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In the United States, health care organizations are often biased toward deficit-based quality and safety improvement techniques, such as incident reporting and peer review. However, deficit-based techniques may elicit negative sentiments from frontline health care professionals, causing disengagement and adverse event underreporting. To complement deficit-based quality improvement, our institution developed an organizationwide asset-based quality improvement tool. Inspired by asset-based quality improvement methodologies such as appreciative inquiry, Safety-II, and positive deviance, this tool facilitates the identification and analysis of clinical excellence. Resultant best practices and quality improvement projects are then propagated throughout our organization. Ultimately, asset-based quality improvement tools are logistically and technologically feasible for organizationwide deployment, and they potentially improve care quality and team culture. Health care organizations should consider adding these tools to their quality and safety improvement initiatives.
All health care organizations seek to improve the quality and safety of patient care. In the United States, incident reporting and clinical peer review are the predominant venues where frontline health care professionals (HCPs) participate in quality and safety improvement within health care organizations.
Incident reports generally involve the identification of adverse events, whereas clinical peer review involves adverse event investigations that explicitly question the quality of care and/or behavior of specific HCPs. An incident report may or may not trigger clinical peer review, depending on the details of the relevant HCP's involvement in the event. For the purposes of this article, incident reporting and clinical peer review are aggregated under the term adverse event reporting (AER). During AER processes, patient safety teams and/or peer review committees investigate the events, determine what went wrong, and implement solutions to prevent adverse event recurrence. Peer review investigations also adjudicate if the involved HCPs were meeting the standard of care. AER processes are requirements of The Joint Commission
require AER processes for quality assurance, solidifying their importance.
AER, including incident reporting processes and clinical peer review, exemplifies deficit-based quality improvement (DBQI). DBQI projects begin by asking “What went wrong?” or “Are we meeting benchmarks?” Decision-makers then search for durable solutions to the problems or suboptimal performance. Deficit-based approaches are prevalent in health care, as institutions have invested significant resources into safety programs to combat medical errors and iatrogenic harm.
Although it is a critical component of health care organizations’ safety and quality programs, DBQI has disadvantages. AER inherently elicits defensive responses from HCPs. Because the investigations originate from adverse events, HCPs must explain what allegedly went wrong. Many HCPs believe that peer review, specifically, is a punitive process.
These litigious, defensive, and negative sentiments contribute to HCPs underreporting adverse events and disengaging from quality and safety initiatives, whether originating from incident reporting processes or clinical peer review. An estimated 50% to 96% of adverse events in the United States are not reported, most commonly due to punitive repercussion fears.
Unreported adverse events represent lost organizational learning opportunities. Another disadvantage of DBQI is the second victim phenomenon: frontline HCPs themselves experience harmful effects from adverse events and ensuing investigations, including stress, anxiety, sleep disturbance, and lowered clinical confidence.
To counterbalance the disadvantages of the DBQI approach, some organizations have implemented asset-based quality improvement (ABQI) projects. For simplicity in this article, ABQI is a generic term that encompasses specific ABQI techniques, such as positive deviance,
In contrast to deficit-based approaches, when using asset-based approaches, decision-makers do not initially seek to resolve problems or fulfill needs. Instead, the goal is to improve overall performance by identifying and expanding existing strengths within an organization (Table 1). Asset-based approaches ask “What are our strengths?” and “Where do we excel?” When sources of excellence are identified, subsequent analyses tease out root causes for circulation throughout the organization. By highlighting existing positive behaviors, resources, and processes within the organization, ABQI benefits from frontline team members’ inherent sense of ownership of these strengths, thereby increasing these team members’ engagement with the quality improvement effort.
Asset-based approaches have accomplished successful outcomes in multiple industries outside of health care. For example, in education, instructors employing asset-based teaching have successfully increased historically minoritized students’ engagement by acknowledging and capitalizing on diverse native languages, cultural backgrounds, and viewpoints.
