Correspondence to Dr Petar Popivanov; [email protected]
WHAT IS ALREADY KNOWN ON THIS TOPIC
Healthcare organisations around the world have variably adopted quality improvement (QI) methods in efforts to enhance care quality. The spread of improvement principles among front-line healthcare workers remains poor, with low methodological rigor, and limited guideline adherence and documentation.
WHAT THIS STUDY ADDS
This study provides a quality improvement coaching roadmap for small and intermediate initiatives. In doing so, it seeks to equip professionals with tools to transform the complex system of healthcare by leading and delivering change and spreading innovation. Due to its peer-to-peer nature, which prioritises power and agency in a shared relationship between coach and coachee to shape the coachee QI outcomes, this protocol can be adopted and adapted to different teams, units and point-of-care sites.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Built on established education, peer coaching and QI concepts, this evidence-based peer quality improvement coaching protocol contributes to the international evidence on how to support front-line healthcare workers in their improvement efforts.
Introduction
Background
Improving the quality of patient care remains a global necessity.1 Healthcare organisations around the world have variably adopted quality improvement (QI) methods in efforts to enhance care quality.2 The growing use of such methods can be attributed to their suitability for resource-constrained environments, such as healthcare.3 4 In this context, the involvement of front-line healthcare workers in QI is crucial and bears numerous advantages, such as leading and delivering change, optimising individual patient care, transforming the complex system of healthcare, spreading innovation and reducing cost.5–7
Problem description (existing knowledge gap)
Despite system and professional benefits, current evidence indicates that the spread of improvement principles among front-line healthcare workers remains poor.8–11 The understanding and application of QI methodologies are generally limited to experts and enthusiastic early adopters, leading to a sense of detachment and isolation from their peers.12 13 When QI models and tools are used in individual QI projects (QIPs), methodological rigour is often low and with limited documentation.11 14 Low level of adherence to guidelines and documentation of learning presents challenges to the legitimacy of QI initiatives.14
Several barriers to wider utilisation of QI concepts have been consistently emphasised in the literature. From a system perspective, Vaughn et al identified that poor organisational culture, inadequate structure for quality, system shocks and dysfunctional external relationships have an effect on staff motivation to engage in QI.15 Staff knowledge, skills, resources and beliefs about QI further impact their individual involvement in improvement initiatives.16 17
Various strategies, such as developing legislation, financial incentives, information dissemination, practice facilitation, among others, have been employed to address the quality and safety gap in healthcare at different levels.18 19 Despite global, national and regional guidelines and programmes aimed at spreading QI approaches, the process of enhancing the knowledge and skills of front-line staff still remains a significant challenge.20 21 In this context, The Health Foundation advocates for ongoing initiatives to equip front-line staff—those closest to the problem of poor quality—with ‘ the time, permission, skills and resources’22 they need, to effectively resolve these issues.
Need for this project
Coaching alongside education forms a multifaceted practice facilitation approach, which could be applied to assist staff in conducting QI work.23 There is evidence that while education and training alone are unlikely to result in consistent improvement practice, coaching can play a critical role in sustainable, evidence-based implementation.24 Coaching is described as an individualised ‘learning and development intervention that uses a collaborative, reflective, goal-focused relationship to achieve professional outcomes that are valued by the coachee’.25 The utility of coaching for the purposes of healthcare QI has been described in different settings. In primary care, QI coaching (QIC) has facilitated infection prevention and vaccination coverage,26–28 enhanced control of acute and chronic conditions,29 30 and optimised medication prescription.31 The feasibility of QI in secondary care settings has similarly been demonstrated in neonatal and adult intensive care units,32–34 paediatrics35 and obstetrics36 among others. However, such reports often focus on local context and specific coaching interventions, reducing the generalisability of their findings. There is a need for a scientifically robust yet pragmatic QIC protocol, which can equip healthcare providers across different point-of-care sites to actively contribute to QI.
