Beyond clinical engagement: A pragmatic model for quality improvement interventions, aligning clinical and managerial priorities

BMJ Quality and Safety

Volumn 25, Issue 9, 2016, Pages 716-725

  Pannick, Samuel ^a   Sevdalis, Nick ^b   Athanasiou, Thanos ^a  

^a IMPERIAL COLLEGE LONDON   (United Kingdom)

^b KING'S COLLEGE LONDON   (United Kingdom)

Author keywords

Healthcare quality improvement; Implementation science; Management; Quality improvement methodologies

Indexed keywords

COORDINATION; HEALTH CARE QUALITY; HUMAN; MANAGER; MODEL; STAFF; TOTAL QUALITY MANAGEMENT; ADMINISTRATIVE PERSONNEL; HEALTH CARE DELIVERY; NONBIOLOGICAL MODEL; ORGANIZATION AND MANAGEMENT; PROFESSIONAL STANDARD; QUALITATIVE RESEARCH; SAFETY; STANDARDS;

ADMINISTRATIVE PERSONNEL; DELIVERY OF HEALTH CARE; HUMANS; MODELS, ORGANIZATIONAL; PROFESSIONAL ROLE; QUALITATIVE RESEARCH; QUALITY IMPROVEMENT; SAFETY MANAGEMENT;

EID: 84986598833     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs-2015-004453     Document Type: Article

References (96)

1. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA 2001; 286: 415-20
2. Briant R, Buchanan J, Lay-Yee R, et al. Representative case series from New Zealand public hospital admissions in 1998- III: adverse events and death. N Z Med J 2006; 119: U1909
3. Zegers M, de Bruijne MC, Wagner C, et al. Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Qual Saf Health Care 2009; 18: 297-302
4. Hogan H, Healey F, Neale G, et al. Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. BMJ Qual Saf 2012; 21: 737-45
5. Dunn EJ, Mills PD, Neily J, et al. Medical team training: applying crew resource management in the Veterans Health Administration. Jt Comm J Qual Patient Saf 2007; 33: 317-25
6. Andersen H, Røvik KA, Ingebrigtsen T. Lean thinking in hospitals: is there a cure for the absence of evidence? A systematic review of reviews. BMJ Open 2014; 4: e003873
7. Fung CH, Lim YW, Mattke S, et al. Systematic review: the evidence that publishing patient care performance data improves quality of care. Ann Intern Med 2008; 148: 111-23
8. Wachter RM. Patient safety at ten: unmistakable progress, troubling gaps. Health Aff (Millwood) 2010; 29: 165-73
9. Woolf SH, Johnson RE. The break-even point: when medical advances are less important than improving the fidelity with which they are delivered. Ann Fam Med 2005; 3: 545-52
10. Huang C, Loewen P, Pelletier T, et al. Implementation of proven interventions in general medical inpatients: development and evaluation of a new quality indicator for drug therapy. Qual Saf Health Care 2008; 17: 269-74
11. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360: 491-9
12. Haugen AS, Søfteland E, Almeland SK, et al. Effect of the World Health Organization checklist on patient outcomes: a stepped wedge cluster randomized controlled trial. Ann Surg 2015; 261: 821-8
13. Urbach DR, Govindarajan A, Saskin R, et al. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med 2014; 370: 1029-38
14. Reames BN, Scally CP, Thumma JR, et al. Evaluation of the effectiveness of a surgical checklist in Medicare patients. Med Care 2015; 53: 87-94
15. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355: 2725-32
16. Marsteller JA, Sexton JB, Hsu YJ, et al. A multicenter, phased, cluster-randomized controlled trial to reduce central line-associated bloodstream infections in intensive care units. Crit Care Med 2012; 40: 2933-9
17. Bion J, Richardson A, Hibbert P, et al. Matching Michigan : a 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. BMJ Qual Saf 2013; 22: 110-23
18. Benning A, Dixon-Woods M, Nwulu U, et al. Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase. BMJ 2011; 342: d199
19. Taitz JM, Lee TH, Sequist TD. A framework for engaging physicians in quality and safety. BMJ Qual Saf 2012; 21: 722-8
20. Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci 2015; 10: 53
21. Taylor SL, Dy S, Foy R, et al. What context features might be important determinants of the effectiveness of patient safety practice interventions? BMJ Qual Saf 2011; 20: 611-17
22. Kaplan HC, Provost LP, Froehle CM, et al. The Model for Understanding Success in Quality (MUSIQ): building a theory of context in healthcare quality improvement. BMJ Qual Saf 2012; 21: 13-20
23. Harvey G, Jas P, Walshe K. Analysing organisational context: case studies on the contribution of absorptive capacity theory to understanding inter-organisational variation in performance improvement. BMJ Qual Saf 2015; 24: 48-55
24. Dixon-Woods M, Bosk CL, Aveling EL, et al. Explaining Michigan: developing an ex post theory of a quality improvement program. Milbank Q 2011; 89: 167-205
25. Dixon-Woods M, Leslie M, Tarrant C, et al. Explaining Matching Michigan: an ethnographic study of a patient safety program. Implement Sci 2013; 8: 70
26. MacLeod D, Clarke N. Engaging for success: enhancing performance through employee engagement. Department for Business, Innovation, & Skills, 2011
27. Schaufeli W, Salanova M, González-romá V, et al. The measurement of engagement and burnout: a two sample confirmatory factor analytic approach. J Happiness Stud 2002; 3: 71-92
28. Spurgeon P, Mazelan PM, Barwell F. Medical engagement: a crucial underpinning to organizational performance. Health Serv Manage Res 2011; 24: 114-20
29. Milliken AD. Physician engagement: a necessary but reciprocal process. CMAJ 2014; 186: 244-5
30. Clark J. Medical engagement: too important to be left to chance. The King s Fund, 2012
31. Wilkinson J, Powell A, Davies H. Are clinicians engaged in quality improvement? A review of the literature on healthcare professionals views on quality improvement initiatives. London: The Health Foundation, 2011
32. Evans SM, Berry JG, Smith BJ, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care 2006; 15: 39-43
33. Farley DO, Haviland A, Champagne S, et al. Adverseevent-reporting practices by US hospitals: results of a national survey. Qual Saf Health Care 2008; 17: 416-23
34. Russ SJ, Sevdalis N, Moorthy K, et al. A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the "Surgical Checklist Implementation Project". Ann Surg 2015; 261: 81-91
