Characteristics of healthcare organisations struggling to improve quality: Results from a systematic review of qualitative studies

BMJ Quality and Safety

Volumn 28, Issue 1, 2019, Pages 74-84

  Vaughn, Valerie M ^a,b   Saint, Sanjay ^a,b   Krein, Sarah L ^a,b   Forman, Jane H ^b   Meddings, Jennifer ^a,b   Ameling, Jessica ^a,b   Winter, Suzanne ^a,b   Townsend, Whitney ^c   Chopra, Vineet ^a,b  

^a UNIVERSITY OF MICHIGAN MEDICAL SCHOOL   (United States)

^b VA ANN ARBOR HEALTHCARE SYSTEM   (United States)

^c UNIVERSITY OF MICHIGAN   (United States)

Author keywords

healthcare quality improvement; leadership; patient safety; qualitative research; quality improvement

Indexed keywords

ADULT; ARTICLE; CINAHL; COCHRANE LIBRARY; DRUG SAFETY; ELECTRONIC HEALTH RECORD; EMBASE; EMERGENCY CARE; FEMALE; HEALTH CARE ORGANIZATION; HUMAN; INFORMATION TECHNOLOGY; LEADERSHIP; MALE; MEDLINE; MORTALITY; NURSE; ORGANIZATIONAL CULTURE; OUTPATIENT; PATIENT SAFETY; QUALITATIVE RESEARCH; REGISTRATION; SKILL; STAFF; SYNTHESIS; SYSTEMATIC REVIEW; TOTAL QUALITY MANAGEMENT; TURNOVER TIME; WEB OF SCIENCE; HEALTH CARE FACILITY; HOSPITAL MANAGEMENT; ORGANIZATION; ORGANIZATION AND MANAGEMENT;

HEALTH FACILITIES; HEALTH FACILITY ADMINISTRATION; INFORMATION TECHNOLOGY; LEADERSHIP; ORGANIZATIONAL CULTURE; ORGANIZATIONAL OBJECTIVES; OWNERSHIP; QUALITY IMPROVEMENT;

EID: 85050623988     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs-2017-007573     Document Type: Review

References (87)