Similarly, in public health and social work, asset-based community development cultivates existing resources (for example, people, infrastructure, local organizations) in a community to improve public health outcomes, as opposed to deficit-based approaches in which external parties identify problems and infuse resources to resolve them.
ABQI initiatives have also been implemented in health care. For example, Cohen et al. used ABQI to identify and learn from physicians in their hospital who employed unique central line insertion techniques that added infection control barriers exceeding Centers for Disease Control and Prevention guidelines.
Dewar and Nolan employed ABQI to study the word choices and body language of ward nurses who consistently achieved compassionate nurse-patient interactions, and they subsequently normalized these behaviors for the entire nursing staff.
Notably, most published health care ABQI projects have been at the department level or smaller. Widescale institutional adoption is lacking, as most health care organizations allocate the majority of their quality improvement resources into DBQI initiatives and meeting deficit-based regulatory requirements.
Our goal was to complement our institution's DBQI initiatives by launching a practical systemwide ABQI tool to discover and propagate existing clinical excellence throughout our organization. This pilot project would ascertain the logistical and technological feasibility of creating and incorporating the ABQI tool into our institutional quality program to (1) generate quality improvement initiatives worth systemwide spread, (2) disseminate stories of clinical excellence to inspire other HCPs to improve their clinical practices, and (3) foster frontline HCP engagement with quality and safety efforts.
Organizational Context: Peer Review Committee Challenges and Appreciative Inquiry Team Origin
Our organization is an integrated health system that operates more than 30 hospitals and more than 200 outpatient health centers across six states in the United States. The organization's medical group employs more than 2,000 physicians and advanced practice providers, and these employed HCPs manage approximately 2.1 million ambulatory and 1.7 million acute care patient encounters per year.
The medical group launched an ambulatory peer review committee in 2014. In 2019 this committee consisted of 16 physicians and one advanced practice provider, encompassing primary care and diverse specialty practices. At its monthly meetings, the committee reviewed adverse events involving medical group–employed physicians and advanced practice providers, with referrals originating from incident reports, risk management, practice leadership, or patient complaints. Investigations routinely involved chart reviews and conversations between peer reviewers and the HCPs under review, allowing the HCPs to provide clinical context to the event. Peer reviewers typically reviewed 0 to 2 events per month. By reviewing adverse events, the peer review committee's goal was to improve the quality of care provided by the organization's HCPs. This committee predominantly focused on care at the outpatient health centers, as each hospital's medical staff operated its own peer review committee.
In 2014 the ambulatory peer review committee reviewed 68 cases, and this volume increased to 88 cases in 2017. However, in subsequent years, case volumes steadily declined, with 57 cases in 2019. Given the increasing size of the medical group and large number of patient encounters, peer review committee leadership was concerned that these declining case volumes were, at least in part, secondary to adverse event underreporting. This opinion was bolstered by negative feedback that committee members regularly received from HCPs undergoing peer review. Such feedback included the following statements: “I wouldn't have submitted this incident report had I known it would result in a peer review investigation” and “I'm glad to be retiring soon I won't have to deal with peer review anymore.” Some HCPs refused to communicate with peer review committee members and referred the committee to lawyers. Ultimately, the committee believed that its AER processes, although necessary for quality assurance, may be detracting from the organization's quality improvement goals and unintentionally contributing to an emotionally negative culture among HCPs.
Given the negative sentiment surrounding the peer review process, the medical group's peer review committee investigated ABQI as a complementary quality improvement approach to AER. The hope was that ABQI would surface impactful quality improvement topics, and by highlighting stories of excellence it would counteract HCPs’ negative sentiments toward the medical group's quality initiatives and promote a positive culture.
The ABQI pilot project was sponsored by organizational executive leadership and supported by medical group physician leadership, with the intent to expand throughout the organization pending results of the pilot. The ABQI planning group included physicians from the peer review committee, medical group physician leaders, quality improvement nurses, patient safety nurses and staff, and information technology staff who support the peer review process. The ABQI group was called the Appreciative Inquiry Team (AIT) because their mentality was inspired by the appreciative inquiry technique.
