Measuring and increasing the effectiveness of the quality improvement implementation change practices of front-line maternity physician and nurse leaders

Measuring and increasing the effectiveness of the QI implementation change practices of front-line leaders offers the promise of saving lives and reducing harm and suffering to patients. Leaders have limited information on how to measure and increase the effectiveness of their QI implementation practices. Design: Qualitative, non-experimental, retrospective, cross-case study. Sample: Purposive sample of 7 front-line physician and nurse leaders and 12 QI projects, controlled for multiple context variables. Conclusions: The conceptual framework, Leaders' Expectations of Change Compliance, emerged based on the analysis of the reasons leaders did not set target dates. The QI implementation tactics used by the leaders were determined to be components of three types of strategies: education, data and discourse. QI project patterns were identified; there was no single combination of strategies, tactics, and barriers that led to greater QI progress. The five critical determinants of the QI patterns were: 1) Amount of leader persuasion, 2) Whether a leader had fully conceptualized the QI project, 3) Amount of clinician persuasion, 4) Presence or absence of meaningful data, and 5) How leaders responded to resisters. The patterns are similar for QI projects with the same QI topics and goals. Counting the number of QI implementation tactics the leaders used is not an accurate measure of QI implementation progress. Four types of implementation barriers: Leader, clinician, characteristics of the QI Projects, climate, and resource barriers. There was no distinguishable relationship between the number of tactics used and the number of barriers identified. Implementation Plan Objective: Increase leaders' abilities to conceptualize their QI implementation strategy and how they choose their QI implementation tactics based on the barriers they anticipate and encounter. Research Recommendations: Conduct further research on QI regarding: concepts, project timing, health information technology (HIT), setting target dates, discourse and change, creative types of implementation tactics, and multi-hospital and multi-stakeholder collaboratives. Health Policy Recommendations: Develop hospital-based Rapid Response QI Teams that can be activated during a quality and safety emergency, train new and current clinicians to conceptualize, implement and reach QI goals, increase QI implementation research funding, develop a QI topic-specific implementation registry, and integrate QI and HIT