Factors Associated with Successful Implementation of Quality Improvement Efforts: The IHI 100,000 Lives Campaign

Background: Little is known about hospital organizational and cultural factors associated with successful implementation of quality initiatives such as the Institute for Healthcare Improvement’s (IHI) 100,000 Lives Campaign (Campaign). 

Objective: To develop a framework for understanding factors associated with successful implementation of quality improvement (QI) programs. 

Methods: A “Trilogic Evaluation Model” was developed using mixed qualitative and quantitative methods applied across three strata of hospital staff (executive leadership, midlevel, and frontline) at six sample hospitals selected from among 68 acute-care Georgia hospitals that joined the IHI Campaign before June 2006.  Sample hospitals were stratified by teaching status, bed size, urban/rural setting, and a composite performance and QI measure derived from the CMS Annual Payment Update, AHRQ Patient Safety Indicators and Inpatient Quality Indicators, and Hospital Standardized Mortality Ratios. Focus groups and surveys were conducted and data were thematically coded and analyzed according to hospitals grouped by an observed “high” vs. “low” perception of quality score.

Results: Quantitative surveys were completed by 135 hospital personnel (midlevel 43.7%, frontline 38.5%, and executive 17.8%) who also participated in 20 qualitative focus groups in 2008.  Overall, 93% of participants were aware of the IHI Campaign in their hospital and perceived that 58% (SD=22.7) of improvements in quality at their hospital were a direct result of the Campaign.  Participants at higher performing hospitals (Mean=4.4 [5-point Likert scale]) were significantly more likely than low performing hospitals (Mean=4.0) to agree that the IHI Campaign was useful to their hospital (p < 0.001).  Participants at high performing hospitals had significantly better hospital leadership support than lower performing hospitals (Mean=8.40 vs. Mean=7.71 [factor score of two 5-point Likert items], p=0.023) and were significantly more likely than lower performing hospital participants to agree that executive/senior leadership was motivated to implement the IHI Campaign (Mean=4.42 vs. Mean=4.06 [5-point Likert scale], p =.005).   Both high and low performing hospitals defined “success” as patient satisfaction and employee satisfaction; lower performing hospitals also tended to define success as financial growth and stability and higher performing hospitals as “meeting the measures that matter” (e.g., scorecards).  

Conclusions: The “Trilogic Evaluation Model” was able to demonstrate several convergent themes that demarcated a small sample of hospitals based upon high vs. low performance in QI and the IHI Campaign.  Further research using this framework should be conducted in a larger sample of healthcare facilities to identify the key organizational and cultural factors necessary for successful implementation of new quality initiatives.