Tool Creation, Iterative Improvement, and Integration into Reporting Platform
The AIT initiated planning in late 2019 (Figure 1). Their objective was to create a tool into which frontline HCPs input stories describing consistent clinical excellence involving themselves and/or colleagues. The AIT would then use the tool to analyze these stories with just as much rigor as the peer review committee analyzes adverse events. These analyses included direct communication with the reported HCPs, as these conversations would add personal context to the stories and provide immediate positive feedback to the frontline HCPs. Elicited best practices and operational efficiencies would then be shared organizationwide.
Our institution uses Converge Platform (RLDatix, Chicago) for its AER tracking and management. Thus, the AIT engaged with RLDatix to adapt Converge Platform for its ABQI project. The AIT first drafted a series of questions that HCPs would answer when inputting stories of excellence—the front-end component of the ABQI tool. To facilitate frontline HCP participation, the planning group prioritized ease of use. Therefore, the HCP questionnaire consisted of mostly one-click answers and minimal open-ended questions that required typing answers. Drafts of this questionnaire were streamlined through iterative feedback with peer review committee physicians and medical group physician leaders. For the analysis portion of the ABQI process, the AIT drafted a questionnaire for AIT team members to complete after their review of the submitted stories and direct conversations with the reported frontline HCPs—the back-end component of the ABQI tool. The aim was to create open-ended questions that catalyzed AIT team member reflection and team discussions. These back-end component questions were inspired by just culture methodology,
which is currently employed by the medical group's peer review committee. Drafts of these analysis questions were iteratively edited using feedback from peer review committee physicians and medical group physician leaders. When finalized, RLDatix incorporated the front-end and back-end component questionnaires into an AIT program within Converge Platform, thereby creating our ABQI tool. To ensure functionality, the AIT extensively tested the tool by inputting fictitious stories and simulating analyses.
Implementation: Target Sites, Team Recruitment and Training, Organizational Communication
After the tool was operational, the AIT planned for launch in January 2021. The ABQI tool would be accessible on the organizational intranet for use by frontline HCPs and staff. Importantly, because this project originated from the medical group's ambulatory peer review committee, the AIT planned to pilot the ABQI tool systemwide within all outpatient health centers.
To perform the ABQI story analyses, the AIT recruited a multidisciplinary team of nine medical group–employed primary care and specialist HCPs as well as six nurses. Team membership was voluntary, and to facilitate project implementation, all initial team members intentionally had current or previous roles in quality and safety improvement teams. Eight AIT members were concurrent members of the peer review committee. Over two orientation sessions, the AIT clinical team members were taught the reasoning behind ABQI and trained in the use of the ABQI tool prior to pilot launch.
Finally, the AIT engaged with the medical group's internal communications team to create electronic informational flyers for distribution at project launch, targeting frontline HCPs, managers, and medical group leaders. These flyers described the intent of the ABQI project and included tip sheets covering the ABQI tool's use. These communications specifically emphasized that the AIT was requesting stories with replicable effective processes or positive outcomes, rather than simple accolades. The team planned to widely circulate these internal communications at one month and one week prior to project launch and on the day of launch. The AIT also planned to include informational flyer hyperlinks with all subsequent organizational communications, including messages sharing best practices and quality improvement ideas.
Evaluation for Project Success
To determine ABQI tool pilot project success, predefined criteria were created. As this was a nascent project for our institution, the ABQI team set achievable but meaningful targets for the first year of launch: (1) generate at least two quality improvement initiatives worthy of systemwide propagation, (2) disseminate at least three stories of clinical excellence to inspire HCPs to improve their practices, and (3) receive at least 20% of the clinical excellence stories directly from frontline HCPs. These data would be collected from Converge Platform and reviewed at the planned monthly AIT meetings.
