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3 State of the Science of Quality Improvement Research
Pages 8-24

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From page 8...
... 2. How do you/does your organization approach quality improvement research/evaluation?
From page 9...
... Hospital and Stanford Evidence-based Practice Center (EPC) presented the EPC's approach to evaluating quality improvement research.
From page 10...
... For example, nearly all the quality improvement strategies had a positive impact in the hypertension evaluation, with an average reduction of 4.5 mmHg. Specific quality improvement strategies, such as organizational change and patient education, had greater impacts than others, Heidenreich said.
From page 11...
... In contrast, quality improvement research generates generalizable knowledge by evaluating the effects of and exploring the mechanism of action and potential effect modifiers of different quality improvement interventions across a range of settings. Its goal is to make strong causal inferences, which requires use of a broad range of study designs.
From page 12...
... Quality improvement research should be actionable in a policy sense by being predictive, allowing for conclusions to be drawn, such as "if X intervention is implemented, Y benefits are likely to occur." Quality improvement research requires use of diverse methods, such as ways to create and appraise clinical practice guidelines and cluster randomized trials in implementation research. Rigorous evaluations, such as RCTs, are needed to provide evidence of effectiveness to ensure that the effects are not a result of secular change.
From page 13...
... MULTIPLE RESEARCH METHODS Whereas Heidenreich and Grimshaw discussed methods of working with the complexity of and barriers to quality improvement research, Trish Greenhalgh of University College London discussed the problem that quality improvement research is undertheorized. As examples of how theories can be used in quality improvement research, Greenhalgh described two approaches to quality improvement undertaken by her own team: language interpretation services and electronic medical records.
From page 14...
... Although RCTs have a place in quality improvement research, other methods also must be employed to get a full picture. VETERANS ADMINISTRATION Brian Mittman of the VA and the journal Implementation Science spoke about his experiences with quality improvement research, in particular the VA's Quality Enhancement Research Initiative (QUERI)
From page 15...
... Quality improvement research should be supported by social scientists, Mittman said. Additionally, quality improvement researchers should have some minimum level of training in the social and clinical sciences.
From page 16...
... For example, use of health care services, vital signs, and test results are easily derived from electronic medical records. However, aspects of care important to patients -- how they feel, their quality of life, functional status, and preferences in care -- are more difficult to measure, are not routinely recorded by health care providers, and therefore are often left out of quality improvement efforts.
From page 17...
... , retrospective cohort studies (e.g., comparing electronic medical records with chart audit programs for quality indicators) , and cross-sectional studies.
From page 18...
... Finally, appropriate measures of costs should be developed. PATIENT SAFETY Kaveh Shojania of the Ottawa Hospital and the University of Ottawa spoke about quality improvement research from the patient safety perspective.
From page 19...
... Common arguments for suggesting quality improvement research must respond to different standards of evidence, including the following: the urgency for evidence; the complexity of quality improvement; the understanding that some solutions do not require evidence; the evaluation of quality improvement interventions is too costly; and the side effects of quality improvement interventions are not the cause of major problems. Shojania refuted each argument to maintain that quality improvement research actually should not require separate standards of evidence.
From page 20...
... The fourth argument for having different standards of evidence in quality improvement is that evaluating quality improvement interventions is too costly, citing a cost of more than $1 million for trials of computerized provider order entry systems (CPOE) (Leape et al., 2002)
From page 21...
... . Figure 3-1 new models of evidence in quality improvement research, but for investments comparable to other areas in medicine in terms of time, money, and human resources.
From page 22...
... For example, quality improvement studies aimed at improving care delivery in specific hospitals and practices without generating new knowledge should not need IRB approval. However, as an editor of a medical journal, Tierney acknowledged that most journals require studies to be reviewed by an IRB, and this might drive quality improvement researchers to obtain IRB approval for their studies that otherwise might not require such approval.
From page 23...
... When asked whether patients themselves should be randomized, Heidenreich said it depended on the intervention, but for the majority of cases, the point of randomization should be the physician or facility. Grimshaw agreed, noting that quality improvement interventions, and thus quality improvement research, often operate at the level of the provider or organization and not the level of individual patients.
From page 24...
...  QUALITY IMPROVEMENT AND IMPLEMENTATION RESEARCH many of the speakers suggested, all available research methods are valuable and researchers must learn which methods are most appropriate in answering different questions. The result will likely be multifaceted, multilevel research approaches and will require input from a number of disciplines.


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