Improvements in quality improvement
Article Outline
The field of quality improvement (QI) in medicine is witnessing a period of development and change. Quality improvement studies are no longer limited to single-center observational experiences. Now, researchers publish the results of large, multicenter efforts often tested under more rigorous and controlled settings. However, although the field has made great strides recently, there is still much to learn before the field can be said to have fully matured.
The study by Zhang et al in this issue of the Journal1 is exemplary of the current state of QI investigations. This study reports the results of a multicenter initiative designed to improve care processes for acute myocardial infarction (MI). The study is commendable for many reasons. Most notably, the program was impressive in its scope—involving 38 Tenet hospitals and more than 11
000 patients with MI. Initiating a QI effort among multiple centers presents many challenges, but when accomplished, this markedly improves the generalizability of the study's findings. The authors should also be credited for the program's success. Over an 18-month intervention period, both acute and discharge MI therapies demonstrated consistent improvement. Finally, the authors should be commended for the program's simplicity. The program began with the creation of QI teams at each participating hospital that regularly reviewed site-specific treatment data and implemented plans to promote QI based on these data. Beyond this supportive infrastructure, the means of change and the specific tools used to achieve these changes were left up to the local providers.
Although the results of this QI study were impressive, many questions remain unanswered. First, the program lacked an adequate control group of hospitals not participating in the QI initiative. Without such a control, the study may have overestimated the effect of the QI program due to unrelated secular changes in care. Similarly, documentation of quality indicators was filled out by nonblinded QI personnel and more complete documentation overtime could also have partially accounted for the differences seen. Third, the study did not assess hospital variability in response to the QI initiative. It would be interesting to know whether all centers benefited to a similar degree or whether a large improvement among a few centers drove the overall findings. And if it were the latter, then it would be important to understand the reasons why these providers improved so much whereas others were resistant. Fourth, clinical outcomes were not described, so the impact of improvements in care processes was not ascertained. Finally, the long-term sustainability of this QI effort remains untested. Many prior QI studies have shown a regression to baseline after the initiative has ended.
Despite these unanswered questions, the study does further our understanding of the key components necessary for achieving successful QI. Zhang et al first emphasized their rapid-cycle data feedback system. However, it is clear from multiple prior studies that provider feedback alone is not sufficient to achieve substantial practice change without further augmentation.2., 3. In addition to feedback systems, Bradley et al,4 in a prior qualitative analysis, noted that hospitals that improve care tend to have shared goals for QI among caregivers, strong administrative support for QI, and committed clinician champions. These general features can also be found in Tenet's Partnership for Change program. The initiative was strongly supported by administrations both at the individual hospital and system levels. The targets for QI in MI care were clearly defined and evidence based. Finally, although not explicitly reviewed, clinicians at participating hospitals were called upon to transform these identified needs for change into actionable plans. These specific tools have been well described in other studies and include standardized admission orders, reminder checklists, nurse QI monitors, and discharge patient “flight-plans”.5., 6.
In summary, the success of Tenet's Partnership for Change should provide motivation to hospitals everywhere. This study has demonstrated that system-wide improvement is possible when appropriate resources and motivational forces are applied. With each such successful program, we also learn more about what is needed to achieve meaningful and lasting QI. Thankfully, these ingredients are within the reach of most centers. No longer would hospitals not know where to start. If motivated, centers only need to follow the tried and true path of their predecessors. As more hospitals initiate similar QI programs, ultimately, care on a national level should witness transformational change.
References
- Data feedback and clinical process improvement in acute myocardial infarction. Am. Heart J. 2005;149:856–861
- . Changing physicians' practices. N. Engl. J. Med. 1993;329:1271–1273
- Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ. 1998;317:465–468
- A qualitative study of increasing β-blocker use after myocardial infarction. Why do some hospitals succeed?. JAMA. 2001;285:2604–2611
- Improving quality of care for acute myocardial infarction. The guidelines applied in practice (GAP) initiative. JAMA. 2002;287:1269–1276
- Improved treatment of coronary heart disease by implementation of a cardiac hospitalization atherosclerosis management program (CHAMP). Am. J. Cardiol. 2001;87:819–822
PII: S0002-8703(04)00580-0
doi:10.1016/j.ahj.2004.08.032
© 2005 Published by Elsevier Inc.
