Explanation & Elaboration

9. Planning the intervention

1. Describes the intervention and its component parts in sufficient detail that others could reproduce it
2. Indicates main factors that contributed to choice of the specific intervention (for example, analysis of causes of dysfunction; matching relevant improvement experience of others with the local situation)
3. Outlines initial plans for how the intervention was to be implemented: e.g., what was to be done (initial steps; functions to be accomplished by those steps; how tests of change would be used to modify intervention), and by whom (intended roles, qualifications, and training of staff)

Example

"Twenty-three primary care organizations voluntarily enrolled in the Depression Breakthrough Series. This intervention was coordinated by the Improving Chronic Illness Care team and the Institute for Health Care Improvement and supported by the Robert Wood Johnson Foundation. Six private-sector organizations each paid a fee of $12,500, and 11 public-sector organizations that were financed by the Health Resources and Services Administration received a scholarship from the Robert Wood Johnson Foundation to cover the fee. Each team (typically a physician, a care manager, and a coordinator) attended three learning sessions for training by institute faculty on "plan-do-study-act" cycles and other techniques for rapid quality improvement and by experts in implementing the chronic care model. Between sessions, teams attempted to make changes and participated in monthly cross-site conference calls with expert faculty.

On the basis of the chronic care model, which envisions the delivery of effective treatment for chronic illness by restructuring care systems, teams were encouraged to design programs that implement changes within each of six areas...." [28]

Elaboration

Readers can best understand the meaning and applicability of a quality improvement intervention when the key features of the planning process are well-documented. Unlike tightly controlled research studies, which tend to be studies of "conceptually neat and procedurally unambiguous" interventions like drugs, tests, or procedures, studies of quality improvement interventions are intended to help others predict whether a particular approach to changing performance is likely to result in improved routine care. Routine care cannot be dissociated from its contexts, so readers need to understand how a quality improvement intervention influenced and was influenced by the context within which it was carried out. The planning of the intervention is a key component of this.

In the example, contextual factors include intervention financing and number and type of organizations. Additional contextual factors, such as the size, academic affiliations, rural or urban location, region of the country, and characteristics of the patient population are known to have major effects on quality of care and intervention implementation. Organizational characteristics of participating sites, particularly those characteristics relating to elements of the Chronic Illness Care model, as well as those describing an organization's culture or leadership, should also be included in this section.

The example contains very specific information about the details of the initial intervention. It specifies the organizations, teams, faculty members, and theoretical background (PDSA, model for improvement, chronic care model) used in setting up the interventions. Basic planning steps included three learning sessions and monthly telephone calls. Local improvement teams modified and adapted their intervention plans at each step. All of these facets of the initial planning process help the reader to anticipate the conditions under which the quality improvement intervention's results would be most applicable.

In some cases, intervention planning focuses on policy change, with little structuring of the specific change in the local setting. In other cases, an organization, community, or microsystem within an organization may adopt a previously-designed set of changes as its intervention. If the focus is adoption of pre-set changes, the planning phase may particularly emphasize the development of evaluation goals, standards, and methods. In each case, the report of the planning phase should identify the focus of the quality improvement intervention, and the design decisions related to that focus. For example, if the QI intervention is being developed de novo (or if it requires substantial adaptation from prior models), the report of the planning phase write-up should focus on piloting changes, such as through PDSA cycles. If the QI intervention is a policy change alone, the planning phase write-up should focus more on what was done to garner feedback from stakeholders or to pilot early evaluation designs.

In many cases, such as in the example above, an organization or community intends either to substantially adapt a prior intervention. Describing the financial and technical support for the planning process and for the interventions is important, since both the type and degree of support provided for both the planning phase and the interventions can influence the scope of changes that are undertaken. In addition, as is usually the case, the specific sources of financial support may raise issues of actual or potential conflicts of interest, even when the sources are not-for-profit. Some of this information may be cross-referenced with information in the section 7. Ethical Issues and/or 19. Funding. Readers need to understand each of these issues to predict how well the quality improvement intervention may apply under other circumstances.

References

28. Meredith L, Mendel P, Pearson M. Implementation and maintenance of quality improvement for treating depression in primary care. Psychiatr Serv. Jan 2006;57(1):48-55.

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