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Fellows, Mary Kawonga and Nancy Zionts, summarize take-away messages of day four

On the fourth day of the session Better Health Care: How do we learn about improvement? Fellows considered the synthesis of approaches for evaluating quality improvement.

Purpose of the Session:

To synthesize take-aways from all prior sessions in order to formulate key points that participants would like to see in the guidance document.

The session included three presentations followed by facilitator-guided discussions in three groups, based on the three case studies from day 3.

The first presentation entitled “towards guidance for evaluating improvements – for investigators, improvers and funders” provided key definitions, tools and ideas) for participants to think about when developing guidance. The presentations explored the question: what guidance do we think would be useful to give to people in order to make a faster and better difference?

Some key take-away messages:

• Careful attention to language (“the tools to see”): working definitions of key concepts enhance common understanding. Improvement was defined as “the new better way” of doing things. Other key concepts discussed include: implementation (the actions to enable people to perform the “better way”), intervention, outcome, and context.
• Context is an active player rather than background. It is the conditions in which interventions “grow” / affect how to get from the current state / practice to the new better way. Tools and approaches for documenting context are available. Readiness assessments are important to assess the suitability of a given context.
• Clearly describe the intervention. Did they gather the right data?
•  Be clear about what are we evaluating: the new better way of doing things or how to enable people to do the better way? There are multiple ways of helping people to change practice, a key QI question is: which is most effective?
• Match investigation methods to needs. A continuum of designs ranging from the RCT (stronger) to one person’s opinion (weaker). Key questions: is the evidence strong enough for generalization? Important to match methods to needs and resource availability.

The “painter’s palette” was presented, depicting ten accountability questions that can help people think about the kinds of issues they should consider for undertaking improvement initiatives in a results-oriented manner. This “outcomes-thinking” aims for results of an improvement initiative designed on the basis of needs and resources. The questions can be applied for accountability to stakeholders at different levels (from national level to the client).

In break-away groups participants worked through developing guidance statements so that those involved in research and in improvement initiatives can do this better. The possible domains for which we may generate guidance statements were identified as:

• Context: their understanding and measurement of it
• Adaptation: how to anticipate, plan for, measure and analyse adaptation
• Causal mechanisms: explicit apriori causal models / mechanisms
• Formative evaluation
• Distinguishing clinical research from implementation.