Asset-Based Quality Improvement Report & Tip Sheet

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The Joint Commission Journal on Quality and Patient Safety 2022; 48:599–608 TOOL TUTORIAL An Asset-Based Quality Improvement Tool for Health Care Organizations: Cultivating Organizationwide Quality Improvement and Health Care Professional Engagement Vilert A. Loving, MD, MMM; Connell Nolan, MS; Marjorie Bessel, MD In the United States, health care organizations are often biased toward deficit-based quality and safety improvement tech- niques, 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 technolog- ically 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. A ll health care organizations seek to improve the quality and safety of patient care. In the United States, inci- dent 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. 1 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 in- cident report may or may not trigger clinical peer review, de- pending 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 ad- verse event reporting (AER). During AER processes, patient safety teams and/or peer review committees investigate the events, determine what went wrong, and implement solu- tions to prevent adverse event recurrence. Peer review inves- tigations also adjudicate if the involved HCPs were meeting the standard of care. AER processes are requirements of The Joint Commission 2 and other regulatory groups. Moreover, many insurers in the United States, including Medicare, 3 re- quire AER processes for quality assurance, solidifying their importance. AER, including incident reporting processes and clin- ical peer review, exemplifies deficit-based quality improve- ment (DBQI). DBQI projects begin by asking "What went wrong?" or "Are we meeting benchmarks?" Decision- 1553-7250/$-see front matter © 2022 The Author(s). Published by Else- vier Inc. on behalf of The Joint Commission. This is an open access article under the CC BY license ( ) makers then search for durable solutions to the problems or suboptimal performance. Deficit-based approaches are prevalent in health care, as institutions have invested sig- nificant resources into safety programs to combat medical errors and iatrogenic harm. 4 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. 5 , 6 Further, because AER outcomes could negatively impact HCPs' credentialing, professional reputation, and career, HCPs may seek legal counsel when undergoing peer review inquiries. 5 These litigious, defensive, and negative sentiments contribute to HCPs un- derreporting 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 repercus- sion fears. 7 Physicians are particularly disengaged from patient safety projects and rarely report adverse events. 8 , 9 Unreported adverse events represent lost organizational learning opportunities. Another disadvantage of DBQI is the second victim phenomenon: frontline HCPs them- selves experience harmful effects from adverse events and ensuing investigations, including stress, anxiety, sleep disturbance, and lowered clinical confidence. 10 In extreme cases, these harms persist for weeks or longer and may con- tribute to disengagement, burnout, and HCPs leaving their profession. 11

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