Improving the Quality of Quality Improvement

Medical quality improvement (QI) has always focused on improving outcomes. Originally, the goal of QI efforts was to identify and fix the negative aspects of medical care, or to remove the “bad apples.” A well-known example is from the mid-1800s when hospital-acquired diseases were proliferating, often transmitted via contact with health care workers. Investigation revealed that hand-washing was not a part of standard procedure; by introducing proper hand hygiene, researchers were able to remove the negative behavior (insufficient hand-washing) and thereby reduce negative outcomes. Since the 1800s, though, there has been a shift. Instead of focusing on weeding out suboptimal behaviors, QI research is increasingly focusing on improvement.

Quite simply: QI research appeals to my intellectual curiosity. Although I never grew to love bench research during my medical education and training, I quickly fell in love with QI research. I enjoyed the instant clinical application and potential system enhancements — the idea of delivering health care to entire populations. I enjoy diagnosing and treating individual patients, but I have been equally interested in creating systems to help increase medication compliance for all patients. 

Recently, I had the opportunity to review different QI manuscripts for possible publication in a medical journal. The experience taught me something important: all QI efforts are not created equal. All residents are required to conduct a QI project, but there is considerable variation in terms of value, and I quickly realized that high-quality QI research necessitates identifying a significant and realistic clinical problem. Similar to biotechnology and medical device development, the key to success with QI is identifying an accurate problem, and then formulating multiple possible solutions. If the process is done in reverse order, it usually results in a subpar project and adds no value to nor improvement of the clinical landscape. 

My experience as a QI editor has taught me a few critical principles:

Focus on long-term solutions, not short-term projects

When QI is a requirement (for residency, CME, etc.), there is a tendency to view it as a checklist item, rather than an opportunity to make a significant change and improve patient outcomes. Not only is this apparent to the reader, but it also tends to make the QI process boring and uneventful. Instead of looking at it as a dead-end activity, medical professionals should look at it as an opportunity to create programs, resources, and system changes to improve patient outcomes on a larger scale. Many medical societies and public health recommendations originated from QI research. For example, the hand hygiene QI initiative I mentioned previously ultimately led to the first national hand hygiene guidelines in the 1980s. With a long-term projection and new perspective, QI can be enjoyable, intellectually challenging, and impactful.

Anticipate for realistic scaling and replication

Pursuing short-term process models and solutions that are difficult or unrealistic to replicate (or to scale beyond a small sample size) is a common pitfall. In a health care environment where costs need to decrease, resources are limited, and there is a demand for higher quality, we must be intelligent and creative with our potential solutions. I have reviewed proposed QI solutions that are very innovative and provide answers to the problem in question, but in many cases, the solution was not affordable. In one case, a medical team created a non-invasive method to test and track A1C at home for patients. The technology was incredible, but the price point was not congruent with most patients’ household income. Similarly, I observed a clinic propose and prove a new method of screening for depression using pre-screening software and mobile technology — but when other clinics in the same area trialed the same methodology, it failed because the patient population lacked resources (namely, mobile technology). As a QI team collaborates to create a vast number of potential solutions, it is important to narrow the list. Focus on solutions that are reproducible with known limitations, such as decreased cost and resources.

Learn to evaluate the quality of quality improvement research

Although this article has stressed the importance of designing and conducting high-quality QI research, the most important aspect of any endeavor is that it delineates the realistic solutions from the plethora of unrealistic solutions. As medical professionals, our number one priority is patient safety and improved outcomes. It is absolutely essential that all medical professionals understand what constitutes “evidence-based” research and are able to critically summarize, assess, and apply quality improvement from research. 

In our current system, there are many QI projects and solutions that do not truly lower costs or improve clinical outcomes. The goal of QI is to be able to identify high-quality solutions to improve the medical industry as a whole. As medical professionals, we must focus on functionality, satisfaction, costs, reproducibility, clinical significance, and patient safety. If we do this, we will begin to create long-term solutions.

Tyson Schwab, MD, MS is a clinician at Intermountain Healthcare. He practices at Utah Valley Hospital as part of the Utah Valley Family Medicine Residency program. His medical interests includes primary care, innovation, technology, health policy, and improving medical quality. Dr. Schwab is a 2019-2020 Doximity Fellow.

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