Tool Description and How-To
Frontline HCPs and staff access the ABQI tool through an organizational intranet hyperlink. This hyperlink brings users directly to the front-end component of the ABQI tool (Figure 2). The tool first collects the user's basic identifying information. Next, the tool asks the user to select whether the excellence occurred at one location or multiple locations, as some HCPs practice across multiple outpatient health centers. Because stories of excellence may involve an individual or a team of people, the tool allows the user to input the relevant individual's or team's name. The tool then requests descriptive data points: the clinical role of the individual or team being described, as well as categories of excellence. The AIT intends to collate these descriptive data points for quality improvement feedback to organizational leadership and future direction planning. After these descriptive data points, the front-end component of the ABQI tool poses its one open-ended question: The user is asked to detail the story of excellence. Finally, to encourage frontline HCP engagement with quality initiatives, the tool inquires if the user wishes to be involved with any quality improvement projects triggered by their story. If the user selects “yes,” an e-mail address is requested for follow-up communication.
The next step in the ABQI tool is story analysis. After frontline HCPs and staff submit ABQI stories, AIT leads preview the stories to ensure that they are appropriate for further review. For example, when submissions consist of simple accolades for colleagues without reference to replicable processes or outcomes, AIT leads stop the process. For stories deemed worthy of in-depth review, the AIT leads refer the submissions to AIT members for evaluation. The AIT members then examine the stories and contact the reported HCPs to add context to the submitted stories. When AIT members have sufficient understanding of the clinical excellence story, they access the back-end component of the ABQI tool (Figure 3).
The back-end component of the ABQI tool first asks the reviewer to consider what usually happens in this clinical scenario. Presumably, the usual clinical process is suboptimal relative to the story of excellence being described. Next, to inspire potential quality improvement project ideas, the reviewer is asked to imagine an ideal state with limitless resources to address this clinical scenario. The expectation is that this thought process will highlight performance gaps between the current state and the ideal state. The ABQI tool then asks the AIT reviewer to consider whether the submitted story is a best practice. If so, the reviewer should explicitly detail the clinical best practice. Finally, based on all the above considerations, the ABQI tool probes whether the reviewer believes further resource allocation is warranted to initiate quality improvement projects and/or propagate elucidated best practices.
Following AIT members’ analyses, all stories are discussed at monthly AIT meetings. AIT members share their preliminary thoughts and follow-up suggestions with the multidisciplinary AIT. Because all AIT members had experience with quality improvement projects, most were previously trained to use the medical literature to support follow-up suggestions. The multidisciplinary meetings also routinely emphasize evidence-based best practices for propagation. The reported HCPs are always invited to optionally join the AIT meetings. At the conclusion of each story's review, the AIT completes the final section of the ABQI tool's back-end component: an action item summary for follow-up.
The following clinical vignette illustrates the ABQI tool in action. Using the ABQI tool's front-end component, a frontline HCP described a colleague, “Dr. Smith” (not the HCP's real name), who consistently achieved exceptional hypertension control for her patients. Our institution closely tracks hypertension control not only for its clinical importance but as a quality metric, as it affects financials for our Accountable Care Organization. The submitting HCP felt that Dr. Smith achieved these successful outcomes due to strong leadership and effective teamwork.
The AIT believed this story worthy of review to determine the root cause of Dr. Smith's successful outcomes. First, an AIT member accessed the ABQI tool's front-end component to review the submitted story. The AIT member then interviewed Dr. Smith to determine her routine workflow when encountering hypertensive patients. After the interview, the AIT member accessed the back-end component of the ABQI tool. Within the tool's back-end component, the AIT member described the usual clinical action as follows: “Medical assistant measures the patient's blood pressure soon after registration, using an automated sphygmomanometer. If hypertensive, the medical assistant may recheck blood pressure at the end of the appointment. The physician then prescribes a treatment plan. All of these findings and recommendations are ‘usually’ documented in the patient's chart on a laptop in the exam room with the patient.” Regarding what should happen in an ideal state, the AIT member was inspired by many of Dr. Smith's actions: routine blood pressure rechecks with manual cuffs rather than automated cuffs, rechecking with medical assistants two weeks after the initial appointment to determine treatment effectiveness, and building patient rapport by leaving laptops out of the exam room and maintaining constant eye contact. Dr. Smith intentionally completes all patient charting outside of exam rooms immediately following patient appointments. The AIT member further proposed that these procedures were best practices that should be widely propagated throughout the medical group.
