Research versus practice in quality improvement? Understanding how we can bridge the gap

The gap between implementers and researchers of quality improvement (QI) has hampered the degree and speed of change needed to reduce avoidable suffering and harm in health care. Underlying causes of this gap include differences in goals and incentives, preferred methodologies, level and types of evidence prioritized and targeted audiences. The Salzburg Global Seminar on 'Better Health Care: How do we learn about improvement?' brought together researchers, policy makers, funders, implementers, evaluators from low-, middle- and high-income countries to explore how to increase the impact of QI. In this paper, we describe some of the reasons for this gap and offer suggestions to better bridge the chasm between researchers and implementers. Effectively bridging this gap can increase the generalizability of QI interventions, accelerate the spread of effective approaches while also strengthening the local work of implementers. Increasing the effectiveness of research and work in the field will support the knowledge translation needed to achieve quality Universal Health Coverage and the Sustainable Development Goals.Fil: Hirschhorn, Lisa R.. Northwestern University; Estados UnidosFil: Ramaswamy, Rohit. University of North Carolina; Estados UnidosFil: Devnani, Mahesh. Post Graduate Institute of Medical Education & Research; IndiaFil: Wandersman, Abraham. University Of South Carolina; Estados UnidosFil: Simpson, Lisa A.. Academy Health; Estados UnidosFil: Garcia Elorrio, Ezequiel. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentin

Exploring New Research Frontiers in Offshoring Knowledge and Service Processes

This paper provides an introduction to a special issue on the offshoring of service and knowledge work. Brief descriptions are provided for 13 papers that fall into three categories including strategic and organizational issues, global and knowledge supply chain issues, and tactical issues. The intent of this special issue was to provide a venue for presenting numerous perspectives on the operational and cross‐disciplinary challenges and opportunities in the area of service and knowledge offshoring

Challenges for Transformation: A Situational Analysis of Mental Health Care Services in Sehore District, Madhya Pradesh.

The proportion of individuals with mental disorders receiving evidence based treatments in India is very small. In order to address this huge treatment gap, programme for improving mental health care is being implemented in Sehore district of Madhya Pradesh, India. The aim of this study was to complete the situational analysis consisting of two parts; document review of Sehore district mental health programme followed by a qualitative study. The findings suggest that there are major health system challenges in developing and implementing the mental health care plan to be delivered through primary health care system in Sehore district

Unpacking the black box of improvement

During the Salzburg Global Seminar Session 565-Better Health Care: How do we learn about improvement, participants discussed the need to unpack the black box of improvement. The black box refers to the fact that when quality improvement interventions are described or evaluated, there is a tendency to assume a simple, linear path between the intervention and the outcomes it yields. It is also assumed that it is enough to evaluate the results without understanding the process of by which the improvement took place. However, quality improvement interventions are complex, nonlinear and evolve in response to local settings. To accurately assess the effectiveness of quality improvement and disseminate the learning, there must be a greater understanding of the complexity of quality improvement work. To remain consistent with the language used in Salzburg, we refer to this as unpacking the black box of improvement. To illustrate the complexity of improvement, this article introduces four quality improvement case studies. In unpacking the black box, we present and demonstrate how Cynefin framework from complexity theory can be used to categorize and evaluate quality improvement interventions. Many quality improvement projects are implemented in complex contexts, necessitating an approach defined as probesense- respond. In this approach, teams experiment, learn and adapt their changes to their local setting. Quality improvement professionals intuitively use the probe-sense-respond approach in their work but document and evaluate their projects using language for simple or complicated' contexts, rather than the complex contexts in which they work. As a result, evaluations tend to ask 'How can we attribute outcomes to the intervention, rather than 'What were the adaptations that took place. By unpacking the black box of improvement, improvers can more accurately document and describe their interventions, allowing evaluators to ask the right questions and more adequately evaluate quality improvement interventions.Fil: Ramaswamy, Rohit. University of North Carolina; Estados UnidosFil: Reed, Julie. Nihr Clarch Northwest London; Estados UnidosFil: Livesley, Nigel. Institute for Healthcare Improvement; Estados UnidosFil: Boguslavsky, Victor. University Research Co; Estados UnidosFil: Garcia Elorrio, Ezequiel. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Sax, Sylvia. University of Heidelberg; AlemaniaFil: Houleymata, Diarra. Applying Science to Strengthen and Improve Systems Project,; MalíFil: Kimble, Leighann. University Research Co; Estados UnidosFil: Parry, Gareth. Institute of Healthcare Improvement; Estados Unido

