Toward better evidence for improving the quality of primary care: a synthesis of what we know about the effectiveness of continuous quality improvement and development of a framework to strengthen future research.

<b>Background: </b>Delivering high quality health care requires an ongoing effort at all levels of the health system to adopt new knowledge in routine practice, to identify and resolve persistent quality problems, and to meet the evolving needs of populations. Continuous quality improvement (CQI) is among the most promising approaches for tackling these challenges in primary care. CQI brings teams of health professionals together to develop and test changes to the systems and processes used to deliver care. The result is expected to be substantial and sustained improvement in healthcare quality. Yet limited research on how (and indeed if) CQI works creates uncertainty over its true value and weakens our ability to predict the circumstance in which CQI will be effective. Aims The overarching aim of this thesis is to examine what we know about the effectiveness of CQI in primary care and develop a framework to strengthen future research. More specifically, the aims are to: (1) synthesise existing research on the effects, and factors that modify the effects, of CQI in primary care, (2) support the design of CQI research by developing a framework intended to help evaluators identify and measure factors salient to our understanding of CQI in primary care, and (3) guide selection of the best available instruments for measuring factors in the framework. Methods Three types of research synthesis methods were used in this thesis. Systematic review methods and metaanalysis of randomised trials were used to evaluate the effectiveness of CQI. Qualitative synthesis of prevailing concepts of CQI and factors thought to influence its effectiveness was used to develop a theorybased framework for evaluating CQI. Systematic review methods were used to identify and evaluate the measurement properties of quantitative self-report instruments suitable for measuring factors in the developed framework. Framework-based synthesis methods were used to categorise instrument content in a taxonomy designed to enable direct comparison of instruments and illustrate coverage of the framework. Results Based on existing evidence from randomised trials, the effects of CQI on health professional performance and patient outcomes in primary care are uncertain. AnalysiS of more than 170 papers contributed to development of the lnforming Q!!ality Improvement Research (InQuiRe) framework. InQuiRe covers four domains (CQI process, implementation approaches, enabling context, outcomes) and includes (1) a -taxonomy of factors thought relevant to understanding and predicting the process and outcomes of CQI, (2) definition of these factors, and (3) description of the mechanism by which CQI process and context are thought to interact to yield improvements in health care. Content analysis of 319 instruments identified 160 instruments measuring factors in the InQuiRe framework, 78 of which are suitable for primary care. Conclusions Despite an expansive literature, existing evidence is yet to address important policy and practice questions about how best to implement and ensure the success of CQI in different contexts. Addressing these questions will require evaluations that examine the interplay between CQI process, context, and outcomes. The InQuiRe framework provides a tool and suite of instruments to support the design of such evaluations