Best implementation techniques not enough
'Positive cultural context' required
You've successfully identified an important area for quality improvement. You've researched all the literature and identified best practices. You've even joined a nationwide collaborative so you can learn from the successes of top performers. Your odds of success are pretty good, right?
Not necessarily, according to a new study sponsored by the VA Ann Arbor (MI) Healthcare System.1 The researchers looked at QI efforts to prevent central line-associated bloodstream infections (CLABSI) in a number of U.S. hospitals in an attempt to understand why some initiatives were more successful than others. "This study reveals that among a number of hospitals that focused on implementing practices to prevent CLABSI, the experience and outcomes varied considerably despite using similar implementation strategies," the researchers said.
What made the difference, then? "Our results showed that among a number of hospitals that focused on preventing CLABSI, despite using similar implementation strategies, the experiences and outcomes of these efforts varied considerably given the organizational context," wrote the researchers.
What is organizational context?
Organizational context, as the paper described, basically speaks to the culture of the organization, the relationships among individuals, and resources to accomplish goals. Sarah L. Krein, PhD, RN, research investigator, VA Ann Arbor HSR&D COE, research associate professor, division of general medicine, and lead author of the study, breaks down the four key elements identified and what they mean in terms of a hospital's context:
Structure: "Here, you really think about the resources in your organization the leadership in your organization, and how good you think those various aspects are," says Krein. "Do you feel you have all the resources you need, is leadership supportive of what you're trying to do, do you have the manpower needed for activities?"
Politics: This covers all the relationships within the organization, Krein explains. "This may involve administrative and clinical relationships, as well as relationships among frontline providers anyone involved in the improvement project," says Krein. "What are the relationships among those individuals how good are their communications, and how well do they work with one another?"
Culture: "Everyone has to have the same mission and priorities, a shared understanding that this is what the organization is all about," says Krein. A shared mission statement she cited from the study, for example, was "we serve underserved people, and we do it well."
Emotions: "This is related to culture the commitment and passion of the people about what they're doing," says Krein.
Without these elements, is it possible for QI projects to achieve optimal results? "I suppose you could get lucky and your project would work, but the odds are you would not be as successful as one would hope," Krein asserts.
Collaboratives: A two-edged sword
Involvement in collaboratives has been growing in popularity, and a number of them have touted excellent results. While Krein's study does not dispute that, she warns that they can sometimes have unintended consequences. In fact, the study stated, in hospitals that have positive emotional and cultural context "such initiatives...could work against organizations by diverting resources and impeding necessary changes in other areas."
"Part of the problem is that everybody gets on this bandwagon which is not necessarily bad but after a while you put a lot of energy and time into those activities and you're so focused on it that when other things come along you can't really invest in them; you just don't have the energy," Krein explains. "In addition, sometimes what you see in collaboratives is that the hospitals that are most successful have others turn to them and ask for assistance. That's a good thing, but it takes a lot of effort to respond."
The researchers made a special effort to point out the value of "local champions" are they preferable to participation in a collaborative? "For some things, you're better off with local champions, but sometimes you want to be part of a larger network," Krein observes. "You've got to weigh it out do you want to jump on everything that comes along? One high-performing organization we interviewed was selective about wanting to participate in collaboratives."
On the other hand, the researchers noted that participation in collaboratives could be very positive for facilities with less positive emotional and cultural contexts. "They help weaker organizations because they bring in new ideas, they may provide resources you did not have initially, and support from the outside," says Krein. "If you're a quality manager and you're not getting internal support, it may be of benefit to you to have that external support system."
Where do you fall?
Krein notes that many quality managers have a pretty good idea of where their organization stands. The study included quotes from leaders at several facilities that provide insight into both the good and the bad.
For example, here are some comments from the study from a facility with a "positive" environment:
- "I have a separate budget for clinical, education, research, and administrative work."
- "Everybody is involved in the care of the patients... The patients and the people that touch the patient are part of the care of the patient."
- "My philosophy has always been, what if it's your mother, your father, your brother; we always want the best care for those we love and try to bring that point home to everyone."
And here are some from a facility that did not fare so well:
- A major barrier to implementing evidence-based practices is "getting people coordinated; who's going to do it, who's going to spearhead it, who's going to monitor it?"
- "It's better received if it's from the top down."
- "We're probably not implementing all these practices the way we should. I think we say we are, but it's a fantasy."
What are your options if you feel your organization falls into the latter category? "That's a tough one," Krein says. "But sometimes it's not necessarily the entire hospital that has to change all at once, but just the culture in your own area. Some other people may see that and see you're doing well and ask what you're doing. You should focus on those things you can really impact."
[For additional information, contact: Sarah L. Krein, PhD, RN, Research Investigator, VA Ann Arbor HSR&D COE, Research Associate Professor, Division of General Medicine. Phone: (734) 845-3621. Fax: (734) 845-3250. E-mail: [email protected].]
Reference
- Krein SL, Damschroder LJ, Kowalski CP, Forman J, et al. The influence of organizational context on quality improvement and patient safety efforts in infection prevention: A multi-center qualitative study. Soc Sci Med 2010 Nov;71(9):1692-701.
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