Heather C. Kaplan

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.

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.

Variation in treatment of neonatal abstinence syndrome in US children's hospitals, 2004-2011.

Objective:Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome experienced by opioid-exposed infants. There is no standard treatment for NAS and surveys suggest wide variation in pharmacotherapy for NAS. Our objective was to determine whether different pharmacotherapies for NAS are associated with differences in outcomes and to determine whether pharmacotherapy and outcome vary by hospital.Study Design:We used the Pediatric Health Information System Database from 2004 to 2011 to identify a cohort of infants with NAS requiring pharmacotherapy. Mixed effects hierarchical negative binomial models evaluated the association between pharmacotherapy and hospital with length of stay (LOS), length of treatment (LOT) and hospital charges, after adjusting for socioeconomic variables and comorbid clinical conditions.Result:Our cohort included 1424 infants with NAS from 14 children’s hospitals. Among hospitals in our sample, six used morphine, six used methadone and two used phenobarbital as primary initial treatment for NAS. In multivariate analysis, when compared with NAS patients initially treated with morphine, infants treated with methadone had shorter LOT (incidence rate ratio (IRR)=0.55; P<0.0001) and LOS (IRR=0.60; P<0.0001). Phenobarbital as a second-line agent was associated with increased LOT (IRR=2.09; P<0.0001), LOS (IRR=1.78; P<0.0001) and higher hospital charges (IRR=1.84; P<0.0001). After controlling for case-mix, hospitals varied in LOT, LOS and hospital charges.Conclusion:We found variation in hospital in treatment for NAS among major US childrens hospitals. In analyses controlling for possible confounders, methadone as initial treatment was associated with reduced LOT and hospital stay.

Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature

Since its publication in 2008, SQUIRE (Standards for Quality Improvement Reporting Excellence) has contributed to the completeness and transparency of reporting of quality improvement work, providing guidance to authors and reviewers of reports on healthcare improvement work. In the interim, enormous growth has occurred in understanding factors that influence the success, and failure, of healthcare improvement efforts. Progress has been particularly strong in three areas: the understanding of the theoretical basis for improvement work; the impact of contextual factors on outcomes; and the development of methodologies for studying improvement work. Consequently, there is now a need to revise the original publication guidelines. To reflect the breadth of knowledge and experience in the field, we solicited input from a wide variety of authors, editors and improvement professionals during the guideline revision process. This Explanation and Elaboration document (E&E) is a companion to the revised SQUIRE guidelines, SQUIRE 2.0. The product of collaboration by an international and interprofessional group of authors, this document provides examples from the published literature, and an explanation of how each reflects the intent of a specific item in SQUIRE. The purpose of the guidelines is to assist authors in writing clearly, precisely and completely about systematic efforts to improve the quality, safety and value of healthcare services. Authors can explore the SQUIRE statement, this E&E and related documents in detail at http://www.squire-statement.org.

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.

Understanding variation in vitamin A supplementation among NICUs.

OBJECTIVE: We examined and characterized variation among NICUs in the use of vitamin A supplementation for the prevention of bronchopulmonary dysplasia in extremely low birth weight infants. METHODS: An historical cohort study of extremely low birth weight infants admitted within 7 days after birth to NICUs participating in the Pediatric Health Information System database, between January 1, 2005, and March 31, 2008, was performed. NICU medical directors were surveyed to determine attitudes and decision-making regarding adoption of vitamin A supplementation. The proportion of infants receiving vitamin A at each center was measured over time. Patient and hospital characteristics associated with vitamin A use were examined. RESULTS: Among 4184 eligible infants cared for in 30 NICUs, 1005 infants (24%) received vitamin A. Eighteen centers (60%) used vitamin A for some patients. Infants discharged in 2007 (odds ratio: 2.7 [95% confidence interval: 1.4–5.3]) and 2008 (odds ratio: 2.8 [95% confidence interval: 1.4–5.8]), compared with 2005, were more likely to receive vitamin A. NICU medical directors from centers using vitamin A, compared with centers that did not adopt vitamin A supplementation, reported stronger beliefs in the efficacy of vitamin A to reduce the incidence of bronchopulmonary dysplasia (83% vs 33%; P = .03) and in the ease with which vitamin A could be implemented (75% vs 22%; P = .02). CONCLUSIONS: Although the use of vitamin A is increasing, marked variation across NICUs remains. Provider attitudes and system characteristics seem to influence vitamin A adoption.

