Innovations in Quality Improvement Research for more useful answers to research users’ questions

Abstract

Quality Improvement Research (QIR) is any systematic inquiry that generates actionable knowledge, enables prac-titioners and patients to improve care and health, and reduces bias to maximize the validity and reliability of the knowledge gained. Some QIR evaluates complex health-care innovations, such as bundled interventions to reduce infections. Such innovations often involve multiple com-ponents (e.g., hand hygiene, review of device necessity), may be directed at various levels of the system (e.g., practi-tioner, provider teams, hospital units), and may change in content or implementation strategy across time and con-text. Such innovations are affected by contextual factors emanating from different levels of the system. If QIR addresses practitioners' questions, it is more likely to be used. There are seven questions relevant to quality improvement (QI) practice: 1) Efficacy: does it work in controlled situations? 2) Effectiveness: will the intervention work in a setting and with patients like the practitioner's own?; 3) Implementation: what are successful ways to implement change?; 4) Sustainability: what is needed to sustain the change?; 5) Fidelity: should the intervention be copied exactly?; which parts can be adapted?; 6) Cost: what are the costs and savings of making and sustaining the change?; and 7) De-implementation: how are ineffec-tive practices modified? Research designs and methods must be chosen to match research users' needs. Designs frequently used in research, such as randomized controlled trials (RCTs), might not address questions of interest to stakeholders (e.g., clinicians, administrators, patients, payers). QIR can be broadened to include adherence studies and multi-morbidity studies, and to use budget impact analyses, action evaluation, research syntheses, and context-and-theory-informed program eva-luations, as well as RCTs that incorporate process evalua-tions. Secondly, to be more relevant to current initiatives, such as Patient Centered Medical Homes, QIR could include estimates of costs and savings of improvements. Thirdly, QIR can be extended to non-hospital settings to study improvements that significantly affect patients' health and cost. In these settings, QIR could be used to study epi-demiology of adherence, conditions that facilitate or impede health behaviors, and interventions to improve self-care and self-management. Finally, an important point raised during conference discussion is the need to under-stand how practitioners and administrators use QIR. Because the goal of QIR is to provide actionable knowledge, researchers need to know how and even if, their findings are being used.