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Learning and understanding for quality improvement under different conditions: An analysis of quality registry-based collaboratives in acute and chronic care
Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The demands that are placed on healthcare systems continue to increase, but several studies show that patient care and healthcare system outcomes are not as good as they could be. To come to terms with these problems, many stakeholders turn to systematic quality improvement methods. However, research and practice also shows that change in organisations is difficult. Consequently many quality improvement projects fail. Quality Improvement Collaboratives (QICs), introduced through the use of the Breakthrough series model, represent a commonly used approach. Despite their widespread application, uncertainty remains regarding the effectiveness of QICs. In Sweden, a number of national quality registries document healthcare actions and outcomes for different patient-groups and problem-areas. While these registries have long been used for follow-up purposes and for clinical research, they have not been used extensively for systematic clinical improvement purposes. The overall aim of this thesis was to examine if, and how, QICs which are supported by national quality registries can contribute to quality improvement in the provision of healthcare. The aim was also to examine what learning and new understanding occurred in the application of QICs in different settings.

The empirical material in this thesis comes from three QICs which included participating teams from different hospitals and health centres in Sweden. Each QIC included a national quality registry: the National Quality Registry for Acute Myocardial Infarction Care (RIKS-HIA); the National Diabetes Registry (NDR); and the Swedish Paediatric Diabetes Quality Registry (SWEDIABKIDS).

The thesis draws on an interactive research approach. The data collection and analysis employed both qualitative and quantitative methods. Data fromthe National Quality Registries, final team reports, focus-group interviews, and team members’ experiences were analysed and triangulated.

The studies shows that QICs which are supported by national quality registries helped teams to close a number of gaps between ordinary clinical practice and evidence-based guidelines, thereby contributing to the provision of better care and better clinical outcomes (Study I, Study II, and Study III). Important factors for success included stakeholders’ learning andunderstanding of the organisational context; structures that supported improvement efforts; and team members’ and managers’ commitment to improvement (Study IV). Furthermore, support by an internal team coach also promoted success (Study IV).

This thesis shows how national quality registries can be used in combination with systematic improvement efforts to produce better clinical results. It concludes that different areas of QIC application pose different challenges; for example, addressing care for acute disease versus chronic disease and evaluating professionally influenced process measures versus patient dependent outcome measures. While different organizational contexts and care characteristics can pose challenges to QIC efforts, the formation of “Communities of Practice” during QICs enhanced the learning for improvement with and from others.

Place, publisher, year, edition, pages
Jönköping: Jönköping University, School of Health and Welfare , 2015. , 123 p.
Series
Hälsohögskolans avhandlingsserie, ISSN 1654-3602 ; 65
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
URN: urn:nbn:se:hj:diva-28322ISBN: 978-91-85835-64-5 (print)OAI: oai:DiVA.org:hj-28322DiVA: diva2:871675
Public defence
2015-12-18, Originalet, Qulturum, Region Jönköpings län, Jönköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2015-11-16 Created: 2015-11-16 Last updated: 2015-11-20Bibliographically approved
List of papers
1. Improving guideline adherence through intensive quality improvement and the use of a National Quality Register in Sweden for acute myocardial infarction
Open this publication in new window or tab >>Improving guideline adherence through intensive quality improvement and the use of a National Quality Register in Sweden for acute myocardial infarction
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2007 (English)In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 16, no 1, 25-37 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: Data from the Swedish National Register in Cardiac Care have shown over the last 10 years an enduring gap between optimal treatment of acute myocardial infarction (AMI) according to current guidelines and the treatment actually given. We performed a controlled, prospective study in order to evaluate the effects of applying a multidisciplinary team-based improvement methodology to the use of evidence-based treatments in AMI, together with the use of a modified National Quality Register. The project engaged 25% of the Swedish hospitals.

METHOD: Multidisciplinary teams from 20 hospitals participating in the National Register in Cardiac Care, ranging from small to large hospitals, were trained in continuous quality improvement methodology. Twenty matched hospitals served as controls. Our efforts were focused on finding and applying tools and methods to increase adherence to the national guidelines for 5 different treatments for AMI. For measurement, specially designed quality control charts were made available in the National Register for Cardiac Care.

RESULTS: To close the gap, an important issue for the teams was to get all 5 treatments in place. Ten of the hospitals in the study group reduced the gap in 5 of 5 treatments by 50%, while none of the control hospitals did so.

CONCLUSIONS: This first, controlled prospective study of a registry supported by multidisciplinary team-based improvement methodology showed that this approach led to rapidly improved adherence to AMI guidelines in a broad spectrum of hospitals and that National Quality Registers can be helpful tools.

