Jeffrey Alexander of the University of Michigan opened the session, offering high-level impressions of the state of quality improvement research and suggesting changes likely to make quality improvement research more relevant, useful, and practical to decision makers.

Beginning with his perspective on quality improvement research, Alexander noted that many studies are performed in single organizations (e.g., large university teaching hospitals), which raises questions about whether the interventions would be effective in community hospitals, small inner-city hospitals, or other institutions. Second, the literature indicates that research tends to be opportunistic rather than systematic. Research is often conducted by faculty members at large teaching hospitals who see opportunities for testing interventions, such as process changes that have been introduced by administrative or clinical leaders in their organizations. However, research should be conducted in a more planned, systematic manner. Third, quality improvement research often suffers from imprecise measurement and description of the quality improvement intervention, which limits adoption of the intervention by other organizations or replication of the research by others. In contrast to the way clinical research is advanced (i.e., replication of trials with different samples in different settings), little replication exists in quality improvement research. Fourth, most studies are of relatively short duration, often lasting 12 to 18 months or less, precluding conclusions from being drawn about sustainability of changes. Fifth, there are often no explicit considerations of the organizational contexts or factors affecting implementation of an intervention. Sixth, explicit considerations of cost or value are often lacking.

As a result of these six problems with the quality improvement literature, Alexander concluded there is inconsistent information regarding what works, when it works, where it works, and what it costs. An opportunity therefore exists to rethink how quality improvement research could be conducted to become more valid, generalizable, and useful to decision makers.

To act on the opportunity for quality improvement, Alexander looked toward policy, informational, and financial barriers to quality improvement. The reimbursement system does not pay for quality, despite the Centers for Medicare & Medicaid Services’ (CMS’) recent efforts to not pay for preventable errors and pay for performance. The tipping point has not yet been reached where these programs will make large differences in care, Alexander said. From the per-

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