The influence of organizational context on quality improvement and patient safety efforts in infection prevention: A multi-center qualitative study
Introduction
Over the last decade, the long-standing effort to improve patient safety has become a priority on the health policy agenda and most hospitals are engaged in numerous activities to improve care quality, safety and outcomes (IOM, 1999, WHO, 2008). Despite these efforts we have limited understanding of why quality improvement efforts are successful in some hospitals and not others or, when successful, how different quality improvement strategies might contribute to the observed outcomes (Benn et al., 2009, Grol et al., 2007, Ovretveit et al., 2002).
A systematic review of nine studies of quality improvement collaboratives identified improvements in some but not all of the target outcomes in seven studies and there were no significant effects in two studies (Schouten, Hulscher, van Everdingen, Huijsman, & Grol, 2008). These results raise questions about the extent to which the collaboratives were responsible for improvements, potential determinants of success, and whether some organizations might respond better than others to this type of intervention (Schouten et al., 2008). The marginal overall success of other quality improvement strategies, such as audit and feedback, raises similar questions (Grimshaw et al., 2004).
The mixed success of quality improvement efforts has increased appreciation of organizational complexities and processes that influence the implementation of evidence-based practices in health care settings (Benn et al., 2009, Grol et al., 2007, Lukas et al., 2007, Pawson et al., 2005). Yet, few studies have gone below the surface to examine these complex organizational factors. In “Organizing for Quality”, Bate and colleagues (Bate, Mendel, & Robert, 2008) suggest that one reason for the continuing lack of understanding of quality variation within and between healthcare systems has been the traditional focus on identifying ‘what’ works rather than ‘how’ or ‘why’ something works.
With this in mind we use data collected as part of a mixed-methods study to closely examine quality improvement efforts and the implementation of recommended practices to prevent central line-associated bloodstream infections (CLABSI) in United States (U.S.) hospitals. Specifically, we identify CLABSI prevention practices implemented by each hospital, the quality improvement or implementation strategies employed to promote practice use, and the organizational context in which these activities occurred. We then compare and contrast the experiences among hospitals to better understand ‘how’ and ‘why’ certain hospitals were more successful with practice implementation. Our objective is to provide insights about which quality improvement activities have the greatest likelihood of success, given the organizational context, for improving the quality and safety of health care in U.S. hospitals.
Section snippets
Design and setting
This study is part of a larger multi-center project investigating the prevention of hospital-acquired infections by U.S. hospitals (Krein et al., 2006). The project started with a survey to identify what practices hospitals were using to prevent hospital-acquired infections, followed by qualitative interviews and site visits to understand why hospitals were using certain practices and not others. The survey, conducted in May 2005, was sent to a random sample of U.S. general medical/surgical
Results
General site characteristics, practices used to prevent CLABSI, and implementation strategies the hospitals employed are shown in Table 1. All of the sites reported using MSB and CHG at some point during the study timeframe. The use of chlorhexidine during insertion was generally introduced at the same time as MSB; thus, these two practices are combined. Three sites used the Biopatch™ and two used antimicrobial catheters to prevent bloodstream infections.
Most of the study sites used a mix of
Discussion
Identifying and effectively implementing practices to improve quality and safety in health care is a clear priority (IOM, 1999, WHO, 2008). However, in addition to focusing greater attention on identifying what works (e.g., comparative effectiveness) we also need to better understand when, how, or even which practices and implementation strategies might work given the organizational context (Dougherty and Conway, 2008, Rycroft-Malone et al., 2009). Our results show that among a number of
Acknowledgments
The authors would like to thank the hospitals and individuals who participated in interviews as well as Todd Greene and Molly Harrod for their assistance and review during manuscript preparation. This project was supported by the Department of Veterans Affairs, Health Services Research and Development Service (SAF 04-031) and the Ann Arbor VAMC/University of Michigan Patient Safety Enhancement Program. Dr. Saint was supported by an Advanced Career Development Award from the Health Services
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