Learning Evaluation: Blending Quality Improvement and Implementation Research Methods to Study Healthcare Innovations

Background: In healthcare change interventions, on-the-ground learning about the implementation process is often lost because of a primary focus on outcome improvements. This paper describes the Learning Evaluation, a methodological approach that blends quality improvement and implementation research methods to study healthcare innovations. Methods: Learning Evaluation is an approach to multi-organization assessment. Qualitative and quantitative data are collected to conduct real-time assessment of implementation processes while also assessing changes in context, facilitating quality improvement using run charts and audit and feedback, and generating transportable lessons. Five principles are the foundation of this approach: (1) gather data to describe changes made by healthcare organizations and how changes are implemented; (2) collect process and outcome data relevant to healthcare organizations and to the research team; (3) assess multi-level contextual factors that affect implementation, process, outcome, and transportability; (4) assist healthcare organizations in using data for continuous quality improvement; and (5) operationalize common measurement strategies to generate transportable results. Results: Learning Evaluation principles are applied across organizations by the following: (1) establishing a detailed understanding of the baseline implementation plan; (2) identifying target populations and tracking relevant process measures; (3) collecting and analyzing real-time quantitative and qualitative data on important contextual factors; (4) synthesizing data and emerging findings and sharing with stakeholders on an ongoing basis; and (5) harmonizing and fostering learning from process and outcome data. Application to a multi-site program focused on primary care and behavioral health integration shows the feasibility and utility of Learning Evaluation for generating real-time insights into evolving implementation processes. Conclusions: Learning Evaluation generates systematic and rigorous cross-organizational findings about implementing healthcare innovations while also enhancing organizational capacity and accelerating translation of findings by facilitating continuous learning within individual sites. Researchers evaluating change initiatives and healthcare organizations implementing improvement initiatives may benefit from a Learning Evaluation approach

Use of Quality Improvement Strategies Among Small to Medium-Size US Primary Care Practices

PURPOSE Improving primary care quality is a national priority, but little is known about the extent to which small to medium-size practices use quality improvement (QI) strategies to improve care. We examined variations in use of QI strategies among 1,181 small to medium-size primary care practices engaged in a national initiative spanning 12 US states to improve quality of care for heart health and assessed factors associated with those variations. METHODS In this cross-sectional study, practice characteristics were assessed by surveying practice leaders. Practice use of QI strategies was measured by the validated Change Process Capability Questionnaire (CPCQ) Strategies Scale (scores range from −28 to 28, with higher scores indicating more use of QI strategies). Multivariable linear regression was used to examine the association between practice characteristics and the CPCQ strategies score. RESULTS The mean CPCQ strategies score was 9.1 (SD = 12.2). Practices that participated in accountable care organizations and those that had someone in the practice to configure clinical quality reports from electronic health records (EHRs), had produced quality reports, or had discussed clinical quality data during meetings had higher CPCQ strategies scores. Health system–owned practices and those experiencing major disruptive changes, such as implementing a new EHR system or clinician turnover, had lower CPCQ strategies scores. CONCLUSION There is substantial variation in the use of QI strategies among small to medium-size primary care practices across 12 US states. Findings suggest that practices may need external support to strengthen their ability to do QI and to be prepared for new payment and delivery models

Healing Relationships and the Existential Philosophy of Martin Buber.

The dominant unspoken philosophical basis of medical care in the United States is a form of Cartesian reductionism that views the body as a machine and medical professionals as technicians whose job is to repair that machine. The purpose of this paper is to advocate for an alternative philosophy of medicine based on the concept of healing relationships between clinicians and patients. This is accomplished first by exploring the ethical and philosophical work of Pellegrino and Thomasma and then by connecting Martin Buber\u27s philosophical work on the nature of relationships to an empirically derived model of the medical healing relationship. The Healing Relationship Model was developed by the authors through qualitative analysis of interviews of physicians and patients. Clinician-patient healing relationships are a special form of what Buber calls I-Thou relationships, characterized by dialog and mutuality, but a mutuality limited by the inherent asymmetry of the clinician-patient relationship. The Healing Relationship Model identifies three processes necessary for such relationships to develop and be sustained: Valuing, Appreciating Power and Abiding. We explore in detail how these processes, as well as other components of the model resonate with Buber\u27s concepts of I-Thou and I-It relationships. The resulting combined conceptual model illuminates the wholeness underlying the dual roles of clinicians as healers and providers of technical biomedicine. On the basis of our analysis, we argue that health care should be focused on healing, with I-Thou relationships at its core