Developing Complexity-Informed COVID-19 Responses to Optimize Community Well-Being: A Systems Thinking Approach

Despite a range of federal and state interventions to slow the spread of COVID-19, the US has seen millions of infections and hundreds of thousands of deaths. Top-down mandates have been ineffective because the community spread of the pandemic has been influenced by complex local dynamics that have evolved over time. Systems thinking approaches, specifically causal loop diagrams, and leverage points, are important techniques for representing complexity at the local level and identifying responsive systems change opportunities. This commentary presents a causal loop diagram highlighting the progressive effects of prolonged state-level COVID-19 mandates at the community level. We also identify potential system leverage points that address these effects and present an imagined future state causal loop diagram in which these solutions are implemented. Our future system demonstrates the importance of collaborations to enable community-driven, bottom-up approaches to public health crises, such as the COVID-19 pandemic, that are adaptive and responsive to local needs

Putting the “Global” Back in Global Public Health Education: Designing an Inclusive and Relevant Global Health Curriculum for Public Health Professionals around the World

In this age of globalization, global public health has become a topic of vital importance and interest, involving superstars such as Jeffrey Sachs and Paul Farmer, who are shaping the debate about the best approaches for meeting critical health needs around the world. This surge in interest in global health has created a demand for educating public health professionals who can be leaders in designing and implementing successful health programs around the world. Many schools of public health have created global health programs to meet this demand. However, much of the funding, research and training programs in global health are based in universities in wealthier countries and are focused on educating students from these countries who want to work in the international health field. Public health is an interdisciplinary community-based field that depends strongly on knowledge of local conditions for its success. Even the best intervention approaches based on solid research may not be effective in the field if they are not specifically tailored to the social, economic, environmental or demographic conditions of the local community A truly “global” public health curriculum that serves practitioners worldwide needs to find a way to integrate research with the knowledge that is needed for successful implementation of programs on the ground. Such a curriculum should allow public health professionals from around the world to get trained on skills and methods that will be useful to them in their day-today work, but should also allow them to use the capabilities of modern internet technology to interact, to share experiences, to bring their expertise to a common virtual “table” and to collaborate on tackling the problems that affect each and every one of us as human beings, irrespective of our economic circumstances and our geography.Master of Public Healt

A learning approach to community response during the COVID‐19 pandemic: Applying the Cynefin framework to guide decision‐making

Introduction: The United States has been unsuccessful in containing the rapid spread of COVID-19. The complex epidemiology of the disease and the fragmented response to it has resulted in thousands of ways in which spread has occurred, creating a situation where each community needs to create its own local, context-specific learning model while remaining compliant to county or state mandates. Methods: In this paper, we demonstrate how cross sector collaborations can use the Cynefin Framework, a tool for decision-making in complex systems, to guide community response to the COVID-19 pandemic. Results: We explore circumstances under which communities can inhabit each of the four domains of systems complexity represented in the Cynefin framework: simple, complicated, chaotic, and complex, and describe the decision-making process in each domain that balances health, economic, and social well-being. Conclusion: This paper serves as a call to action for the creation of community learning systems to improve community resilience and capacity to make better-informed decisions to address complex public health problems during the pandemic and beyond

Making complex interventions work in low resource settings: developing and applying a design focused implementation approach to deliver mental health through primary care in India