The multidisciplinary AIT subsequently discussed this story and invited Dr. Smith to further elaborate on her workflow. Potential root causes of excellence were dissected (Figure 4). Based on these brainstorming sessions, the AIT highlighted the following key best practices: (1) using a manual sphygmomanometer to confirm readings from an automated sphygmomanometer; (2) employing visual cues to alert attending HCPs of patients with high blood pressure readings that required action planning; (3) eliminating laptops in exam rooms to foster rapport and treatment compliance with patients; and (4) multiple blood pressure rechecks to gauge treatment effectiveness, including medical assistant appointments between visits, which require no additional copayments. Through internal electronic communications and medical group leadership updates, the AIT shared these best practices and inspired other outpatient health centers to launch quality improvement projects emulating these practices.
Results and Lessons
As a pilot project in its first year of use, from January through December 2021, the AIT received 26 ABQI stories. Of these 26 stories, 3 were worth sharing for potential systemwide quality improvement initiatives, and 5 were stories of clinical excellence that the AIT disseminated to inspire practice improvement among other HCPs. Therefore, a total of 8 stories (30.8%) resulted in replicable best practices or actionable quality improvement projects that were shared organizationwide. Examples of projects and practices collected by the AIT include workflows to decrease pediatric vaccine waste, electronic medical record templates that increase HCP efficiency and serve as clinical history-taking checklists for complex diseases, and open-ended questioning techniques to promote efficient and effective patient interactions. In addition, 13 (50.0%) stories were submitted by frontline HCPs, with the remainder submitted by administrators describing frontline HCPs at their specific health center locations. Ultimately, at the end of its first pilot year, the AIT project achieved its baseline target goals.
One of the lessons that we learned is that frontline HCPs require constant reminders of quality improvement tools’ availability and benefits. Most story submissions immediately followed organizationwide communications from the AIT. For example, following the initial launch communications, multiple stories were submitted. Story submissions subsequently slowed over the next month, until the first round of best practices was shared organizationwide. Then the AIT received another batch of stories. Close collaborations with the internal communications team proved critical to keep this project's availability and quality improvement goals at the top of mind for organizational HCPs and employees. To this end, the AIT now includes communications team members in the monthly AIT meetings, thus continuously generating dialogues regarding effective communications strategies and releasing monthly medical group updates.
Another pitfall is frontline HCPs’ limited time for nonclinical data entry. Cognizant of this time limitation, we attempted to streamline the front-end component of the ABQI tool with few questions, most of which required quick single-click responses. However, we ultimately could not avoid open-ended text for the story description. As a result, we encountered several overly brief story descriptions that made it difficult to discern if the stories were worthwhile for AIT review. In these scenarios, AIT leads remained open-minded and carefully considered whether best practices could be surfaced, despite the curt descriptions. For example, one story described how patient flows “don't run as smooth when [“HCP X”] is gone!” At first glance, this story may be dismissed as a simple accolade. However, the AIT opted to contact the HCP to thoroughly investigate the processes and workflow efficiencies underlying this accolade. The AIT leads now routinely pause and give all submitted stories a second thought before dismissing them from review. Also, in all frontline communications, the AIT now reemphasizes its process- and outcome-improvement goals with the ABQI tool, and these communications include multiple sample scenarios to promote HCP understanding.
Finally, a future challenge may be unintended consequences of propagated workflow practices. For example, in the previously described clinical vignette, some HCPs may find that their efficiency or note-taking accuracy are hindered if their laptops are not used in exam rooms. To counter such consequences, in all communications, the AIT encourages feedback from HCPs to stimulate dialogues and iterative improvements. In addition, the AIT emphasizes that shared best practices are not meant to be prescriptive, as each health center likely has nuanced workflows. Instead, HCPs are encouraged to consider these best practices and adapt them into practice workflows however appropriate.
