Towards evidence-based quality improvement: The theory/practice balancing act

Objectives: We discuss how theoretical approaches to evidence-based quality improvement are used and interpreted across implementation projects in health care settings. We draw lessons about the mechanisms affecting theory-guided translation of evidence into improvement practice.


Methods: Practitioners and researchers in improvement are encouraged to use more theory when implementing projects to prevent wasted effort and maximise the benefits of evidence-based practice. However, it can be difficult to balance theoretical input with the need to remain responsive to local context without engendering unnecessary variation in project delivery. We describe our experience in executing theory-guided quality improvement projects within the Collaboration for Leadership in Applied Health Research and Care for Greater Manchester (GM CLAHRC), a large scale initiative focused on developing and implementing research around the management of four cardiovascular conditions (stroke, chronic kidney disease, diabetes and heart failure). The GM CLAHRC implementation activities were underpinned by the following theoretical ‘building blocks’: (1) a conceptual framework for research implementation (the Promoting Action on Research Implementation in Health Services [PARIHS] framework), (2) an operational framework for service improvement (the Model for Improvement), (3) use of multi-professional teams with designated knowledge transfer roles to support implementation and (4) embedded evaluation and learning. We draw on four internal project-specific mid-term evaluations and a qualitative case study of knowledge-sharing across the GM CLAHRC which collected data through 69 hours of direct observation, 45 semi-structured interviews and documentary analysis.


Results: We find that the use of theoretical models to guide quality improvement work is affected by three mechanisms acting at the level of practice: a) Use of rhetoric, whereby theoretical building blocks are only mentioned in project reports without actually being used in practice (e.g. citation of the Model for Improvement); b) Shifts of meaning, whereby the interpretation of building blocks or their elements over time moves away from the original concept (e.g. staff employed to carry out knowledge transfer acting as project managers); c) Privileging of certain aspects of work, whereby theoretical 'building blocks' or their elements (e.g. capacity building as part of ‘embedded evaluation and learning’) receive less emphasis than practical, short-term, tangible, measurable aspects of quality improvement practice (such as numbers of practices enrolled). Factors contributing to all three mechanisms included the extent of shared understanding of the theoretical notions among stakeholders, strategic commitment to theory-informed approaches by leaders, and reinforcement of these approaches through learning opportunities.


Conclusions: Applying a theory-informed approach requires attention to the design, delivery and ongoing evaluation of improvement projects. Theoretical models are, perhaps inevitably, unable to capture the complexity of social interactions in which improvement projects are embedded, or to address practical and operational concerns. There is a delicate balance to be achieved between making use of available theory and evidence to ensure that the most scientifically sound approaches to improvement are adopted, at the same time as recognising and supporting the need for local flexibility and tailoring. We suggest that theoretical models are more likely to influence across the lifespan of an improvement project where there is:


• understanding, agreement and commitment amongst key stakeholders about the nature, scope, value and key features of underlying theory;


• design and management of improvement projects with reference to theory;


• continuous reinforcement of the use of theory by establishing learning, development and knowledge sharing opportunities;


• strategic vision and sufficient resource investment to introduce and affirm the selected approach and adapt it to project-specific contextual factors.