View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Carolina Digital Repository Measuring and Increasing the Effectiveness of the Quality Improvement Implementation Change Practices of Front-Line Maternity Physician and Nurse Leaders Debra Bingham, MS, RN A dissertation submitted to the faculty of the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctorate of Public Health in the Department of Health Policy and Management of the School of Public Health Chapel Hill 2009 Approved by: Peggy Leatt, PhD Cheryl B. Jones, PhD, RN Jeffery B. Gould, MD, MPH Carol Sakala, PhD, MSPH Rebecca Wells, PhD © 2009 Debra Bingham, MS, RN ALL RIGHTS RESERVED ii Abstract Debra Bingham, MS, RN Measuring and Increasing the Effectiveness of the Quality Improvement Implementation Change Practices of Front-Line Maternity Physician and Nurse Leaders (Under the direction of Peggy Leatt, PhD, Cheryl B. Jones, PhD, RN, Jeffery B. Gould, MD, MPH, Carol Sakala, PhD, MSPH and Rebecca Wells, PhD) Measuring and increasing the effectiveness of the QI implementation change practices of front-line leaders offers the promise of saving lives and reducing harm and suffering to patients. Leaders have limited information on how to measure and increase the effectiveness of their QI implementation practices. Design: Qualitative, non-experimental, retrospective, cross-case study. Sample: Purposive sample of 7 front-line physician and nurse leaders and 12 QI projects, controlled for multiple context variables. Conclusions: The conceptual framework, Leaders’ Expectations of Change Compliance , emerged based on the analysis of the reasons leaders did not set target dates. The QI implementation tactics used by the leaders were determined to be components of three types of strategies : education, data and discourse. QI project patterns were identified; there was no single combination of strategies, tactics, and barriers that led to greater QI progress. The five critical determinants of the QI patterns were: 1) Amount of leader persuasion, 2) Whether a leader had fully conceptualized the QI project, 3) Amount of clinician persuasion, 4) iii Presence or absence of meaningful data, and 5) How leaders responded to resisters. The patterns are similar for QI projects with the same QI topics and goals. Counting the number of QI implementation tactics the leaders used is not an accurate measure of QI implementation progress. Four types of implementation barriers : Leader, clinician, characteristics of the QI Projects, climate, and resource barriers. There was no distinguishable relationship between the number of tactics used and the number of barriers identified. Implementation Plan Objective: Increase leaders’ abilities to conceptualize their QI implementation strategy and how they choose their QI implementation tactics based on the barriers they anticipate and encounter. Research Recommendations: Conduct further research on QI regarding: concepts, project timing, health information technology (HIT), setting target dates, discourse and change, creative types of implementation tactics, and multi-hospital and multi-stakeholder collaboratives. Health Policy Recommendations: Develop hospital-based Rapid Response QI Teams that can be activated during a quality and safety emergency, train new and current clinicians to conceptualize, implement and reach QI goals, increase QI implementation research funding, develop a QI topic-specific implementation registry, and integrate QI and HIT. iv Dedication To My Husband: Kent Hamilton To My Parents: VerNon and Bernice Bingham To My Children and Their Spouses: Tara and Shawn Steenson David Jones and Sarah Sacuto Lauren and Jeff Wind Tiffany and Fred Schoppe To My Grandchildren: Shawn Curtis, Mariah, Joshua, Caleb, and Katie Steenson Oslo Wind Olivia Jones To My Sisters: Brenda Anderson and Linda Coy v Acknowledgements There are many people who supported me through my doctoral studies and dissertation. With their support and encouragement the journey has been more rewarding; the end product of higher quality. My husband, Kent Hamilton deserves the most thanks and acknowledgement. Kent’s continuous love and support is invaluable. Kent spent countless hours participating in discussions about my work and reading, editing, and re-reading multiple drafts. His optimism about my abilities, coupled with his willingness to jump in and help, provided me with a kind and productive environment to work within. My long-time friends, Zola Golub and Reesa Vaughter inspire me to strive for excellence not only throughout the dissertation process, but through all aspects of my life. I am particularly grateful to Reesa for regularly spending many hours reading very rough drafts of my work, providing me with insightful comments and questions, and helping me see the flaws in my work in such a way that I was not discouraged to keep pressing forward. Reesa’s