Getting going on getting better: how is systematic quality improvement established in a healthcare organization? : Implications for change management theory and practice

Despite the widespread application of quality improvement (QI), there is enduring uncertainty about its effectiveness in healthcare as an approach to the inevitable, but challenging, task of managing organizational change. This uncertainty is due, at least in part, to our limited understanding of what it takes to apply QI fully in healthcare organizations as well as to the difficulties involved in evaluating QI efforts. Understanding the degree of application – both its depth and breadth – is key for assessing the impact of QI. This thesis examines how QI was established in one large healthcare organization, Huddinge University Hospital (HUH) outside Stockholm, Sweden, between 1997 and 2001 (Studies I, II, and IV). The thesis also includes a systematic literature review of how Statistical Process Control, a key approach to QI, has been applied to healthcare QI (Study III). Together, the four studies and a review of related literature form the basis for a model of how QI is established in a healthcare organization. Studies I, II, and IV rely on a case study of a natural experiment: the introduction of process management – an application of QI – at HUH. Drawing on participant observation and extensive documentation from over 1000 QI team sessions at the hospital, Study I examines how QI efforts were initiated through collaboration between multi-professional clinical teams and managers; Study II how QI facilitators helped such teams apply QI methods and principles in practice and improved their own approach as they went; and Study IV how the QI program evolved and with what outcomes over the study period. Study I showed that waiting times emerged as a dominant problem identified by teams, and that a strategy combining a bottom-up with a top-down approach to identifying problems enabled management teams to harness staff insights and motivation. Study II demonstrated how facilitators provided a framework and methods’ support for QI efforts and how they continuously adapted the QI approach based on their own learning and participant feedback. Study IV found that 58 % of QI projects (39/67) demonstrated success, a comparatively high proportion. The study also showed that the QI program – and the conditions for its conduct – changed continuously over the study period. The biggest difficulty participants reported was a lack of time for improvement efforts, while reported benefits included an increased ability to see the “bigger picture” and improvements for both patients and employees. In Study III, Statistical Process Control was shown to be a versatile tool, which can enable diverse stakeholders to manage and document change in healthcare and to improve patients’ health. Establishing QI in a healthcare organization is an evolutionary process involving continuous adaptation to organizational needs, ambitions, and circumstances, as the model developed in this thesis shows. This corresponds with change management theory, which is mostly derived from studies in other industries. The evolutionary aspects need to be taken into account both by practitioners and researchers, when introducing, or evaluating, QI programs, more than has typically been the case. LIST OF PUBLICATIONS This thesis is based on the following studies, which will be referred to by their Roman numerals (I-IV): I. Thor J, Herrlin B, Wittlov K, Skar J, Brommels M, Svensson O. Getting going together: Can clinical teams and managers collaborate to identify problems and initiate improvement? Quality Management in Health Care. 2004; 13(2):130-42. II. Thor J, Wittlov K, Herrlin B, Brommels M, Svensson O, Skar J, Ovretveit J. Learning helpers: How they facilitated improvement and improved facilitation – lessons from a hospital-wide quality improvement initiative. Quality Management in Health Care. 2004; 13(1):60-74. III. Thor J, Lundberg J, Ask J, Olsson J, Carli C, Pukk Harenstam K, Brommels M. Systematic review: Statistical Process Control application in healthcare improvement. Quality and Safety in Health Care, in press (2007). IV. Thor J, Herrlin B, Wittlov K, Ovretveit J, Brommels M. Evolution and outcomes of a quality improvement program. Submitted.