Tips to improve success of QI efforts

Improvement efforts are critical to ensuring a resilient health care system and quality patient care. But if designed and implemented poorly, they can waste time, resources and, in fact, create new problems.

Quality improvement (QI) interventions are just as significant for patient wellbeing as drugs and devices, and research about improvement needs the same kind of rigour. Too often, when a challenge presents itself, and the nature of such challenges are often urgent, an obvious solution may be hastily implemented.

The reality is that some well-intentioned, initially plausible improvement efforts fail for a whole host of reasons, said Dr. Brian Wong, a Staff General Internist at Sunnybrook Health Sciences Centre and Director, University of Toronto Centre for Quality Improvement and Patient Safety (CQuIPS). Dr. Wong was speaking to a virtual audience at the annual meeting of Choosing Wisely Canada in late May.

Some of the reasons for QI failure? The project may be led by individuals who lack the expertise, authority or resources to instigate the changes required. Or the quality improvement intervention may be seen as a “magic bullet” that will produce improvement, regardless of the situation. Another common error is the improvement work is done in isolation at a local level, rather than pooling resources to develop collective situations.

Dr. Wong, through his work at CQuIPS, has been involved in a number of quality improvement efforts. During the pandemic, for example, his team used QI to implement a new collaborative care program to support 56 long-term care homes in Toronto.

To help improve the success of a quality improvement effort, Dr. Wong shared his list of tips.

Don’t Re-invent the Wheel

Before a quality improvement effort is implemented, search the literature to determine what can be learned from health care professionals outside one’s own institution or even province.

Treating QI as a series of local projects may increase the tendency for wheel reinvention — different ‘solutions’ to the same problem. Don’t be in a rush to innovate before investigating the success of solutions found elsewhere. Dr Wong cited some initiatives health care professionals may wish to take a closer look at — such as the pharmacy–led initiative that reduced benzodiazepine prescriptions among the frail elderly through patient education (the EMPOWER Cluster Randomized Trial) or clinical decision support interventions to decrease inappropriate PRBC (packed red blood cells) transfusion.

Plan-Do-Study-Act

The Plan-Do-Study-Act (PDSA) cycle lies at the heart of continuous improvement and is shorthand for planning a test of change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made as part of next steps (Act).

Since bumps in the road are a likely outcome of trying something new, it’s not surprising that not all PDSA cycles will lead to a rewarding step forward. In fact, many will not. But when change ideas are unsuccessful, those cycles that are initially disappointing may very well yield the most useful information about what to change and how best to proceed. Trial by error, says Dr. Wong, is crucial to quality improvement.

Dr. Wong says “fake PDSA” tend to follow a similar course: A single hypothesis is formed about the change idea; implementation proceeds uneventfully; and the final intervention looks similar to the initial change idea.

Authentic PDSA, however, looks much different. Multiple consecutive predictions will be made throughout development and implementation of change; the barriers to implementation will be identified and addressed; and the final intervention will be substantially modified from the initial change idea.

Fully Understand Root Causes

Too often, a “solution” is identified before a problem and its root causes are fully understood. For example, in addressing antibiotic overuse in children with otitis media, an obvious response might be to implement more physician education.

But physicians involved in designing one QI initiative came to understand that further MD education was not likely to be the best lever to initiate change — after all, physicians already understood the drawbacks of injudicious antibiotic prescribing. The real question was, what might compel physicians to write a prescription against their better judgment? The likely answer? The parent in front of them with a crying child on their lap who is desperate to leave the office with a prescription
in hand.

“What came to be understood,” said Dr. Wong “is that the parent needed to take something away with them and that was driving physicians to write prescriptions even if they believed them to be unnecessary. Parents don’t want to take time out of their busy schedules to make a return trip to the doctor’s office for a prescription if the symptoms don’t resolve,” said Dr. Wong.

The solution? The delayed prescription — one that could be handed to the parent during their initial visit with the agreement that it only be filled if the child’s symptoms do not resolve in a specified number of days.

In only 30 percent of cases is a delayed prescription ever filled, as compared with 90 percent of immediate prescriptions. And according to studies, the satisfaction rate is just as high as among the parents who received the immediate prescription.

Identify and Address Barriers to Implementation

One overlooked aspect of quality improvement research is intervention fidelity, which is the extent to which the intervention is delivered as it was intended.

Project teams should measure fidelity because if the change is not implemented correctly, nothing will improve, said Dr. Wong.

In the case of the delayed prescription, for example, did the primary care physician give the delayed prescription to the parent? If audit or feedback report cards were the intervention, did the providers receiving the care report cards open and read them?

Dr. Wong said that such barriers to implementation need to be identified and addressed.

Help Others Easily See Benefits

Dr. Wong described institutional or departmental resistance as the “scariest” part of any change initiative. But people can be made into enthusiastic participants, if the advantages and benefits are apparent and can be experienced.

Dr. Wong applied “Roger’s Diffusion of Innovation Theory” to a successful — and widely adopted — QI initiative at Sunnybrook Health Sciences Centre. The initiative reduces inappropriate catheterization of patients by implementing a medical directive for urinary catheter removal by nurses on general medical wards.

Immediate Advantage — Bedside nurses no longer need to provide catheter care.
Observable Benefit — Patients avoid catheter-related complications.
Compatibility — Integrate review of urinary catheter appropriateness into nursing shift assessment.
Trialability — Nurses try different ways to integrate the urinary catheter review into their daily workflow.
Complexity — List of indications for appropriate catheter use limited to four indications; if none are present, remove catheter.