ability to give timely, broad and detailed guidance was invaluable. Zola is my mentor and friend. Words do not adequately describe the gratitude I feel toward Zola for the positive influence she has on the course of my life. As with many other endeavors I have chosen to pursue, Zola provided me keen insight and support every step of the way. Because of Zola, I am more confident and my life is richer and fuller. vi I have the good fortune to be the daughter of VerNon and Bernice Bingham. My parents are life-long learners, big dreamers, and hard workers. They have accomplished goals that others told them were impossible. For example, during the years that my father was the High School Spanish teacher in Brigham City, Utah, they organized inexpensive trips to Mexico that thousands of youth participated in. Their trips grew into a phenomenon that changed the cultural landscape of several communities. My parents were raised with minimal means on small farms in small towns. But their humble roots did not constrain or define them. They have lived and worked in many countries in the world and continue in their 80’s to seek educational and cultural experiences by continuing to travel the world. Their example and their love sustain me and motivate me in countless ways. My children, their spouses, and my grandchildren bring me great joy. I look at them and marvel at the miracle of life. In fact, one of the major reasons I have been striving to learn more and accomplish more is to, in my sphere of influence, improve health care for them and my other loved ones. Thus, it was timely and fitting that during the writing of my dissertation two new grandchildren were born; Oslo Wind and Olivia Jones. It is also personally rewarding that my son, David Jones has also chosen to pursue a career in Public Health. Although my studies at the University of North Carolina were begun prior to his starting his Masters of Science in Public Health, I pushed myself harder so that we could graduate on the same day, from the same Department, from the same University. I acknowledge both of my sisters, Brenda and Linda. Brenda died an untimely death during my coursework. However, despite the loss of being able to call her on the phone and visit her in person, I have felt encouraged throughout my studies by how Brenda lived her life. When I was the most exhausted, I would think of Brenda. Remembering how Brenda vii lived, even when her body was dying a painful death, encouraged me to keep challenges in perspective. Linda and I are close in age. Thus, Linda has been both my sister and a trusted friend throughout my life. I could always count on her to be there for me. I have always admired Linda and turn regularly to her for advice and support; my doctoral studies were no different. Thus, I want to acknowledge her on-going support for my entire life, of which only a few years included my doctoral studies. Throughout my life, Brenda’s and Linda’s consistent faith in my abilities gave me greater courage not to shy away from challenges that were new and often daunting. My brothers, brothers-in-law, and sister-in-law are also very dear to me. I acknowledge them for their support and encouragement. I also thank John Gruntkowski, Bonnie Seelos and my nieces and nephews, of which I am blessed to have many. I thrill at their accomplishments and I value their interest in my work. Since I am the first person in my immediate and extended family to get a doctorate degree, I hope that my accomplishments will make the educational and professional goals for all members of my family seem less formidable and more approachable than they have often appeared to me. Many friends and colleagues in New York City encouraged me to pursue my doctorate degree. I acknowledge them for the positive influence they have on my work and their on-going encouragement throughout the process. There are too many of them to name each one individually. Moving to California during the second semester of my coursework, added the necessary stress and opportunity of finding new employment and developing new professional colleagues. I am grateful to everyone in California who welcomed me and supported my educational goals; there are too many for me to be able to name each one viii individually. However, I particularly want to thank Barbara Murphy and Elliott Main for providing me an employment environment that has been both stimulating and flexible; they understood and valued the fact that my studies informed my work. Without Barbara’s and Elliott’s interest in and support of my doctoral studies, the difficult task of juggling multiple priorities would have been even that much more difficult. For the past three years, Elliott and I have traveled together all over California and to the East coast in order to form the precedent-setting California Maternal Quality Care Collaborative (CMQCC).