| dc.description.abstract | Background
Robust evaluations of the effectiveness of Quality Improvement (QI) remain rare, and subsequently the evidence for the use of QI, and what may influence the success of such efforts, is weak.
Methods
EPOCH was a stepped-wedge, randomised trial of a QI programme, in 93 hospitals, designed to reduce mortality in patients requiring emergency abdominal surgery. CholeQuIC was a controlled evaluation of a 12-hospital project designed to reduce time to emergency laparoscopic cholecystectomy for patients with acute gallstone disease. Both studies had concurrent process evaluations.
Results
The EPOCH trial found no reduction in 90-day mortality associated with the improvement programme (16% mortality in both groups (Hazard ratio, QI vs usual care: 1.11 [0.96-1.28])). Hospital-level time-series analysis identified that only a small cohort of hospitals (14/93) improved half or more of the target care processes, suggesting a degree of implementation failure. Major influences included limited time and scarce resources to support clinicians leading improvement, including an onerous burden of data collection. CholeQuIC demonstrated that eight of 12 participating hospitals significantly reduced time to surgery when compared to national data from the same period (relative change in surgery ≤8 days, QI vs control group: 1.45 vs. 1.08 ([1.29-1.62]). Major influences include stakeholder
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engagement, allocated time to lead plus effective project support and a willingness to test out new ideas. The QI methods used in both projects were similar, but the scale and complexity of the change required was less in CholeQuIC and more within the control of clinicians to improve.
Conclusions
Concurrent outcome and process evaluations are necessary to understand if and how Quality Improvement projects work. Choosing a problem amenable to clinician-led Quality Improvement, using QI multiple methods that focus on effective stakeholder engagement and protected time for clinicians to lead improvement are major influences on whether Quality Improvement is effective or not. | en_US |
