Craig M. Froehle

The Influence of Context on Quality Improvement Success in Health Care: A Systematic Review of the Literature

CONTEXT The mixed results of success among QI initiatives may be due to differences in the context of these initiatives. METHODS The business and health care literature was systematically reviewed to identify contextual factors that might influence QI success; to categorize, summarize, and synthesize these factors; and to understand the current stage of development of this research field. FINDINGS Forty-seven articles were included in the final review. Consistent with current theories of implementation and organization change, leadership from top management, organizational culture, data infrastructure and information systems, and years involved in QI were suggested as important to QI success. Other potentially important factors identified in this review included: physician involvement in QI, microsystem motivation to change, resources for QI, and QI team leadership. Key limitations in the existing literature were the lack of a practical conceptual model, the lack of clear definitions of contextual factors, and the lack of well-specified measures. CONCLUSIONS Several contextual factors were shown to be important to QI success, although the current body of literature lacks adequate definitions and is characterized by considerable variability in how contextual factors are measured across studies. Future research should focus on identifying and developing measures of context tied to a conceptual model that examines context across all levels of the health care system and explores the relationships among various aspects of context.

Antecedents of New Service Development Effectiveness: An Exploratory Examination of Strategic Operations Choices

This article examines the strategic process of new service development (NSD). The authors empirically explore the strategic influence of team-based organizational structure, NSD process design, and information technology (IT) choices on the speed and effectiveness of NSD efforts. Several literature-based relationships are tested with a recursive path model using a multi-industry sample of U.S. service organizations. Most results for the service sector are similar to those found in manufacturing: (a) NSD cross-functional team structures directly influence the effectiveness of the firm’s NSD efforts, (b) more formalized NSD processes indirectly influence the firm’s ability to develop new services by increasing the speed of NSD, and (c) IT choices directly affect both the speed of the NSD process and the general effectiveness of the firm’s NSD activities. Contrary to expectations, no direct relationship between the use of cross-functional team structures and the speed of NSD was found.

The Model for Understanding Success in Quality (MUSIQ): building a theory of context in healthcare quality improvement

Background Quality improvement (QI) efforts have become widespread in healthcare, however there is significant variability in their success. Differences in context are thought to be responsible for some of the variability seen. Objective To develop a conceptual model that can be used by organisations and QI researchers to understand and optimise contextual factors affecting the success of a QI project. Methods 10 QI experts were provided with the results of a systematic literature review and then participated in two rounds of opinion gathering to identify and define important contextual factors. The experts subsequently met in person to identify relationships among factors and to begin to build the model. Results The Model for Understanding Success in Quality (MUSIQ) is organised based on the level of the healthcare system and identifies 25 contextual factors likely to influence QI success. Contextual factors within microsystems and those related to the QI team are hypothesised to directly shape QI success, whereas factors within the organisation and external environment are believed to influence success indirectly. Conclusions The MUSIQ framework has the potential to guide the application of QI methods in healthcare and focus research. The specificity of MUSIQ and the explicit delineation of relationships among factors allows a deeper understanding of the mechanism of action by which context influences QI success. MUSIQ also provides a foundation to support further studies to test and refine the theory and advance the field of QI science.

Research Opportunities in Service Process Design

Abstract This paper presents an overview of the new issues and research opportunities related to four service operations design topics—the design of retail and e-tail service processes, design of service processes involving waiting lines and workforce staffing, service design for manufacturing, and re-engineering service processes. All four topics are motivated by new technologies (particularly web-based technologies) and require a multi-disciplinary approach to research. For each topic, the paper presents an overview of the topic, the relevant frameworks, and a discussion of the research opportunities.