Objective
The objective of the study was to develop and pilot an evidence-based protocol for implementation and evaluation of an on-site peer QIC (PQIC) for front-line staff engaged in small to intermediate improvement initiatives. For the purpose of the study, we defined a QI coach as a front-line worker or manager, with previous training and/or experience in applying QI methodologies, who is willing and/or responsible to support other colleagues in their improvement work. Likewise, a QI coachee was defined as a point of care staff member, who intends to undertake improvement work but lacks previous training and/or experience in improvement science. Healthcare managers, clinical consultants and leads are contractually obliged within their work-practice plans to provide support to personnel in this capacity. Our aim was to equip these leaders with a readily available, literature-based, PQIC roadmap for local initiatives of small to intermediate scale. Furthermore, small to intermediate improvement projects were considered in the context of micro (ie, individual clinical team) and meso (ie, multidisciplinary teams (MDTs) within an organisation) levels of the healthcare system, respectively.37
Peer coaching is a distinct form of coaching within the organisation where the didactic relationship is either lateral, that is, between two individuals of equal status, or vertical, that is, between direct reports or supervisors.38 39 The focus is on placing the power and agency in the shared relationship between coach and coachee rather than in the coach to shape the coachees outcomes.38 While employing external improvement specialists can assist the QI work of an organisation, this practice is typically sporadic and requires additional resources and time. Our coaching protocol has the potential to enhance the internal QI capacity and capability of any healthcare organisation, thereby enabling them to self-direct and more effectively leverage external expertise when required.
Methods
The protocol underwent a multistage case-study design and implementation process. First, a systematised literature review was performed in January 2023 to identify what is known about the theory and practice of QIC, describe the emerging themes and highlight any potential gaps in knowledge.40 Second, identified themes guided the development of a PQIC protocol. Finally, the protocol was piloted and evaluated among staff in a single-centre tertiary maternity hospital. PQIC effectiveness was assessed using the evaluation tools identified in the literature.
Literature search strategy, data extraction and analysis
Relevant publications in English were identified in the following databases: Medline (PubMed), Embase, CINAHL, Emerald, Health Business Elite and Business Source Premier. To define the appropriate keyword combination, a research question was formulated using the PICO tool: To assess the role and effect(s) of QIC (I) in enhancing the quality of the improvement initiatives (O) carried out by MDTs (P) (see online supplemental appendix 1).41
The keyword combination included the following terms: “coaching” AND “healthcare” AND “quality improvement”. The predefined Index terms (Mesh/Emtree/subject heading) for “quality improvement” and “healthcare” were used in databases operating with index terms. Coaching had no index term; hence it was used in the descriptor as a keyword.
The search was limited to peer-reviewed articles and books, published in English between 2000 and 2022, which met one or more of the following criteria: focus on QIC strategies and/or models grounded in improvement science whether stand-alone or in combination with other education or facilitation activities; demonstrate the effectiveness of QIC; and discuss moderating factors for QIC. Publications outside the selected time period, not in English, opinion articles, letters to editor, newspaper and magazine items were excluded.
Protocol design and piloting
The objective of the protocol design was to provide a roadmap for PQIC, guided by empirical evidence. The themes that emerged in the literature review led to the development of a three-step QIC protocol (see results). Each step had a specific aim, interventions, outcomes and measures. The sequential nature of the tool is based on the evidence that combining QI education (step 1) with coaching (step 2) can lead to higher chances of completing teams’ improvement work (step 3).42–44 The feasibility of this protocol was assessed by piloting each step in a single-centre tertiary maternity hospital. PQIC effectiveness was assessed based on evaluation tools identified in the literature.45–47 A self-reported survey, coachees’ storyboards, coach’s logs, fieldnotes, team debriefs and QIP reports were also used as data sources.42 48
Results
Results for the literature search, protocol design, piloting and evaluation are detailed here. From the literature search, 301 relevant articles were identified. Online supplemental file 5 provides the detailed return list for each database. A further 33 publications were obtained through snowballing, grey literature review (Google Scholar) and guidelines issued by national and international regulatory bodies.49 Search results were entered into Endnote, where duplicates were removed.50 Articles were then screened against the selection criteria, first based on title and abstract, followed by full texts, resulting in the inclusion of 32 articles (figure 1). Data were extracted and appraised in Excel (online supplemental file 6) according to population, intervention, comparison and outcome.51 The literature originated primarily from North America (n=26) and Europe (n=4), with some African (n=2) countries. Only six articles addressed the area of interest in hospital settings. The remaining 26 studies focused on primary care.
