ADVANCING QUALITY IMPROVEMENT RESEARCH

CHALLENGES AND OPPORTUNITIES

WORKSHOP SUMMARY

Samantha Chao, Rapporteur

Forum on the Science of Health Care Quality Improvement and Implementation

Board on Health Care Services

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
www.nap.edu



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Advancing Quality Improvement Research: Challenges and Opportunities - Workshop Summary ADVANCING QUALITY IMPROVEMENT RESEARCH CHALLENGES AND OPPORTUNITIES WORKSHOP SUMMARY Samantha Chao, Rapporteur Forum on the Science of Health Care Quality Improvement and Implementation Board on Health Care Services INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Advancing Quality Improvement Research: Challenges and Opportunities - Workshop Summary THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This study was supported by a grant between the National Academy of Sciences and the Robert Wood Johnson Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reffect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13 978-0-309-10623-8 International Standard Book Number-10 0-309-10623-0 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2007 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Institute of Medicine (IOM) 2007. Advancing quality improvement research: Challenges and opportunities, workshop summary. Washington, DC: The National Academies Press.

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Advancing Quality Improvement Research: Challenges and Opportunities - Workshop Summary “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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Advancing Quality Improvement Research: Challenges and Opportunities - Workshop Summary THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Advancing Quality Improvement Research: Challenges and Opportunities - Workshop Summary FORUM ON THE SCIENCE OF HEALTH CARE QUALITY IMPROVEMENT AND IMPLEMENTATION THOMAS F. BOAT (Co-Chair), Director, Children’s Hospital Research Foundation and Chair, Department of Pediatrics, University of Cincinnati College of Medicine, OH PAUL H. O’NEILL (Co-Chair), Former U.S. Secretary of the Treasury, Pittsburgh, PA PAUL B. BATALDEN, Director, Health Care Improvement Leadership Development, Dartmouth Medical School, Hanover, NH IGNATIUS BAU, Program Director, The California Endowment, San Francisco, CA JAY E. BERKELHAMER, Senior Vice President of Medical Affairs, Children’s Healthcare of Atlanta, GA MARSHALL H. CHIN, Associate Professor of Medicine and Co-Director, General Internal Medicine Research, University of Chicago, IL CAROLYN M. CLANCY,* Director, Agency for Healthcare Research and Quality, Rockville, MD CATHERINE D. DE ANGELIS, Editor in Chief, Journal of the American Medical Association Scientific Publications and Multimedia Applications, Chicago, IL JULIE L. GERBERDING,* Director, Centers for Disease Control and Prevention, Atlanta, GA JEREMY GRIMSHAW, Director, Clinical Epidemiology Program, Ottawa Health Research Institute, Ontario, Canada JEROME H. GROSSMAN, Senior Fellow, John F. Kennedy School of Government, Harvard University, Cambridge, MA JUDITH GUERON, Scholar in Residence, Manpower Demonstration Research Corporation, New York ANDREA KABCENELL, Executive Director for Pursuing Perfection, Institute for Healthcare Improvement, Cambridge, MA RICHARD KAHN, Chief Scientific and Medical Officer, American Diabetes Association, Alexandria, VA RAYNARD S. KINGTON,* Deputy Director, Office of the Director, The National Institutes of Health, Bethesda, MD JOEL KUPERSMITH,* Chief Research and Development Officer, Veterans Health Administration, Washington, DC LAURA C. LEVITON, Senior Program Officer, The Robert Wood Johnson Foundation, Princeton, NJ * Denotes Ex-Officio Members

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Advancing Quality Improvement Research: Challenges and Opportunities - Workshop Summary BRIAN S. MITTMAN, Co-Editor in Chief, Implementation Science and VA Greater Los Angeles Healthcare System, Sepulveda, CA LESLIE NORWALK,* Acting Administrator, Centers for Medicare and Medicaid Services, Washington, DC STEPHEN M. SHORTELL, Blue Cross of California Distinguished Professor of Health Policy and Management, University of California, Berkeley MARITA G. TITLER, Director, Institute for Translational Practice, University of Iowa City Health Care System and University of Iowa, Department of Nursing Services and Patient Care, Iowa City IOM Forum Staff SAMANTHA CHAO, Forum Director MICHELLE BAZEMORE, Senior Program Assistant MICHELE ORZA, Acting Board Director, Board on Health Care Services

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Advancing Quality Improvement Research: Challenges and Opportunities - Workshop Summary Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: ANDREA KABCENELL, Institute for Healthcare Improvement, Cambridge, MA PETER J. PRONOVOST, Departments of Anesthesiology and Critical Care, Surgery, and Health Policy and Management, Center for Innovations in Quality Patient Care, Quality and Safety Research Group, The Johns Hopkins University, Baltimore, MD STEPHEN M. SHORTELL, School of Public Health, University of California, Berkeley MARITA G. TITLER, Research, Quality and Outcomes Management, Department of Nursing Services and Patient Care, The University of Iowa, Iowa City

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Advancing Quality Improvement Research: Challenges and Opportunities - Workshop Summary Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by coordinator ARTHUR A. LEVIN, of the Center for Medical Consumers, New York. Appointed by the Institute of Medicine, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the author and the institution.

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Advancing Quality Improvement Research: Challenges and Opportunities - Workshop Summary Contents     SUMMARY   1     INTRODUCTION   9 1   LESSONS IN QUALITY IMPROVEMENT   11      Non-Health Care Service Sector,   11      Integrated Health Care Delivery System,   14      Hospital Perspective,   17      Nursing Perspective,   19 2   APPROACHES TO QUALITY IMPROVEMENT RESEARCH   21      Methods,   24      Areas Where More Knowledge Is Needed,   25 3   BARRIERS TO QUALITY IMPROVEMENT AND QUALITY IMPROVEMENT RESEARCH   27      Barrier of Focus,   28      The Role of Context,   28      Where Does It Belong?,   29      Resource Barriers,   29      Barriers to Recruitment and Training,   30      Levers for Strengthening Quality Improvement Research,   32      Barriers to Performing Quality Improvement and Quality Improvement Research,   33      Barrier of Sustainability,   35

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Advancing Quality Improvement Research: Challenges and Opportunities - Workshop Summary 4   OPPORTUNITIES   37      Short Term,   37      Long Term,   38      The Importance of Strategies for Change,   38 5   GENERAL REACTIONS   40      Leveraging Other Industries,   40      Context,   41      Areas for Further Discussion,   41      Clarifying Communication,   42      The Need for Further Knowledge,   42     REFERENCES   44     APPENDIXES     A   Workshop Agenda   45 B   Workshop Participants   47