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New Process for Quality Improvement Suggests Local Focus on Improving, in Addition to Measuring Quality


  • Authors suggest reforming quality improvement (QI) so that instead of a focus on measures with national benchmarks, there is a focus on rewarding local actions that improve quality of care using local norms to guide progress. This helps create a climate of openness that facilitates the identification and discussion of errors in day-to-day operations; it also helps focus resources on identifying solutions to problems, and acknowledges that QI efforts are an ongoing process.
  • Quality improvement efforts should be tied to local actions and local results rather than national norms, acknowledging that QI efforts are not generalizable – one size does not fit all. For example, local QI teams would identify problems and solutions, implement interventions, and document local improvement. Measures would be tailored to each institution to reflect local core causes.
  • Measurement could remain a key part of local QI initiatives. For example, outcome measures such as an individual hospital’s rate of hospital-acquired infections may be used to identify areas with quality deficits. However, the measurement of core causes and incentives to improve would be conducted at the local sites.

Improving quality of care is an important national priority, with current QI incentives based on measured performance and benchmarked to national norms. The focus of improving the quality of medical care through initiatives such as public reporting and pay-for-performance is based on the belief that measuring quality of care is an essential first step to improving health care. Yet despite large efforts, the effects of quality improvement initiatives based on measuring quality have been modest. Moreover, quality measures typically target individual care processes, and thus rely on individuals to change their behavior based on existing knowledge. This discourages the discovery of new approaches to improve quality, lacks flexibility to adapt to new knowledge, and fails to address the fact that quality is locally determined by organizations. Therefore, it may be time to rethink the current approach. This Commentary highlights limitations in the current approach to QI and proposes a new model for improving quality of care.

Dr. Werner is a Career Development Awardee with HSR&D’s Center for Health Equity Research and Promotion in Philadelphia.

PubMed Logo Werner R and McNutt R. A New Strategy to Improve Quality: Rewarding Actions Rather than Measures. JAMA “Commentary” April 1, 2009;301(13):1375-1377.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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