Enlarge this image.Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram (PRISMA) flow diagram.
Themes identified in the literature review
Four prevalent themes on QIC were identified in the retrieved articles to inform the development of the protocol: effectiveness; strategies and models; moderating factors and methods for evaluation. Online supplemental file 7 provides details about data curation and the articles informing each of the four themes.
Effectiveness of QIC
QIC impacts healthcare outcomes at clinical (patient care) and non-clinical (process or structure) levels.52 53 Despite a trend towards increased number of publications on the topic between 2005 and 2013, the number of studies reporting relevant patient care outcomes reduced.54 More recent studies tend not to iteratively emphasise clinical outcomes but report them as part of QIP completion and guideline implementation.54 In relation to patient care, evidence suggests that (1) QIC enhances patient outcomes when compared with no coaching or other forms of facilitation (audit, feedback and QI training alone);18 55 56 (2) a larger effect size is associated with higher intensity coaching, tailored towards local needs and a smaller number of coaching sites per facilitator;18 (3) curricula inclusive of QIC are more likely to result in project completion with improved direct patient care and higher sustainability than non-coached teams and42 43 47 57–59 (4) full completion of a training and coaching programme may be an important factor for enhanced clinical effectiveness.60
Regarding non-clinical outcomes, the literature tells us that coaching: (1) improves organisational processes (ie, appropriate documentation, medication prescription, ordering labs and vital signs, and appropriate counselling;44 (2) enhances cost-effectiveness (ie, reduced waiting time, work hours saved or potentially increased revenues)55 61–63 and (3) develops organisation-wide improvement language, culture, codesign and staff self-efficacy.17 47 64
QIC strategies and models
The model for improvement (MFI) was used in five studies.47 65–69 Lean Six Sigma featured in one.70 The remaining publications did not explicitly specify the utilised models. Strategies identified in the studies as achieving stronger effects included having employees of the organisation act as coaches;25 47 67 having the coach tailor facilitation to the needs of the local improvement team;18 71 72 and combining both educational lectures and practice coaching in a face-to-face or online format, for different periods of time.63 66 73 While having employees act as coaches was an effective strategy, so too were externally sourced coaches: the core strategy seems to be about tailoring to local context.63 71 73
QIC moderating factors
Factors diminishing the effectiveness of QIC include limited time, competing interests, reduced resources, lack of knowledge about QI methodology and any confusion related to solving a work-related problem.23 64 70 74 On the other hand, positive moderation can occur through prioritising experiential learning, team empowerment to reduce overreliance on the coach for task management and greater leadership involvement.23 62–64 The latter has been associated with employee involvement, reduced staff turnover and incentivising QI work.48 57 60 64 73 74
Evaluation of QIC
Three primary evaluation tools were identified: one each for coachees, coaches and organisations. The ‘IHI Assessment Scale for Collaboratives’, originally developed at the Institute for Healthcare Improvement (IHI) to assess teams’ participating in IHI Breakthrough Series Collaboratives, has been adapted and applied to various improvement initiatives (online supplemental appendix 2).45 The tool allows the improvement coach to evaluate how well the team is progressing in their project on a scale of 1–5.75 This tool is sequential: all elements need to be satisfied before considering the next level, and the score can be maintained and improved but not reduced.
