Sustaining quality improvement efforts: emerging principles and practice

Burke, Robert E.; Mheen, P.J. Marang-van de

doi:10.1136/bmjqs-2021-013016

Cited by 16 publications

(17 citation statements)

References 32 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Our prospective approach—which allowed us to examine quantitative change in performance and qualitative interview data—highlighted the perils among clinical teams during sustainment who perceived their work to be complete after achieving quality improvement during active implementation. These results align with the literature that has identified the need for ongoing review of performance data as key to maintaining quality; the qualitative results, especially the quotations, provide real-life reminders of the emotional and cognitive perspectives that may serve as barriers to sustainment [ 2 , 6 ].…”

Section: Discussionsupporting

confidence: 76%

The Perils of a “My Work Here is Done” perspective: a mixed methods evaluation of sustainment of an evidence-based intervention for transient ischemic attack

Bravata

Miech

Myers

et al. 2022

BMC Health Serv Res

View full text Add to dashboard Cite

Background To evaluate quality improvement sustainment for Transient Ischemic Attack (TIA) and identify factors influencing sustainment, which is a challenge for Learning Healthcare Systems. Methods Mixed methods were used to assess changes in care quality across periods (baseline, implementation, sustainment) and identify factors promoting or hindering sustainment of care quality. PREVENT was a stepped-wedge trial at six US Department of Veterans Affairs implementation sites and 36 control sites (August 2015—September 2019). Quality of care was measured by the without-fail rate: proportion of TIA patients who received all of the care for which they were eligible among brain imaging, carotid artery imaging, neurology consultation, hypertension control, anticoagulation for atrial fibrillation, antithrombotics, and high/moderate potency statins. Key informant interviews were used to identify factors associated with sustainment. Results The without-fail rate at PREVENT sites improved from 36.7% (baseline, 58/158) to 54.0% (implementation, 95/176) and settled at 48.3% (sustainment, 56/116). At control sites, the without-fail rate improved from 38.6% (baseline, 345/893) to 41.8% (implementation, 363/869) and remained at 43.0% (sustainment, 293/681). After adjustment, no statistically significant difference in sustainment quality between intervention and control sites was identified. Among PREVENT facilities, the without-fail rate improved ≥2% at 3 sites, declined ≥2% at two sites, and remained unchanged at one site during sustainment. Factors promoting sustainment were planning, motivation to sustain, integration of processes into routine practice, leadership engagement, and establishing systems for reflecting and evaluating on performance data. The only factor that was sufficient for improving quality of care during sustainment was the presence of a champion with plans for sustainment. Challenges during sustainment included competing demands, low volume, and potential problems with medical coding impairing use of performance data. Four factors were sufficient for declining quality of care during sustainment: low motivation, champion inactivity, no reflecting and evaluating on performance data, and absence of leadership engagement. Conclusions Although the intervention improved care quality during implementation; performance during sustainment was heterogeneous across intervention sites and not different from control sites. Learning Healthcare Systems seeking to sustain evidence-based practices should embed processes within routine care and establish systems for reviewing and reflecting upon performance. Trial registration Clinicaltrials.gov (NCT02769338)

show abstract

Section: Discussionsupporting

confidence: 76%

The Perils of a “My Work Here is Done” perspective: a mixed methods evaluation of sustainment of an evidence-based intervention for transient ischemic attack

Bravata

Miech

Myers

et al. 2022

BMC Health Serv Res

View full text Add to dashboard Cite

show abstract

“…Only through understanding the problem, both an effective and a sustainable intervention can be created that becomes part of everyday practice in the long term 44. This may require that first an effective intervention needs to be found, to then solve how it can be adapted for everyday practice to be sustainable, using resources that remain available after the QI intervention ends 45. In the present study’s design, it was taken into account that intervention components would remain available for the LROI to apply them in other hospitals if the intervention proved to be effective.…”

Section: Discussionmentioning

confidence: 99%

Effectiveness of a multifaceted quality improvement intervention to improve patient outcomes after total hip and knee arthroplasty: a registry nested cluster randomised controlled trial