35. Treadwell JR, Lucas S, Tsou AY. Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf 2014; 23: 299-318
36. Fourcade A, Blache JL, Grenier C, et al. Barriers to staff adoption of a surgical safety checklist. BMJ Qual Saf 2012; 21: 191-7
37. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg 2008; 143: 12-17; discussion 18
38. O Connor P, Reddin C, O Sullivan M, et al. Surgical checklists: the human factor. Patient Saf Surg 2013; 7: 14
39. Øvretveit J. Understanding the conditions for improvement: research to discover which context influences affect improvement success. BMJ Qual Saf 2011; 20(Suppl 1): i18-23
40. Øvretveit JC, Shekelle PG, Dy SM, et al. How does context affect interventions to improve patient safety? An assessment of evidence from studies of five patient safety practices and proposals for research. BMJ Qual Saf 2011; 20: 604-10
41. Weingart SN, Ship AN, Aronson MD. Confidential clinicianreported surveillance of adverse events among medical inpatients. J Gen Intern Med 2000; 15: 470-7
42. Evans SM, Smith BJ, Esterman A, et al. Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals. Qual Saf Health Care 2007; 16: 169-75
43. Schuerer DJ, Nast PA, Harris CB, et al. A new safety event reporting system improves physician reporting in the surgical intensive care unit. J Am Coll Surg 2006; 202: 881-7
44. Provenzano A, Rohan S, Trevejo E, et al. Evaluating inpatient mortality: a new electronic review process that gathers information from front-line providers. BMJ Qual Saf 2015; 24: 31-7
45. Dijkema LM, Keus F, Dieperink W, et al. Real-time information on preventable death provided by email from frontline intensivists: results in high response rates with useful information. BMJ Qual Saf 2015; 24: 288
46. Nabors C, Peterson SJ, Aronow WS, et al. Physician reporting of clinically significant events through a computerized patient sign-out system. J Patient Saf 2011; 7: 155-61
47. Nabors C, Peterson SJ, Aronow WS, et al. Mobile physician reporting of clinically significant events-a novel way to improve handoff communication and supervision of resident on call activities. J Patient Saf 2014; 10: 211-17
48. Sujan MA, Ingram C, McConkey T, et al. Hassle in the dispensary: pilot study of a proactive risk monitoring tool for organisational learning based on narratives and staff perceptions. BMJ Qual Saf 2011; 20: 549-56
49. Lear R, Vincent C, Van Herzeele I, et al. Structured team self-report of intraoperative error can identify obstacles to safe surgery. Jt Comm J Qual Patient Saf 2013; 39: 480
50. King ES, Moyer DV, Couturie MJ, et al. Getting doctors to report medical errors: project DISCLOSE. Jt Comm J Qual Patient Saf 2006; 32: 382-92
51. McMullen H, Griffiths C, Leber W, et al. Explaining high and low performers in complex intervention trials: a new model based on diffusion of innovations theory. Trials 2015; 16: 242
52. Leape LL. The checklist conundrum. N Engl J Med 2014; 370: 1063-4
53. Burnett S, Benn J, Pinto A, et al. Organisational readiness: exploring the preconditions for success in organisation-wide patient safety improvement programmes. Qual Saf Health Care 2010; 19: 313-17
54. Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med 2013; 158(5 Pt 2): 365-8
55. Shekelle PG, Wachter RM, Pronovost PJ, et al. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Comparative Effectiveness Review No. 211. (Prepared by the Southern California-RAND Evidencebased Practice Center under Contract No. 290-2007-10062-I.) AHRQ Publication No. 13-E001-EF. Rockville, MD: Agency for Healthcare Research and Quality. 2013
56. Jones B, Woodhead T. Building the foundations for improvement. How five UK trusts built quality improvement capability at scale within their organisations. London: The Health Foundation, 2015
57. Jha A, Epstein A. Hospital governance and the quality of care. Health Aff (Millwood) 2010; 29: 182-7
58. Jha AK, Epstein AM. A survey of board chairs of English hospitals shows greater attention to quality of care than among their US counterparts. Health Aff (Millwood) 2013; 32: 677-85
59. Parand A, Dopson S, Renz A, et al. The role of hospital managers in quality and patient safety: a systematic review. BMJ Open 2014; 4: e005055
60. Jiang HJ, Lockee C, Bass K, et al. Board oversight of quality: any differences in process of care and mortality? J Healthc Manag 2009; 54: 15-30
61. Birken SA, Lee SY, Weiner BJ. Uncovering middle managers role in healthcare innovation implementation. Implement Sci 2012; 7: 28
62. Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to hospital performance on clinical quality metrics. Health Aff (Millwood) 2015; 34: 1304-11
63. Parand A, Dopson S, Vincent C. The role of chief executive officers in a quality improvement: a qualitative study. BMJ Open 2013; 3
64. Parand A, Burnett S, Benn J, et al. The disparity of frontline clinical staff and managers perceptions of a quality and patient safety initiative. J Eval Clin Pract 2011; 17: 1184-90
65. Federico F, Bonacum D. Strengthening the core. Middle managers play a vital role in improving safety. Healthc Exec 2010; 25: 68-70
