20150330 qi elements health social care evidence summary v0.3 1 · 2015-07-13 · area in social...

File Name: Evidence summary Version: 0.3 Date: 30/03/2015

Produced by: Iain Stewart Page: 1 of 13 Review Date: n/a

Evidence summary

What are the elements needed to support quality improvement in integrated

health and social care systems?

1. Why is the question important?

The Scottish Government’s A route map to the 2020 vision for health and social care (Scottish

Government, 2013) has quality and Quality Improvement (QI) as a fundamental component.

With the introduction of the 2014 Health and Social Care Act health and social care services will

be delivered in a more integrated way. It is, therefore, an opportune/appropriate time to

review how quality improvement could be best delivered in this new integrated system.

Healthcare Improvement Scotland (HIS) is the national healthcare improvement organisation

with a focus on driving quality improvement in healthcare in Scotland. HIS, and partner

organisations, have a wealth of knowledge about the models and methodology to support QI.

Much of this knowledge is shared via the Quality Improvement Hub website

(http://www.qihub.scot.nhs.uk/). Recent work, such as the Building a Quality Improvement

Infrastructure programme, has focused on understanding the key components required to

create a national QI infrastructure (NHSScotland Quality Improvement Hub, 2014). This

evidence summary compliments this work and aims to investigate the infrastructure needed to

support QI in an integrated health and social care system.

2. Review question(s) or related questions

The purpose of this evidence summary is to identify and summarise systematic reviews about

how to create the conditions, at an organisational and policy level to support QI in integrated

health and social care systems. In order to do this the following question was set:

What are the elements needed to support quality improvement in integrated health and social

care systems?

This question is fairly general and in order to focus this evidence summary the following sub-questions

were created:

• Which QI models/interventions are most effective at improving quality / patient

outcomes?

• What are the elements that are important to implement successful QI systems?

• What are the elements that are important to deliver high quality services/care?



We defined elements to support QI in general terms, such as: conditions, context, environment,

factors, and infrastructure as well as more specific terms relating to the characteristics of High

Performing Organisations (HPO): culture, leadership, strategy and policy, structure, resources,

information, communication channels, skills training, and clinician involvement.

QI is hard to define (The Health Foundation, 2013). In addition this evidence summary sought

to draw upon a wide range of QI research from health, social care and integrated health and

social care systems to answer the question therefore a specific definition for QI was not put

forward.

3. Methods

This evidence summary was part of a pilot project looking to establish a new service within

NHSScotland. The model for evidence summaries was designed by NES and EPPI Center. Based

on this model, the general nature of the question and the large quantity of research published

on QI it was decided that this evidence summary should draw upon systematic review level

publications.

A systematic search of four relevant health and social care databases was conducted during

February 2015: Social Care Online, The Cochrane Library, Health Systems Evidence, and Epistemonikos.

The search was conducted for studies published in English since 2004 using a mixture of free

text terms and phrases plus subject headings. The search strategies for each database are

included in Appendix 1.

Citations were imported to EPPI Reviewer 4 software for the selection and screening process.

Appendix 2 shows the process for inclusion in this evidence summary. Citations were assessed

for relevance by one reviewer and had to meet all of the following inclusion criteria:

• systematic reviews,

• English language,

• published 2004 - Feb 2015,

• relevant countries: UK, Western Europe and Scandinavia, North America and

Australasia,

• relevant setting: health care, social care or both, and

• focus on organisational, management or policy aspects of QI and any HPO

characteristics, or conditions/infrastructure for QI, or enablers/barriers to QI, or system,

service or organisational level studies.

4. Results



This evidence summary was compiled using nine systematic reviews. No quality assessment of

reviews was conducted. We could not find any systematic reviews that directly answered the

main study question. Neither did we identify any systematic reviews that investigated the topic

area in social care contexts. All the included reviews had a health care focus. The included

reviews do however provide useful insights that may help determine the elements needed to

support QI in an integrated health and social care system.

Table 1 provides a summary of the systematic reviews included in this evidence summary,

more specific information can be found in the reviews themselves.

5. Evidence

This section indicates how the included reviews answer some of the sub-questions of this

evidence summary.

Sub question 1: Which QI models/interventions most effective at improving quality / patient

outcomes?

Scott (2009) performed a systematic review to establish the most effective strategies for

improving the quality and safety of care in health settings. Many different quality improvement

strategies were identified and these were all scored on their level of effectiveness. Scott (2009)

found when grouping the different QI intervention types in to patient/clinician mediated or

manager/policy-maker mediated QI interventions then the patient/clinician interventions

tended to be more effective.

