Exploring the black box of quality improvement collaboratives: modelling relations between conditions, applied changes and outcomes

<p>Abstract</p> <p>Introduction</p> <p>Despite the popularity of quality improvement collaboratives (QICs) in different healthcare settings, relatively little is known about the implementation process. The objective of the current study is to learn more about relations between relevant conditions for successful implementation of QICs, applied changes, perceived successes, and actual outcomes.</p> <p>Methods</p> <p>Twenty-four Dutch hospitals participated in a dissemination programme based on QICs. A questionnaire was sent to 237 leaders of teams who joined 18 different QICs to measure changes in working methods and activities, overall perceived success, team organisation, and supportive conditions. Actual outcomes were extracted from a database with team performance indicator data. Multi-level analyses were conducted to test a number of hypothesised relations within the cross-classified hierarchical structure in which teams are nested within QICs and hospitals.</p> <p>Results</p> <p>Organisational and external change agent support is related positively to the number of changed working methods and activities that, if increased, lead to higher perceived success and indicator outcomes scores. Direct and indirect positive relations between conditions and perceived success could be confirmed. Relations between conditions and actual outcomes are weak. Multi-level analyses reveal significant differences in organisational support between hospitals. The relation between perceived successes and actual outcomes is present at QIC level but not at team level.</p> <p>Discussion</p> <p>Several of the expected relations between conditions, applied changes and outcomes, and perceived successes could be verified. However, because QICs vary in topic, approach, complexity, and promised advantages, further research is required: first, to understand why some QIC innovations fit better within the context of the units where they are implemented; second, to assess the influence of perceived success and actual outcomes on the further dissemination of projects over new patient groups.</p

Towards an organisation-wide process-oriented organisation of care: A literature review

<p>Abstract</p> <p>Background</p> <p>Many hospitals have taken actions to make care delivery for specific patient groups more process-oriented, but struggle with the question how to deal with process orientation at hospital level. The aim of this study is to report and discuss the experiences of hospitals with implementing process-oriented organisation designs in order to derive lessons for future transitions and research.</p> <p>Methods</p> <p>A literature review of English language articles on organisation-wide process-oriented redesigns, published between January 1998 and May 2009, was performed.</p> <p>Results</p> <p>Of 329 abstracts identified, 10 articles were included in the study. These articles described process-oriented redesigns of five hospitals. Four hospitals tried to become process-oriented by the implementation of coordination measures, and one by organisational restructuring. The adoption of the coordination mechanism approach was particularly constrained by the functional structure of hospitals. Other factors that hampered the redesigns in general were the limited applicability of and unfamiliarity with process improvement techniques.</p> <p>Conclusions</p> <p>Due to the limitations of the evidence, it is not known which approach, implementation of coordination measures or organisational restructuring (with additional coordination measures), produces the best results in which situation. Therefore, more research is needed. For this research, the use of qualitative methods in addition to quantitative measures is recommended to contribute to a better understanding of preconditions and contingencies for an effective application of approaches to become process-oriented. Hospitals are advised to take the factors for failure described into account and to take suitable actions to counteract these obstacles on their way to become process-oriented organisations.</p

Applying the quality improvement collaborative method to process redesign: a multiple case study

<p>Abstract</p> <p>Background</p> <p>Despite the widespread use of quality improvement collaboratives (QICs), evidence underlying this method is limited. A QIC is a method for testing and implementing evidence-based changes quickly across organisations. To extend the knowledge about conditions under which QICs can be used, we explored in this study the applicability of the QIC method for process redesign.</p> <p>Methods</p> <p>We evaluated a Dutch process redesign collaborative of seventeen project teams using a multiple case study design. The goals of this collaborative were to reduce the time between the first visit to the outpatient's clinic and the start of treatment and to reduce the in-hospital length of stay by 30% for involved patient groups. Data were gathered using qualitative methods, such as document analysis, questionnaires, semi-structured interviews and participation in collaborative meetings.</p> <p>Results</p> <p>Application of the QIC method to process redesign proved to be difficult. First, project teams did not use the provided standard change ideas, because of their need for customised solutions that fitted with context-specific causes of waiting times and delays. Second, project teams were not capable of testing change ideas within short time frames due to: the need for tailoring changes ideas and the complexity of aligning interests of involved departments; small volumes of involved patient groups; and inadequate information and communication technology (ICT) support. Third, project teams did not experience peer stimulus because they saw few similarities between their projects, rarely shared experiences, and did not demonstrate competitive behaviour. Besides, a number of project teams reported that organisational and external change agent support was limited.</p> <p>Conclusions</p> <p>This study showed that the perceived need for tailoring standard change ideas to local contexts and the complexity of aligning interests of involved departments hampered the use of the QIC method for process redesign. We cannot determine whether the QIC method would have been appropriate for process redesign. Peer stimulus was non-optimal as a result of the selection process for participation of project teams by the external change agent. In conclusion, project teams felt that necessary preconditions for successful use of the QIC method were lacking.</p

