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Advancing Quality Improvement Research: Challenges and Opportunities - Workshop Summary 5 General Reactions The following general reactions were offered by members of the forum as well as members of the audience during the last session of the workshop. LEVERAGING OTHER INDUSTRIES Thomas Boat of the University of Cincinnati commented on the need to learn from industry about how to market one’s efforts. Reducing variation in health care practices will be a challenge, but may potentially yield great results. In response to Boat’s comments, Jay Berkelhamer of Children’s Healthcare of Atlanta offered the example of mass-customization automobile manufacturer Maserati, which produces between 5,000 and 10,000 cars a year (Cropley, 2007). No two Maseratis are alike, as they are all made to specification, but the production of the cars is standardized. Lessons may potentially be learned about how to standardize while allowing for individual differences, Berkelhamer said. Judith Gueron of Manpower Demonstration Research Corporation also discussed lessons learned from other industries. For example, she pointed out that 40 years ago educational reforms were suggested, with the recommendation that changes take place in schools of education, but significant advances have yet to be seen. Applying that lesson to health care, Gueron suggested that medical schools might not be the best place to focus reform efforts.
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Advancing Quality Improvement Research: Challenges and Opportunities - Workshop Summary Laura Leviton of the Robert Wood Johnson Foundation discussed positive deviance and similar methods from other areas. In education literature, for example, the term “school improvement methods” is used. Some of these methods have been successfully implemented in other fields and could be useful in health care, Leviton said. CONTEXT The difficult portion of reducing variation, Boat said, will be allowing medical practices to account for context while treating individual patients and understanding the various confounders of genomic background, environmental exposures, and psychosocial contexts. Ignatius Bau of the California Endowment agreed that the discussion of context is critical. There is the assumption that context does not matter in quality improvement, he said, but this assumption conflicts with the research agenda that attempts to produce generalizable processes. What is known about changing culture, such as changing provider behavior and changing processes of care in team-based environments, should be a necessary component of this conversation. Bau also discussed the need to understand both resistance to change and why, according to performance measures, best practices are not followed every time a patient is treated. AREAS FOR FURTHER DISCUSSION There is a large co-occurrence of mental, addictive, and general health conditions, Pincus said, citing the findings of the IOM report Improving the Quality of Health Care for Mental and Substance-Use Conditions (Institute of Medicine, 2006). But resource investment in a quality improvement infrastructure and improvements in quality that have been made in health care have not been paralleled in mental health care. Partnerships, among other strategies, should also be considered, he said. AHRQ’s Integrated Delivery System Research Network1 could be applied in mental health settings, for example. Quality improvement methods have not yet permeated the areas of mental health and substance use, where they could potentially have a great impact. 1 The Integrated Delivery System Research Network is a research model, connecting top researchers and health care systems (Agency for Healthcare Research and Quality, 2002).
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Advancing Quality Improvement Research: Challenges and Opportunities - Workshop Summary David Introcaso of the Department of Health and Human Services noted that the forum could benefit from listening to the perspectives of patient advocates and hearing about the disease burdens of vulnerable populations. There is a great need to think about innovation and how to guide innovation, Introcaso said, and a model should be developed of how research is created, how knowledge is created, and how knowledge is transferred. The questions of how to define and develop a discipline are complicated, but they are ones that should be considered by the forum, said Alex Ommaya of the Department of Veterans Affairs. Anthony Rosner of the Foundation for Chiropractic Education and Research remarked on the future challenges chronic conditions will bring, asking the forum to address health promotion and prevention in future discussions. Boat also urged the forum to consider the large variety of settings in which health care is delivered. CLARIFYING COMMUNICATION Marshall Chin and Jeremy Grimshaw recognized the many complementarities discussed during the workshop. The workshop also reflected the plethora of activities around quality improvement and quality improvement research throughout the country and the world. In order to build on all these efforts, there is a need to become more specific in writing about these efforts. Researchers also must be cognizant of describing the level at which an intervention is acting, Grimshaw said. Berkelhamer commented that those institutions in the academic community doing the research are not necessarily those doing well in practice centers. Titler described the current state of communication in the field. For the most part, implementers and researchers work in silos and do not communicate well with each other. This lack of communication perhaps signals the need for these groups to move away from these distinctions and work together, Titler said. THE NEED FOR FURTHER KNOWLEDGE Kahn emphasized the role of leadership. The presentations made in the morning sessions largely reflected much of what is already known to work, noted Kahn. The questions that naturally arise are: Why did it take so long to adopt? Why isn’t everybody doing it? What are the environmental characteristics that allow people to improve?
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Advancing Quality Improvement Research: Challenges and Opportunities - Workshop Summary Davidoff discussed the need to understand dynamic knowledge, or knowledge in action. This is the knowledge that people harness in doing their jobs, but it is generally not articulated well. Gueron responded that dynamic knowledge comes from a different conceptual base for innovation and leadership than static knowledge.
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