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Background: New opportunities to record, collate, and analyze routine patient data have prompted optimism about the potential of learning health systems. However, real-life examples of such systems remain rare and few have been exposed to study. We aimed to examine the views of design stakeholders on designing and implementing a US-based registry-enabled care and learning system for cystic fibrosis (RCLS-CF)., Methods: We conducted a two-phase qualitative study with stakeholders involved in designing, implementing, and using the RCLS-CF. First, we conducted semi-structured interviews with 19 program personnels involved in design and delivery of the program. We then undertook 11 follow-up interviews. Analysis of interviews was based on the constant comparative method, supported by NVivo software., Results: The organizing principle for the RCLS-CF was a shift to more partnership-based relationships between patients and clinicians, founded in values of co-production, and facilitated by technology-enabled data sharing. Participants proposed that, for the system to be successful, the data it collects must be both clinically useful and meaningful to patients and clinicians. They suggested that the prerequisites included a technological infrastructure capable of supporting data entry and joint decision-making in an accessible way, and a set of social conditions, including willingness from patients and clinicians alike to work together in new ways that build on the expertise of both parties. Follow-up interviews highlighted some of the obstacles, including technical challenges and practical constraints on refiguring relationships between clinicians and patients., Conclusions: The values and vision underlying the RCLS-CF were shared and clearly and consistently articulated by design stakeholders. The challenges to realization were often not at the level of principle, but were both practical and social in character. Lessons from this study may be useful to other systems looking to harness the power of "big data" registries, including patient-reported data, for care, research, and quality improvement.

Patients at the center of care is often the stated focus of clinicians and healthcare services. The quality and safety movement has shown that effective organization of care is needed, in addition to professional skills. This movement has provided professionals and others with methods to improve both organization and practice for patients. These methods include measurement to give those carrying out improvement feedback about the effects of their changes. New types of measures that enable patients to report treatment outcomes can now be use in quality improvement and quality reporting to bring a renewed focus on making care more patient-centered. Although used for some time in research, these measures are relatively new tools for quality improvement and not all research measures are suitable for everyday feedback or improvement projects. The purpose of the paper is to provide an introduction to the use and value of patient-reported outcome measures in quality improvement and to give practical guidance and resources for using PROMs for quality improvement. It draws on the authors' experiences using patient reported outcomes measures for quality research and improvement and their workshop at the 2016 Tokyo ISQUA conference, as well as on reviews and guidance documents about the use of PROMs. It does not provide a comprehensive and systematic review of research, but an overview and introduction to PROMs for quality improvement., (© The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: There is a distinct difference between what we know and what we do in healthcare: a gap that is impairing the quality of the care and increasing the costs. Quality improvement efforts have been made worldwide by learning collaboratives, based on recognized continual improvement theory with limited scientific evidence. The present study of 132 quality improvement projects in Norway explores the conditions for improvement from the perspectives of the frontline healthcare professionals, and evaluates the effectiveness of the continual improvement method., Methods: An instrument with 25 questions was developed on prior focus group interviews with improvement project members who identified features that may promote or inhibit improvement. The questionnaire was sent to 189 improvement projects initiated by the Norwegian Medical Association, and responded by 70% (132) of the improvement teams. A sub study of their final reports by a validated instrument, made us able to identify the successful projects and compare their assessments with the assessments of the other projects. A factor analysis with Varimax rotation of the 25 questions identified five domains. A multivariate regression analysis was used to evaluate the association with successful quality improvements., Results: Two of the five domains were associated with success: Measurement and Guidance (p = 0.011), and Professional environment (p = 0.015). The organizational leadership domain was not associated with successful quality improvements (p = 0.26)., Conclusion: Our findings suggest that quality improvement projects with good guidance and focus on measurement for improvement have increased likelihood of success. The variables in these two domains are aligned with improvement theory and confirm the effectiveness of the continual improvement method provided by the learning collaborative. High performing professional environments successfully engaged in patient-centered quality improvement if they had access to: (a) knowledge of best practice provided by professional subject matter experts, (b) knowledge of current practice provided by simple measurement methods, assisted by (c) improvement knowledge experts who provided useful guidance on measurement, and made the team able to organize the improvement efforts well in spite of the difficult resource situation (time and personnel). Our findings may be used by healthcare organizations to develop effective infrastructure to support improvement and to create the conditions for making quality and safety improvement a part of everyone's job.

