Overcoming the ‘self-limiting’ nature of QI: can we improve the quality of patient care while caring for staff?

Lawton, Rebecca; Thomas, Eric J.

doi:10.1136/bmjqs-2022-015272

Cited by 11 publications

(11 citation statements)

References 20 publications

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“… 24 Indeed, improvement initiatives may not only have positive but also negative consequences and, hence, alone, are not necessarily the solution for service improvement in complex care systems. 25 A systems approach to quality improvement could be strengthened by considering measures of staff wellbeing, team relationships and culture. Such measures would allow consideration of the most impactful areas to focus on to achieve improvement – be that the environment within which staff work, enacting policies that promote a just culture and encouraging partnership working.…”

Section: Discussionmentioning

confidence: 99%

Assessing progress in managing and improving quality in nascent integrated care systems in England

Lalani,

Sugavanam,

Caiels

et al. 2023

J Health Serv Res Policy

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Objectives In 2022, England embarked on an ambitious reorganisation to produce an integrated health and care system, intended also to maximise population health. The newly created integrated care systems (ICSs) aim to improve quality of care, by achieving the best outcomes for individuals and populations through the provision of evidence-based services. An emerging approach for managing quality in organisations is the Quality Management System (QMS) framework. Using the framework, this study assessed how ICSs are managing and improving quality. Methods Four ICSs were purposively sampled, with the data collected between November 2021 and May 2022. Semi-structured interviews with system leaders ( n=60) from health and social care, public health and local representatives were held. We also observed key ICS meetings and reviewed relevant documents. A thematic framework approach based on the QMS framework was used to analyse the data. Results The ICSs placed an emphasis on population health, reducing inequity and improving access. This represents a shift in focus from the traditional clinical approach to quality. There were tensions between quality assurance and improvement, with concerns that a narrow focus on assurance would impede ICSs from addressing broader quality issues, such as tackling inequalities and unwarranted variation in care and outcomes. Partnerships, a key enabler for integration, was seen as integral to achieving improvements in quality. Overall, the ICSs expressed concerns that any progress made in quality development and in improving population health would be tempered by unprecedented system pressures. Conclusion It is unclear whether ICSs can achieve their ambition. As they move away from an assurance-dominated model of quality to one that emphasises openness, learning and improvement, they must simultaneously build the digital infrastructure, staff expertise and culture to support such a shift.

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Section: Discussionmentioning

confidence: 99%

Assessing progress in managing and improving quality in nascent integrated care systems in England

Lalani,

Sugavanam,

Caiels

et al. 2023

J Health Serv Res Policy

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“…Granja et al [3] found workload to be overrepresented as a barrier within their systematic review, and Carlfjord et al [2] describe workload to reduce the ability to engage into the implementation process. The implementation of new QI programmes therefore needs to align adoption efforts to workload, or else the implementation process may end up as a burden for healthcare workers already in a pressed and hectic work situation [36]. Bates and Singh [1] describe workarounds, for time saving purposes, as outcomes if the QI programme and implementation process are not aligned with workload.…”

Section: Organizational Factorsmentioning

confidence: 99%

Barriers and enablers for externally and internally driven implementation processes in healthcare: a qualitative cross-case study

Lyng,

Ree,

Strømme

et al. 2024

BMC Health Serv Res

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Background Quality in healthcare is a subject in need of continuous attention. Quality improvement (QI) programmes with the purpose of increasing service quality are therefore of priority for healthcare leaders and governments. This study explores the implementation process of two different QI programmes, one externally driven implementation and one internally driven, in Norwegian nursing homes and home care services. The aim for the study was to identify enablers and barriers for externally and internally driven implementation processes in nursing homes and homecare services, and furthermore to explore if identified enablers and barriers are different or similar across the different implementation processes. Methods This study is based on an exploratory qualitative methodology. The empirical data was collected through the ‘Improving Quality and Safety in Primary Care – Implementing a Leadership Intervention in Nursing Homes and Homecare’ (SAFE-LEAD) project. The SAFE-LEAD project is a multiple case study of two different QI programmes in primary care in Norway. A large externally driven implementation process was supplemented with a tracer project involving an internally driven implementation process to identify differences and similarities. The empirical data was inductively analysed in accordance with grounded theory. Results Enablers for both external and internal implementation processes were found to be technology and tools, dedication, and ownership. Other more implementation process specific enablers entailed continuous learning, simulation training, knowledge sharing, perceived relevance, dedication, ownership, technology and tools, a systematic approach and coordination. Only workload was identified as coincident barriers across both externally and internally implementation processes. Implementation process specific barriers included turnover, coping with given responsibilities, staff variety, challenges in coordination, technology and tools, standardizations not aligned with work, extensive documentation, lack of knowledge sharing. Conclusion This study provides understanding that some enablers and barriers are present in both externally and internally driven implementation processes, while other are more implementation process specific. Dedication, engagement, technology and tools are coinciding enablers which can be drawn upon in different implementation processes, while workload acted as the main barrier in both externally and internally driven implementation processes. This means that some enablers and barriers can be expected in implementation of QI programmes in nursing homes and home care services, while others require contextual understanding of their setting and work.

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“…As a consequence, service improvement in complex organisations following interventions cannot be assumed. 9 Improvement initiatives are not without costs – the addition of extra tasks for staff without clear rationale and obvious benefit, may further contribute to staff burden at a time in which burnout is prevalent across the workforce. 10 The need to provide enhanced performance data whilst within the programme, uses up further resources especially when the organisation has limited power and capacity to change the drivers of key performance indicators.…”

Section: Why Do National Improvement Programmes Struggle To Deliver I...mentioning

confidence: 99%

The Evolution of External Healthcare Regulation in England; From Performance Oversight to Supporting Improvement; Comment on "The Special Measures for Quality and Challenged Provider Regimes in the English NHS: A Rapid Evaluation of a National Improvement Initiative for Failing Healthcare Organisations"

Lalani

Hogan

2023

Int J Health Policy Manag

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The Special Measures and Challenged Provider (SMCP) Regime introduced for struggling healthcare organisations in England represents a subtle shift to the scope of external regulation from performance oversight to include supporting internal service improvement. External regulation alone has a had a mixed impact on the quality of care and Vindrola-Padros et al’s study highlights that externally driven improvement initiatives may also struggle to succeed in turning around performance. Principally, this is due to a failure in acknowledgment that poor performance results from a myriad of external and internal factors which coalesce to impede organisational performance. A struggling organisation may be indicative of wider issues in the local health and care system. Whole systems approaches to improvement with collaboration across providers and the effective use of data may support struggling organisations but their role maybe tempered with the increased centralisation of the delivery of improvement regimes such as SMCP.

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Overcoming the ‘self-limiting’ nature of QI: can we improve the quality of patient care while caring for staff?

Cited by 11 publications

References 20 publications

Assessing progress in managing and improving quality in nascent integrated care systems in England

Assessing progress in managing and improving quality in nascent integrated care systems in England

Barriers and enablers for externally and internally driven implementation processes in healthcare: a qualitative cross-case study

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