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Mello MM, Studdert DM, Kachalia AB, Brennan TA.
"Health courts" and accountability for patient safety.
Milbank Q
2006;
84:
459-92.
Abstract
Proposals that medical malpractice claims be removed from the tort system and processed in an alternative system, known as administrative compensation or "health courts," attract considerable policy interest during malpractice "crises," including the current one. This article describes current proposals for the design of a health court system and the system's advantages for improving patient safety. Among these advantages are the cultivation of a culture of transparency regarding medical errors and the creation of mechanisms to gather and analyze data on medical injuries. The article discusses the experiences of foreign countries with administrative compensation systems for medical injury, including their use of claims data for research on patient safety; choices regarding the compensation system's relationship to physician disciplinary processes; and the proposed system's possible limitations.
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Mello MM, Studdert DM, Thomas EJ et al.
Who Pays for Medical Errors?: An Analysis of Adverse Event Costs, the Medical Liability System, and Incentives for Patient Safety Improvement.
Journal of Empirical Legal Studies
2007;
4:
835-60.
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Mercer, Shawna L. MSc, PhD, Barbara J. DeVinney, PhD, Lawrence J. Fine, MD, DrPH, Lawrence W. Green, DrPH, Denise Dougherty, PhD.
Study Designs for Effectiveness and Translation Research Identifying Trade-offs.
Am J Prev Med
2007;
33:
139-154.
Abstract
Background: Practitioners and policymakers need credible evidence of effectiveness to justify allocating
resources to complex, expensive health programs. Investigators, however, face challenges
in designing sound effectiveness and translation research with relevance for “real-world”
settings.
Methods: Research experts and federal and foundation funders (n!"120) prepared for and
participated in a symposium, held May 4–5, 2004, to weigh the strengths, limitations, and
trade-offs between alternate designs for studying the effectiveness and translation of
complex, multilevel health interventions.
Results: Symposium attendees acknowledged that research phases (hypothesis generating, efficacy,
effectiveness, translation) are iterative and cyclical, not linear, since research in advanced
phases may reveal unanswered questions in earlier phases. Research questions thus always
need to drive the choice of study design. When randomization and experimental control
are feasible, participants noted that the randomized controlled trial with individual
random assignment remains the gold standard for safeguarding internal validity. Attendees
highlighted trade-offs of randomized controlled trial variants, quasi-experimental designs,
and natural experiments for use when randomization or experimental control or both are
impossible or inadequately address external validity. Participants discussed enhancements
to all designs to increase confidence in causal inference while accommodating greater
external validity. Since no single study can establish causality, participants encouraged
replication of studies and triangulation using different study designs. Participants also
recommended participatory research approaches for building population relevance,
acceptability, and usefulness.
Conclusions: Consideration of the study design choices, trade-offs, and enhancements discussed here
can guide the design, funding, completion, and publication of appropriate policy- and
practice-oriented effectiveness and translational research for complex, multilevel health
interventions.
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Neuhauser D, Diaz M.
Daniel: Using the Bible to Teach Quality Improvement Methods.
Qual Saf Health Care
2004;
13:
153-155.
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Neuhauser D, Diaz M.
Quality Improvement Research: Are Randomised Trials Necessary?.
Qual Saf Health Care
2007;
16:
77-80.
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Ormes, WS, Brim, MB, Coggan, P.
Quantitative Study Designs Used in Quality Improvement and Assessment.
Journal for Healthcare Quality
2001;
23:
Abstract
This article describes common quantitative design techniques that can be used to collect and analyze quality data. An understanding of the differences between these design techniques can help healthcare quality professionals make the most efficient use of their time, energies, and resources. To evaluate the advantages and disadvantages of these various study designs, it is necessary to assess factors that threaten the degree with which quality professionals may infer a cause-and-effect relationship from the data collected. Processes, the conduits of organizational function, often can be assessed by methods that do not take into account confounding and compromising circumstances that affect the outcomes of their analyses. An assumption that the implementation of process improvements may cause real change is incomplete without a consideration of other factors that might also have caused the same result. It is only through the identification, assessment, and exclusion of these alternative factors that administrators and healthcare quality professionals can assess the degree to which true process improvement or compliance has occurred. This article describes the advantages and disadvantages of common quantitative design techniques and reviews the corresponding threats to the interpretability of data obtained from their use.