1. Institute of Medicine Committee on Quality of Health Care in A. Crossing the quality chasm: a new health system for the 21st Century. Washington DC: National Academies Press, 2001.
2. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348:2635-45.
3. Suter LG, Li SX, Grady JN, et al. National patterns of risk-standardized mortality and readmission after hospitalization for acute myocardial infarction, heart failure, and pneumonia: update on publicly reported outcomes measures based on the 2013 release. J Gen Intern Med 2014;29:1333-40.
4. Wakeam E, Hevelone ND, Maine R, et al. Failure to rescue in safety-net hospitals: availability of hospital resources and differences in performance. JAMA Surg 2014;149:229-35.
5. Allison JJ, Kiefe CI, Weissman NW, et al. Relationship of hospital teaching status with quality of care and mortality for Medicare patients with acute MI. JAMA 2000;284:1256-62.
6. Pines JM, Localio AR, Hollander JE, et al. The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia. Ann Emerg Med 2007;50:510-16.
7. Jha AK, Orav EJ, Epstein AM. Low-quality, high-cost hospitals, mainly in South, care for sharply higher shares of elderly black, Hispanic, and medicaid patients. Health Aff 2011;30:1904-11.
8. Joynt KE, Orav EJ, Jha AK. Mortality rates for Medicare beneficiaries admitted to critical access and non-critical access hospitals, 2002-2010. JAMA 2013;309:1379-87.
9. Damschroder LJ, Aron DC, Keith RE, et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009;4:50.
10. Braithwaite J, Herkes J, Ludlow K, et al. Association between organisational and workplace cultures, and patient outcomes: systematic review. BMJ Open 2017;7.
11. Weiner BJ. A theory of organizational readiness for change. Implement Sci 2009;4:67.
12. Krein SL, Damschroder LJ, Kowalski CP, et al. The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study. Soc Sci Med 2010;71:1692-701.
13. Weaver SJ, Weeks K, Pham JC, et al. On the CUSP: Stop BSI: evaluating the relationship between central line-associated bloodstream infection rate and patient safety climate profile. Am J Infect Control 2014;42:S203-8.
14. Saint S, Kowalski CP, Banaszak-Holl J, et al. The importance of leadership in preventing healthcare-associated infection: results of a multisite qualitative study. Infect Control Hosp Epidemiol 2010;31:901-7.
15. Zingg W, Holmes A, Dettenkofer M, et al. Hospital organisation, management, and structure for prevention of health-care-associated infection: a systematic review and expert consensus. Lancet Infect Dis 2015;15:212-24.
16. Taylor N, Clay-Williams R, Hogden E, et al. High performing hospitals: a qualitative systematic review of associated factors and practical strategies for improvement. BMC Health Serv Res 2015;15:244.
17. Forman J, Creswell JW, Damschroder L, et al. Qualitative research methods: key features and insights gained from use in infection prevention research. Am J Infect Control 2008;36:764-71.
18. Dixon-Woods M. Using framework-based synthesis for conducting reviews of qualitative studies. BMC Med 2011;9:39.
19. Carroll C, Booth A, Cooper K. A worked example of "best fit" framework synthesis: a systematic review of views concerning the taking of some potential chemopreventive agents. BMC Med Res Methodol 2011;11:29.
20. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 2009;62:1006-12.
21. Schneider B, Ehrhart MG, Macey WH. Organizational climate and culture. Annu Rev Psychol 2013;64:361-88.
22. Baxter R, Taylor N, Kellar I, et al. What methods are used to apply positive deviance within healthcare organisations? A systematic review. BMJ Qual Saf 2016;25:190-201.
23. Higgins J, Green S. Cochrane Handbook for Systematic Reviews of Interventions, Version 5. 1. 0. 2011 http://www. cochrane-handbook. org/ (accessed 2 Jul 2015).
24. Curry LA, Spatz E, Cherlin E, et al. What distinguishes topperforming hospitals in acute myocardial infarction mortality rates? A qualitative study. Ann Intern Med 2011;154:384-90.
25. Forbes-Thompson S, Leiker T, Bleich MR. High-performing and low-performing nursing homes: a view from complexity science. Health Care Manage Rev 2007;32:341-51.
26. Bergs J, Lambrechts F, Simons P, et al. Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence. BMJ Qual Saf 2015;24:776-86.
27. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008;8:45.
28. Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet 2001;358:483-8.
29. Verboom B, Montgomery P, Bennett S. What factors affect evidence-informed policymaking in public health? Protocol for a systematic review of qualitative evidence using thematic synthesis. Syst Rev 2016;5:61.
30. Creswell JW. Qualitative inquiry and research design: choosing among five approaches: SAGE Publications, 2012.
31. CASP Qualitative Research Checklist. 2017 http://www. caspuk. net/ casp-tools-checklists (accessed 12 Jun 2017).