Scott (2009) also reported a possible positive publication bias, a low quality to some of the

included studies as well as the variety in the approaches and reporting between studies made it

difficult to draw robust conclusions about effectiveness. Two other systematic reviews also

report that it is difficult to draw general conclusions about QI intervention effectiveness for

similar reasons. Vest and Gamm (2009) examined the effectiveness of three transformational

change QI interventions: Six Sigma, Lean and StuderGroup’s Hardwiring Excellence. In their

systematic review Vest and Gamm (2009) found it difficult to accurately measure or compare

effectiveness of these interventions because of the heterogeneous nature of the different

interventions and weaknesses in some of the research. Conry et al (2012) also found that the

diverse nature of the intervention type meant comparing studies and drawing general

conclusions about effectiveness was difficult.



TABLE 1

Overview of included systematic reviews

Review Years

searched

by review

Countries

covered by

review

Number

of

included

articles

AMSTAR

rating*

Relevance of the review to the evidence

summary

Summary of findings

Compas,

Hopkins

and

Townsley

2008

1997-

2007

Not stated Not

stated

4/9 This review sought to examine “studies,

projects, and initiatives that strived to

develop more efficient systems to support

an infrastructure” for improving quality of

care in nursing homes. This review

investigates the conditions needed to

implement QI and to sustain QI.

Three features for successfully implementing QI initiatives; they should be clearly stated, multifaceted, and

leadership driven.

Successful QI initiatives have seven essential components: “a specific, measurable mission or goal statement;

multidepartmental and multidisciplinary involvement; resource and educational materials; reward/incentive

programs; established internal and external stakeholders; a project champion; and a feedback-based process and

outcome measurement system.”

Lack of evidence about how QI interventions can be sustained.

Conry,

Humphries,

Morgan et

al 2012

2000-

2010

Not stated 20 6/10 Reviews what QI interventions have been

used in hospital settings and makes

recommendation about effectiveness of

these interventions for future QI efforts. The

review splits hospital QI interventions in to

two groups: interpersonal interventions and

technical interventions

Huge volume of literature (>13,000 articles) but only 20 studies included due to tight inclusion criteria and poor

quality of much of the evidence.

Included studies varied in design and scientific rigour, they also ranged in size, scope, setting, intervention type

and outcome so were difficult to compare or draw meaningful comparisons.

The review suggested technical interventions tended to show larger improvements in quality of care – but unable

to say exactly why (it could be that they are more measurable being quantitative in nature).

The review suggests future QI interventions will be most effective if have a “collaborative approach, use

multidisciplinary teams, utilise available resources, involve physicians and recognise the unique requirements of

each patient group.”

Kaplan,

Brady, Dritz

et al 2010

1980-

2008

USA, Canada,

Australia,

Iran, South

Korea, UK

47 7/10 The review examines the contextual factors

(environment, leadership, culture etc) that

influence QI effectiveness in health settings.

66 contextual factors were identified as influencing QI effectiveness. Most of which had a positive influence on QI

success, except “ownership, teaching status, and competition”.

The following were identified in at least nine of the articles as having a positive association with QI success:

“organizational characteristics, (e.g., size, ownership, teaching status), leadership from top management,

competition, organizational culture, years involved in QI, and data infrastructure/information systems”.

The following were identified less frequently but also had positive associations with QI success: “board leadership

for quality; organizational structure, particularly clinical integration across departments; customer focus;

physician involvement in QI; microsystem motivation to change; resources; and QI team leadership”.

McMurchy

2009

1990-

2008

Not stated Not

stated

2/9 This review examines the elements that are

needed to develop a high quality primary

One of the factors that would “facilitate the delivery of comprehensive and coordinated care” is “accountability

supported by a culture of continuous quality improvement and ongoing performance measurement”.



care system in Canada. It has a focus on high

quality care and discusses the elements that

would support this at a national level.

The review identified some key research gaps, one of these is “models for improving the coordination of care

within primary care and with the rest of the health system”.

Nadeem,

Olin, Hill et

al 2013

2006-

2012

USA,

Netherlands,

Sweden,

Canada

24 4/11 This review investigates the factors that

make a successful quality improvement

collaborative (QIC).

Few studies are able to say what the critical features/conditions are for QIC and then to replicate QIC elsewhere.