Understanding organisational development, sustainability, and diffusion of innovations within hospitals participating in a multilevel quality collaborative

<p>Abstract</p> <p>Background</p> <p>Between 2004 and 2008, 24 Dutch hospitals participated in a two-year multilevel quality collaborative (MQC) comprised of (a) a leadership programme for hospital executives, (b) six quality-improvement collaboratives (QICs) for healthcare professionals and other staff, and (c) an internal programme organisation to help senior management monitor and coordinate team progress. The MQC aimed to stimulate the development of quality-management systems and the spread of methods to improve patient safety and logistics. The objective of this study is to describe how the first group of eight MQC hospitals sustained and disseminated improvements made and the quality methods used.</p> <p>Methods</p> <p>The approach followed by the hospitals was described using interview and questionnaire data gathered from eight programme coordinators.</p> <p>Results</p> <p>MQC hospitals followed a systematic strategy of diffusion and sustainability. Hospital quality-management systems are further developed according to a model linking plan-do-study-act cycles at the unit and hospital level. The model involves quality norms based on realised successes, performance agreements with unit heads, organisational support, monitoring, and quarterly accountability reports.</p> <p>Conclusions</p> <p>It is concluded from this study that the MQC contributed to organisational development and dissemination within participating hospitals. Organisational learning effects were demonstrated. System changes affect the context factors in the theory of organisational readiness: organisational culture, policies and procedures, past experience, organisational resources, and organisational structure. Programme coordinator responses indicate that these factors are utilised to manage spread and sustainability. Further research is needed to assess long-term effects.</p

Disaster Exercises to Prepare Hospitals for Mass-Casualty Incidents : Does it Contribute to Preparedness or is it Ritualism?

Introduction: The central question this study sought to answer was whether the team members of Strategic Crisis Teams (SCTs) participating in mass-casualty incident (MCI) exercises in the Netherlands learn from their participation. Methods: Evaluation reports of exercises that took place at two different times were collected and analyzed against a theoretical model with several dimensions, looking at both the quality of the evaluation methodology (three criteria: objectives described, link between objective and items for improvement, and data-collection method) and the learning effect of the exercise (one criterion: the change in number of items for improvement). Results: Of all 32 evaluation reports, 81% described exercise objectives; 30% of the items for improvement in the reports were linked to these objectives, and 22% of the 32 evaluation reports used a structured template to describe the items for improvement. In six evaluation categories, the number of items for improvement increased between the first (T1) and the last (T2) evaluation report submitted by hospitals. The number of items remained equal for two evaluation categories and decreased in six evaluation categories. Conclusion: The evaluation reports do not support the ideal-typical disaster exercise process. The authors could not establish that team members participating in MCI exercises in the Netherlands learn from their participation. More time and effort must be spent on the development of a validated evaluation system for these simulations, and more research into the role of the evaluator is needed. Verheul MLMI, Dückers MLA, Visser BB, Beerens RJJ, Bierens JJLM. Disaster exercises to prepare hospitals for mass-casualty incidents: does it contribute to preparedness or is it ritualism? Prehosp Disaster Med

Developing and testing an instrument to measure the presence of conditions for successful implementation of quality improvement collaboratives

Background: In quality improvement collaboratives (QICs) teams of practitioners from different health care organizations are brought together to systematically improve an aspect of patient care. Teams take part in a series of meetings to learn about relevant best practices, quality methods and change ideas, and share experiences in making changes in their own local setting. The purpose of this study was to develop an instrument for measuring team organization, external change agent support and support from the team's home institution in a Dutch national improvement and dissemination programme for hospitals based on several QICs. Methods: The exploratory methodological design included two phases: a) content development and assessment, resulting in an instrument with 15 items, and b) field testing (N = 165). Internal consistency reliability was tested via Cronbach's alpha coefficient. Principal component analyses were used to identify underlying constructs. Tests of scaling assumptions according to the multi trait/multi-item matrix, were used to confirm the component structure. Results: Three components were revealed, explaining 65% of the variability. The components were labelled 'organizational support', 'team organization' and 'external change agent support'. One item not meeting item-scale criteria was removed. This resulted in a 14 item instrument. Scale reliability ranged from 0.77 to 0.91. Internal item consistency and divergent validity were satisfactory. Conclusion: On the whole, the instrument appears to be a promising tool for assessing team organization and internal and external support during QIC implementation. The psychometric properties were good and warrant application of the instrument for the evaluation of the national programme and similar improvement programmes.