66. Buchanan D. Pure plays and hybrids: acute trust management profile and capacity. J Health Serv Res Policy 2013; 18: 90-7
67. Doherty C, Gatenby M, Hales C. Role of the ward sister: tensions, pressures and opportunities. Nurs Stand 2010; 24: 35-40
68. Walshe K, Rundall TG. Evidence-based management: from theory to practice in health care. Milbank Q 2001; 79: 429-57, IV-V
69. Edwards C, Fox R, Gillard S, et al. Explaining health managers information seeking behaviour and use. Final report. NIHR Service Delivery and Organisation Programme, 2013
70. Dopson S, Bennett C, Fitzgerald L, et al. Health care managers access and use of management research. Final report. NIHR Service Delivery and Organisation Programme, 2013
71. Morgan L, New S, Robertson E, et al. Effectiveness of facilitated introduction of a standard operating procedure into routine processes in the operating theatre: a controlled interrupted time series. BMJ Qual Saf 2015; 24: 120-7
72. Birken SA, Lee SY, Weiner BJ, et al. From strategy to action: how top managers support increases middle managers commitment to innovation implementation in health care organizations. Health Care Manage Rev 2015; 40: 159-68
73. Floyd SW, Wooldridge B. Middle management s strategic influence and organizational performance. J Manage Stud 1997; 34: 465-85
74. Birken SA, Lee SY, Weiner BJ, et al. Improving the effectiveness of health care innovation implementation: middle managers as change agents. Med Care Res Rev 2013; 70: 29-45
75. Braithwaite J, Runciman WB, Merry AF. Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems. Qual Saf Health Care 2009; 18: 37-41
76. Proudlove N, Moxham C, Boaden R. Lessons for Lean in healthcare from using six sigma in the NHS. Public Money Manage 2008; 28: 27-34
77. Rycroft-Malone J, Seers K, Chandler J, et al. The role of evidence, context, and facilitation in an implementation trial: implications for the development of the PARIHS framework. Implement Sci 2013; 8: 28
78. Stewart GL, Manges KA, Ward MM. Empowering sustained patient safety: the benefits of combining top-down and bottom-up approaches. J Nurs Care Qual 2015; 30: 240-6
79. Trebble TM, Paul M, Hockey PM, et al. Clinically led performance management in secondary healthcare: evaluating the attitudes of medical and non-clinical managers. BMJ Qual Saf 2015; 24: 212-20
80. Haugen AS, Softeland E, Eide GE, et al. Impact of the World Health Organization s surgical safety checklist on safety culture in the operating theatre: a controlled intervention study. Br J Anaesth 2013; 110: 807-15
81. Dixon-Woods M, Martin G, Tarrant C, et al. Safer clinical systems: evaluation findings. London: The Health Foundation, 2014
82. Dixon-Woods M. The problem of context in quality improvement. Perspectives on context. London: Health Foundation, 2014
83. Pannick S, Beveridge I, Ashrafian H, et al. A stepped wedge, cluster controlled trial of an intervention to improve safety and quality on medical wards: the HEADS-UP study protocol. BMJ Open 2015; 5: e007510
84. Sheard L, O Hara J, Armitage G, et al. Evaluating the PRASE patient safety intervention-a multi-centre, cluster trial with a qualitative process evaluation: study protocol for a randomised controlled trial. Trials 2014; 15: 420
85. McElroy LM, Khorzad R, Nannicelli AP, et al. Failure mode and effects analysis: a comparison of two common risk prioritisation methods. BMJ Qual Saf 2016; 25: 329-36
86. Pinnock H, Epiphaniou E, Pearce G, et al. Implementing supported self-management for asthma: a systematic review and suggested hierarchy of evidence of implementation studies. BMC Med 2015; 13: 127
87. Pendharkar SR, Woiceshyn J, da Silveira GJ, et al. What happens when healthcare innovations collide? BMJ Qual Saf 2016; 25: 9-13
88. Davidoff F, Dixon-Woods M, Leviton L, et al. Demystifying theory and its use in improvement. BMJ Qual Saf 2015; 24: 228-38
89. Bhattacharyya O, Reeves S, Garfinkel S, et al. Designing theoretically-informed implementation interventions: fine in theory, but evidence of effectiveness in practice is needed. Implement Sci 2006; 1: 5
90. Oxman AD, Fretheim A, Flottorp S. The OFF theory of research utilization. J Clin Epidemiol 2005; 58: 113-16; discussion 17-20
91. Davies L, Ogrinc G. New SQUIRE publication guidelines: supporting nuanced reporting and reflection on complex interventions. BMJ Qual Saf 2015; 24: 184-5
92. ISRCTN registry. HEADS-UP: a structured team intervention to improve safety and quality on medical wards. 2015. dx.doi. org/10.1186/ISRCTN34806867 (accessed 1 Oct 2015
93. Marshall M, Pagel C, French C, et al. Moving improvement research closer to practice: the researcher-in-residence model. BMJ Qual Saf 2014; 23: 801-5
94. Watson TJ. Ethnography, reality, and truth: the vital need for studies of how things work in organizations and management. J Manage Stud 2011; 48: 202-17
95. Shaw SE, Russell J, Parsons W, et al. The view from nowhere? How think tanks work to shape health policy. Crit Policy Stud 2014; 9: 58-77
96. Martin GP, McKee L, Dixon-Woods M. Beyond metrics? Utilizing soft intelligence for healthcare quality and safety. Soc Sci Med 2015; 142: 19-26