Summary and Next Steps
Our ABQI tool represents an attempt to purposefully incorporate asset-based methods into organizationwide quality and safety improvement operations. To be clear, our goal was not to replace DBQI methods, such as peer review and incident reporting. Rather, ABQI complements DBQI by providing an additional route to identify best practices and quality improvement initiatives worthy of resource allocation for further dissemination. Our ABQI tool proved logistically and technologically feasible for organizationwide utilization. Although the results are preliminary, this tool successfully exposed value-added best practices and quality improvements that were circulated throughout the medical group. Over the long term, the impact of our ABQI tool on quality improvement will be determined through outcomes measures. As part of an Accountable Care Organization, our institution tracks key quality metrics, such as hypertension management, cancer screening adherence, and tobacco cessation intervention. When the AIT propagates systemwide quality improvements that affect tracked metrics, they will annually review outcomes with the institution's quality team to determine if relevant tracked metrics were measurably and sustainably improved.
In addition to clinical quality benefits, we also sought to determine if the ABQI tool fostered frontline HCP engagement. Half of our clinical excellence stories were submitted by frontline HCPs using the ABQI tool. This is a promising outcome and suggests that ABQI may provide a viable pathway to increase frontline HCP engagement. However, as mentioned previously, one of our key lessons was that we needed to keep this tool at the top of HCPs’ minds as a quality improvement resource, otherwise referrals dwindled. Previous studies suggest that frontline HCPs disengage from quality improvement efforts when they do not receive regular feedback from the investigating team.
Therefore, with continued use and sustained organizational communication team partnership, we are hopeful that ABQI will become permanently incorporated into our organization's culture. We have also begun including the ABQI tool in new employee orientation sessions so that all incoming HCPs immediately associate the asset-based mindset with our organization. The long-term impact of our ABQI tool on frontline HCP engagement will be measured through our institution's annual employee engagement survey. Aggregated frontline HCP data for the following three questions will be collated for yearly AIT review: (1) “I know my contributions are valued at Banner Health”; (2) “How often are providers in this office open to staff ideas about how to improve office processes?”; and (3) “Staff are encouraged to express alternative viewpoints in this office.”
For other institutions planning to launch the ABQI tool, we suggest adapting the institution's existing AER software. In our experience, the software vendor readily programmed Converge Platform to track stories of excellence, as this workflow was similar to their current adverse event tracking functions. Adding the ABQI tool's front-end and back-end components’ questions also proved uncomplicated for the vendor. Therefore, other institutions may similarly reformat our ABQI tool questionnaire into a configuration that is native to their existing software. Due to our institutional contract with the vendor, there were no software startup costs nor additional operating expenses for our ABQI tool, but other institutions should consider such costs before implementation. Staffing costs should also be considered for institutions that compensate team members for quality improvement–related committee work.
In the future, we plan to expand the ABQI tool into our organization's acute care facilities, urgent care centers, and other health care delivery entities. Furthermore, instead of relying solely on stories reported by frontline staff, the AIT is planning to explore clinical quality metrics (for example, hemoglobin A1C control, mammography screening) and patient experience feedback surveys to identify high-performing HCPs. The AIT will then work with these high-performing HCPs to proliferate the root causes of their success. With expanded ABQI tool utilization, future studies may include cost-effective analyses of our ABQI tool, quantitative and qualitative feedback from frontline HCPs and downstream AIT communication recipients, and detailed clinical and organizational culture outcomes analyses. By sharing this ABQI tool, we are confident that other institutions can adopt this asset-based mentality and transform quality improvement efforts throughout health care. Ultimately, if these ABQI tools prove universally successful, regulatory agencies and insurers may eventually openly recognize their value, and health care organizations may then place just as much emphasis on these asset-based initiatives as they currently do with deficit-based quality assurance.
Conflicts of Interest
All authors report no conflicts of interest.
In pursuit of quality and safety: an 8-year study of clinical peer review best practices in US hospitals.