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Transforming health care through research and education.

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Leveraging research and education to create a society of healthy communities, where all individuals reach their highest potential for health.

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Assessing the Evidence on Continuous Quality Improvement Initiatives

Edward Hughes, MD, MPH, Northwestern University
Stephen Shortell, PhD, Northwestern University

Creating high-quality outcomes requires identifying both the barriers to and facilitators of continuous quality improvement.

Hospitals and physicians are under constant pressure to control costs and expand access to services while maintaining or improving the quality of care they provide their patients.  As a result, health care organizations are searching for ways to deliver more cost effective, higher quality care.  Some organizations are applying quality-control principles developed for industry to the health care field.  Continuous quality improvement/total quality management (CQI/TQM) is a structured, systematic process for creating organization-wide participation in planning and implementing continuous improvement in quality.  Five key criteria of CQI/TQM are:

  • focus on underlying organizational processes and systems as causes of failure,
  • structured problem-solving approaches based on statistical analysis,
  • use of cross-functional employee teams,
  • employee empowerment to identify problems and opportunities and to take appropriate action,
  • and explicit focus on internal and external customers.

Applying CQI/TQM has been proven successful in industry, but does it make a difference in health care organizations?  To find out, a research initiative led by Drs. Shortell and Hughes examined the relationship between quality improvement processes and selected outcomes in 61 hospitals.  As part of their study, primary data were collected from more than 7,000 respondents on measures related to their organization’s:

  • implementation of CQI/TQM key criteria,
  • culture,
  • approaches to implementation,
  • and the perceived impact of quality improvement initiatives.

The data were combined with independently collected data on perceived impact and objective measures of clinical efficiency (based on charges and length of stay) for six clinical conditions: acute myocardial infarction, chronic obstructive pulmonary disease, congestive heart failure, pneumonia, stroke, and hip replacement.

Among the study’s results, researchers found that hospital culture and implementation approach are strongly associated with a greater degree of quality improvement implementation—data revealed a significant reduction in the duration of hospital stays as well as reduced charges for several acute conditions.  Hospitals with cultures that emphasized teamwork, support, development of everyone’s potential, and willingness to take risks experienced a high degree of reported quality improvement.  Hospitals whose approach to implementation emphasized decentralized control, empowerment, and “just-in-time” training of physicians also reported a greater degree of implementation.  Whether or not a hospital adopted all five “essential” criteria for CQI/THM did not make a difference in the actual degree of quality implementation that occurred.  What really mattered was whether the hospital’s culture supported quality improvement work and whether its approach encourages flexible implementation methods.

A more negative finding revealed that most of the 61 organizations that took part in the study had failed to integrate a strategic vision into the understanding and implementation of their quality process.  This omission resulted in lack of physician involvement in clinical applications of best practice standards and lack of understanding by medical staff responsible for implementing the strategy.  Among the researchers’ practical suggestions is that health care organizations actively engage physician interest in CQI/THM by focusing on strategically important clinical objectives. This is integral to the successful implementation of a quality improvement plan.

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