The ‘IHI Improvement Advisor Self-assessment Tool’ provides opportunity for coachee’s QI proficiency self-evaluation at the end of the coaching course (online supplemental appendix 3). This tool was originally developed by the Associates in Process Improvement/Institute for Healthcare Improvement to appraise the learning progress of improvement advisors and has since been adapted and applied in assessing teams’ QI knowledge and skills.46 76 Each coached team member self-identifies their initial and final knowledge about the individual QI tools taught throughout the meetings on a 1–100 scale for information (1–20), skill (21–40), knowledge (41–60), understanding (61–80) or wisdom (81–100).
Finally, the ‘IHI Improvement Capability Self-Assessment Tool’ was designed to assist healthcare organisations in assessing their improvement capability (online supplemental appendix 4).77 The six areas are leadership for improvement, results, resources, workforce and human resources, data infrastructure and management, and improvement knowledge and competence. Coaching interventions target the last area by expanding organisational capacity for improvement knowledge and competence. Each of the six areas is assessed across five levels of capacity—beginning, developing, making progress, significant impact and exemplary.77
Protocol design
Identified themes on QIC provided the basis for the PQIC protocol. First, based on the reported positive outcomes of peer coaching, the protocol was designed to be peer led and multidisciplinary from the outset.23 62 63 Second, the evidence for combining education and coaching led to the development of a ‘QI in a nutshell’ lecture prior to commencing the MDT coaching journey.42 43 46 71 Third, the protocol was kept broad enough to accommodate different contexts and change ideas, despite being robust and evidence based.45 59 Fourthly, it transitioned from providing general knowledge (lecture—step 1), through building individual and team QI skills (coaching—step 2), to finally examine organisational QI competence and governance (step 3).45 47
Furthermore, two well-established educational models facilitated the protocol’s design. Bloom’s taxonomy assisted the outline of the educational objectives and Kirkpatrick’s model provided a framework for evaluating the outcomes from these objectives.78–80 The final PQIC protocol was organised in three steps. Each step incorporated two sequential educational objectives based on Bloom’s taxonomy (table 1).
Table 1Peer quality improvement coaching protocol (steps, desired outcomes and measures)
| Step 1: increased QI awareness through education. Aims to encourage and streamline staff involvement in QI work | |
| Interventions: |
|
| Outcomes: Bloom’s level 1 (remember) and level 2 (understand) | Following the delivery of the above interventions, attendees will be able to:
|
| Measures: |
|
| Step 2: Improved MDTs’ understanding and application of QI methods through coaching | |
| Interventions: |
|
| Outcomes: Bloom’s level 3 (apply) and level 4 (analyse). | All MDTs who avail of the QI coaching will be able to
|
| Measures: |
|
| Step 3: Successful QIP completion by the coached teams | |
| Interventions: |
|
| Outcomes: Bloom’s level 5 (evaluate) and level 6 (create) |
|
| Measures: |
|
IHI, Institute for Healthcare Improvement; MDT, multidisciplinary team; MFI, Model for Improvement; QI, quality improvement; QIP, QI project.
