Domains associated with successful quality improvement in healthcare - a nationwide case study.

BACKGROUND: There is a distinct difference between what we know and what we do in healthcare: a gap that is impairing the quality of the care and increasing the costs. Quality improvement efforts have been made worldwide by learning collaboratives, based on recognized continual improvement theory with limited scientific evidence. The present study of 132 quality improvement projects in Norway explores the conditions for improvement from the perspectives of the frontline healthcare professionals, and evaluates the effectiveness of the continual improvement method. METHODS: An instrument with 25 questions was developed on prior focus group interviews with improvement project members who identified features that may promote or inhibit improvement. The questionnaire was sent to 189 improvement projects initiated by the Norwegian Medical Association, and responded by 70% (132) of the improvement teams. A sub study of their final reports by a validated instrument, made us able to identify the successful projects and compare their assessments with the assessments of the other projects. A factor analysis with Varimax rotation of the 25 questions identified five domains. A multivariate regression analysis was used to evaluate the association with successful quality improvements. RESULTS: Two of the five domains were associated with success: Measurement and Guidance (p = 0.011), and Professional environment (p = 0.015). The organizational leadership domain was not associated with successful quality improvements (p = 0.26). CONCLUSION: Our findings suggest that quality improvement projects with good guidance and focus on measurement for improvement have increased likelihood of success. The variables in these two domains are aligned with improvement theory and confirm the effectiveness of the continual improvement method provided by the learning collaborative. High performing professional environments successfully engaged in patient-centered quality improvement if they had access to: (a) knowledge of best practice provided by professional subject matter experts, (b) knowledge of current practice provided by simple measurement methods, assisted by (c) improvement knowledge experts who provided useful guidance on measurement, and made the team able to organize the improvement efforts well in spite of the difficult resource situation (time and personnel). Our findings may be used by healthcare organizations to develop effective infrastructure to support improvement and to create the conditions for making quality and safety improvement a part of everyone's job.

Local emergency medical response after a terrorist attack in Norway: a qualitative study.

INTRODUCTION: On 22 July 2011, Norway suffered a devastating terrorist attack targeting a political youth camp on a remote island. Within a few hours, 35 injured terrorist victims were admitted to the local Ringerike community hospital. All victims survived. The local emergency medical service (EMS), despite limited resources, was evaluated by three external bodies as successful in handling this crisis. This study investigates the determinants for the success of that EMS as a model for quality improvement in healthcare. METHODS: We performed focus group interviews using the critical incident technique with 30 healthcare professionals involved in the care of the attack victims to establish determinants of the EMS' success. Two independent teams of professional experts classified and validated the identified determinants. RESULTS: Our findings suggest a combination of four elements essential for the success of the EMS: (1) major emergency preparedness and competence based on continuous planning, training and learning; (2) crisis management based on knowledge, trust and data collection; (3) empowerment through multiprofessional networks; and (4) the ability to improvise based on acquired structure and competence. The informants reported the successful response was specifically based on multiprofessional trauma education, team training, and prehospital and in-hospital networking including mental healthcare. The powerful combination of preparedness, competence and crisis management built on empowerment enabled the healthcare workers to trust themselves and each other to make professional decisions and creative improvisations in an unpredictable situation. CONCLUSION: The determinants for success derived from this qualitative study (preparedness, management, networking, ability to improvise) may be universally applicable to understanding the conditions for resilient and safe healthcare services, and of general interest for quality improvement in healthcare.

Development and Validation of the CPO Scale, a New Instrument for Evaluation of Health Care Improvement Efforts.

OBJECTIVE: To develop and validate an instrument for guidance and evaluation of quality and safety improvement efforts in health care. CONTEXT: The instrument is based on the Plan-Do-Study-Act cycle and the 3 fundamental improvement questions regarding aims, measurement, and change-making. METHODS: An interdisciplinary team of improvement experts developed the Change Process and Outcome (CPO) scale. After studying the improvement literature, the scale was tested and refined on a sample of 5 projects. The CPO evaluation process and classification system was developed when evaluating 189 of the quality improvement projects of the Norwegian Medical Association by their final reports. The scale was validated by applying statistical testing to the evaluation results. RESULTS: The final CPO scale consists of 13 process items and 7 outcome items. Interrater reliability ranged from 0.53 to 0.79, and test-retest reliability was 0.82. Factor analyses with Varimax rotation identified 2 significant process domains: Aims/change-making and Measurement/reporting, with Cronbach α values 0.88 and 0.95, respectively. The classification system produced 3 performance levels: successful, promising, and uncertain. CONCLUSION: The CPO scale shows good internal consistency, reliability, and validity for evaluating the success of quality improvement initiatives.

Three success factors for continual improvement in healthcare: an analysis of the reports of improvement team members.

INTRODUCTION: The objectives of the Breakthrough Series Collaborative are to close the gap between what we know and what we do, and to contribute to continuous quality improvement (CQI) of healthcare through collaborative learning. The improvement efforts are guided by a systematic approach, combining professional and improvement knowledge. OBJECTIVES: To explore what the improvement teams have learnt from participating in the collaborative and from dealing with promoting and inhibiting factors encountered. METHOD: Qualitative interviews with 19 team members were conducted in four focus groups, using the Critical Incident Technique. A critical incident is one that makes significant contributions, either positively or negatively, to an activity. RESULTS: The elements of a culture of improvement are revealed by the critical incidents, and reflect the eight domains of knowledge, as a product of collaborative learning. The improvement knowledge and skills of individuals are important elements, but not enough to achieve sustainable changes. 90% of the material reflects the need for a system of CQI to solve the problems that organisations experience in trying to make lasting improvements. CONCLUSION: A pattern of three success factors for CQI emerges: (1) continuous and reliable information, including measurement, about best and current practice; (2) engagement of everybody in all phases of the improvement work: the patient and family, the leadership, the professional environment and the staff; and (3) an infrastructure based on improvement knowledge, with multidisciplinary teams, available coaching, learning systems and sustainability systems.

[Emergency service consultations and the list patient system]. / Legevaktsøkning og fastlegeordning.

BACKGROUND: We wanted to analyse the frequency of list patient consultations in the off-hour emergency service in Skien. MATERIAL AND METHODS: Over one year, all emergency service consultations between 4 PM and 11 PM on workdays were registered according to the general practitioner (GP) patients used and divided by the number of patients on each list. We performed a multiple linear regression analysis with number of consultations adjusted for the total patient number on the list as the dependent variable. RESULTS: We found great variation in the consultation rate among patients listed by various GPs. The consultation rate was significantly associated with the practice in which the GP worked. Quarterly feedback of the results to doctors did not change the consultation pattern. INTERPRETATION: The use of the off-hour emergency service is associated with certain practice characteristics. We assume that the variation results from differences in accessibility by telephone, in the capacity for taking in patients needing urgent attention, and in varying degree of attention to service in the practices.