et al. 2022

Self Cite

View full text Add to dashboard Cite

ObjectiveTo assess the effectiveness of a prospective multifaceted quality improvement intervention on patient outcomes after total hip and knee arthroplasty (THA and TKA).DesignCluster randomised controlled trial nested in a national registry. From 1 January 2018 to 31 May 2020 routinely submitted registry data on revision and patient characteristics were used, supplemented with hospital data on readmission, complications and length of stay (LOS) for all patients.Setting20 orthopaedic departments across hospitals performing THA and TKA in The Netherlands.Participants32 923 patients underwent THA and TKA, in 10 intervention and 10 control hospitals (usual care).InterventionThe intervention period lasted 8 months and consisted of the following components: (1) monthly updated feedback on 1-year revision, 30-day readmission, 30-day complications, long (upper quartile) LOS and these four indicators combined in a composite outcome; (2) interactive education; (3) an action toolbox including evidence-based quality improvement initiatives (QIIs) to facilitate improvement of above indicators; and (4) bimonthly surveys to report on QII undertaken.Main outcome measuresThe primary outcome was textbook outcome (TO), an all-or-none composite representing the best outcome on all performance indicators (ie, the absence of revision, readmissions, complications and long LOS). The individual indicators were analysed as secondary outcomes. Changes in outcomes from pre-intervention to intervention period were compared between intervention versus control hospitals, adjusted for case-mix and clustering of patients within hospitals using random effect binary logistic regression models. The same analyses were conducted for intervention hospitals that did and did not introduce QII.Results16,314 patients were analysed in intervention hospitals (12,475 before and 3,839 during intervention) versus 16,609 in control hospitals (12,853 versus 3,756). After the intervention period, the absolute probability to achieve TO increased by 4.32% (95% confidence interval (CI) 4.30-4.34) more in intervention than control hospitals, corresponding to 21.6 (95%CI 21.5-21.8), i.e., 22 patients treated in intervention hospitals to achieve one additional patient with TO. Intervention hospitals had a larger increase in patients achieving TO (ratio of adjusted odds ratios 1.24, 95%CI 1.05-1.48) than control hospitals, a larger reduction in patients with long LOS (0.74, 95%CI 0.61-0.90) but also a larger increase in patients with reported 30-day complications (1.34, 95%CI 1.00-1.78). Intervention hospitals that introduced QII increased more in TO (1.32, 95%CI 1.10-1.57) than control hospitals, with no effect shown for hospitals not introducing QII (0.93, 95%CI 0.67-1.30).ConclusionThe multifaceted QI intervention including monthly feedback, education, and a toolbox to facilitate QII effectively improved patients achieving TO. The effect size was associated with the introduction of (evidence-based) QII, considered as the causal link to achieve better patient outcomes.Trial registration numberNCT04055103.

show abstract

“…In agreement with Burke et al, while investigating the effects on practice, we focused on sustainable implementations, that remain effective for at least six months. [53] Other studies could investigate the applicability of the development methodology to other topics, especially in the case of a systems approach, as there were few opportunities to do so to date.…”

Section: Discussionmentioning

confidence: 99%

An intermediate step in bridging the gap between evidence and practice: developing and applying a methodology for “general good practices”

Safadi

Lám

Baranyi

et al. 2022

Preprint

View full text Add to dashboard Cite

The gap between evidence and clinical practice has been in the focus of researches for decades. Although successful implementation means the new knowledge must work in particular environments, it doesn’t mean that the entire process should exclusively be executed by the individual institutes. This is the point where we assumed that an intermediate step, the “general good practice”, could help to ensure that translation is done in a more professional way.The development of the general good practice methodology was based on our infinitE model, which organized the factors of successful translation into an evidence-editing-embedding-effect on practice framework, using tools from the disciplines of Evidence-Based Medicine, Quality Improvement and Change Management.The methodology organised the editing and embedding part of the development into a process involving three full-day sessions carried out with different health professionals, experts and moderators. After pilot testing, it was finalized and applied to other topics as well.The methodology presented in detail in this paper, centred on flow chart, process analysis, failure mode identification and Kotter’s 8-step model. Beside the pilot topic of the institutional process of resuscitation, the methodology has also proved applicable to more than ten other topics, meaning that at least all the core elements of the proposed bundle of general good practice have been produced in the development process.Compared to the guidelines, general good practices demonstrate the evidence in operation, helping to develop workflows, responsibilities, documentation, trainings, etc. and can also be a starting point for the digitalisation of care processes.The next step is to examine how healthcare institutions can build on these in their own editing and embedding activities, and what the results will be. Further studies could explore the applicability of the development methodology in different healthcare systems or at different levels of maturity in terms of quality.

show abstract

Sustaining quality improvement efforts: emerging principles and practice

Cited by 16 publications

References 32 publications

The Perils of a “My Work Here is Done” perspective: a mixed methods evaluation of sustainment of an evidence-based intervention for transient ischemic attack

The Perils of a “My Work Here is Done” perspective: a mixed methods evaluation of sustainment of an evidence-based intervention for transient ischemic attack

Effectiveness of a multifaceted quality improvement intervention to improve patient outcomes after total hip and knee arthroplasty: a registry nested cluster randomised controlled trial

An intermediate step in bridging the gap between evidence and practice: developing and applying a methodology for “general good practices”

Contact Info

Product

Resources

About