PMID: 11378972 [PubMed - indexed for MEDLINE]
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Pearson, ML; Wu, S; Schaefer, J; Bonomi, AE; Shortell, SM; Mendel, PJ; Marsteller, JA; Louis, TA; Rosen, M; Keeler, EB.
Assessing Implementation of Chronic Care Model in QI Collaboratives.
Health Services Research
2005;
40:
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Pronovost PJ, Berenholtz SM, Goeschel CA, Needham DM, Sexton JB, Thompson DA, Lubomski LH, Marstellar JA, Makary MA, Hunt E.
Creating High Reliability in Health Care Organizations.
Health Services Research
2006;
41:
1599 - 1617.
Abstract
OBJECTIVE: The objective of this paper was to present a comprehensive approach to help health care organizations reliably deliver effective interventions. CONTEXT: Reliability in healthcare translates into using valid rate-based measures. Yet high reliability organizations have proven that the context in which care is delivered, called organizational culture, also has important influences on patient safety. MODEL FOR IMPROVEMENT: Our model to improve reliability, which also includes interventions to improve culture, focuses on valid rate-based measures. This model includes (1) identifying evidence-based interventions that improve the outcome, (2) selecting interventions with the most impact on outcomes and converting to behaviors, (3) developing measures to evaluate reliability, (4) measuring baseline performance, and (5) ensuring patients receive the evidence-based interventions. The comprehensive unit-based safety program (CUSP) is used to improve culture and guide organizations in learning from mistakes that are important, but cannot be measured as rates. CONCLUSIONS: We present how this model was used in over 100 intensive care units in Michigan to improve culture and eliminate catheter-related blood stream infections--both were accomplished. Our model differs from existing models in that it incorporates efforts to improve a vital component for system redesign--culture, it targets 3 important groups--senior leaders, team leaders, and front line staff, and facilitates change management-engage, educate, execute, and evaluate for planned interventions.
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Shortell, SM; O'Brien, JL; Carman, JM; Foster, RW; Hughes, EFX; Boerstler, H; O'Connor, EJ.
Assessing Impact of Continuous QI/TQM: Concept Versus Implementation.
Health Services Research
1995;
30:
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Shortell, SS; Bennett, CL; Byck, GR.
Assessing Impact of Continuous QI on Clinical Practice: What Will it Take to Accelerate Progress.
Milbank Quarterly
1998;
76:
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Sobo, EJ; Bowman, C; Gifford, AL.
Behind the scenes in health care improvement: The complex structures and emergent strategies of Implementation Science.
Social Science and Medicine
2008;
67:
1530-1540.
Abstract
Implementation Science (IS) is a new branch of health services research (HSR) that strives
to increase the efficiency and effectiveness of health care quality improvement (QI) efforts.
Despite the fact that IS takes a systems approach, building contextual factors into its
research designs, the complex systems context of IS itselfdand the impact this context has
on IS practicedhas never been scrutinized. Using individual interviews and participant
observation, the research described here characterizes key contextual factors affecting how
implementation scientists in one large health care organization approach and conduct
their research. Some of the organizational and professional system forces structuring their
attitudes and actions were grant-related timelines, administrative burdens, and team
turnover. The need for publications also figured highly. While such pressures (and related
responses to them) may be rife in most grant-funded health care research settings, IS’s
particularly marginal position drove these implementation scientists to strategically
highlight particular aspects of their work depending on which audience or part of the
system they required favor from. Their narratives illuminate the contradictions and
contests entailed within and engendered by organizational and professional structures,
and the strategies used to negotiate these. They also reveal a great deal about the struggles
underwriting disciplinary identity claims in a complex systems context.
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Subramanian, U et al.
Facility-Level Factors Influencing Chronic Heart Failure Care Process Performance in a National Integrated Health Delivery System.
Medical Care
2007;
45:
28-45.
Abstract
Background: Gaps between evidence and practice in the care of
patients with chronic heart failure (CHF) in the United States
suggest major opportunities for improvement. However, the organizational
factors and implementation approaches that influence adherence
to national guidelines are poorly understood.
