The State of Quality Improvement and Implementation Research Expert Views: Workshop Summary (2007) / Chapter Skim
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Appendix C Submitted Responses
Appendix C Submitted Responses
Pages 67-96
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From page 67... ...
a study of primary care interpreting services in a multiethnic area of London, and (2) a recently commenced study of Internetbased electronic patient records across the United Kingdom.
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From page 68... ...
a. If you think the type of evidence required for quality improvement differs from that in the rest of medicine, is it because you think quality improvement interventions intrinsically require less testing or that the need for action trumps the need for evidence?
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APPENDIX C • Evaluation (and much QI work) is decision oriented and (hence)
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, a compendium of systematic reviews of the evidence supporting more than 80 specific interventions aimed at improving patient safety (Shojania et al., 2001)
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Though I am still engaged in evidence synthesis work related to patient safety and health care quality, I have more recently become involved in leading an extensive qualitative research project in which we are interviewing senior administrators, physicians, nurses, pharmacists, patient safety officers, and information technologists at hospitals across Canada in order to identify barriers and facilitators in efforts to implement three widely recommended patient safety interventions. I have also participated in several studies led by my colleague in Ottawa, Dr.
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, so my research has necessarily involved closer ties with my hospital's administration. However, the Ottawa Hospital has also taken a special interest in patient research, funding its own Center for Patient Safety with a budget of approximately $100,000 per year.
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4. Do you think the type of evidence required for evaluating quality improvement interventions is fundamentally different from that required for interventions in clinical medicine?
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results. A patient safety example involves the removal of concentrated potassium chloride (KCl)
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Hypoglycemia represents an easily anticipated consequence of efforts to intensify diabetes care, but adverse consequences of many other improvement efforts have been less predictable, including errors introduced by computerized provider order entry (Koppel et al., 2005; Campbell et al., 2006; Ash et al., 2007) , bar coding (Patterson et al., 2002)
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However, the basic sciences in QI happen to be psychology, organizational theory, and human factors research, not molecular biology and physiology. Research in these basic sciences of QI may involve using qualitative research techniques or mixed-methods research techniques.
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When conclusive evidence about a practice has not emerged, we tend not to regard the practice as "established" or "standard of care." Thus, in the case of QI, individual hospitals may pursue promising strategies on the basis of scant evidence, including results of early "basic research," anecdotal reports of success, or face validity. However, just as clinical practices based on such limited evidence would never become broad standards of care, much less mandatory for accreditation or reimbursement, so with quality improvement: Widely disseminating a given QI strategy would require evidence in much the same way we would require in the rest of clinical medicine.
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. For instance, in order for a solution to the problem of resident work hours to be cost-effective, it would need to improve care more than any published safety intervention (Nuckols and Escarce, 2005)
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students. Another book that is now widely used for both practitioners and researchers of quality improvement is Improving Patient Care: Implementation of Change in Clinical Practice (Grol et al., 2005)
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methods are used in the average QI project, such as systematic reviews, variation and determinant studies, analysis of routine data, clinimetrics and psychometrics (in the development and validation of indicators and instruments to measure quality and change) , (cluster)
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a. If you think the type of evidence required for quality improvement differs from that in the rest of medicine, is it because you think quality improvement interventions intrinsically require less testing or that the need for action trumps the need for evidence?
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KFHP includes the insurance and financing activities; KFH owns large portions of the physical assets of the delivery system, including hospitals and clinics; and the PMGs are responsible for care delivery and overall medical management. KFHP and KFH are referred to collectively as Kaiser Foundation Health Plan and Hospitals (KFHP-H)
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, the penultimate organizational, operational governance group that includes the most senior Health Plan and Medical Group Leadership. A recent example of KPPG endorsement is a national effort to implement palliative care programs.
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CMI supports defined networks of regionally based individuals involved in implementation and program evaluation and analysis. CMI is overseen by a Care Management Committee that itself is accountable to the KP National Quality Committee.
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that best represents an effort to improve quality through documented institutionalized changes in direct patient care, with potential for transfer to other locations. Recent examples include initiatives for hypertension control, breast cancer screening, and management of chronic pain.
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C-2 "Top down": National KP internal organizations such as the Care Management Institute and the Care Experience Council devote resources to ongoing "environmental scanning" within and external to KP to identify evolving and promising innovations for potential expanded implementation. Many of the areas of eventual focus have had their roots in the health services research activities of the regionally based KP Research Centers.
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Care Management Institute, Care Experience Council, National Product Council, KP Aging Network FIGURE C-3 Channel B: top down. o An innovation-focused agenda, such as convening those C-3 working on palliative care program implementation.
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• Identified executive sponsors at the regional and national levels willing to commit appropriate resources. • Consideration given to the degree to which an initiative complements and extends current efforts and capabilities, including leveraging existing network relationships that can be adapted to support spread versus the need to develop and sustain a new network.
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From page 89... ...
In addition to initiative-specific evaluation, the portfolio of innovation and diffusion is periodically reviewed in total or in part at multiple levels of the organization, including KPPG, the KP National Quality Committee, entities like CMI and the Care Experience Council, and within regional governance and oversight structures. Crosscutting organizational goals for overall spread have been implemented, such as a recent accountability for CMI to support and document annually the spread between regions of at least 10 innovations related to chronic care management.
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• Internal communication: We selectively use newsletters and e-mails to highlight QI programs. Our Clinical Connection newsletter is produced quarterly and is transmitted to the entire health care delivery team.
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THE ROLE OF HISTORY Guenter B Risse The theories and practices designed to improve quality of care demand changes in the conduct of health systems and their institutions.
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It functions as our collective identity, revealing human nature and evolution. The 1970s transformed medicine into a "health care delivery service," solidly placed in " the business world, something to be competitively offered and sold like other commodities.
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2006. Types of unintended consequences related to computerized provider order entry.
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2002. Improving patient safety by iden tifying side effects from introducing bar coding in medication administration.
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2006b. Graduate medical education and patient safety: A busy -- and occasionally hazardous -- intersection.
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