To evaluate the PQIC protocol, the extended Barr-Kirkpatrick model was used, as it lends itself well when applied to interprofessional learning occurring in MDT coaching.80 The first level ‘reaction’ examines participants’ feelings and thoughts about the educational intervention. The second level ‘learning’ is expressed as an increase in knowledge or capacity. The third level ‘behaviour’ addresses the extent to which the improvement and implementation have changed behavioural capacity of the individual learner. The fourth and final level deals with the wider impact of the intervention—the effect of trainees’ performance on the organisation or environment. Table 2 outlines the extended four levels of the Barr-Kirkpatrick evaluation model, how these levels apply to the proposed QIC protocol and the tools used to evaluate each step.81
Table 2QIC protocol evaluation based on Barr-Kirkpatrick hierarchy of educational outcomes (adapted from Barr et al80)
| Educational outcome | Assessment | Tool | Objective evaluated |
| 1.Reaction | Staff members who attend the ‘QIP in a nutshell’ talk would be asked to fill in a feedback survey | Paper feedback survey for lecture attendees (table 4) | Steps 1 and 2 (table 1) |
| 2a. Modification of attitudes/perceptions | |||
| 2b. Acquisition of knowledge/skills | For coached MDTs: Assessment of the team’s ability to identify an improvement need, write a SMART aim statement, identify appropriate measures, propose a change test (PDSA) etc | IHI improvement advisor self-assessment tool (online supplemental appendix 2) | |
| Behavioural change | For coached MDTs: Assessment of the team’s ability to advance and complete the QIP | IHI assessment scale for collaboratives (online supplemental appendix 3) | |
| 4a. Change in organisational practice | Comparison between the successfully completed coached and non-coached QIPs. | IHI improvement capability self-assessment tool for organisations. (online supplemental appendix 4) | Step 3 (table 1) |
| 4b. Benefits to patients and staff |
IHI, Institute for Healthcare Improvement; MDT, multidisciplinary team; PDSA, Plan-Do-Study-Act; QIC, quality improvement coaching; QIP, quality improvement project.
Table 4Survey results
| Strongly agree | Agree | Disagree | Strongly disagree | |
| Lecture evaluation | ||||
| 80% | 20% | |||
| 80% | 20% | |||
| 70% | 30% | |||
| 50% | 40% | 10% | ||
| Teaching evaluation | ||||
| 100% | ||||
| 100% | ||||
| 90% | 10% | |||
| Student’s reflection | ||||
| 80% | 20% | |||
| 50% | 50% | |||
| 80% | 20% | |||
QI, quality improvement; QIPs, QI projects.
Table 3'IHI improvement advisor self-assessment tool completed by MDT1 and MDT2 leaders
| Specific method, tool, or skill | Information: know what tool is | Skill: can apply in identified situations | Knowledge: know how, when and where to use | Understanding experience: Can adapt, explain why | Wisdom: can teach theory and use of method | |
| Assessment Scale: (mark anywhere on scale) | 1-10-20 | 21-30-40 | 41-50-60 | 61-70-80 | 81-90-100 |
| Skill, method or tool | Complete assessment prior to QI coaching, MDT1 | Complete assessment after QI coaching, MDT1 | Points increase MDT1 | Complete assessment prior to QI coaching, MDT2 | Complete assessment after QI coaching, MDT2 | Points increase MDT2 |
| Understanding background | 20 | 50 | 30 | 10 | 50 | 40 |
| Stakeholder map | 10 | 50 | 40 | 5 | 55 | 50 |
| Flow diagram | 0 | 50 | 50 | 5 | 50 | 45 |
| Model for improvement | 0 | 45 | 45 | 0 | 45 | 45 |
| SMART aim statement | 10 | 50 | 40 | 10 | 55 | 45 |
| Measurement for improvement | 10 | 45 | 35 | 5 | 40 | 35 |
| Outcome measure | 10 | 50 | 40 | 15 | 45 | 30 |
| Process measures | 0 | 35 | 35 | 0 | 40 | 40 |
| Balance measures | 0 | 30 | 30 | 0 | 35 | 35 |
| Driver diagram | 0 | 40 | 40 | 0 | 40 | 40 |
| Developing changes | 10 | 45 | 35 | 5 | 40 | 35 |
| Testing changes | 10 | 40 | 30 | 0 | 40 | 40 |
| Implementing changes | 10 | 40 | 30 | 0 | 40 | 40 |
| Spread and scale up of changes | 0 | 15 | 15 | 0 | 10 | 10 |
| PDSA cycle | 0 | 35 | 35 | 5 | 45 | 40 |
| Run chart | 0 | 45 | 45 | 0 | 35 | 35 |
| Sustainability and spread | 0 | 10 | 10 | 0 | 10 | 10 |
| Gathering strategic information | 0 | 20 | 20 | 5 | 35 | 30 |
| Planning for improvement | 0 | 30 | 30 | 0 | 41 | 41 |
| Managing improvement | 0 | 20 | 20 | 0 | 35 | 35 |
IHI, Institute for Healthcare Improvement; MDT, multidisciplinary team; PDSA, Plan-Do-Study-Act.