32. Hannes K. Chapter 4: Critical appraisal of qualitative research. In: Noyes JBA, Hannes K, Harden A, Harris J, Lewin S. eds. Supplementary guidance for inclusion of qualitative research in cochrane systematic reviews of interventions: cochrane collaboration qualitative methods group, 2011.
33. Dixon-Woods M, Bonas S, Booth A, et al. How can systematic reviews incorporate qualitative research? A critical perspective. Qual Res 2006;6:27-44.
34. Bickell NA, Moss AD, Castaldi M, et al. Organizational factors affect safety-net hospitals' breast cancer treatment rates. Health Serv Res 2017;52:2137-55.
35. Brewster AL, Cherlin EJ, Ndumele CD, et al. What works in readmissions reduction: how hospitals improve performance. Med Care 2016;54:600-7.
36. D'Aunno T, Broffman L, Sparer M, et al. Factors that distinguish high-performing accountable care organizations in the medicare shared savings program. Health Serv Res 2018;53:120-37.
37. Fetene N, Linnander E, Fekadu B, et al. The ethiopian health extension program and variation in health systems performance: what matters? PLoS One 2016;11.
38. Gabbay RA, Friedberg MW, Miller-Day M, et al. A positive deviance approach to understanding key features to improving diabetes care in the medical home. Ann Fam Med 2013;11 Suppl 1:S99-S107.
39. Gagliardi AR, Nathens AB. Exploring the characteristics of high-performing hospitals that influence trauma triage and transfer. J Trauma Acute Care Surg 2015;78:300-5.
40. Hafner JM, Williams SC, Morton DJ, et al. From bad to better: a qualitative assessment of low-performing hospitals that improved their smoking cessation counseling performance. J Clin Outcomes Manag 2008;15:329-37.
41. Hockey PM, Bates DW. Physicians' identification of factors associated with quality in high-and low-performing hospitals. Jt Comm J Qual Patient Saf 2010;36:217-23.
42. Hogg W, Baskerville N, Nykiforuk C, et al. Improved preventive care in family practices with outreach facilitation: understanding success and failure. J Health Serv Res Policy 2002;7:195-201.
43. Hysong SJ, Best RG, Pugh JA. Clinical practice guideline implementation strategy patterns in Veterans Affairs primary care clinics. Health Serv Res 2007;42:84-103.
44. Kirsh S, Hein M, Pogach L, et al. Improving outpatient diabetes care. Am J Med Qual 2012;27:233-40.
45. Landman AB, Spatz ES, Cherlin EJ, et al. Hospital collaboration with emergency medical services in the care of patients with acute myocardial infarction: perspectives from key hospital staff. Ann Emerg Med 2013;61:185-95.
46. Mannion R, Davies HT, Marshall MN. Cultural characteristics of "high" and "low" performing hospitals. J Health Organ Manag 2005;19:431-9.
47. McAlearney AS, Hefner JL. Getting to Zero: Goal Commitment to Reduce Blood Stream Infections. Med Care Res Rev 2016;73:458-77.
48. Scheck McAlearney A, Hefner JL, Robbins J, et al. Preventing central line-associated bloodstream infections: a qualitative study of management practices. Infect Control Hosp Epidemiol 2015;36:557-63.
49. Newby KV, Parsons J, Brooks J, et al. Identifying strategies to increase influenza vaccination in GP practices: a positive deviance approach. Fam Pract 2016;33:318-23.
50. Ravaghi H, Mannion R, Sajadi HS. Organizational Failure in an NHS Hospital Trust: A Qualitative Study. Health Care Manag 2015;34:367-75.
51. Rose AJ, Petrakis BA, Callahan P, et al. Organizational characteristics of high-and low-performing anticoagulation clinics in the Veterans Health Administration. Health Serv Res 2012;47:1541-60.
52. Scott-Cawiezell J, Main DS, Vojir CP, et al. Linking nursing home working conditions to organizational performance. Health Care Manage Rev 2005;30:372-80.
53. Shin MH, Sullivan JL, Rosen AK, et al. Examining the validity of AHRQ's patient safety indicators (PSIs): is variation in PSI composite score related to hospital organizational factors? Med Care Res Rev 2014;71:599-618.
54. Wakeam E, Hyder JA, Ashley SW, et al. Barriers and Strategies for Effective Patient Rescue: A Qualitative Study of Outliers. Jt Comm J Qual Patient Saf 2014;40:503-6.
55. Young GJ, Charns MP, Daley J, et al. Best practices for managing surgical services: the role of coordination. Health Care Manage Rev 1997;22:72-81.
56. Caris MG, Kamphuis PGA, Dekker M, et al. Patient Safety Culture and the Ability to Improve: A Proof of Concept Study on Hand Hygiene. Infect Control Hosp Epidemiol 2017;38:1277-83.
57. Chang AM, Cohen DJ, Lin A, et al. Hospital Strategies for Reducing Emergency Department Crowding: A Mixed-Methods Study. Ann Emerg Med 2018;71:25.
58. Chuang E, Cabrera C, Mak S, et al. Primary care team-and clinic level factors affecting HPV vaccine uptake. Vaccine 2017;35:4540-7.
