The take-home message of healthcare economics expert Dr. Regina Herzlinger and others has been that while the U.S. healthcare industry is one of the most expensive in the world, the quality of care can often be described as mediocre at best in many cases. A new study announced today suggests that outcomes in many clinical settings leave a lot to be desired, which means that research into quality improvement (QI) in clinical care has the potential to greatly improve patients’ experiences. The study, which appears in the journal Medical Care Research and Review, suggests that theoretical and practical improvements in QI effectiveness studies could make these into much more powerful tools for positive change.

Evidence suggests that 1 in 4 hospital deaths may be preventable, one-third of certain clinical procedures expose patients to risk without improving their health, one-third of drugs are prescribed erroneously and one third of abnormal laboratory results are not chased up by clinicians in the U.S. QI focuses on understanding, controlling, and improving work processes, analyzing problems' root causes, making work processes predictable, and then continuously improving process performance. Patients and clinicians need QI.

University of Michigan researchers Jeffrey Alexander and Larry Hearld reviewed 185 recent articles from clinical journals on QI's effects. QI effectiveness research is a developing area, and the authors aimed to find out just how useful this research is in providing managers and policy makers with evidence on the real impact of quality improvements.

Nearly 62 percent of the articles Alexander and Hearld reviewed focused on hospital QI interventions, the majority in university teaching hospitals. Most hospital admissions are in community hospitals and not teaching hospitals, raising questions about the extent of research relevance to those settings.

Physician practices and other healthcare organizations represented one-quarter and one- tenth, respectively, of further studies the authors reviewed.

More than 30 percent of studies focused on multiple interventions. This meant that the effects of the interventions could not be independently identified. This was particularly true in QI studies set in hospitals and physician practice settings.

Information technology and consumer engagement in healthcare are current hot topics in QI studies. Yet similar to nursing home studies, much of the literature in these areas focuses on describing the development or implementation of information technology or consumer engagement, with researchers paying less attention to evaluating of how these changes relate to QI.

Physicians argue that quality-of-care outcomes based on administrative databases don't provide subtle enough data to be of value. However, research gleaned from individual patient charts is expensive. Researchers evaluating QI effectiveness have to weigh up these considerations. It is also easy to mistakenly draw conclusions about how effective a particular QI intervention is by comparing studies that draw upon different sample types. Only QI studies in nursing homes, physician practices, and other health delivery organizations tend to be large enough to statistically test how effective QI changes are across certain organizational conditions. Most hospital QI studies are too small.

"The impact of QI changes may be overstated," says Alexander. "Our review highlights issues of inadequate study duration, potential selection bias of study participants, and difficulty making generalizations to other organizations due to unique study contexts or variation in intervention characteristics."

Short-term studies simply do not provide enough information to ascertain whether changes are going to have long-term effects on quality in these organizational settings. Also, many complex QI interventions, such as those requiring simultaneous, multiple changes in organizational process and structure, may need extended periods to actually demonstrate intended results.

The authors suggest that QI research needs to make use of theoretical and conceptual frameworks relevant to group relationships, organizational change, organizational learning, or innovation adoption and implementation to get on track. They recommend applying systems theory to QI research, and say that study designs would benefit from a multidisciplinary approach bringing onboard economists, organizational behaviourists, or other related disciplines. Today's narrow focus on medical aspects of QI ignores the critical roles of organizational context, cost-effectiveness, and perhaps most important, the value added by the QI intervention to the patient or organization.

Reference: Alexander JA and Hearld LR. What Can We Learn From Quality Improvement Research? A Critical Review of Research Methods. Medical Care Research and Review. 2009; 66; 235.

Has your ambulatory surgery center or surgical hospital “gone green” to become more environmentally friendly? Tell us what you’ve done to improve the “greenness” and reduce the carbon footprint of your facility, for publication in an upcoming article in SurgiStrategies magazine. Send your information to me at kpyrek@vpico.com

Newsweek writer Jerry Adler has penned a thought-provoking essay, File Under ‘Hodgepodge,’ that advocates for a national system of electronic medical records. A relative of mine who works as a medical records director at a large healthcare facility in the Phoenix area is representative of many MRDs who are caught with one foot in the dark ages of paper records and a tentative toe placed in the 21^st century, where “paperless” systems should be able to deliver us from the evils of chaos.

Adler writes, “A major change is occurring in medical record keeping, driven by the embarrassing realization that until now the information systems that keep track of Americans' cancer treatments have mostly lagged behind the ones they use to buy movie tickets online.” Adler quotes David Kibbe, a consultant on healthcare technology, as noting, “Eighty percent [of small practices], which provide more than half the medical care in the country, do not have computerized clinical record keeping. They keep patient records in file drawers; the doctors scribble prescriptions on pads of paper and communicate with other healthcare providers by picking up the phone and calling. The Obama administration's economic-stimulus package allocates almost $20 billion to help move this jury-rigged system into the 21st century, including direct subsidies to physicians for purchasing health-records systems ... as soon as the nation figures out what the system should be.”

Adler says that an “historic opportunity” will be missed if physicians continue to “adopt a hodgepodge of stand-alone systems that don't readily communicate with each other” and lists the abilities of a solid national electronic health records system. To read more, CLICK HERE.