The research is not able to define how effective QICs are at improving patient care and what the key attributes are

to make successful QICs.

Nicholson,

Jackson

and Marley

2013

2006-

2012

Australia,

Canada, UK,

USA, NZ,

Sweden

21 Not

stated

This review examines the factors needed to

support successful service integration. The

review focuses on primary-secondary care

integration but some of the main findings

may be relevant to integration in general.

Ten elements identified as being necessary for integrated care - one element was measurement using quality

improvement data/methodology.

Key enabler for integration is building relationship between people. A major factor in this is leadership with a

focus on quality and a commitment to partnership working.

Several barriers were identified – one being that often macro-level reforms are not linked/co-ordinated with

meso- and micro-level change.

Parand,

Dopson,

Renz et al

2014

1983-

2010

Canada,

Australia,

USA, UK

19 Not

stated

The review examines: the amount of time

managers spent on quality and safety, the

different quality and safety activities

managers perform, and the impact

managers have on quality and safety

outcomes.

There is a lack of evidence to establish the extent hospital management influence quality of care.

The review suggests that the following managerial activities can affect quality performance: “establishing goals

and strategy to improve care, setting the quality agenda, engaging in quality, promoting a QI culture, managing

resisters and procurement of organisational resources for quality.”

Some evidence suggests that the time hospital mangers spend working on quality improvement can positively

influence patient outcomes. Conversely some studies suggest there is no influence.

The review suggests that many Board managers do not spend a sufficient time focusing on quality and safety.

Scott 2009 1985-

2008

Australia,

Canada,

Netherlands,

New Zealand,

USA, France,

UK, Ireland,

Norway,

Sweden

97 2/11 This review examines what makes effective

QI strategies (QIS) in health care.

Review grouped QIS in to two groups (clinician/patient driven and manger/policy-maker driven) to find out which

type are most effective at delivering improvement in quality and patient care.

Although evidence is not robust it points towards clinician/patient driven QIS being more effective.

There was a low quality of many of the studies (with few RCTs) as well as different ways of approaching and

reporting made it hard to generalise findings. In addition there is a possible bias towards a positive reporting of

effects.

Vest and

Gamm

2009

Up to

2007

USA 19 1/10 This review investigates the effectiveness of

three QI (transformational change) methods

on health care quality.

The review identified organizational culture as a key theme in the success of any of the QI initiatives.

The review mentions the variable quality of some of the published evidence about the effectiveness of QI - few

studies met all five inclusion criteria, potential methodological weakness in some studies and a potential for

positive publication bias.

Note: *An indication of the quality of the systematic review, as reported by Health Systems Evidence.



Sub-question 2: What are the elements that are important to implement successful QI

systems?

Kaplan et al (2010) examined the contextual factors that affect the success of QI

interventions in healthcare. This review identified 66 contextual factors across the 47

included articles. Most of the contextual factors identified had a positive influence on QI

success. The following contextual factors were reported in at least nine of the articles as

having a positive association with QI success: “organizational characteristics, (e.g., size,

ownership, teaching status), leadership from top management, competition, organizational

culture, years involved in QI, and data infrastructure/information systems”. Kaplan et al

(2010) also identified the following factors less frequently in the articles they reviewed as

being positively associated with QI success: “board leadership for quality; organizational

structure, particularly clinical integration across departments; customer focus; physician

involvement in QI; microsystem motivation to change; resources; and QI team leadership”.

Nadeem et al (2013) investigated what were the essential components needed for

successful a quality improvement collaborative. They found there was a wealth of research

and publications about QICs in health but few studies were able to outline what the critical

features/conditions were for QIC and then replicate them elsewhere. This means that

despite the vast amount of work done in the field there was not a solid understanding of the

key attributes needed for a successful quality improvement collaborative.

Sub-question 3: What are the elements that are important to deliver high quality

services/care?

A systematic review by Compas et al (2008) found that there were three key features that

were needed to improve quality of care. They found that QI interventions that sought to

improve quality of care should be “clearly stated, multifaceted and leadership driven”. They

elaborate on this and suggest that the interventions should contain a further seven

components in order to be successfully implemented. The interventions should have “a

specific, measurable mission or goal statement; multidepartmental and multidisciplinary

involvement; resource and educational materials; reward/incentive programs; established

internal and external stakeholders; a project champion; and a feedback-based process and

outcome measurement system.”