Objectives: The objectives of this study were to explore the degree
to which providers in the Veterans Health Administration system
adhere to CHF clinical practice guidelines, and to identify facilitylevel
factors influencing adherence.
Design: In a national cross-sectional study, facility quality managers
were surveyed regarding quality improvement efforts, guideline
implementation, and context. These data were linked to organizational
structure data and provider adherence data from chart reviews.
The unit of analysis was the facility. The data were adjusted for the
average number of comorbidities per CHF patient. Multivariate
logistic regression models were constructed to model factors affecting
adherence to CHF guidelines.
Sample: The sample consisted of 143 Veterans Administration
Medical Centers with ambulatory care clinics.
Results: The quality manager survey included data from 91% of
facilities. Facility-level estimates of provider adherence measures were,
on average, 85% or more for most measures. In multivariate analyses,
facilities with higher levels of adherence were more likely to have: (1)
providers who had been given a brief guideline summary, (2) providers
receptive to the guidelines, (3) guideline-specific task forces to support
implementation, and 4) a well-planned implementation process.
Conclusions: Healthcare organizations should adapt implementation
to meet local conditions, including creating guideline-specific task
forces, developing a well-planned implementation process, fostering
provider buy-in, and providing guideline summaries to providers.
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The Joint Commission.
Behaviors that undermine a culture of safety.
The Joint Commission, Sentinel Event
2008;
40:
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van den Berg, Mireille, Rianne Frenken and Roland Bal.
Quantitative data management in quality improvement collaboratives.
BMC Health Services Research
2009;
9:
Abstract
Background: Collaborative approaches in quality improvement have been promoted since the
introduction of the Breakthrough method. The effectiveness of this method is inconclusive and
further independent evaluation of the method has been called for. For any evaluation to succeed,
data collection on interventions performed within the collaborative and outcomes of those
interventions is crucial. Getting enough data from Quality Improvement Collaboratives (QICs) for
evaluation purposes, however, has proved to be difficult. This paper provides a retrospective
analysis on the process of data management in a Dutch Quality Improvement Collaborative. From
this analysis general failure and success factors are identified.
Discussion: This paper discusses complications and dilemma's observed in the set-up of data
management for QICs. An overview is presented of signals that were picked up by the data
management team. These signals were used to improve the strategies for data management during
the program and have, as far as possible, been translated into practical solutions that have been
successfully implemented.
The recommendations coming from this study are:
From our experience it is clear that quality improvement programs deviate from experimental
research in many ways. It is not only impossible, but also undesirable to control processes and
standardize data streams. QIC's need to be clear of data protocols that do not allow for change. It
is therefore minimally important that when quantitative results are gathered, these results are
accompanied by qualitative results that can be used to correctly interpret them.
Monitoring and data acquisition interfere with routine. This makes a database collecting data in a
QIC an intervention in itself. It is very important to be aware of this in reporting the results. Using
existing databases when possible can overcome some of these problems but is often not possible
given the change objective of QICs.
Introducing a standardized spreadsheet to the teams is a very practical and helpful tool in collecting
standardized data within a QIC. It is vital that the spreadsheets are handed out before baseline
measurements start.
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Wallin, Lars.
Knowledge translation and implementation research in nursing.
Int J Nursing Studies
2009;
2009:
576-587.
Abstract
What is already known about the topic?
Knowledge translation research in nursing is predominated
of descriptive studies.
A valid knowledge base for issuing recommendations on
implementation strategies is lacking.
What this paper adds?
A description of intervention strategies used in recent
implementation research in nursing.
An analysis and discussion of issues involved in the
evaluation of complex interventions for implementing
evidence-based practice.
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Walshe, K.
Understanding what works—and why—in quality improvement: the need for theory-driven evaluation.
International Journal for Quality in Health Care
2007;
19:
57-59.
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Waring, JJ.
Beyond blame: cultural barriers to medical incident reporting.
Social Science and Medicine
2005;
60:
1927-1935.
