05/11/2019
Looking across studies to draw
Why do frontline healthcare staff struggle to
undertake quality improvement work? An
‘interpretive synthesis’ of four studies
Natasha Hardicre, PhD (@NatashaHardicre)
on behalf of Laura
Sheard, PhD @laurainbradford
Bradford Teaching Hospitals, UK
ISQua: 22nd October 2019
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Background
- Improving the quality of healthcare is
moving at too slow a pace when
contrasted
against the millions of patients harmed
every day across the world
- Why has quality improvement stagnated?
- Literature tends to focus on macro or
micro level with minimal discussion of
meso factors
- Understanding the problems which
frontline staff face when implementing QI
is crucial
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Looking across studies to draw
out high level themes…
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out high level themes…
The four studies….
- All took place across the North of England,
variably between 2013 – 2018, across
multiple healthcare providers and sites,
mostly acute hospital settings
- All focused on bottom up QI work with
ward based staff, either implementation or
research studies
- Teams of ward staff identified quality
problems and developed then implemented
solutions, with QI facilitator support
- The essential ethos underpinning each
study was to improve quality of care for
patients
The four datasets….
Study A (18 months, research study) – a process evaluation of the
trial of a patient safety intervention, involving 17 hospital ward teams
through observational research and interviews. 102 participants
Study B (27 months, implementation study) – evaluation of how
hospital volunteers can facilitate feedback from patients about
safety, using focus groups and interviews. 48 participants
Study C (12 months, research study) – action research with six
teams of ward based staff to improve local patient experience. 50
participants
Study D (4 months, implementation study) – evaluation of healthcare
staff perceptions of the implementation of a framework for improving
safety, using interviews. 16 participants
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QI is at odds with how healthcare

Interpretive synthesis or Witchcraft?! organisations are structured and
managed

- QI interventions introduced with

best of intentions but often cannot supply
resources and ‘organisational navigation’
to enact real, sustainable, lasting change

- Collegiate interdepartmental working is

required but acute sector implicitly
rewards siloed working

- Improvement fatigue evident but also

lots of ‘improvement duplication’

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Three findings which may QI runs contrary to a pervasive

explain why frontline staff find culture of audit, monitoring and
QI difficult… performance management

QI asks staff to think and act differently - Is it QI or is it an audit? Staff often

thought the latter and then acted
QI is at odds with how healthcare defensively
organisations are structured and - Idea of “Getting into trouble” for not
managed engaging with QI initiative

QI runs contrary to a pervasive culture - ‘Careful work’ on behalf of QI

of audit, monitoring and facilitators to protect emotions of
staff close to burnout
performance management
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QI asks staff to think and act differently Implications

Most healthcare staff want to
- Series of tasks to be completed or undertake QI which will benefit their
holistic process to be engaged with? patients but they are frustrated and
worn out by intractable issues
surrounding culture and structure
- Reflection, discussion and ‘taking a
step back’ versus fast paced healthcare
delivery which focuses on throughput
A fundamental
misalignment
- Theoretical underpinnings of QI work exists
often based on predicting future harm in between bottom
contrast to standard practice of reviewing up QI and the
nature
past harm of the modern
day NHS QI work risks repeating the same
mistakes

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Acknowledgements
The individual research studies were funded by:
- NIHR Health Services and Delivery programme
- NIHR Programme Grants for Applied Research
- The Health Foundation

The views expressed are those of the author and not

necessarily those of the NHS, the NIHR, the Health
Foundation or the Department of Health

I gratefully acknowledge the generosity of the Brocher

Foundation, Geneva for hosting me during the month of
February 2018 to undertake this work

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