Piloting the QIC protocol
The hospital Audit and Quality Improvement Advisory Group was informed about the availability of the protocol and via that group, staff members who were interested in availing from QIC were encouraged to approach the team. Step 1 began with piloting the ‘QIP in a nutshelI’ lecture. 12 doctors attended the lecture and completed a feedback survey with 83% response rate. The questions were designed to capture thoughts and emotions (levels 1 and 2 a Bar-Kirkpatrick model) of staff who attended the lecture in three areas. In the first section, attendees reported on their perceptions of lecture design, format, content relevance, usefulness, volume and complexity. 100% agreed or strongly agreed that the lecture’s objectives, structure and content were clear and relevant, with one noting the information as too complex. The second set of questions assessed the lecturer’s teaching abilities. 100% agreed or strongly agreed the presenter was knowledgeable and enthusiastic about QI and used clear examples. Attendees’ self-reflection formed the third section. 100% of the respondents agreed or strongly agreed that their knowledge and interest in QI increased as a result of the lecture, and that they were clearer on the steps required to undertake a QIP. The free-text section of the survey resembled many of the above results with additional suggestions to have a ‘quiz at the end to reinforce learning’, ‘increase the presentation time’ and ‘give random QIP topics and allow the group to apply the QI tools to each’. Based on this feedback, the presentation was further amended. While step 1 was still rolling out, two MDT leaders requested to be coached and so the second step of the protocol was piloted. MDT 1 focused on enhancing the early identification and management of urinary incontinence in pregnant women. This team was led by a physiotherapist and included collaboration with midwives, obstetricians, the physiotherapy manager, an administrator and antenatal patients. MDT 2 aimed to reduce wait times for gynaecological patients with non-complex pelvic floor dysfunction. This team was led by a physiotherapist and included an advanced nurse practitioner specialising in urogynaecology, urogynaecology consultants, an administrator and the chief clinical officer.
Step 2: During the second stage, leaders of the two MDTs had four scheduled meetings with the first author between February and May 2023. The first author held certified training and experience in both QI methods and coaching. Between the scheduled meetings, coachees had direct access to the coach via email for resolving any immediate questions. Over the course of 4 months, the two MDTs covered the outcomes of step 2 (table 1). Each team leader maintained a storyboard depicting the progress of their project. The coach noted content of each meeting with the team in a logbook. Both coach and coachees updated and shared their logbooks and storyboards after each meeting to further enhance learning and collaboration. Both teams received institutional approval for their projects and presented them at the hospital annual ‘Project Day’ following their successful completion.
Step 3: At the end of the coaching journey, each team leader completed the ‘IHI improvement advisor self-assessment tool’ so that they could self-identify their initial and final knowledge about different QI tools and IHI MFI (step 3, table 1). The coach completed the ‘IHI assessment scale for collaboratives’ during the two coaching journeys. Both teams accomplished 4.5 ‘sustainable improvement’, with changes embedded into clinical practice and continuing at the time of writing this manuscript. This concluded step 3 of the protocol for these two projects.
Discussion
This study set out to develop and pilot an evidence-based protocol for implementation and evaluation of an on-site PQIC for front-line staff engaged in small to intermediate improvement initiatives. The themes that emerged from the systematised literature review—on QI effectiveness, strategies and models, moderating factors, and evaluation—informed the design of our protocol. In piloting the protocol, all phases were implemented in a stepwise manner and evaluated satisfactory.