Abstract
The paper explores the attitudes of medical physicians towards adverse incident reporting in health care, with
particular focus on the inhibiting factors or barriers to participation. It is recognised that there are major barriers to
medical reporting, such as the ‘culture of blame’. There are, however, few detailed qualitative accounts of medical
culture as it relates to incident reporting. Drawing on a 2-year qualitative case study in the UK, this paper presents data
gathered from 28 semi-structured interviews with specialist physicians. The findings suggest that blame certainly inhibits
medical reporting, but other cultural issues were also significant. It was commonly accepted by doctors that errors are
an ‘inevitable’ and potentially unmanageable feature of medical work and incident reporting was therefore ‘pointless’. It
was also found that reporting was discouraged by an anti-bureaucratic sentiment and rejection of excessive
administrative duties. Doctors were also apprehensive about the increased potential for managers and non-physicians
to engage in the regulation of medical quality through the use of incident data. The paper argues that the promotion of
incident reporting must engage with more than the ubiquitous ‘culture of blame’ and instead address the ‘culture of
medicine’, especially as it relates to the collegial and professional control of quality.
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Waring, JJ.
Doctors’ thinking about ‘the system’ as a threat to patient safety.
Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine
2007;
11:
29-46.
Abstract
‘Systems thinking’ is an important feature of the emerging
‘patient safety’ agenda. As a key component of a ‘safety culture’, it encourages
clinicians to look past individual error to recognize the latent factors that
threaten safety. This article investigates whether current medical thinking is
commensurate with the idea of ‘systems thinking’ together with its implications
for policy. The fi ndings are based on qualitative semi-structured interviews with
specialist physicians working within one NHS District General Hospital in the
English Midlands. It is shown that, rather then favouring an individualized or
‘person-centred’ perspective, doctors readily identify ‘the system’ as a threat
to patient safety. This is not necessarily a refl ection of the prevailing safety
discourse or knowledge of policy, but refl ects a tacit understanding of how
services are (dis)organized. This line of thinking serves to mitigate individual
wrongdoing and protect professional credibility by encouraging doctors
to accept and accommodate the shortcomings of the system, rather than
participate in new forms of organizational learning.
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Waring, JJ.
A qualitative study of the intra-hospital variations in incident reporting.
International Journal for Quality in Health Care
2004;
16:
347-352.
Abstract
Objective. To determine the relationship between variations in hospital incident reporting and the corresponding attitudes and
participation of medical professionals.
Methods. An in-depth qualitative case study using semi-structured interviews with hospital managers and clinicians. Twelve
participants were theoretically sampled based on their involvement with clinical risk management and patient safety. Twentyfive
medical physicians and four risk leads were selected from the specialist hospital departments of Obstetrics, Anaesthesia,
General Surgery, Acute Medicine, and Rehabilitation. The data were analysed to develop a descriptive account of the intrahospital
variations in reporting and the associated attitudes of physicians.
Setting. The research was conducted in a single acute National Health Service Hospital Trust in the English Midlands.
Results. The qualitative data revealed significant variations in the intra-hospital organization of incident reporting between
medical specialities that corresponded with the attitudes and participation of medical staff. Specifically, it was found that medical
doctors were more inclined to report incidents where the process of reporting was localized and integrated within medical
rather than managerial systems of quality improvement. Underlying these variations, it is suggested that medical reporting is
more likely when physicians have greater control or ownership of incident reporting, as this fosters confidence in the purpose
of reporting, in particular its capacity to make meaningful service improvements whilst maintaining a sense of collegiality and
professionalism.
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Weick KE, Sutcliffe KM.
Hospitals as Cultures of Entrapment: A Re-Analysis of the British Royal Infirmary.
California Management Review
2003;
45:
73 - 84.
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West, MA et al.
The link between the management of employees and patient mortality in acute hospitals.
Int J Human Resource Management
2002;
13:
1299-1310.
Abstract
The relationship between human resource management practices and organizational
performance (including quality of care in health-care organizations) is an important
topic in the organizational sciences but little research has been conducted
examining this relationship in hospital settings. Human resource (HR) directors from sixtyone
acute hospitals in England (Hospital Trusts) completed questionnaires or interviews
exploring HR practices and procedures. The interviews probed for information about the
extensiveness and sophistication of appraisal for employees, the extent and sophistication
of training for employees and the percentage of staff working in teams. Data on patient
mortality were also gathered. The ndings revealed strong associations between HR
practices and patient mortality generally. The extent and sophistication of appraisal in the
hospitals was particularly strongly related, but there were links too with the sophistication
of training for staff, and also with the percentages of staff working in teams.
