Question

Discuss a situation that creates a barrier in the improvement of health care. Provide one input, one output, and your expected outcomes

Answer 1

BARRIER OF FOCUS:

The quality improvement efforts can have many divergent purposes. Some believe the purpose is improving performance, a process that occurs mainly through experiential learning and which differs significantly from scientific research, whose purpose, Davidoff noted, is to discover generalizable truths through hypothesis testing.

The emphasis on experiential learning that has evolved may lead to the conclusion that many of those doing quality improvements are uninterested in studying and writing about their experiences, Davidoff said. For them, discovering the generalizable truths about the efficacy and effectiveness of quality improvement interventions may be largely a secondary consideration.

THE ROLE OF CONTEXT

Understanding specific contexts and what is generalizable across settings is extremely valuable in the implementation of interventions, Many Experts stated that work in the field attempts to generate evidence while considering context and its effect on processes.

If local contexts are not considered, then the lessons learned from interventions will not be generalizable and will fail to improve the health care system, Batalden cautioned. For example, the practice of health care policy is local, while the policy of health care is not, Batalden added. The local uptake of health care policies, thus, must be considered when working to improve care. Active research and knowledge development are needed, both locally and across local settings.

RESOURCE BARRIERS

Limited data exist about the resources allocated to health care quality improvement. According to the Coalition for Health Services Research, an estimated $1.5 billion of federal funding was spent on health services research in fiscal year 2006 (Coalition for Health Services Research, 2006). In another study, about 1.5 percent of 2002 biomedical research funding was in health services and policy research, equating to less than 0.1 percent of total U.S. health care expenditures (Moses et al., 2005), cited Pincus. Because these statistics refer to funding for all of health services research, not just quality improvement research, even less is actually spent on understanding what works to improve performance. In countries outside the United States, Grimshaw said, the situation is no better, with funding policies that are often insufficient and inconsistent.

A related issue, Pincus said, is stakeholders’ lack of motivation to build the infrastructure that is needed to attract health services researchers. The main sources of funding for health services research include several federal agencies such as the Agency for Healthcare Research and Quality (AHRQ), the U.S Department of Veterans Affairs (VA), and the Centers for Medicare and Medicaid Services (CMS), foundations, and to a lesser degree, the National Institutes of Health (NIH). Very little funding comes from industry (i.e., hospitals, insurance, and pharmaceuticals) and voluntary health organizations, Pincus said. Thus it is important to develop strategies for diversifying funding sources and enhancing contributions from both industry and the NIH.

During the discussion, Richard Kahn of the American Diabetes Association (ADA) noted that as a voluntary health organization, the ADA does not receive many applications for quality improvement research grants. The applications that it does receive tend not to be well put together and are not of highly sophisticated research designs. Despite the general feeling that the organization awards few grants for quality improvement research, Kahn said that more funding would be provided if better applications were received.

LEVERS FOR STRENGTHENING QUALITY IMPROVEMENT RESEARCH

Pincus identified three levers to improve quality improvement research. The first is humanistic—that is, the research will ultimately result in better care for patients. The second lever is in the policy arena. Policy levers, such as accreditation or payors providing matching funds for quality improvement research, must be utilized. Quality improvement research can also be leveraged by strategies focused on individual researchers, for example, providing salary support for protected research time or altering tenure and promotion policies to respond to the special barriers of interdisciplinary research.

BARRIERS TO PERFORMING QUALITY IMPROVEMENT AND QUALITY IMPROVEMENT RESEARCH

Ethics

Ethical oversight in quality improvement remains largely ambiguous. For example, Davidoff, citing the work of continuing education expert Philip Nowlen, said that what distinguishes professionals from other people is “the obligation of professionals to ‘move unceasingly toward new levels of performance.’” From this perspective, quality improvement can be seen as an intrinsic element of clinical care. Others, however, believe quality improvement to be a form of clinical research, which raises the question of whether quality improvement research is human-subjects research. This is an important question because human-subjects research requires ethics review and institutional review board (IRB) approval.

The purpose of IRB approval is not to decide whether clinical care is ethical, Davidoff said, but the prospect of undergoing IRB approval, which can be extremely slow and inconsistent, has deterred some people from studying quality improvement. At the heart of this issue is determining whether a project falls under the rubric of quality improvement, which would not be subject to an ethics review, or whether it is research that would require ethics review. Currently, the distinction between these types of projects is not well delineated, Davidoff said. Constructs need to be developed that can help sharpen the distinction.

One member of the audience brought up the issue of confidentiality, asking how the Health Insurance Portability and Accountability Act (HIPAA) impedes researchers’ abilities to collect data. Davidoff responded that HIPAA does not prevent quality improvement research from being conducted, although there are many rules that need to be followed, referencing the more complete discussion of this issue in a report from the Hastings Center

BARRIER OF SUSTAINABILITY

Scot Webster spoke of the important role that culture change plays in improving quality. In particular, Webster noted Medtronic’s culture of grass roots, bottom-up sustainability. Due to this corporate culture, individual employees and units are able to initiate improvement projects on their own. If the employees did not believe in quality improvement as part of their culture, sustained change would not occur, Webster said.

Marita Titler observed that overcoming problems with employee engagement requires addressing the false notion that interventions and improving the quality of care do not affect employees. This means that employees must understand why interventions are important. Otherwise, interventions are at risk of being seen merely as additional short-term projects adding to workloads, and not as priorities. People have to believe in the improvements, not just see them as short-term solutions, Webster agreed, adding that culture change and change management must be included as areas of focus