Practitioners Navigating Context in Healthcare Quality Improvement

Terwilliger, Iva Alyse

doi:https://doi.org/10.21985/n2-xhws-yx87

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Practitioners Navigating Context in Healthcare Quality Improvement

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In this dissertation, I conducted 2 studies that resulted in 3 manuscripts. This dissertation consists of 6 chapters that include the 3 manuscripts. The overarching research question is How does context affect the work of quality improvement (QI) practitioners? To answer this larger research question, which is central to the quality field, I answer 3 narrower questions related to QI and context: (1) What is known and not known in the literature about how context is operationalized as a concept? (2) How do QI practitioners navigate context in practice? And (3) How do experienced QI practitioners gain QI skills and apply skills in projects?In my first study and manuscript, through a scoping review of reviews, I explored what is known and unknown in the QI literature about how context is operationalized by scholars. The results of my study of 24 reviews show that there is considerable variation regarding how context is operationalized and defined within literature review studies, but the consensus within the reviews is that context is composed of factors that influence project success. Most reviews viewed context as everything but the interventions. Thus, the concepts of context and factors overlap, but there are factors (i.e., factors related to the intervention) that are not part of context. To help prevent the conflation of the 2 terms ‘context’ and ‘factors’, authors should define the terms and/or clarify the type of factors they are referring to (e.g., organizational factors). Building from the finding from the first study that less is known about the connection between process and context, in my second study and manuscript, I conducted semi-structured interviews with QI practitioners to understand how practitioners are navigating context to obtain stakeholder buy-in. Throughout the interviews, QI practitioners told me how they employ strategies in response to the context to obtain buy-in. I identified ways in which practitioners navigate context to manage the complexity of interrelationships with stakeholders in QI projects. The participants described 5 strategies: (1) involve multiple levels of stakeholders, (2) reframe problems for different stakeholders, (3) utilize information from quantitative and qualitative data to tell stories, (4) make tradeoffs to match priorities, and (5) defer to expertise. The strategies identified demonstrate that QI practitioners are trying to obtain buy-in across multiple levels of the context through using multiple sources of data, making trade-offs, and reframing problems. In my third manuscript, using the same data as in manuscript 2 from the qualitative interview study, I aimed to explore the skills used in QI work and how practitioners learned these skills. I found that QI practitioners use interpersonal, intrapersonal, project, and technical skills. Further, QI practitioners learn their skills and knowledge through formal training, from others, teaching, doing, and self-reflection. These findings show that QI practitioners use skills beyond QI technical skills and are using skills that comprise leadership capabilities. Further, QI practitioners are continuously learning and improving their practice. Collectively, these findings can be used to inform curriculum for training QI practitioners and continuous education. In this dissertation, I operationalize context as a concept based on literature reviews, identify strategies for obtaining stakeholder buy-in, and examine how skills are applied and learned within QI. With my findings in mind, I create a conceptual model of how QI practitioners obtain QI project success by using the Donabedian model as a starting point. My conceptual model shows QI practitioners use QI processes—including formal methods, strategies, and tasks—to navigate and adapt the structures within and outside the organization to complete projects. This dissertation contributes to the QI field’s understanding of how QI practitioners approach QI projects. Most importantly, the findings inform QI training curricula through highlighting the importance of context, the role of strategies, and diverse set of skills used to complete QI work.

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