Explanation & Elaboration

13a. Outcomes

Nature of setting and improvement intervention

1. Characterizes relevant elements of setting or settings (for example, geography, physical resources, organizational culture, history of change efforts), and structures and patterns of care (for example, staffing, leadership) that provided context for the intervention
2. Explains the actual course of the intervention (for example, sequence of steps, events or phases; type and number of participants at key points), preferably using a time-line diagram or flow chart
3. Documents degree of success in implementing intervention components
4. Describes how and why the initial plan evolved, and the most important lessons learned from that evolution, particularly the effects of internal feedback from tests of change (reflexiveness)

Example

Table 2. Example of a display of the changes that occurred over time.

“The project began with the creation of four working groups that met regularly to work on specific component parts of the pathway.  The results from each working group are summarized on Table 1 and discussed in detail below.” [24]

Elaboration

The results section should include a detailed explanation of the characteristics of the intervention, such as intensity and integrity, changes in the intervention over time, cost, attrition rates, and sustainability. Because quality improvement studies evolve in “real-world” settings, and improvement involves context-sensitive change mechanisms, reporting the local context is essential see 4. Local Problem, and 8. Setting.  If not included in the Local Problem or Setting section, authors should include specific details about the clinic setting, patient population, prior experience with system change, and how the context contributed to understanding the problem for which the study was designed. This article discussed these specifics in 8. Setting section. Ideally, this section should also discuss the nature of the facility’s prior experience with, and commitment to, meaningful change.

It is likely that an intended improvement strategy will evolve over time in response to feedback from the environment and in response to changes in that environment over time. Improvement leaders and researchers should anticipate this evolution. When reporting on the results, this evolution should be captured. Often this is best done with a timeline or table that demonstrates changes over time, as in this example. The table from this example shows that the intended initial change strategy involved independent working groups that met in isolation. As the project progressed, however, it became clear that the work needed to be integrated. The table shows this evolution by indicating that by the Spring of 2003, all of the working groups were participating in the same process of mock drills.

The success or failure of an individual improvement plan will be related to the inherent nature of the improvement as well as the interaction of that improvement within a particular setting. This example demonstrates the change in the improvement over time and how that affected the individuals in the organization. Readers are then able to determine how their own organization is similar to and different from the one whose change is described.

References

24. Mooney SE, Ogrinc G, Steadman W. “Improving Emergency Caesarean Delivery Response Times at a Rural Community Hospital”. Quality & Safety in Health Care. 2007;16(1):60-66

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