Article Text
Abstract
Background Improving integration and continuity of care across sectors within resource constraints is a priority in many health systems. Qualitative operational research methods of problem structuring have been used to address quality improvement in services involving multiple sectors but not in combination with quantitative operational research methods that enable targeting of interventions according to patient risk. We aimed to combine these methods to augment and inform an improvement initiative concerning infants with congenital heart disease (CHD) whose complex care pathway spans multiple sectors.
Methods Soft systems methodology was used to consider systematically changes to services from the perspectives of community, primary, secondary and tertiary care professionals and a patient group, incorporating relevant evidence. Classification and regression tree (CART) analysis of national audit datasets was conducted along with data visualisation designed to inform service improvement within the context of limited resources.
Results A ‘Rich Picture’ was developed capturing the main features of services for infants with CHD pertinent to service improvement. This was used, along with a graphical summary of the CART analysis, to guide discussions about targeting interventions at specific patient risk groups. Agreement was reached across representatives of relevant health professions and patients on a coherent set of targeted recommendations for quality improvement. These fed into national decisions about service provision and commissioning.
Conclusions When tackling complex problems in service provision across multiple settings, it is important to acknowledge and work with multiple perspectives systematically and to consider targeting service improvements in response to confined resources. Our research demonstrates that applying a combination of qualitative and quantitative operational research methods is one approach to doing so that warrants further consideration.
- Quality improvement methodologies
- Healthcare quality improvement
- Implementation science
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Footnotes
Contributors SC contributed to the design and conception of the study, the analysis and interpretation of data, and drafting of the work. KB, JT, JW, RK, DAR and CB contributed to the interpretation of data. MU contributed to the design of the study and drafting of the work. All authors revised the work critically for important intellectual content. SC is the guarantor of the paper and takes responsibility for the integrity of the work as a whole, from inception to published article.
Funding SC was supported by the Health Foundation, an independent charity working to continuously improve the quality of healthcare in the UK. KB, JT, JW, RK, DAR and CB were funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme (Project No: 10/2002/29). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR HS&DR programme or the Department of Health. MU was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Bart's Health NHS Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
Competing interests KB declares participation on the steering committee of the UK National Congenital Heart Diseases Audit.
Provenance and peer review Not commissioned; externally peer reviewed.