Examining the key contextual influences on the sustainability of healthcare quality improvement at the clinical micro level

Introduction Research into the implementation of healthcare quality improvement collaborative (QIC) programmes has steadily grown in recent years. However, there has been little research into quality improvement (QI) after the collaborative has ended, and only recently has the issue of QI sustainability been discussed within the existing literature. The long term sustainability of QI remains a significant issue for all improvement efforts in healthcare. Variations in sustainability are likely to be attributed to differences in a range of contextual factors, for example, the environment, the organisational/patient safety culture, management styles and clinical practice. However, these influences do not expose the contextual factors that may be important at differing levels of an organisation. Aim The overall aim of the study is to identify the key contextual influences on the sustainability of healthcare QI success. The focus will be on the interaction between the meso (organisational) and micro (clinical front-line) levels, and how the processes and the context at all levels may affect sustainability. Methods A multiple, comparative case study, mixed methods approach was implemented, comprising of five comparative case studies from four clinical quality improvement teams and one management team providing renal replacement therapy within secondary and tertiary care in a regional healthcare provider. The study progressed in two sequential phases: Phase One of the study involved reviewing the statistical process charts of clinical indicators, to determine if success had been sustained two years hence. The Hospital xviii Survey of Patient Safety Culture questionnaire (AHRQ, 2007) was distributed to all clinical staff within the service to identify the patient safety culture across all clinical areas of the service. The questionnaire measured components such as teamwork, communication and adverse event reporting. Previously used in the pre-collaborative phase in 2010 (Nache, 2012), the questionnaire was repeated to all clinical staff (n=188) to enable comparative data three years after commencing the QIC. Phase Two consisted of 19 semi-structured interviews of staff at the micro and meso level of the organisation, including healthcare professionals directly involved in the QIC, line managers and members of the executive management team within the organisation. Results Phase One: The Statistical Process Control (SPC) charts indicated that 50% of the four cases studied sustained their initial QI success after a two year period. From a 50% return of the patient-safety culture questionnaire (n=95), analysis indicated a significant decrease in all components of communication, leadership, management and organisational culture across the service. Phase Two: Following thematic analysis, initial results indicate that the complexities of the healthcare environment can prevent QI spread, and lack of continuity in management at the meso level can influence QI sustainability. Organisational sub-cultures impacted on QI both positively and negatively, and the motivation of team members appeared to influence sustainability. Conclusion The study findings extracted three main contextual themes of management, communication and organisational culture that influenced the sustainability of QI. Macro driven targets and the influence on meso level sub cultures impact on QI at the clinical front line. Positive, consistent leadership at the clinical level can enable front-line staff to lead on QI initiatives and promote a culture of continuous learning and new emergent behaviours. However, changing meso level priorities can challenge the sustainability of micro level healthcare improvement