59. Ellerbe LS, Manfredi L, Gupta S, et al. VA residential substance use disorder treatment program providers' perceptions of facilitators and barriers to performance on pre-admission processes. Addict Sci Clin Pract 2017;12:10.
60. Engle RL, Tyler DA, Gormley KE, et al. Identifying barriers to culture change: a qualitative analysis of the obstacles to delivering resident-centered care. Psychol Serv 2017;14:316-26.
61. Mabuchi S, Sesan T, Bennett SC. Pathways to high and low performance: factors differentiating primary care facilities under performance-based financing in Nigeria. Health Policy Plan 2018;33:41-58.
62. Miller-Day M, Applequist J, Zabokrtsky K, et al. A tale of four practices: a comparative analysis of high and low performing patient-centered medical homes. J Health Organ Manag 2017;31:630-46.
63. Ralston SL, Atwood EC, Garber MD, et al. What works to reduce unnecessary care for bronchiolitis? A qualitative analysis of a national collaborative. Acad Pediatr 2017;17:198-204.
64. McAlearney AS, Hefner J, Robbins J, et al. Toward a highperformance management system in health care, part 4: Using high-performance work practices to prevent central lineassociated blood stream infections-a comparative case study. Health Care Manage Rev 2016;41:233-43.
65. Bradley EH, Brewster AL, McNatt Z, et al. How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study. BMJ Qual Saf 2018;27:218-25.
66. Constand MK, MacDermid JC, Dal Bello-Haas V, et al. Scoping review of patient-centered care approaches in healthcare. BMC Health Serv Res 2014;14:271.
67. Wick EC, Galante DJ, Hobson DB, et al. Organizational culture changes result in improvement in patientcentered outcomes: implementation of an integrated recovery pathway for surgical patients. J Am Coll Surg 2015;221:669-77.
68. Nelson KM, Helfrich C, Sun H, et al. Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use. JAMA Intern Med 2014;174:1350-8.
69. O'Mara-Eves A, Brunton G, Oliver S, et al. The effectiveness of community engagement in public health interventions for disadvantaged groups: a meta-analysis. BMC Public Health 2015;15:129.
70. Scott JT, Rundall TG, Vogt TM, et al. Kaiser Permanente's experience of implementing an electronic medical record: a qualitative study. BMJ 2005;331:1313-6.
71. Jay W, Lorsch EM. Culture is not the culprit. Harv Bus Rev. Boston, MA: Harvard Buiness School Publishing Corporation, 2016.
72. Wachter RM. The digital doctor: hope, hype, and harm at the dawn of medicine's computer age. New York, NY: McGraw-Hill Education, 2015.
73. Pokharel K, Biswas BK, Tripathi M, et al. Missed central venous guide wires: a systematic analysis of published case reports. Crit Care Med 2015;43:1745-56.
74. Dixon-Woods M, Baker R, Charles K, et al. Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Qual Saf 2014;23:106-15.
75. Mannion R, Konteh FH, Davies HT. Assessing organisational culture for quality and safety improvement: a national survey of tools and tool use. Qual Saf Health Care 2009;18:153-6.
76. Curry LA, Brault MA, Linnander EL, et al. Influencing organisational culture to improve hospital performance in care of patients with acute myocardial infarction: a mixed-methods intervention study. BMJ Qual Saf 2018;27:207-17.
77. Curry LA, Linnander EL, Brewster AL, et al. Organizational culture change in U. S. hospitals: a mixed methods longitudinal intervention study. Implement Sci 2015;10:29.
78. Pronovost P. Interventions to decrease catheter-related bloodstream infections in the ICU: the Keystone Intensive Care Unit Project. Am J Infect Control 2008;36:S171. e1-S171. e5.
79. Lin DM, Weeks K, Bauer L, et al. Eradicating central lineassociated bloodstream infections statewide: the Hawaii experience. Am J Med Qual 2012;27:124-9.
80. Lin DM, Weeks K, Holzmueller CG, et al. Maintaining and sustaining the On the CUSP: stop BSI model in Hawaii. Jt Comm J Qual Patient Saf 2013;39:51-60.
81. Mody L, Greene MT, Meddings J, et al. A National implementation project to prevent catheter-associated urinary tract infection in nursing home residents. JAMA Intern Med 2017;177:1154-62.
82. Saint S, Greene MT, Krein SL, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med 2016;374:2111-9.
83. Flanders SA, Greene MT, Grant P, et al. Hospital performance for pharmacologic venous thromboembolism prophylaxis and rate of venous thromboembolism: a cohort study. JAMA Intern Med 2014;174:1577-84.
84. Chopra V, Smith S, Swaminathan L, et al. Variations in peripherally inserted central catheter use and outcomes in michigan hospitals. JAMA Intern Med 2016;176:548-51.
85. Wells S, Tamir O, Gray J, et al. Are quality improvement collaboratives effective? A systematic review. BMJ Qual Saf 2018;27:226-40.
86. Fondrevay JJ. After a Merger, Don't Let "Us vs. Them" Thinking Ruin the Company: Harvard Business Review, 2018.
87. Katherine B. Is Transparency always the best policy? Harvard Business Review 2009.