A measurement instrument for spread of quality improvement in healthcare.

OBJECTIVE: The aim of this study was to develop and test a measurement instrument for spread of quality improvement in healthcare. The instrument distinguishes: (i) spread of work practices and their results and (ii) spread practices and effectiveness. Relations between spread and sustainability of changed work practices were also explored to assess convergent validity. DESIGN: We developed and tested a measurement instrument for spread in a follow-up study. The instrument consisted of 18-items with four subscales. SETTING AND PARTICIPANTS: The sample consisted of former improvement teams in a quality improvement program for long-term care (nteams = 73, nrespondents = 127). Data were collected in a questionnaire about 1 year post-pilot site improvement implementation. INTERVENTIONS: Quality improvements in long-term care practices. MAIN OUTCOME MEASURES: Four variables were construed: (i) actions for spread of work practices, (ii) actions for spread of results, (iii) effectiveness of spread of work practices and (iv) effectiveness of spread of results. RESULTS: Psychometric analysis yielded positive results on the item level. The intended four-factor model yielded satisfactory fit. The internal consistency of each scale was fine (Cronbach's α 0.70-0.93). Bivariate correlations revealed that the spread variables were strongly related but distinct, and positively related to the sustainability variables. CONCLUSIONS: The psychometric properties are in line with methodological standards. Convergent validity was confirmed with sustainability. The measurement instrument offers a good starting point for the analysis of spread.

Quality improvement in long-term mental health: results from four collaboratives.

This multiple case study evaluates four quality improvement collaboratives (QICs) in long-term mental health care focusing on social psychiatric care, recovery oriented care, social participation and somatic co-morbidity of psychiatric patients. The aim is to explore (1) effectiveness in terms of objective outcome indicators and impact of changes as perceived by team members; and (2) associations between collaborative-, organizational- and team-level factors and perceived effectiveness. Most objective outcomes, such as health, loneliness and clients' problem areas, showed significant improvement. Because of the diversity in content no single measure for objective effectiveness could be computed across the four collaboratives. Perceived effectiveness of team members was used as an indicator of the overall impact. In all, 55 of the 94 participating team leaders and 117 remaining team members completed a written survey at the end of each quality improvement collaborative. Multilevel regression analyses indicated that innovation attributes, appropriate measures, usable data collection tools and an innovative team culture could explain variation in perceived effectiveness. In conclusion, overall positive changes for clients were realized as demonstrated by objective outcomes and team members' perceptions of improvements in care processes. The results supported the notion that a layered approach is necessary to achieve improvements in quality of care.

Constructing the social: an evaluation study of the outcomes and processes of a 'social participation' improvement project.

This paper reports on an evaluation of a 'social participation' improvement project in a mental health care and care for the intellectually disabled setting. The main research question is how sociality (i.e. clients' social lives) was constructed and what consequences this had for the project and for the clients. We undertook a dual approach: investigating the predefined outcomes and analysing the improvement processes in terms of how these processes construct sociality. As to the predefined outcomes, clients' social networks were not widened, but clients felt significantly less lonely at the end of the project. In a bottom-up analysis of data gathered on the improvement processes, we articulated two ways of constructing sociality: individualization, in which clients had to verbalize their wishes (verbalization) and to act upon them more actively (enterprising); and normalization, in which a good social life was one embedded in 'normal' community. We argue that this (explorative) way of conceptualizing change corresponds with some of the quantitative findings but also brings to light aspects that would have gone unnoticed by using only the predefined outcomes. Therefore, a mixed methods approach in studying effectiveness is a fruitful addition to the quality improvement literature.