Service Personnel, Technology, and Their Interaction in Influencing Customer Satisfaction*

Managing both the technologies and the personnel needed for providing high-quality, multichannel customer support creates a complex and persistent operational challenge. Adding to this difficulty, it is still unclear how service personnel and these new communication technologies interact to influence the customer’s perceptions of the service being provided. Motivated by both practical importance and inconsistent findings in the academic literature, this exploratory research examines the interaction of media richness, represented by three different technology contexts (telephone, e-mail, and online chat), with six customer service representative (CSR) characteristics and their influences on customer satisfaction. Using a large-sample customer survey data set, the article develops a multigroup structural equation model to analyze these interactions. Results suggest that CSR characteristics influence customer service satisfaction similarly across all three technology-mediated contexts. Of the characteristics studied, service representatives contribute to customer satisfaction more when they exhibit the characteristics of thoroughness, knowledgeableness, and preparedness, regardless of the richness of the medium used. Surprisingly, while three other CSR characteristics studied (courtesy, professionalism, and attentiveness) are traditionally believed to be important in face-to-face encounters, they had no significant impact on customer satisfaction in the technology-mediated contexts studied. Implications for both practitioners and researchers are drawn from the results and future research opportunities are discussed.

Design, Implementation, and Assessment of a Radiology Workflow Management System

OBJECTIVE The objective of this article is to describe the development, launch, and outcomes studies of a paperless workflow management system (WMS) that improves radiology workflow in a filmless and speech-recognition environment. MATERIALS AND METHODS The WMS prioritizes cases automatically on the basis of medical and operational acuity factors, automatically facilitates communication of critical radiology results, and provides permanent documentation of these results and communications. It runs in parallel with an integrated radiology information system (RIS)-PACS and speech-recognition system. Its effects on operations, staff stress and satisfaction, and patient satisfaction were studied. RESULTS Despite an increase in caseload volume after the launch of the WMS, case turnaround times, defined as the time between case availability on PACS and signing of the final radiology staff interpretation, decreased for all case types. Median case turnaround time decreased by 33 minutes (22%) for emergency department, 47 minutes (37%) for inpatient, and 22 minutes (38%) for outpatient radiology cases. All reductions were significant at a p value of < 0.05. Interruptions were reduced, consuming an estimated 28% less radiology staff time, after implementation. Patient perceptions of radiology service timeliness showed modest improvement after the WMS was implemented. Staff satisfaction showed no significant change. CONCLUSION There is room for improvement in radiology workflow even in departments with integrated RIS-PACS and speech-recognition systems. This study has shown that software tools that coordinate decentralized workflow and dynamically balance workloads can increase the efficiency and efficacy of radiologists. Operational benefits, such as reduced reading times, improvements in the timeliness of care (both actual and as perceived by patients), and reduced interruptions to radiologists, further reinforce the benefits of such a system. Secondary benefits, such as documenting communication about a case and facilitating review of results, can also promote more timely and effective care. Although use of the system did not result in a substantial improvement in staff perceptions, neither did it reduce their satisfaction, suggesting that these operational improvements were not achieved as a trade-off against the quality of the work environment.

An exploratory analysis of the model for understanding success in quality.

BACKGROUND Experience suggests that differences in context produce variability in the effectiveness of quality improvement (QI) interventions. However, little is known about which contextual factors affect success or how they exert influence. PURPOSE Using the Model for Understanding Success in Quality (MUSIQ), we perform exploratory quantitative tests of the role of context in QI success. METHODOLOGY We used a cross-sectional design to survey individuals participating in QI projects in three settings: a pediatric hospital, hospitals affiliated with a state QI collaborative, and organizations sponsoring participants in an improvement advisor training program. Individuals participating in QI projects completed a questionnaire assessing contextual factors included in MUSIQ and measures of perceived success. Path analysis was used to test the direct, indirect, and total effects of context variables on QI success as hypothesized in MUSIQ. FINDINGS In the 74 projects studied, most contextual factors in MUSIQ were found to be significantly related to at least one QI project performance outcome. Contextual factors exhibiting significant effects on two measures of perceived QI success included resource availability, QI team leadership, team QI skills, microsystem motivation, microsystem QI culture, and microsystem QI capability. There was weaker evidence for effects of senior leader project sponsors, organizational QI culture, QI team decision-making, and microsystem QI leadership. These initial tests add to the validity of MUSIQ as a tool for identifying which contextual factors affect improvement success and understanding how they exert influence. PRACTICE IMPLICATIONS Using MUSIQ, managers and QI practitioners can begin to identify aspects of context that must be addressed before or during the execution of QI projects and plan strategies to modify context for increased success. Additional work by QI researchers to improve the theory, refine measurement approaches, and validate MUSIQ as a predictive tool in a wider range of QI efforts is necessary.