Objective: To develop and validate an instrument for guidance and evaluation of quality and safety improvement efforts in health care., Context: The instrument is based on the Plan-Do-Study-Act cycle and the 3 fundamental improvement questions regarding aims, measurement, and change-making., Methods: An interdisciplinary team of improvement experts developed the Change Process and Outcome (CPO) scale. After studying the improvement literature, the scale was tested and refined on a sample of 5 projects. The CPO evaluation process and classification system was developed when evaluating 189 of the quality improvement projects of the Norwegian Medical Association by their final reports. The scale was validated by applying statistical testing to the evaluation results., Results: The final CPO scale consists of 13 process items and 7 outcome items. Interrater reliability ranged from 0.53 to 0.79, and test-retest reliability was 0.82. Factor analyses with Varimax rotation identified 2 significant process domains: Aims/change-making and Measurement/reporting, with Cronbach α values 0.88 and 0.95, respectively. The classification system produced 3 performance levels: successful, promising, and uncertain., Conclusion: The CPO scale shows good internal consistency, reliability, and validity for evaluating the success of quality improvement initiatives.

Patient-reported outcomes (PROs) can show how patients perceive their illness burden over time. Active use of PROs by clinicians at the point of service can help illuminate the patients' longitudinal changes in outcomes, thereby advancing shared decision making, patient engagement, and self-care. This article offers principles and lessons learned from using PROs and provides 3 case studies to demonstrate how to overcome the challenges in using PROs in routine clinical practice to improve outcomes. These cases demonstrate that it is possible to embed patient-generated data into the flow of care and to track outcomes for improvement and research.

Aim: To investigate health care improvement team coaching activities from the perspectives of coachees, coaches and unit leaders in two national improvement collaboratives., Background: Despite numerous methods to improve health care, inconsistencies in success have been attributed to factors that include unengaged staff, absence of supportive improvement resources and organisational inertia., Methods: Mixed methods sequential exploratory study design, including quantitative and qualitative data from interprofessional improvement teams who received team coaching. The coachees (n = 382), coaches (n = 9) and leaders (n = 30) completed three different data collection tools identifying coaching actions perceived to support improvement activities., Results: Coachees, coaches and unit leaders in both collaboratives reported generally positive perceptions about team coaching. Four categories of coaching actions were perceived to support improvement work: context, relationships, helping and technical support., Conclusions: All participants agreed that regardless of who the coach is, emphasis should include the four categories of team coaching actions., Implications for Nursing Management: Leaders should reflect on their efforts to support improvement teams and consider the four categories of team coaching actions. A structured team coaching model that offers needed encouragement to keep the team energized, seems to support health care improvement., (© 2013 John Wiley & Sons Ltd.)

