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What Works to Reduce Unnecessary Care for Bronchiolitis? A Qualitative Analysis of a National Collaborative
Shawn L Ralston1, Emily Carson Atwood2, Matthew D Garber3
1Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Children's Hospital at Dartmouth, Lebanon, NH.
Insights
Team engagement is key for improving pediatric care quality in community hospitals. Overcoming resource competition, especially for information technology, drives success in quality improvement initiatives.
Area of Science:
- Pediatric Quality Improvement
- Health Services Research
- Implementation Science
Background:
- Unnecessary care is a significant quality issue in acute viral bronchiolitis, a common pediatric illness.
- Existing quality improvement literature predominantly focuses on freestanding children's hospitals.
- There is a need to understand quality improvement challenges in community and non-freestanding children's facilities.
Purpose of the Study:
- To identify barriers and drivers of successful quality improvement in community and non-freestanding children's hospitals.
- To understand correlates of success in a bronchiolitis quality improvement collaborative.
- To compare factors influencing quality improvement in diverse pediatric healthcare settings.
Main Methods:
- A mixed-methods study was conducted with community and children's hospitals within adult hospitals.
- Quantitative assessment included site demographics, intervention compliance, and team engagement.
- Qualitative interviews explored performance differences between top and bottom quartiles.
Main Results:
- Team engagement was the sole quantitative factor associated with improved performance.
- Qualitative findings highlighted team buy-in as crucial for success and lack of colleague engagement as a barrier.
- Competition for institutional resources, particularly information technology (IT), emerged as a significant challenge.
Conclusions:
- Team engagement consistently correlates with quality improvement success in pediatric settings.
- Resource competition, especially for IT, presents a key barrier for non-freestanding children's programs.
- Strategies to enhance team engagement and secure resources are vital for quality improvement initiatives.
Objective:
Unnecessary care is well established as a quality problem affecting acute viral bronchiolitis, one of the most common pediatric illnesses. Although there is an extensive quality improvement literature on the disease, published work primarily reflects the experience of freestanding children's hospitals. We sought to better understand the specific barriers and drivers for successful quality improvement in community and nonfreestanding children's facilities.
Methods:
We undertook a mixed methods study to identify correlates of success in a bronchiolitis quality improvement collaborative of community hospitals and children's hospitals within adult hospitals. We assessed site demographic characteristics, compliance with project interventions, and team engagement for association with end of project performance. We then used performance quartiles on a composite assessment of project measures (use of bronchodilators and steroids) to design a purposive sample of sites approached for qualitative interviews.
Results:
Team engagement was the only factor quantitatively associated with better performance in the overall cohort. Fifteen sites, from the total cohort of 21, completed qualitative interviews. Qualitative themes around team engagement, including the presence of buy-in for successful sites and the inability to engage colleagues at unsuccessful sites, were important differentiating factors between top and bottom performance quartiles. Regardless of performance quartile, most programs cited intrainstitutional competition for limited resources to do quality improvement work as a specific barrier for pediatrics. The ability to overcome such barriers and specifically garner information technology (IT) resources also differentiated the top and bottom performance quartiles.
Conclusions:
Team engagement showed a consistent association with success across our quantitative and qualitative evaluations. Competition for limited resources in this cohort of nonfreestanding children's programs, particularly those in hospital IT, was a key qualitative theme.
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