Communication in Diagnostic Radiology: Meeting the Challenges of Complexity

OBJECTIVE As patients and information flow through the imaging process, value is added step-by-step when information is acquired, interpreted, and communicated back to the referring clinician. However, radiology information systems are often plagued with communication errors and delays. This article presents theories and recommends strategies to continuously improve communication in the complex environment of modern radiology. CONCLUSION Communication theories, methods, and systems that have proven their effectiveness in other environments can serve as models for radiology.

Transient and Sustained Changes in Operational Performance, Patient Evaluation, and Medication Administration During Electronic Health Record Implementation in the Emergency Department

STUDY OBJECTIVE Little is known about the transient and sustained operational effects of electronic health records on emergency department (ED) performance. We quantify how the implementation of a comprehensive electronic health record was associated with metrics of operational performance, test ordering, and medication administration at a single-center ED. METHODS We performed a longitudinal analysis of electronic data from a single, suburban, academic ED during 28 weeks between May 2011 and November 2011. We assessed length of stay, use of diagnostic testing, medication administration, radiologic imaging, and patient satisfaction during a 4-week baseline measurement period and then tracked changes in these variables during the 24 weeks after implementation of the electronic health record. RESULTS Median length of stay increased and patient satisfaction was reduced transiently, returning to baseline after 4 to 8 weeks. Rates of laboratory testing, medication administration, overall radiologic imaging, radiographs, computed tomography scans, and ECG ordering all showed sustained increases throughout the 24 weeks after electronic health record implementation. CONCLUSION Electronic health record implementation in this single-center study was associated with both transient and sustained changes in metrics of ED performance, as well as laboratory and medication ordering. Understanding ways in which an ED can be affected by electronic health record implementation is critical to providing insight about ways to mitigate transient disruption and to maximize potential benefits of the technology.

The Flex Track: Flexible Partitioning Between Low- and High-Acuity Areas of an Emergency Department

STUDY OBJECTIVE Emergency departments (EDs) with both low- and high-acuity treatment areas often have fixed allocation of resources, regardless of demand. We demonstrate the utility of discrete-event simulation to evaluate flexible partitioning between low- and high-acuity ED areas to identify the best operational strategy for subsequent implementation. METHODS A discrete-event simulation was used to model patient flow through a 50-bed, urban, teaching ED that handles 85,000 patient visits annually. The ED has historically allocated 10 beds to a fast track for low-acuity patients. We estimated the effect of a flex track policy, which involved switching up to 5 of these fast track beds to serving both low- and high-acuity patients, on patient waiting times. When the high-acuity beds were not at capacity, low-acuity patients were given priority access to flexible beds. Otherwise, high-acuity patients were given priority access to flexible beds. Wait times were estimated for patients by disposition and Emergency Severity Index score. RESULTS A flex track policy using 3 flexible beds produced the lowest mean patient waiting time of 30.9 minutes (95% confidence interval [CI] 30.6 to 31.2 minutes). The typical fast track approach of rigidly separating high- and low-acuity beds produced a mean patient wait time of 40.6 minutes (95% CI 40.2 to 50.0 minutes), 31% higher than that of the 3-bed flex track. A completely flexible ED, in which all beds can accommodate any patient, produced mean wait times of 35.1 minutes (95% CI 34.8 to 35.4 minutes). The results from the 3-bed flex track scenario were robust, performing well across a range of scenarios involving higher and lower patient volumes and care durations. CONCLUSION Using discrete-event simulation, we have shown that adding some flexibility into bed allocation between low and high acuity can provide substantial reductions in overall patient waiting and a more efficient ED.