High-quality health systems in the Sustainable Development Goals era: time for a revolution

Background Plan–do–study–act (PDSA) cycles provide a structure for iterative testing of changes to improve quality of systems. The method is widely accepted in healthcare improvement; however there is little overarching evaluation of how the method is applied. This paper proposes a theoretical framework for assessing the quality of application of PDSA cycles and explores the consistency with which the method has been applied in peer-reviewed literature against this framework. Methods NHS Evidence and Cochrane databases were searched by three independent reviewers. Empirical studies were included that reported application of the PDSA method in healthcare. Application of PDSA cycles was assessed against key features of the method, including documentation characteristics, use of iterative cycles, prediction-based testing of change, initial small-scale testing and use of data

https://qualitysafety.bmj.com/content/qhc/23/4/290.full.pdf

Systematic review of the application of the plan–do–study–act method to improve quality in healthcare

Objective To evaluate the effectiveness of quality improvement collaboratives in improving the quality of care. Data sources Relevant studies through Medline, Embase, PsycINFO, CINAHL, and Cochrane databases. Study selection Two reviewers independently extracted data on topics, participants, setting, study design, and outcomes. Data synthesis Of 1104 articles identified, 72 were included in the study. Twelve reports representing nine studies (including two randomised controlled trials) used a controlled design to measure the effects of the quality improvement collaborative intervention on care processes or outcomes of care. Systematic review of these nine studies showed moderate positive results. Seven studies (including one randomised controlled trial) reported an effect on some of the selected outcome measures. Two studies (including one randomised controlled trial) did not show any significant effect. Conclusions The evidence underlying quality improvement collaboratives is positive but limited and the effects cannot be predicted with great certainty. Considering that quality improvement collaboratives seem to play a key part in current strategies focused on accelerating improvement, but may have only modest effects on outcomes at best, further knowledge of the basic components effectiveness, cost effectiveness, and success factors is crucial to determine the value of quality improvement collaboratives.

https://www.bmj.com/content/bmj/336/7659/1491.full.pdf

Evidence for the impact of quality improvement collaboratives: systematic review

The patient-centered medical home (PCMH) is four things: 1) the fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership; 2) new ways of organizing practice; 3) development of practices’ internal capabilities, and 4) related health care system and reimbursement changes. All of these are focused on improving the health of whole people, families, communities and populations, and on increasing the value of healthcare. The value of the fundamental tenets of primary care is well established. This value includes higher health care quality, better whole-person and population health, lower cost and reduced inequalities compared to healthcare systems not based on primary care. The needed practice organizational and health care system change aspects of the PCMH are still evolving in highly related ways. The PCMH will continue to evolve as evidence comes in from hundreds of demonstrations and experiments ongoing around the country, and as the local and larger healthcare systems change.

 Measuring the PCMH involves the following:
 Efforts to transform practice to patient-centered medical homes must recognize, assess and value the fundamental features of primary care that provide personalized, equitable health care and foster individual and population health.

/pdf/defining-and-measuring-the-patient-centered-medical-home-3pgod9p2p5.pdf

Defining and measuring the patient-centered medical home

Changes that can improve patients’ health are often difficult to get into practice, even when backed by good evidence. Peter Pronovost, Sean Berenholtz, and Dale Needham describe a collaborative model that has been shown to work

Translating evidence into practice: a model for large scale knowledge translation.

BACKGROUND AND PURPOSE: The purpose of this study was to explore the effects of a quality improvement program for improving stroke care and the determinants of success at the team and hospital levels. METHOD: For 16 months, 23 multidisciplinary stroke service teams participated in a quality improvement collaborative designed to set up stroke services and reduce the length of hospital stay (LOHS). We monitored the LOHS and the discharge delay during the project and measured indicators of well organized stroke services at baseline and after the intervention. A multiple and multilevel regression model was used to relate the outcome variables to the team and hospital characteristics. National LOHS figures served as reference data. RESULTS: Data regarding 4549 stroke patients were included in the analyses. The LOHS decreased significantly from 18.3 to 13.3 days. The mean LOHS varied substantially (9.2 to 20.9 days) after the intervention. Teams with higher team functioning scores showed lower LOHS scores and higher scores for the indicators of well organized stroke services. Team characteristics explain almost 40% of the variance in LOHS and 53% in the indicators of well organized stroke care. CONCLUSION: Participation in a national quality improvement collaborative effected a significant decrease of the LOHS and a significant increase in the presence of key features of stroke services. Variation in ability to reduce the LOHS and increase key features of stroke services were related to team functioning. The data suggest that the composite of team functioning is pivotal in quality-of-care improvement and may need specific attention in any quality improvement program.

/pdf/factors-that-influence-the-stroke-care-team-s-effectiveness-3fz888wyw0.pdf

Factors That Influence the Stroke Care Team’s Effectiveness in Reducing the Length of Hospital Stay

Introduction
This study examined the short- and long-term effects of a quality improvement collaborative on patient outcomes, professional performance, and structural aspects of chronic care management of type 2 diabetes in an integrated care setting.

/pdf/short-and-long-term-effects-of-a-quality-improvement-3b3frhw14z.pdf

Short- and long-term effects of a quality improvement collaborative on diabetes management

The role of clinical practice guidelines has changed dramatically the past 50 years. Both beneficial, as also having some disadvantageous effects. Considering the international developments, such as a growing body of evidence and evolving methodologies, some limits might be in reach or already been reached. The solution thereof is part nationally and part internationally. Internationally because of new methodologies and technologies, such as use of artificial intelligence, and nationally in a more coherent approach. Coherent not only in medical disciplines, but also in policies of government, regulators, and health insurers. This calls for a renewed, integral and an all-encompassing vision.

Jannes J. E. van Everdingen

Papers

Evidence for the impact of quality improvement collaboratives: systematic review

Factors That Influence the Stroke Care Team’s Effectiveness in Reducing the Length of Hospital Stay

Short- and long-term effects of a quality improvement collaborative on diabetes management

[Guidelines in historical perspective].