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Woolf, Steven H, Richard Grol, Allen Hutchinson, Martin Eccles and Jeremy Grimshaw.
Clinical guidelines: Potential benefits, limitations, and harms of clinical guidelines.
BMJ
1999;
318:
527–530.
Abstract
Visit
Over the past decade, clinical guidelines have increasingly become a familiar part of clinical practice. Every day, clinical decisions at the bedside, rules of operation at hospitals and clinics, and health spending by governments and insurers are being influenced by guidelines. As defined by the Institute of Medicine, clinical guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”1 They may offer concise instructions on which diagnostic or screening tests to order, how to provide medical or surgical services, how long patients should stay in hospital, or other details of clinical practice.
The broad interest in clinical guidelines that is stretching across Europe, North America, Australia, New Zealand, and Africa (box) has its origin in issues that most healthcare systems face: rising healthcare costs, fueled by increased demand for care, more expensive technologies, and an ageing population; variations in service delivery among providers, hospitals, and geographical regions and the presumption that at least some of this variation stems from inappropriate care, either overuse or underuse of services; and the intrinsic desire of healthcare professionals to offer, and of patients to receive, the best care possible. Clinicians, policy makers, and payers see guidelines as a tool for making care more consistent and efficient and for closing the gap between what clinicians do and what scientific evidence supports.
As guidelines diffuse into medicine, there are important lessons to learn from the firsthand experience of those who develop, evaluate, and use them.3 This article, the first of a four part series to reflect on these lessons, examines the potential benefits, limitations, and harms of clinical guidelines. Future articles will review lessons learned about their development,4 legal and emotional ramifications,5 and finally their implementation
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Web resources
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Girion, L.
More C-sections, more problems.
Los Angeles Times
2009;
Download
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Joint Commission.
Providing Culturally and Linguistically Competent Health Care.
Joint Commission
2005;
Visit
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Joint Commission.
Cultural Sensitivity.
Joint Commission
2007;
Visit
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The Commonwealth Fund.
Why Not the Best?.
Abstract
Visit
About WhyNotTheBest.org
WhyNotTheBest.org was created and is maintained by The Commonwealth Fund, a private foundation working toward a high performance health system. It is a free resource for health care professionals interested in tracking performance on various measures of health care quality. It enables organizations to compare their performance against that of peer organizations, against a range of benchmarks, and over time. Case studies and improvement tools spotlight successful improvement strategies of the nation’s top performers.
Currently, the site includes measures of hospital quality that are publicly reported on the Centers for Medicare and Medicaid Services Web site, Hospital Compare. Specifically, it includes 24 Hospital Quality Alliance measures that report how often hospitals deliver recommended care processes for the following four conditions: heart attack, heart failure, pneumonia, and surgical care improvement. In addition, it includes 10 measures from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which reports hospital patients’ satisfaction with their care. We will update these data sets four times a year. Data are included for nearly all U.S. hospitals, some 4,440. Click here to view the specific measures.
We will continue to add new measure sets and develop additional functionality over time. If you would like to stay informed of new data or features on WhyNotTheBest.org, please sign up for e-mail alerts. If you would like to provide feedback on the site or make a suggestion for improvement, please contact wntb@cmwf.org. If you are having technical problems with the site, please contact wntb-support@ipro.us.
For information on how we use these data to create composites measures and rank hospitals according to their performance levels, please visit the Methodology Section.
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Documents
(8) |
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Berwick, D.
The John Eisenberg Lecture: Health Services Research as a Citizen in Improvement.
Health Services Research
2005;
40:
Abstract
Arguably the greatest achievement of academic health services research of the
last half-century has created its greatest unmet challenge. The achievement is
to have documented beyond doubt the widespread defects in health care, even
in wealthy systems. The challenge is to discover what we need to know that we
do not now know in order to create much more effective systems of care.
Health services research has not yet been sufficiently helpful in meeting
the challenge of improving care in part because it has over-constrained both its
methods and its favorite topics. The cost of insisting on formal, classical,
summative, evaluative experimental designs in an uncertain, poorly understood,
nonlinear, system is, unfortunately, to maintain the status quo. When the
status quo is harmful, as health care is today, harm is not a theoretical problem.
