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Study Suggests Hybrid Quality Improvement Approach May Be Best


There is a growing consensus that a hybrid of two common approaches to quality improvement (QI) – local participatory QI and central expert QI – might be the best method for achieving quality care across a variety of conditions. Local participatory QI is a bottom-up approach in which frontline staff members identify problems with the local standard of health care and then develop and implement local solutions to those problems. Central expert QI is a top-down approach in which content experts implement QI programs based on evidence-based best practices, without much, if any, local input; managers are usually involved at least in providing sanction for the program and possible resources. Achieving a hybrid of these two methods requires an ongoing dialogue between content experts and both frontline staff members and managers. Thus, this study examined frontline staff members’ and managers’ preferences regarding how to conduct such a dialogue and provide practical suggestions for implementation. Investigators interviewed 44 frontline staff members and 19 managers participating in HSR&D’s Translating Initiatives for Depression into Effective Solutions (TIDES) project. TIDES is a collaborative care program for treating depression in the VA primary care setting, and utilizes nurse care managers who assist providers in treating Veterans with depression.

Many participants believed that a hybrid of participatory and expert QI models might provide the best formula for improving the quality of care. Frontline staff and managers shared a number of preferences, such as face-to-face communication and that meeting frequently with the experts was important. But there were also some differences. For example, while managers were interested in discussions of business aspects (e.g. costs), frontline staff were concerned with workload issues. Finally, although participants acknowledged that engaging in QI dialogue was time consuming, they believed it was essential if healthcare organizations are to improve the quality of care.

PubMed Logo Parker L, Kirchner J, Bonner L, Fickel J, Ritchie M, Simons C, and Yano E. Creating a quality improvement dialogue: Utilizing knowledge from frontline staff, managers, and experts to foster healthcare quality improvement. Qualitative Health Research February 2009;19(2):229-242.

This study was funded by VA/HSR&D’s Quality Enhancement Research Initiative (QUERI), and Dr. Yano was supported through an HSR&D Research Career Scientist Award.

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What are HSR&D Publication Briefs?

HSR&D requires notification by HSR&D-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR&D 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&D 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&D published articles. Visit the HSR&D citations database for a complete listing of HSR&D articles and presentations.