A Board Level Intervention to Develop Organisation-Wide Quality Improvement Strategies: Cost-Consequences Analysis in 15 Healthcare Organisations.

BACKGROUND: Hospital boards have statutory responsibility for upholding the quality of care in their organisations. International research on quality in hospitals resulted in a research-based guide to help senior hospital leaders develop and implement quality improvement (QI) strategies, the QUASER Guide. Previous research has established a link between board practices and quality of care; however, to our knowledge, no board-level intervention has been evaluated in relation to its costs and consequences. The aim of this research was to evaluate these impacts when the QUASER Guide was implemented in an organisational development intervention (iQUASER). METHODS: We conducted a 'before and after' cost-consequences analysis (CCA), as part of a mixed methods evaluation. The analysis combined qualitative data collected from 66 interviews, 60 hours of board meeting observations and documents from 15 healthcare organisations, of which 6 took part on iQUASER, and included direct and opportunity costs associated with the intervention. The consequences focused on the development of an organisation-wide QI strategy, progress on addressing 8 dimensions of QI (the QUASER challenges), how organisations compared to benchmarks, engagement with the intervention and progress in the implementation of a QI project. RESULTS: We found that participating organisations made greater progress in developing an organisation-wide QI strategy and became more similar to the high-performing benchmark than the comparators. However, progress in addressing all 8 QUASER challenges was only observed in one organisation. Stronger engagement with the intervention was associated with the implementation of a QI project. On average, iQUASER costed £23 496 per participating organisation, of which approximately 44% were staff time costs. Organisations that engaged less with the intervention had lower than average costs (£21 267 per organisation), but also failed to implement an organisation-wide QI project. CONCLUSION: We found a positive association between level of engagement with the intervention, development of an organisation-wide QI strategy and the implementation of an organisation-wide QI project. Support from the board, particularly the chair and chief executive, for participation in the intervention, is important for organisations to accrue most benefit. A board-level intervention for QI, such as iQUASER, is relatively inexpensive as a proportion of an organisation's budget.

Explaining organisational responses to a board-level quality improvement intervention: findings from an evaluation in six providers in the English National Health Service.

BACKGROUND: Healthcare systems worldwide are concerned with strengthening board-level governance of quality. We applied Lozeau, Langley and Denis' typology (transformation, customisation, loose coupling and corruption) to describe and explain the organisational response to an improvement intervention in six hospital boards in England. METHODS: We conducted fieldwork over a 30-month period as part of an evaluation in six healthcare provider organisations in England. Our data comprised board member interviews (n=54), board meeting observations (24 hours) and relevant documents. RESULTS: Two organisations transformed their processes in a way that was consistent with the objectives of the intervention, and one customised the intervention with positive effects. In two further organisations, the intervention was only loosely coupled with organisational processes, and participation in the intervention stopped when it competed with other initiatives. In the final case, the intervention was corrupted to reinforce existing organisational processes (a focus on external regulatory requirements). The organisational response was contingent on the availability of 'slack'-expressed by participants as the 'space to think' and 'someone to do the doing'-and the presence of a functioning board. CONCLUSIONS: Underperforming organisations, under pressure to improve, have little time or resources to devote to organisation-wide quality improvement initiatives. Our research highlights the need for policy-makers and regulators to extend their focus beyond the choice of intervention, to consider how the chosen intervention will be implemented in public sector hospitals, how this will vary between contexts and with what effects. We provide useful information on the necessary conditions for a board-level quality improvement intervention to have positive effects.

Professionals learning together with patients: An exploratory study of a collaborative learning Fellowship programme for healthcare improvement.

Improving the quality of healthcare involves collaboration between many different stakeholders. Collaborative learning theory suggests that teaching different professional groups alongside each other may enable them to develop skills in how to collaborate effectively, but there is little literature on how this works in practice. Further, though it is recognised that patients play a fundamental role in quality improvement, there are few examples of where they learn together with professionals. To contribute to addressing this gap, we review a collaborative fellowship in Northwest London, designed to build capacity to improve healthcare, which enabled patients and professionals to learn together. Using the lens of collaborative learning, we conducted an exploratory study of six cohorts of the year long programme (71 participants). Data were collected using open text responses from an online survey (n = 31) and semi-structured interviews (n = 34) and analysed using an inductive open coding approach. The collaborative design of the Fellowship, which included bringing multiple perspectives to discussions of real world problems, was valued by participants who reflected on the safe, egalitarian space created by the programme. Participants (healthcare professionals and patients) found this way of learning initially challenging yet ultimately productive. Despite the pedagogical and practical challenges of developing a collaborative programme, this study indicates that opening up previously restricted learning opportunities as widely as possible, to include patients and carers, is an effective mechanism to develop collaborative skills for quality improvement.

How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England.

BACKGROUND: Health systems worldwide are increasingly holding boards of healthcare organisations accountable for the quality of care that they provide. Previous empirical research has found associations between certain board practices and higher quality patient care; however, little is known about how boards govern for quality improvement (QI). METHODS: We conducted fieldwork over a 30-month period in 15 healthcare provider organisations in England as part of a wider evaluation of a board-level organisational development intervention. Our data comprised board member interviews (n=65), board meeting observations (60 hours) and documents (30 sets of board meeting papers, 15 board minutes and 15 Quality Accounts). We analysed the data using a framework developed from existing evidence of links between board practices and quality of care. We mapped the variation in how boards enacted governance of QI and constructed a measure of QI governance maturity. We then compared organisations to identify the characteristics of those with mature QI governance. RESULTS: We found that boards with higher levels of maturity in relation to governing for QI had the following characteristics: explicitly prioritising QI; balancing short-term (external) priorities with long-term (internal) investment in QI; using data for QI, not just quality assurance; engaging staff and patients in QI; and encouraging a culture of continuous improvement. These characteristics appeared to be particularly enabled and facilitated by board-level clinical leaders. CONCLUSIONS: This study contributes to a deeper understanding of how boards govern for QI. The identified characteristics of organisations with mature QI governance seemed to be enabled by active clinical leadership. Future research should explore the biographies, identities and work practices of board-level clinical leaders and their role in organisation-wide QI.