Background: Total joint arthroplasty (TJA) is one of the most widely performed elective procedures; however, there are wide variations in cost and quality among facilities where the procedure is performed., Questions/purposes: The purposes of this study were to (1) develop a generalizable clinical care pathway for primary TJA using inputs from clinical, academic, and patient stakeholders; and (2) identify system- and patient-level processes to provide safe, effective, efficient, and patient-centered care for patients undergoing TJA., Methods: We used a combination of quantitative and qualitative methods to design a care pathway that spans 14 months beginning with the presurgical office visit and concluding 12 months after discharge. We derived care suggestions from interviews with 16 hospitals selected based on readmission rates, cost, and quality (n = 10) and author opinion (n = 6). A 32-member multistakeholder panel refined the pathway during a 1-day workshop. Participants were selected based on leadership in orthopaedic (n = 4) and anesthesia (n = 1) specialty societies; involvement in organizations specializing in safety and high reliability care (n = 3), lean production/consumption of care (n = 3), and patient experience of care (n = 3); membership in an interdisciplinary care team of a hospital selected for interviewing (n = 8); recent receipt of a TJA (n = 1); and participation in the pathway development team (n = 9)., Results: The care pathway includes 40 suggested processes to improve care, 37 techniques to reduce waste, and 55 techniques to improve communication. Central themes include standardization and process improvement, interdisciplinary communication and collaboration, and patient/family engagement and education. Selected recommendations include standardizing care protocols and staff roles; aligning information flow with patient and process flow; identifying a role accountable for care delivery and communication; managing patient expectations; and stratifying patients into the most appropriate care level., Conclusions: We developed a multidisciplinary clinical care pathway for patients undergoing TJA based on principles of high-value care. The pathway is ready for clinical testing and context-specific adaptation., Level of Evidence: Level V, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

External groups requiring measures now include public and private payers, regulators, accreditors and others that certify performance levels for consumers, patients and payers. Although benefits have accrued from the growth in quality measurement, the recent explosion in the number of measures threatens to shift resources from improving quality to cover a plethora of quality-performance metrics that may have a limited impact on the things that patients and payers want and need (ie, better outcomes, better care, and lower per capita costs). Here we propose a policy that quality measurement should be: balanced to meet the need of end users to judge quality and cost performance and the need of providers to continuously improve the quality, outcomes and costs of their services; and parsimonious to measure quality, outcomes and costs with appropriate metrics that are selected based on end-user needs.

Introduction: The objectives of the Breakthrough Series Collaborative are to close the gap between what we know and what we do, and to contribute to continuous quality improvement (CQI) of healthcare through collaborative learning. The improvement efforts are guided by a systematic approach, combining professional and improvement knowledge., Objectives: To explore what the improvement teams have learnt from participating in the collaborative and from dealing with promoting and inhibiting factors encountered., Method: Qualitative interviews with 19 team members were conducted in four focus groups, using the Critical Incident Technique. A critical incident is one that makes significant contributions, either positively or negatively, to an activity., Results: The elements of a culture of improvement are revealed by the critical incidents, and reflect the eight domains of knowledge, as a product of collaborative learning. The improvement knowledge and skills of individuals are important elements, but not enough to achieve sustainable changes. 90% of the material reflects the need for a system of CQI to solve the problems that organisations experience in trying to make lasting improvements., Conclusion: A pattern of three success factors for CQI emerges: (1) continuous and reliable information, including measurement, about best and current practice; (2) engagement of everybody in all phases of the improvement work: the patient and family, the leadership, the professional environment and the staff; and (3) an infrastructure based on improvement knowledge, with multidisciplinary teams, available coaching, learning systems and sustainability systems.

Introduction: The Cystic Fibrosis (CF) Foundation sponsored the design, pilot testing, and implementation of the CF Learning Network (CFLN) to explore how the Foundation's Care Center Network (CCN) could become a learning health system. Six years after the design, the Foundation commissioned a formative mixed methods evaluation of the CFLN to assess: CFLN participants' understanding of program goals, attributes, and perceptions of current and future impact. Methods: We performed semi‐structured interviews with CFLN participants to identify perceived goals, attributes, and impact of the network. Following thematic analyses, we developed and distributed a survey to CFLN members and a matched sample of CCN programs to understand whether the themes were unique to the CFLN. Results: Interviews with 24 CFLN participants were conducted. Interviewees identified the primary CFLN goal as improving outcomes for people living with CF, with secondary goals of providing training in quality improvement (QI), creating a learning community, engaging all stakeholders in improvement, and spreading best practices to the CCN. Project management, use of data, common QI methods, and the learning community were seen as critical to success. Survey responses were collected from 103 CFLN members and 25 CCN members. The data revealed that CFLN respondents were more likely than CCN respondents to connect with other CF programs, routinely use data for QI, and engage patient and family partners in QI. Conclusions: Our study suggests that the CFLN provides value beyond that achieved by the CCN. Key questions remain about whether spread of the CFLN could improve outcomes for more people living with CF. [ABSTRACT FROM AUTHOR]

