Can quality improvement improve the quality of care? A systematic review of reported effects and methodological rigor in plan-do-study-act projects

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Abstract

Background

The Plan-Do-Study-Act (PDSA) method is widely used in quality improvement (QI) strategies. However, previous studies have indicated that methodological problems are frequent in PDSA-based QI projects. Furthermore, it has been difficult to establish an association between the use of PDSA and improvements in clinical practices and patient outcomes. The aim of this systematic review was to examine whether recently published PDSA-based QI projects show self-reported effects and are conducted according to key features of the method.

Methods

A systematic literature search was performed in the PubMed, Embase and CINAHL databases. QI projects using PDSA published in peer-reviewed journals in 2015 and 2016 were included. Projects were assessed to determine the reported effects and the use of the following key methodological features; iterative cyclic method, continuous data collection, small-scale testing and use of a theoretical rationale.

Results

Of the 120 QI projects included, almost all reported improvement (98%). However, only 32 (27%) described a specific, quantitative aim and reached it. A total of 72 projects (60%) documented PDSA cycles sufficiently for inclusion in a full analysis of key features. Of these only three (4%) adhered to all four key methodological features.

Conclusion

Even though a majority of the QI projects reported improvements, the widespread challenges with low adherence to key methodological features in the individual projects pose a challenge for the legitimacy of PDSA-based QI. This review indicates that there is a continued need for improvement in quality improvement methodology.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4482-6) contains supplementary material, which is available to authorized users.

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Most cited references 35

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The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration

Alessandro Liberati, Douglas G. Altman, Jennifer Tetzlaff … (2010)

Systematic reviews and meta-analyses are essential to summarise evidence relating to efficacy and safety of healthcare interventions accurately and reliably. The clarity and transparency of these reports, however, are not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users. Since the development of the QUOROM (quality of reporting of meta-analysis) statement—a reporting guideline published in 1999—there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realising these issues, an international group that included experienced authors and methodologists developed PRISMA (preferred reporting items for systematic reviews and meta-analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions. The PRISMA statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this explanation and elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA statement, this document, and the associated website (www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.

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Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

Laura Damschroder, David Aron, Rosalind E Keith … (2009)

Background Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts. Methods We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts. Results The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct. Conclusion The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.

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SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process

Greg Ogrinc, Louise Davies, Daisy Goodman … (2015)

Since the publication of Standards for QUality Improvement Reporting Excellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this manuscript, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) semistructured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) two face-to-face consensus meetings to develop interim drafts and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasises the reporting of three key components of systematic efforts to improve the quality, value and safety of healthcare: the use of formal and informal theory in planning, implementing and evaluating improvement work; the context in which the work is done and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve healthcare, recognising that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (http://www.squire-statement.org).

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Author and article information

Contributors

Søren Valgreen Knudsen:

ORCID: http://orcid.org/0000-0002-3792-8983

soeren.k@rn.dk

Henrik Vitus Bering Laursen: henrikvitus@gmail.com

Søren Paaske Johnsen: soeren.johnsen@rn.dk

Paul Daniel Bartels: pdbartels@dadlnet.dk

Lars Holger Ehlers: lehlers@business.aau.dk

Jan Mainz: jan.mainz@rn.dk

Journal

Journal ID (nlm-ta): BMC Health Serv Res

Journal ID (iso-abbrev): BMC Health Serv Res

Title: BMC Health Services Research

Publisher: BioMed Central (London )

ISSN (Electronic): 1472-6963

Publication date (Electronic): 4 October 2019

Publication date PMC-release: 4 October 2019

Publication date Collection: 2019

Volume: 19

Electronic Location Identifier: 683

Affiliations

[1 ]ISNI 0000 0001 0742 471X, GRID grid.5117.2, Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, , Aalborg University, ; Mølleparkvej 10, 9000 Aalborg, Denmark

[2 ]ISNI 0000 0004 0646 7349, GRID grid.27530.33, Psychiatry, , Aalborg University Hospital, ; The North Denmark Region Mølleparkvej 10, 9000 Aalborg, Denmark

[3 ]ISNI 0000 0001 0742 471X, GRID grid.5117.2, Danish Center for Healthcare Improvements (DCHI), , Aalborg University, ; Fibigerstræde 11, 9220 Aalborg Øst, Denmark

[4 ]Danish Clinical Registries, Denmark, Nrd. Fasanvej 57, 2000 Frederiksberg, Denmark

[5 ]ISNI 0000 0004 1937 0562, GRID grid.18098.38, Department for Community Mental Health, , Haifa University, ; Haifa, Israel

[6 ]ISNI 0000 0001 0728 0170, GRID grid.10825.3e, Department of Health Economics, , University of Southern Denmark, ; Odense, Denmark

Author information

Søren Valgreen Knudsen http://orcid.org/0000-0002-3792-8983

Article

Publisher ID: 4482

DOI: 10.1186/s12913-019-4482-6

PMC ID: 6778385

PubMed ID: 31585540

SO-VID: 759bd984-df37-4e92-a1e7-fecae6ee9a7f

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 7 January 2019

Date accepted : 28 August 2019

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ScienceOpen disciplines: Health & Social care

Keywords: pdsa,plan-do-study-act,quality,health services research,quality improvement

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ScienceOpen disciplines: Health & Social care

Keywords: pdsa, plan-do-study-act, quality, health services research, quality improvement

Can quality improvement improve the quality of care? A systematic review of reported effects and methodological rigor in plan-do-study-act projects

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Most cited references 35

The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration

Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process

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