Nicholson et al (2013) examined some of the important features of service integration by

reviewing the evidence around the conditions needed for primary care and secondary care

integration. This systematic review found ten key elements necessary to support primary-

secondary care integration. Nicholson et al (2013) found one of these elements was QI. This

review found many studies supported the adoption of QI methodology as being important



to service integration. It did not matter the type of QI model used they found that having QI

methodology and principles as a component of integration was an important theme.

Conry et al (2012) conducted a systematic review that investigated quality of care

interventions in hospitals over a ten year period. The authors split the studies in to two

types: technical interventions (which tended to be implemented by physicians) and

interpersonal interventions (which tended to be implemented by nursing staff). Based on

this grouping this review found that technical interventions tended to show larger

improvements in quality of care. Conry et al (2012) concluded that in order for future

quality of care interventions to be most effective they should adopt a “collaborative

approach, use multidisciplinary teams, utilise available resources, involve physicians and

recognise the unique requirements of each patient group.”

Parand et al (2014) conducted a systematic review about the role of hospital managers at

different levels within their organisations and quality and patient safety activities. In a

similar way to other reviews they found the included articles varied in focus and reliability

so drawing general conclusions was difficult. Parand et al (2014) found a mixture of

evidence suggesting different outcomes. Parand et al (2014) found some studies that

showed a positive association between the amount of time hospital managers spent on

quality and safety work and improved patient outcomes and some studies that showed no

measurable influence. Their review did however indicate that Board managers did not

spend a sufficient amount of time on quality and safety and that there should be more

emphasis on QI at Board level.

McMurchy (2009) investigated the conditions that are needed to implement a high quality

primary care system in Canada. Although on a different topic, this systematic review

discusses the complexities of large scale systems and the conditions needed to create a

national system that can deliver high quality care. McMurchy (2009) describes three

attributes needed to facilitate “the delivery of comprehensive and coordinated care:

governance and organizational effectiveness including a clear mission and vision, strong

leadership and change management strategies; accountability supported by a culture of

continuous quality improvement and ongoing performance measurement; and patient

empowerment through education, shared decision making, access to their medical records,

and improved access for at-risk patients.”

6. Research Gaps

This was an evidence summary which only searched four health and social care databases

and did not perform any thematic or statistical analysis. The included systematic reviews



gave some recommendations to the elements required but did not fully answer the

question this evidence summary sought to answer. There is therefore potential for more

work around some of the specific elements needed to support QI in an integrated health

and social care system. This could be done by looking for different types of evidence, such

as policy documents or examples of best practice from specific organisations. As an example

the Health Foundation has recently published three reports which did not meet the

inclusion criteria but are potentially useful for addressing the question this evidence

summary sought to answer: Jones and Woodhead, 2015; Allcock et al, 2015; and de Silva,

2015.

7. Key points

The following key points were identified during this evidence summary:

• Large volume of literature on QI.

• Variable quality of research and different ways of conducting research as well as the

diversity and variety of QI interventions and settings makes it difficult to compare

studies and form general conclusions when conducting systematic reviews.

• Organisational culture is mentioned in some systematic reviews as being important

to facilitate QI.

• For service integration building relationships between people is an enabler for

success and leadership can have an important role to play in this.

• Creating an environment that encourages QI at all levels and allows managers time

to work on QI could influence QI success.

8. References

Allcock C, Dorman F, Taunt R, Dixon J. Constructive comfort: accelerating change in the NHS.

2015 [cited 30 April 2015]; Available from:

http://www.health.org.uk/public/cms/75/76/313/5504/Constructive%20comfort%20-

%20accelerating%20change%20in%20the%20NHS.pdf?realName=R9AogX.pdf

Compas C, Hopkins KA, Townsley E. Best practices in implementing and sustaining quality of

care: a review of the quality improvement literature. Res Gerontol Nurs. 2008; 1(3): 209-

216.



Conry MC, Humphries N, Morgan K, McGowan Y, Montgomery A, Vedhara K, et al. A 10 year

(2000-2010) systematic review of interventions to improve quality of care in hospitals. BMC

Health Serv Res. 2012; 12(275).

