Planning and Studying Improvement in Patient Care: The Use of Theoretical Perspectives

Abstract

A consistent finding in articles on quality improvement in health care is that change is difficult to achieve. According to the research literature, the majority of interventions are targeted at health care professionals. But success in achieving change may be influenced by factors other than those relating to individual professionals, and theories may help explain whether change is possible. This article argues for a more systematic use of theories in planning and evaluating quality-improvement interventions in clinical practice. It demonstrates how different theories can be used to generate testable hypotheses regarding factors that influence the implementation of change, and it shows how different theoretical assumptions lead to different quality-improvement strategies.Keywords: Theories, quality improvement, health care. S ometimes new scientific findings, best practices, or clinical guidelines are easily implemented in practice. Most of the time, however, improving patient care is not easy, particularly if an innovation requires complex changes in clinical routines, better collaboration among disciplines, changes in patients' behavior, or changes in the organization of care. To date, the majority of health care improvements have been targeted at factors related to individual professionals, particularly their knowledge, routines, or attitudes (Grimshaw et al.Address correspondence to: Richard Grol, Centre for Quality of Care Research (WOK), Radboud University Nijmegen Medical Centre (UMCN), KWAZO 117, PO Box 9101, 6500 HB Nijmegen, the Netherlands (email: R.Grol@kwazo.umcn.nl). The Milbank Quarterly, Vol. 85, No. 1, 2007 (pp. 93-138) 94R. Grol, M. Bosch, M. Hulscher, M. Eccles, and M. Wensing 2004), although improvement may be impeded by a much broader range of economic, administrative, and organizational factors or those relating to patients' beliefs or behavior.Because the interaction of factors at multiple levels may influence the success or failure of quality-improvement interventions (Ferlie and Shortell 2001;Grol 1997;Shortell et al. 2000), an understanding of these factors (the obstacles and incentives for change) is crucial to an effective intervention (Grol and Grimshaw 2003;Grol and Wensing 2004;van Bokhoven, Kok, and van der Weijden 2003). An understanding of the theoretical assumptions and hypotheses behind these factors is necessary as well, as it enables the consideration of theory-based interventions for quality improvement. Currently, however, the specific model or approach is usually based on implicit (and potentially biased) personal beliefs about human behavior and change (Grol 1997).In this article we summarize and recommend a set of theories regarding change in health care and argue for a more systematic use of theories in planning and evaluating changes in clinical practice, by following and extending previous overviews of theories (e.g., Ashford 1998;Greenhalgh et al. 2004;Kitson, Harvey, and McCormack 1998;Michie et al. 2005;Robertson, Baker, and Hearnshaw 1996). The Complexity ...

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