QIC is an evidence-based intervention, which can improve clinical and non-clinical outcomes in healthcare.44 59 67 This protocol used the IHI MFI for two reasons. First, it is widely employed in the published evidence concerning QIC. Second, it is the methodology in which the researchers were trained and had previous experience. However, this protocol is not limited to one selected QI methodology. It rather focuses on a stepwise implementation and evaluation of QIC, allowing the coaches and coachees to use their preferred methodology, based on previous training and experience. This is in keeping with the current evidence that the choice of a particular QI method is of less significance, as long as the chosen method is applied consistently for a prolonged period of time across an organisation.82 Application of the protocol allows for a delicate balance that can both promote fitness to the context and maintains its integrity.83 Local stakeholders can carefully consider adjusting the intervention to their specific context (adaptation) and maintain the core components that contribute to its effectiveness (fidelity).45 84 The rigour of this QI work has been demonstrated in the systematic approach to both design and evaluation.85 Therefore, we see the adaptability of our protocol as a strength, supporting the rigour of QI by facilitating fit to local context.
Furthermore, the proposed protocol aims to enhance the rigour of QI methods by focusing the theory and practice of QIC on key practical elements, such as helping teams to diagnose the problem, involve stakeholder, explore, possible options, test and implement change interventions and ensure sustainability.86 A strength of our protocol is that it is founded in the theory of setting up and evaluating educational outcomes while incorporating evidence-based multilevel assessment tools (for coachees, coaches and organisations).45 46 75 76 78–81 The two coached MDT leaders exhibited both subjective and objective learning and practical application of the material, as evidenced by the results. This may suggest that this protocol is applicable across different healthcare settings where front-line healthcare staff could benefit from PQIC. However, our sample size was too small to draw these conclusions.
While the primary goal of this QIC protocol is to support staff at the ‘coal face’, it could be argued that its foundation on the Barr-Kirkpatrick education outcome hierarchy could eventually lead to organisational benefits in terms of developing a culture, knowledge and skills for improvement. The first three levels of the Barr-Kirkpatrick model look at individual or team benefits, while the fourth and final level emphasises organisation–wide change.80 Once a significant number of the improvement work in the hospital has benefited from staff’s enhanced understanding of QI methods through coaching, the first author plans to engage with the hospital management in completing an ‘Improvement Capability Assessment Tool’.77 It should be noted, however, that the selected evaluation tools use data provided by a self-evaluation survey (step 1), and coach’s logbooks, coachees’ storyboards, fieldnotes, debriefings and QIP results (steps 2 and 3). Our study results, therefore, likely reflect to some extent the self-reporting bias in other QIC studies.44 47 59 66 87 Future work should focus on exploring other evaluation methods.
Our literature review demonstrates strong evidence supporting QIC.53 88 89 However, most studies focus on either external or internal QI coaches or do not specify the relational dynamics between coach and coachee. In contrast, PQIC provides a distinct ‘in-house’ approach to QIC by promoting collaborative relationships with shared power and agency, either laterally (among equal peers) or vertically (between supervisors and direct reports).23 38 39 Our protocol provides a roadmap for implementing PQIC, enabling QI experienced staff to guide their peers in small to intermediate QIPs directly at the point of care. Once a strong internal QI capacity is established, organisations can leverage external, professionally led programmes to further enhance the QI skills that staff have already developed, equipping them for larger, macrolevel initiatives.90
Future applications of this protocol can be considered in the context of the thorny fidelity—adaptation dilemma.83 91 Although some evidence indicates that high fidelity is associated with stronger results,92 93 other studies suggest that adapted evidence-based interventions may be more effective than non-adapted ones.94 95 It has been demonstrated that adaptation to reflect local contextual factors including existing capacity, gaps and resources is important to design and implement an acceptable, feasible and effective coaching intervention.59 Our protocol allows for an understanding of context to then adapt the intervention and implementation pathway, providing for an associated increased sustainability.96 97