Keyword
Acute Disease, Guideline Adherence, Intensive Care Units, Myocardial Infarction/therapy, Practice Guidelines as Topic, Prospective Studies, Quality Assurance, Health Care/methods/organization & administration, Registries, State Medicine/organization & administration, Sweden
National Category
Health Sciences
Identifiers
urn:nbn:se:hj:diva-17181 (URN)17235249 (PubMedID)1063-8628 (Print) 1063-8628 (Linking) (ISBN)
Available from: 2012-01-16 Created: 2012-01-16 Last updated: 2017-12-08Bibliographically approved
2. Collaboratively improving diabetes care in Sweden using a National Quality Register: Successes and challenges-A Case Study
Open this publication in new window or tab >>Collaboratively improving diabetes care in Sweden using a National Quality Register: Successes and challenges-A Case Study
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2015 (English)In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 24, no 4, 2012-221 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Since 1996, the Swedish National Diabetes Register (NDR) enabled health care providers to monitor their clinical performance over time and compare it with the national average. All health systems of Swedish county councils report data. By 2014, the NDR included data from 360 000 patients. Comparisons among county councils show significant variations in clinical outcomes and in adherence to evidence-based national guidelines. The purpose of this study was to evaluate whether and how a quality improvement collaborative could influence clinical practice and outcomes.

METHODS: Twenty-three diabetes teams from all over Sweden, both primary care units and internal medicine departments, joined a quality improvement collaborative. The project was inspired by the Breakthrough Collaborative Model and lasted for 20 months. Evaluation data were collected from the teams' final reports and the NDR throughout the study period.

RESULTS AND CONCLUSION: The teams reported improved patient outcomes significantly compared with the national average for systolic blood pressure and low-density lipoprotein levels. In contrast, glycated hemoglobin A1c levels deteriorated in the whole NDR population. Five themes of changes in practice were tested and implemented. Success factors included improved teamwork, with active use of register data, and testing new ideas and learning from others.

Keyword
collaborative, diabetes mellitus, guideline adherence, quality improvement, registries
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:hj:diva-28318 (URN)10.1097/QMH.0000000000000068 (DOI)000369965300007 ()26426323 (PubMedID)2-s2.0-84943428919 (Scopus ID)
Available from: 2015-11-16 Created: 2015-11-16 Last updated: 2017-12-01Bibliographically approved
3. Improved results in paediatric diabetes care using a quality registry in an improvement collaborative: a case study in Sweden
Open this publication in new window or tab >>Improved results in paediatric diabetes care using a quality registry in an improvement collaborative: a case study in Sweden
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2014 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 9, no 5(e97875), 1-6 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

Several studies show that good metabolic control is important for children and adolescents with type 1 diabetes. In Sweden, there are large differences in mean haemoglobin A1c (HbA1c) in different hospitals and difficulties implementing national guidelines in everyday practice. This study shows how the participation in an improvement collaborative could facilitate improvements in the quality of care by paediatric diabetes teams. The Swedish paediatric diabetes quality registry, SWEDIABKIDS was used as a tool and resource for feedback and outcome measures.

METHODS:

Twelve teams at paediatric diabetes centres, caring for 30% (2302/7660) of patients in Sweden, participated in an 18-month quality improvement program. Each team defined treatment targets, areas needing improvement, and action plans. The main outcome was the centre patients' mean HbA1c levels, but other clinical variables and change concepts were also studied. Data from the previous six months were compared with the first six months after starting the program, and the long-term follow up after another eleven months.

RESULTS:

All centres reduced mean HbA1c during the second and third periods compared with the first. The mean reduction for all was 3·7 mmol/mol (p<0.001), compared with non-participating centres who improved their mean HbA1c with 1·7 mmol/mol during the same period. Many of the participating centres reduced the frequency of severe hypoglycaemia and/or ketoacidosis, and five centres reached their goal of ensuring that all patients had some sort of physical activity at least once weekly. Change concepts were, for example, improved guidelines, appointment planning, informing the patients, improving teamwork and active use of the registry, and health promotion activities.

CONCLUSIONS:

By involving paediatric diabetes teams in a quality improvement collaborative together with access to a quality register, the quality of paediatric diabetes care can improve, thereby contributing to a reduced risk of late complications for children and adolescents with diabetes.

National Category
Endocrinology and Diabetes
Identifiers
urn:nbn:se:hj:diva-25619 (URN)10.1371/journal.pone.0097875 (DOI)000336914100025 ()24867418 (PubMedID)2-s2.0-84901446997 (Scopus ID)
Available from: 2015-01-13 Created: 2015-01-13 Last updated: 2017-12-05Bibliographically approved
4. Learning from a successful Quality ImprovementCollaborative. Why did it work? – Experience from teams and team coacheswho improved their care for children with diabetes
Open this publication in new window or tab >>Learning from a successful Quality ImprovementCollaborative. Why did it work? – Experience from teams and team coacheswho improved their care for children with diabetes
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(English)Manuscript (preprint) (Other academic)
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-28320 (URN)
Available from: 2015-11-16 Created: 2015-11-16 Last updated: 2015-11-16

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