Abstract Background Globally, there is a large treatment gap for people with mental disorders, and this gap is especially extreme in Low and Middle Income Countries. This gap can be potentially bridged by integrating evidenced based mental health interventions into primary care, but there is little knowledge about how to do this well, especially in countries with weak health systems. Research into the best implementation approaches is a priority, but in order to do so, it is first necessary to adapt implementation science principles and tools for mental health services in low resource settings. Results The frameworks that have been used to implement evidence-based behavioral health and health care interventions in High Income Countries do not directly apply to contexts where resources and processes for service delivery and support do not exist. We propose an implementation approach for low resource settings, called design-focused implementation, emphasizing the design of delivery systems using systematic design methods as precursor to implementation in severely resource constrained environments. This approach draws from existing literature in design thinking, quality implementation, improvement science and evaluation and we describe its use in creating the processes, organizations and the enabling environment for integration of mental health service delivery into primary care in India. Conclusions Design-focused implementation will be useful for guiding research and practice in closing the implementation gap for a wide variety of complex interventions in low resource settings

A scoping review of the use of quality improvement methods by community organizations in the United States, Australia, New Zealand, and Canada to improve health and well-being in community settings

Abstract Background Health-care facilities have used quality improvement (QI) methods extensively to improve quality of care. However, addressing complex public health issues such as coronavirus disease 2019 and their underlying structural determinants requires community-level innovations beyond health care. Building community organizations’ capacity to use QI methods is a promising approach to improving community health and well-being. Objectives We explore how community health improvement has been defined in the literature, the extent to which community organizations have knowledge and skill in QI and how communities have used QI to drive community-level improvements. Methods Per a published study protocol, we searched Scopus, Web of Science, and Proquest Health management for articles between 2000 and 2019 from USA, Australia, New Zealand, and Canada. We included articles describing any QI intervention in a community setting to improve community well-being. We screened, extracted, and synthesized data. We performed a quantitative tabulation and a thematic analysis to summarize results. Results Thirty-two articles met inclusion criteria, with 31 set in the USA. QI approaches at the community level were the same as those used in clinical settings, and many involved multifaceted interventions targeting chronic disease management or health promotion, especially among minority and low-income communities. There was little discussion on how well these methods worked in community settings or whether they required adaptations for use by community organizations. Moreover, decision-making authority over project design and implementation was typically vested in organizations outside the community and did not contribute to strengthening the capability of community organizations to undertake QI independently. Conclusion Most QI initiatives undertaken in communities are extensions of projects in health-care settings and are not led by community residents. There is urgent need for additional research on whether community organizations can use these methods independently to tackle complex public health problems that extend beyond health-care quality

Quality Improvement in Public-Private Partnerships in Low- And Middle-Income Countries: A Systematic Review

BACKGROUND: Public-private partnerships (PPP) are often how health improvement programs are implemented in low-and-middle-income countries (LMICs). We therefore aimed to systematically review the literature about the aim and impacts of quality improvement (QI) approaches in PPP in LMICs. METHODS: We searched SCOPUS and grey literature for studies published before March 2022. One reviewer screened abstracts and full-text studies for inclusion. The study characteristics, setting, design, outcomes, and lessons learned were abstracted using a standard tool and reviewed in detail by a second author. RESULTS: We identified 9,457 citations, of which 144 met the inclusion criteria and underwent full-text abstraction. We identified five key themes for successful QI projects in LMICs: 1) leadership support and alignment with overarching priorities, 2) local ownership and engagement of frontline teams, 3) shared authentic learning across teams, 4) resilience in managing external challenges, and 5) robust data and data visualization to track progress. We found great heterogeneity in QI tools, study designs, participants, and outcome measures. Most studies had diffuse aims and poor descriptions of the intervention components and their follow-up. Few papers formally reported on actual deployment of private-sector capital, and either provided insufficient information or did not follow the formal PPP model, which involves capital investment for a explicit return on investment. Few studies discussed the response to their findings and the organizational willingness to change. CONCLUSIONS: Many of the same factors that impact the success of QI in healthcare in high-income countries are relevant for PPP in LMICs. Vague descriptions of the structure and financial arrangements of the PPPs, and the roles of public and private entities made it difficult to draw meaningful conclusions about the impacts of the organizational governance on the outcomes of QI programs in LMICs. While we found many articles in the published literature on PPP-funded QI partnerships in LMICs, there is a dire need for research that more clearly describes the intervention details, implementation challenges, contextual factors, leadership and organizational structures. These details are needed to better align incentives to support the kinds of collaboration needed for guiding accountability in advancing global health. More ownership and power needs to be shifted to local leaders and researchers to improve research equity and sustainability