Our study has several limitations. First, it assumes that some front-line healthcare workers have acquired knowledge and skills in QI and coaching and are willing to use these skills in coaching their peers. While these qualities have been widely taught and promoted recently, they continue to be unequally distributed across the healthcare sector. Second, the current protocol targets mainly knowledge and skills as a barrier to front-line improvement activities. Factors such as limited time, insufficient resources and lack of senior leadership commitment to building an improvement culture will limit the potential of any isolated coaching initiative. QI and the associated coaching are often seen as ‘essentially voluntary efforts’,74 which increase the workload rather than optimise it because team members have to ‘carve out’74 time from their daily work commitments. These factors could potentially explain the limited uptake of our pilot study, despite its availability to all staff. Third, the protocol proposes a roadmap for PQIC and does not directly outline the ‘soft skills’ and ‘improver’s habits’ of an effective QI coach.98 99 These are broadly described elsewhere.98–100 Fourthly, the protocol does not define the governance required for QIC. Although variations exist in how different healthcare organisations govern their QI initiatives, the protocol requires transparent lines of responsibilities and accountabilities defined in each context. Fifth, the conceptual difference between QIP and scientific research is also a limitation. This study would have been more scientifically robust if the MDTs were randomly assigned to intervention and non-intervention groups and the confounding factors were controlled. Such a controlled, randomised study would have contributed more precise, evidence-based knowledge in the area of implementation science. Sixth, the testing was conducted with two MDTs in a single institution. Future work could evaluate the protocol in other settings. A limitation of this study is that it did not specifically assess coachees’ behavioural changes. While some behaviours (eg, understanding background, implementing changes, gathering strategic information, planning for and managing improvement) are presented in table 3, others—such as communication, teamwork, decision-making, leadership and problem-solving—were not explicitly measured, though they may also have been impacted by the QIC. Future research could consider including tools that measure these behaviours to provide a more comprehensive understanding of the PQIC. Finally, the project is ultimately built on the staff’s motivation to drive their own change ideas. QI education and coaching could support staff in the more practical aspects of improvement but the culture and practice in the departments, the hospital and the wider healthcare context need to recognise, encourage and reward everyone who has ‘first their job, and then the job of improving it’.101
Conclusion
Improving healthcare quality is a global imperative. Developing basic knowledge and practical skills in QI science, among front-line healthcare professionals, contributes significantly towards better and safer patient care. Built on established education, peer coaching and QI concepts, this evidence-based PQIC protocol provides a roadmap for small and intermediate improvement initiatives. It, therefore, may assist professionals in transforming the complex system of healthcare by leading and delivering change, and spreading innovation. This important work can be progressed by further investigation establishing the link between peer-to-peer coaching and healthcare outcomes, further delineating the most optimal coaching models and engaging different healthcare workers, policy-makers, insurers and the public in overcoming the most common challenges to QI facilitation.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Not applicable.
Ethics approval
The project received approval from the Coombe hospital Audit and Quality Advisory group (AQUA 2022-12-01).
X @SiobhanMCarthy
Contributors PP, MF and SEM conceptualised the study. PP conducted the study in partial fulfilment of their Masters of Science degree (MScQSHM, RCSI). Under the supervision of MF, PP conducted the literature review and analysed the published evidence. Following the initial design of the protocol by PP, MF and SEM critically evaluated the protocol and provided a set of recommendations. Following agreement between the three authors, the final protocol was piloted by PP in a single-centre maternity hospital between February and May 2023. PP led the initial manuscript preparation and MF and SEM contributed with a series of recommendations. All authors contributed to manuscript revisions, read, and approved the final manuscript. The first author, PP, is the guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
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; McCarthy, Siobhan Eithne 2
; Finn, Mairead 2
1 Coombe Women and Infants University Hospital, Dublin, Ireland
2 RCSI University of Medicine & Health Sciences, Dublin, Ireland