What's in a name generator? Choosing the right name generators for social network surveys in healthcare quality and safety research

Background Interest in the use of social network analysis (SNA) in healthcare research has increased, but there has been little methodological research on how to choose the name generators that are often used to collect primary data on the social connection between individuals for SNA. Objective We sought to determine a minimum set of name generators sufficient to distinguish the social networks of a target population of physicians active in quality improvement (QI). Methods We conducted a pilot survey including 8 name generators in a convenience sample of 25 physicians active in QI to characterize their social networks. We used multidimensional scaling to determine what subset of these name generators was needed to distinguish these social networks. Results We found that some physicians maintain a social network organized around a specific colleague who performed multiple roles while others maintained highly differentiated networks. We found that a set of 5 of the 8 name generators we used was needed to distinguish the networks of these physicians. Conclusions Beyond methodology for selecting name generators, our findings suggest that QI networks may require 5 or more generators to elicit valid sets of relevant actors and relations in this target population.

A Statewide Progestogen Promotion Program in Ohio

OBJECTIVE To promote use of progestogen therapy to reduce premature births in Ohio by 10%. METHODS The Ohio Perinatal Quality Collaborative initiated a quality improvement project in 2014 working with clinics at 20 large maternity hospitals, Ohio Medicaid, Medicaid insurers, and service agencies to use quality improvement methods to identify eligible women and remove treatment barriers. The number of women eligible for prophylaxis, the percent prescribed a progestogen before 20 and 24 weeks of gestation, and barriers encountered were reported monthly. Clinics were asked to adopt protocols to identify candidates and initiate treatment promptly. System-level changes were made to expand Medicaid eligibility, maintain Medicaid coverage during pregnancy, improve communication, and adopt uniform data collection and efficient treatment protocols. Rates of singleton births before 32 and 37 weeks of gestation in Ohio hospitals were primary outcomes. We used statistical process control methods to analyze change and generalized linear mixed models to estimate program effects accounting for known risk factors. RESULTS Participating sites tracked 2,562 women eligible for treatment between January 1, 2014, and November 30, 2015. Late entry to care, variable interpretation of treatment guidelines, maintenance of Medicaid coverage, and inefficient communication among health care providers and insurers were identified as treatment barriers. Births before 32 weeks of gestation decreased in all hospitals by 6.6% and in participating hospitals by 8.0%. Births before 32 weeks of gestation to women with prior preterm birth decreased by 20.5% in all hospitals, by 20.3% in African American women, and by 17.1% in women on Medicaid. Births before 37 weeks of gestation were minimally affected. Adjusting for risk factors and birth clustering by hospital confirmed a program-associated 13% (95% confidence interval 0.3-24%) reduction in births before 32 weeks of gestation to women with prior preterm birth. CONCLUSION The Ohio progestogen project was associated with a sustained reduction in singleton births before 32 weeks of gestation in Ohio.

Changing practice to improve patient safety and quality of care in perinatal medicine.

Despite an increased focus on the quality and safety of care, the United States health care system does not reliably deliver safe, high-quality care for all women and infants. In many cases, a gap still exists between best evidence and routine practice and pregnant women and neonates continue to experience preventable harm. Effective change strategies targeting individuals, groups or teams, organizations, and the larger system or environment have been used in the setting of perinatal care to improve quality and safety. In addition, strategies focused on aligning change efforts across multiple levels are increasingly being used to more effectively change practice in the context of the complex health care system. This review examines some of the single-level and multilevel approaches to changing practice that have been used in perinatal safety and quality improvement. Although progress has been slow, improvements in quality and safety measurement, widespread commitment to implementing effective practice change interventions, and advances in perinatal improvement and implementation research will help ensure that the dramatic improvements in perinatal quality and safety that have been anticipated will truly be realized.

Reliable implementation of evidence: a qualitative study of antenatal corticosteroid administration in Ohio hospitals

Background Antenatal corticosteroids (ANCS) reduce complications of preterm birth; however, not all eligible women receive them. Many hospitals and providers do not have the right processes and conditions to enable ANCS administration with high reliability. The objective of this study was to understand conditions that enable delivery of ANCS with high reliability among hospitals participating in an Ohio Perinatal Quality Collaborative (OPQC) ANCS project. Methods We conducted focus groups and semistructured interviews with members of the OPQC project team (n=27) and other care providers (n=70) using a purposeful sample of 6 sites involved in the OPQC ANCS project. Participants including nurses (n=57), attending obstetricians (n=17), physician trainees (n=21) and certified nurse midwives (n=2) were asked to reflect on their experiences and to identify factors contributing to optimal use of ANCS. Focus groups and interviews were transcribed verbatim and were analysed by a multidisciplinary team using an iterative approach that combined inductive and deductive methods to identify and categorise themes. Results Six major themes supporting reliable implementation of ANCS at these hospitals emerged including: (1) presence of a high reliability culture, (2) processes that emphasise high reliability, (3) timely and efficient administration process, (4) multiple disciplines are involved, (5) evidence of benefit supports ANCS use and (6) benefit is recognised at all levels of the care team. Conclusions Our findings identify the key processes and supports needed to ensure delivery of ASCS with high reliability and are reinforced by implementation and reliability science. They are useful for foundation of the successful implementation of other evidence-based practices at high levels of reliability.