Background
Effective quality improvement starts with the recognition of an important problem in the delivery of health care and which can be solved by a change of professional routines or by an innovation in healthcare delivery. In many cases, simple information on the required changes (written guidelines, journal publications) is not sufficient for achieving actual change of professional routines. Many factors influence the change of professional routines and health care delivery processes, related to the practice organisation (e.g. organisational and financial structures) and the individuals involved (e.g. clinicians and patients’ knowledge and attitudes). quality improvement programs are designed to overcome such barriers, but it is still unclear how to develop effective programs. Even complex programs achieve only 10-20% change, and many programs do not result in change at all.

There is a wide range of specific tools and interventions that can be used in quality improvement programs, such as audit, tools for needs assessment, small group learning, outreach visits, financial incentives and tailored interventions. Such methods and activities have to be planned and organised efficiently. quality improvement should be driven by an analysis of barriers, and interventions to achieve change should address those barriers. The development of quality improvement programs is currently a ‘black box’: the expertise, creativity and preferences of the developers seem to determine the content of the program. The developers of quality improvement programs would benefit from a structured approach, that integrates both empirical identification of barriers and facilitators for change and adequate use of evidence-based theories of behavioural change and organisational development. Only when a structured approach is used, will it be possible to evaluate specific components of programs.


Principle activities
1  Critical review of methods for identification of barriers Barrier identification methods include focus group interviews with clinicians and written surveys among patients. There are many examples in the literature and also some overviews of methods. Our review aims to collect this evidence and to assess it in the context of the development of quality improvement programs. An important question is, for instance, how perceived barriers (measured with interviews or surveys) are related to actual determinants of professional behaviour. Another is the extent to which barriers are generalisable across different clinical areas (e.g. is a barrier for diabetes care also a barrier for stop-smoking programs?). We will address such questions, provide a structured overview and provide evidence-based or, where clear evidence is lacking, consensus-based recommendations for developers of quality improvement programs.

2  Critical review of theories on change Many theories on change are available, eg psychological theories (dominant in health education), innovation diffusion theories, organisational theories and economic theories. Overviews of theories have been written. Our review will take the additional step of analysing the theories in more detail and considering the research evidence related to the healthcare field. Our expectation (based on previous theoretical studies) is that theories use different terminology, but refer in part to the same factors. This critical examination will provide an overview of theories, the research evidence, and an analysis of the specific factors in those theories.

3  Development of a model for the development of quality improvement programs. Based on the results of the above, we will develop a structured model for the development of quality improvement programs. Methods such as ‘intervention mapping’ (used in health education) will be examined, but we expect that more specific guidance is needed than the available approaches offer. An important question is how interventions should be related to barriers: there is no direct relation between a barrier and an intervention. Other issues include how to design complex interventions, prioritise barriers and tailor. We will provide a structured approach, based on literature and consensus among experts.


Expected results
The critical reviews of methods for barrier identification and theories of change will be made available through conferences, papers and the ReBEQI website. The model for development of quality improvement programs will be made available in the same way and it will be disseminated to key persons in the area of quality improvement throughout Europe. The tools to facilitate the design of quality improvement programs will be part of the ReBEQI suite of tools and, therefore, also made freely available via the ReBEQI website.


Timeframe
This work began around 1st April 2003 and will be complete in November 2005.