Patient-reported outcomes (PROs) can show how patients perceive their illness burden over time. Active use of PROs by clinicians at the point of service can help illuminate the patients' longitudinal changes in outcomes, thereby advancing shared decision making, patient engagement, and self-care. This article offers principles and lessons learned from using PROs and provides 3 case studies to demonstrate how to overcome the challenges in using PROs in routine clinical practice to improve outcomes. These cases demonstrate that it is possible to embed patient-generated data into the flow of care and to track outcomes for improvement and research. [ABSTRACT FROM AUTHOR]

Purpose Our purpose is to describe how coaches who are clinical faculty help in the developmental process of residents to become better physicians and to lead the improvement of quality and safety in the Dartmouth-Hitchcock Leadership Preventive Medicine Residency Program (DHLPMR). Methods Using a semi-structured interview guide, eight coaches were interviewed and two focus groups were held with a total of nine residents. The qualitative data were content analysed to understand how both the coaches and residents perceive coaches' work and their role. Results The interviews with the coaches suggest that they take great pride in their work: they find it to be challenging and meaningful. The coaches use various skills and techniques - asking questions, listening deeply, observing the resident in action, offering encouragement and challenging the resident to think or act differently. The residents also perceive the work of the coach to help them progress on their learning journey. The role of the coach tends to go beyond coaching residents relative to improving an aspect of health care performance to creating the conditions for transformation and growth for the residents and the coaches. Conclusion The DHLPMR program is a unique residency program that has the intention to foster the development of future physician leaders who have the ability to both practise medicine and improve the clinical practices in which they work. The coaches are a vital ingredient in this program as they convey the residents/fellows on their leadership learning journey. [ABSTRACT FROM AUTHOR]

Purpose: To provide guidance on using measurement to support the conduct of local quality improvement projects that will strengthen the evaluation of results and increase their potential for publication. Target Group: Individuals leading quality improvement efforts who wish to enhance their use of measurement. Procedures to Promote Good Measurement: Eleven procedures are offered to promote intelligent measurement in quality improvement research that may become publishable: 1. Start with an important topic 2. Develop a clear aim statement 3. Turn the aim statement into key questions 4. Develop a theory about causes and effects, process changes and predictable sources of variation 5. Construct a research design and accompanying dummy data displays to answer your primary research questions 6. Develop and use operational definitions for each variable needed to make your dummy data displays 7. Design a data collection plan to gather information on each variable that will enable you to generate reliable, valid, and sensitive measures related to each research question 8. Pilot test the data collection plan, construct preliminary data displays, and revise your methods based on what you learn 9. Stay close to the data collection process as the data plan goes from idea to execution 10. Perform data analysis and display results in a way that answers your key questions 11. Review and document the strengths and limitations of your measurement work and use this knowledge to guide intelligent interpretation of the observed results. [ABSTRACT FROM AUTHOR]

Plan-do-study-act (PDSA) quality improvement is the application of the scientific method to implement and test the effects of change ideas on the performance of the health care system. Users of quality improvement could benefit with markers to gauge the "best" science. Four core questions can determine the value of a quality improvement study: Is the quality improvement study pertinent and relevant? Are the results valid? Are appropriate criteria used to interpret the results? Will the study help you with your practice or organization of care? A set of guidelines is provided to help answer these questions. Similar guidelines exist for randomized clinical trials and clinical-epidemiologic observational studies. Analogous to these existing research guidelines, the PDSA quality improvement guidelines will provide researchers an d reviewers with succinct standards of methodological rigor to assist in critical appraisal of quality improvement protocols an d publications. [ABSTRACT FROM AUTHOR]