In the Literature
U.S. hospitals are strongly committed to the goals of quality improvement, but there appears to be great variation in the implementation and effectiveness of hospital reforms, a Commonwealth Fund-supported survey finds.
The authors of "A Survey of Hospital Quality Improvement Activities" (Medical Care Research and Review, May 28, 2008) surveyed top quality officers at 470 U.S. hospitals to examine the extent to which hospitals are embracing the principles and methods of quality improvement, or QI.
"While it is reassuring to note that a high percentage of quality managers (87%) believed that patient care at their hospitals today was better than three years earlier, the finding that only one-third felt that quality of care and patient satisfaction levels today compared with where they should be had exceeded their expectations suggests that improvement is still needed," write the researchers, who were led by Alan B. Cohen, executive director of Boston University's Health Policy Institute and Joseph D. Restuccia, professor of health care and operations management at Boston University's School of Management.
Taking Quality Improvement Seriously
The researchers developed the Quality Improvement Activities Survey to analyze the nature and extent of improvement efforts, approaches, and methods undertaken by hospitals. The survey, which was sent to each hospital's chief quality officer or quality manager, focused primarily on the current state of hospital QI activities and the relationship between those activities and quality managers' assessments of quality.
Hospitals reported a high level of commitment to QI as an organizational goal, with 93 percent reporting that QI was explicitly stated in their strategic or business plans. Hospitals whose quality managers rated their current patient care as much better or better than it was three years prior were significantly more likely (88% vs. 67%) to have strategic plans in which QI was a stated priority than those who rated care as the same or worse. In addition, hospitals that reported major performance gains resulting from their QI focus were significantly more likely (82% vs. 57%) to make QI a strategic priority than hospitals whose quality managers did not perceive such gains.
While QI is a strategic priority at many hospitals, "it also appears that QI implementation is an evolutionary process that takes years, perhaps a decade or longer, to transform a hospital into a high-performing organization," the authors note.
Missed Opportunities with Physicians
Top hospital executives, managers, and nurses are far more involved in QI activities than are physicians. "These findings are consistent with studies citing the lack of physician involvement in QI efforts as a barrier to improvement," say the authors. For example, only 32 percent of hospitals reported their physicians received formal training in QI, a much lower proportion than nurses (45%), other managers (70%), and senior managers (77%). Physicians were also far less likely to use QI principles and tools in their daily work, the authors said.
The most widely pursued QI activity was benchmarking, either with other hospitals (70%) or within the hospital (64%). Five of the most commonly used clinical QI strategies (i.e., used widely in 62% to 81% of hospitals) were related to the prevention of adverse outcomes—like surgical site infections—or to ensuring that any medications a patient is currently taking are reconciled with those provided by the hospital physician.
Quality measures that most often go unmonitored, meanwhile, include waiting times for outpatient clinic appointments (45%), unplanned intensive care unit readmission rates (43%), procedure-specific mortality rates (35%), and disease-specific mortality rates (30%).
The finding that hospitals with higher perceived quality had significantly better nurse-to-patient ratios is consistent with studies that have shown better outcomes for patients when nurse-to-patient staffing ratios approach 1 to 4. "Yet only 31 percent of all sample hospitals reported hospital-wide use of specific strategies to reduce the number of patients assigned to each nurse, and another 35 percent reported minimal or no use of these strategies," wrote the researchers.
Conclusions
Quality improvement is a dynamic and evolutionary process. "Although progress toward improved patient care is being made in many hospitals, there is a clear need for greater innovation and creativity, sustained achievement of performance gains, and concerted effort by managers, clinicians, and policymakers to attain organizational and systemwide quality goals," conclude the authors.
Facts and Figures- Hospital quality managers' report widespread responsibilities beyond quality improvement, including performance measurement (93%), patient safety (83%), risk management (56%) infection control (55%), or patient satisfaction measurement (50%).
- Hospitals cited the Centers for Medicare and Medicaid Services' Quality Improvement Organizations (89%) and the Institute for Healthcare Improvement's 100,000 Lives Campaign (88%) as positive influences on health care quality.
Hospitals' Use of Clinical Quality Improvement Strategies and Approaches
Quality Improvement Strategy/Approach n Used Widely or Hospital-wide
n(%)Used Moderately
n(%)Used Minimally or Not at All
n(%)Actions to prevent surgical site infections 461 375(81) 68(15) 18(4) Actions to prevent adverse drug events 462 322(70) 106(23) 34(7) Medication reconciliation 461 285(62) 122(26) 54(12) Disease- or condition-specific quality improvement projects 463 231(50) 177(38) 55(12) Evidence-based practice guidelines/ clinical pathways 463 219(47) 170(37) 74(16) Rapid response teams 461 211(46) 63(14) 187(40) Multidisciplinary rounds 463 159(34) 121(26) 183(40) Use of advanced practice nurses to coordinate or manage patient care 460 65(14) 91(20) 304(66) Chronic disease registries 454 43(9) 112(25) 299(66) Source: Adapted from A.B. Cohen, J.D. Restuccia, M. Shwartz et al., "A Survey of Hospital Quality Improvement Activities," Medical Care Research and Review, Published online May 28, 2008.