Quality Improvement Implementation and Hospital Performance on Quality Indicators

Significant opportunities exist for improving the quality of care delivered in U.S. hospitals. As many as one-fourth of hospital deaths might be preventable; nearly 180,000 people die each year partly as a result of iatrogenic conditions. Moreover, as much as one-third of some hospital procedures expose patients to risks without improving their health; one-third of drugs prescribed are not indicated; and one-third of laboratory tests showing abnormal results do not get followed up by clinicians (Dubois and Brook 1988; Brook et al. 1990; Leape 1994; Institute of Medicine 2000). Many believe that quality improvement (QI) represents a promising strategy for improving hospital quality of care. QI is a systemic approach to planning and implementing continuous improvement in performance. QI emphasizes continuous examination and improvement of work processes by teams of organizational members trained in basic statistical techniques and problem solving tools and empowered to make decisions based on their analysis of the data. The systemic focus of QI complements a growing recognition in the field that the quality of the care delivered by clinicians depends substantially on the performance capability of the organizational systems in which they work. While individual clinician competence remains important, many increasingly see the capability of organizational systems to prevent errors, coordinate care among settings and practitioners, and ensure that relevant, accurate information is available when needed as critical elements in providing high quality care (Institute of Medicine 2000). Reflecting the growing emphasis on organizational systems of care, the Joint Commission on Accreditation of Healthcare Organizations, the National Committee for Quality Assurance, and the Peer Review Organizations of the Centers for Medicare and Medicaid have all encouraged hospitals to use QI methods. Although QI holds promise for improving quality of care, hospitals that adopt QI often struggle with its implementation (Shortell, Bennett, and Byck 1998). By implementation, we refer to the transition period, following a decision to adopt a new idea or practice, when intended users put that new idea or practice into use—for example, when clinical and nonclinical staff begin applying QI principles and practices to improve clinical care processes (Klein and Sorra 1996; Rogers 2003). Successful implementation is critical to the effectiveness of a QI initiative (Blumenthal and Kilo 1998; Shortell, Bennett, and Byck 1998). However, QI implementation is demanding on individuals and organizations. It requires sustained leadership, extensive training and support, robust measurement and data systems, realigned incentives and human resources practices, and cultural receptivity to change (Shortell, Bennett, and Byck 1998; Ferlie and Shortell 2001; Institute of Medicine 2001; Meyer et al. 2004). In addition, the systemic nature of many quality problems implies that the effectiveness of a QI initiative may depend on its implementation across many conditions, disciplines, and departments. This too often proves challenging (Gustofson et al. 1997; Blumenthal and Kilo 1998; Meyer et al. 2004). If successful, though, implementing QI in this manner may create a durable infrastructure for enhancing quality organization-wide. In the present study, we examine the association of several dimensions of QI implementation in hospitals and hospital performance on selected indicators of clinical quality. To do so, we combine data from a national survey of hospital QI practices with a group of carefully screened and validated measures indicative of patient safety in hospital settings. In taking this approach, we seek to address several problems associated with existing research on hospital QI and quality of care. First, previous studies do not adequately account for differences in how hospitals implement QI. Consequently, the relative advantage of different implementation strategies remains unknown. Second, previous studies of hospital QI typically make use of small samples. This restricts the generalization of study findings to larger populations of hospitals and limits the extent to which study findings could be used to develop managerial or policy recommendations. Finally, data availability has precluded previous studies from examining a broad range of hospital quality indicators. This, in turn, has limited the opportunity to link specific QI structures and practices with a set of quality indicators that broadly reflect quality at the institutional level. Study results will provide policy makers, accrediting bodies, and consumers with more precise information about how different approaches to QI implementation in hospital settings relate to a range of hospital-level quality indicators. Such information would facilitate the development of QI standards and benchmarks that make use of hospital-level quality indicators that are not only widely available, but also potentially amenable to change through the systematic application of QI practices. For instance, information on QI practices could be useful in the design of financial incentive programs to “make quality pay,” such as the recent CMS program to reward hospitals scoring in the top 10th percentile on various measures. Finally, such information would help hospital managers and clinicians target those approaches to QI implementation that provide the greatest value for resources expended.