It is real, and it is indecent. Health services research should become more
effectively part of the solution. To do that will require that we enrich our
portfolio of methods and broaden our agenda of inquiry. The scientific methods
that we need to enhance and dignify in academic settings will combine
formal classical methods with some pragmatic, immediate, and in many ways
more informative forms of learning and investigation.
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Berwick, D.
A user's manual for the IOM's 'quality chasm' report.
Health Affairs
2002;
21:
Abstract
Download
Fifteen months after releasing its report on patient safety (To Err Is Human), the Institute of Medicine released Crossing the Quality Chasm. Although less sensational than the patient safety report, the Quality Chasm report is more comprehensive and, in the long run, more important. It calls for improvements in six dimensions of health care performance: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity; and it asserts that those improvements cannot be achieved within the constraints of the existing system of care. It provides a rationale and a framework for the redesign of the US health care system at four levels: patients' experiences; the "Microsystems" that actually give care; the organizations that house and support Microsystems; and the environment of laws, rules, payment, accreditation, and professional training that shape organizational action.
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Berwick, D.
The Stories Beneath.
Medical Care
2007;
45:
Abstract
editorial
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Davidoff, F. et al.
Publication guidelines for quality improvement studies in health care: evolution of the SQUIRE project.
British Medical Journal
2009;
338:
Abstract
Studies of quality improvement are often poorly reported. The Standards for Quality Improvement Reporting Excellence (SQUIRE) Group describes how its guidelines could improve standards
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Draper, DA et al.
The Role of Nurses in Hospital Quality Improvement.
Center for Studying Health System Change
2008;
3:
Abstract
As the nation’s hospitals face increasing demands to participate in a wide range of quality improvement activities, the role and influence of nurses in these efforts is also increasing, according to a new study by the Center for Studying Health System Change (HSC). Hospital organizational
cultures set the stage for quality improvement and nurses’ roles in those activities. Hospitals with supportive leadership, a philosophy of quality as everyone’s responsibility, individual accountability, physician and nurse champions, and effective feedback reportedly offer greater promise for successful staff engagement in improvement activities.
Yet hospitals confront challenges with regard to nursing involvement, including: scarcity of nursing resources; difficulty engaging nurses at all levels—from bedside to management; growing demands to participate
in more, often duplicative, quality improvement activities; the burdensome nature of data collection and reporting; and shortcomings of traditional nursing education in preparing nurses for their evolving
role in today’s contemporary hospital setting. Because nurses are the key caregivers in hospitals, they can significantly influence the quality of care provided and, ultimately, treatment and patient outcomes.
Consequently, hospitals’ pursuit of high-quality patient care is dependent, at least in part, on their ability to engage and use nursing resources effectively, which will likely become more challenging as these resources become increasingly limited.
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Liebhaber, Allison; Debra A. Draper and Genna R. Cohen.
Hospital Strategies to Engage Physicians in Quality Improvement .
Center for Studying Health System Change
2009;
Abstract
In the last decade, growing evidence that the quality of U.S. health care is uneven at best has prompted greater attention to quality improvement, especially in the nation’s hospitals. While physicians are integral to hospital quality improvement efforts, focusing
physicians on these activities is challenging because of competing time and reimbursement
pressures. To overcome these challenges, hospitals need to employ a variety of strategies, according to a Center for Studying Health System Change (HSC) study of four communities—Detroit, Memphis, Minneapolis-St. Paul and Seattle. Hospital strategies include employing physicians; using credible data to identify areas that need improvement; providing visible support through hospital leadership; identifying and nurturing physician champions to help engage physician peers; and communicating the importance of physicians’ contributions. While hospitals are making gains in patient care quality, considerably more progress likely could be made through greater alignment
of hospitals and physicians working together on quality improvement.
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Pearson, ML; Wu, S; Schaefer, J; Bonomi, AE; Shortell, SM; Mendel, PJ; Marsteller, JA; Louis, TA; Rosen, M; Keeler, EB.
Methods: Assessing Implementation of Chronic Care Model in QI Collaboratives.
Rand Working Paper
2005;
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Reyes C.
Improving Maternal Health Care: The Next Generation of Research.
Agency for Healthcare Research and Quality
06/01/2002;
Visit
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