De Silva D. What’s getting in the way? Barriers to improvement in the NHS. 2015 [cited 30

April 2015]; Available from:

http://www.health.org.uk/public/cms/75/76/313/5505/Whats%20getting%20in%20the%20

way.pdf?realName=rFMBmO.pdf

Jones B, Woodhead T. Building the foundations for improvement: how five UK trusts built

quality improvement capability at scale within their organisations. 2015 [cited 30 April

2015]; Available from:

http://www.health.org.uk/public/cms/75/76/313/5506/Building%20the%20foundations%2

0for%20improvement.pdf?realName=xaxXoz.pdf

Kaplan HC, Brady PW, Dritz MC, Hooper DK, Linam WM, Froehle CM, et al. The Influence of

context on quality improvement success in health care: a systematic review of the literature.

Milbank Q. 2010; 88(4): 500-559.

McMurchy D. What are the critical attributes and benefits of a high-quality primary

healthcare system? 2009 [cited 2015 Mar 30]; Available from: http://www.cfhi-

fcass.ca/Libraries/Primary_Healthcare/11498_PHC_McMurchy_ENG_FINAL.sflb.ashx

Nadeem E, Olin SS, Hill LC, Hoagwood KE, Horwitz SM. Understanding the components of

quality improvement collaboratives: a systematic literature review. Milbank Q. 2013; 91(2):

354-94.

NHSScotland Quality Improvement Hub. Building a Quality Improvement Infrastructure:

creating the conditions for improvement in NHSScotland: 2013-15 Programme Overview.

2014 [cited 30 April 2015]; Available from:

http://www.qihub.scot.nhs.uk/media/581631/nhsscotland%20qi%20hub%20-

%20qii%20programme%20overview%20final.pdf

Nicholson C, Jackson C, Marley J. A governance model for integrated primary/secondary

care for the health-reforming first world - results of a systematic review. BMC Health Serv

Res. 2013; (13): 528.

Parand A, Dopson S, Renz A, Vincent C. The role of hospital managers in quality and patient

safety: a systematic review. BMJ Open. 2014; (4): e005055.

Scott I. What are the most effective strategies for improving quality and safety of health

care? Intern Med J. 2009; (39): 389-400.



Scottish Government. A route map to the 2020 vision for health and social care. 2013 [cited

30 April 2015]; Available from: http://www.gov.scot/Resource/0042/00423188.pdf

The Health Foundation. Quality improvement made simple: what everyone should know

about healthcare quality improvement. 2013 [cited 30 April 2015]; Available from:

http://www.health.org.uk/public/cms/75/76/313/594/Quality%20improvement%20made%

20simple%202013.pdf?realName=96E7kA.pdf

Vest JR, Gamm LD. A critical review of the research literature on Six Sigma, Lean and

StuderGroup's Hardwiring Excellence in the United States: the need to demonstrate and

communicate the effectiveness of transformation strategies in healthcare. Implement Sci.

2009; (4): 35.



Appendix 1

Social Care Online Search strategy

Cochrane Library search strategy



HSE search strategy

("quality improvement" or "quality assurance" or QI or QA or "performance

improvement" or "system improvement" or "improvement science" or "improvement

program" or "improvement process" or excellence) and (culture or structure or

leadership or policy or "staff training" or "professional development" or communication

or context or condition or environment or infrastructure or national or system) limited

to 2004-15

Epistemonikos search strategy

((title:(excellence OR "improvement process*" OR "improvement program*" OR

"improvement science" OR "system* improvement" OR "performance improvement" OR

(QI OR QA) OR "quality assurance" OR "quality improvement") OR abstract:(excellence

OR "improvement process*" OR "improvement program*" OR "improvement science" OR

"system* improvement" OR "performance improvement" OR (QI OR QA) OR "quality

assurance" OR "quality improvement")) AND (title:(infrastructure OR environment OR

condition* OR communication OR "professional development" OR "staff training" OR

polic* OR leadership OR structure OR culture OR system OR national) OR

abstract:(infrastructure OR environment OR condition* OR communication OR

"professional development" OR "staff training" OR polic* OR leadership OR structure OR

culture OR system OR national)))



Appendix 2

Study selection and screening flowchart

Remove

duplicates

n=10

Screen on title

& abstract

n=180

Exclude on

study type (4)

Exclude on

topic (151)

Exclude on

date (0)

Exclude on

country (7)

Include on

abstract n=18

Retrieve full

text

Available n=18

Screen on full

text

Exclude

model/method

specific (2)

Exclude

profession

focus (1)

Exclude focus

not QI (4)

Exclude

condition

specific (4)

Import results

n=190

20150330 qi elements health social care evidence summary v0.3 1 · 2015-07-13 · area in social...

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