Asset-Based Quality Improvement Report & Tip Sheet

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600 Vilert A. Loving, MD, MMM, et al. An Asset-Based Quality Improvement Tool for Health Care Organizations Table 1. Key Attributes of Deficit-Based Quality Improvement vs. Asset-Based Quality Improvement in Health Care Deficit-Based Asset-Based Focus on apparent problems Focus on existing strengths Brainstorm for solutions Brainstorm to amplify sources of excellence Possibly low/passive stakeholder engagement (depending on team dynamics) Fosters stakeholder engagement Established track record, with many successful problem-solving examples in the literature Relatively nascent to health care Possibly increases burnout through staff disengagement (when adverse event-driven) Staff engagement and meaningfulness combat burnout Fulfills health care agencies' regulatory requirements Not specifically addressed by health care regulatory agencies To counterbalance the disadvantages of the DBQI ap- proach, 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, 12 apprecia- tive inquiry, 13 Safety-II, 14 and learning from excellence. 15 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 expand- ing 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 iden- tified, subsequent analyses tease out root causes for circula- tion throughout the organization. By highlighting existing positive behaviors, resources, and processes within the or- ganization, ABQI benefits from frontline team members' inherent sense of ownership of these strengths, thereby in- creasing these team members' engagement with the quality improvement effort. 12 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 view- points. 16 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 op- posed to deficit-based approaches in which external parties identify problems and infuse resources to resolve them. 17 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 infec- tion control barriers exceeding Centers for Disease Con- trol and Prevention guidelines. 18 Dewar and Nolan em- ployed ABQI to study the word choices and body language of ward nurses who consistently achieved compassionate nurse-patient interactions, and they subsequently normal- ized these behaviors for the entire nursing staff. 19 Kelly et al. piloted an ABQI initiative to identify and teach best prac- tices in their pediatric ICU and found that the positive sen- timent improved staff morale and care quality. 15 Notably, most published health care ABQI projects have been at the department level or smaller. Widescale institutional adop- tion is lacking, as most health care organizations allocate the majority of their quality improvement resources into DBQI initiatives and meeting deficit-based regulatory re- quirements. 20 Health care organizations remain heavily bi- ased toward fixing problems rather than expanding assets. 20 Our goal was to complement our institution's DBQI ini- tiatives by launching a practical systemwide ABQI tool to discover and propagate existing clinical excellence through- out our organization. This pilot project would ascertain the logistical and technological feasibility of creating and incor- porating the ABQI tool into our institutional quality pro- gram to (1) generate quality improvement initiatives worth systemwide spread, (2) disseminate stories of clinical excel- lence to inspire other HCPs to improve their clinical prac- tices, and (3) foster frontline HCP engagement with quality and safety efforts. TOOL DEVELOPMENT Organizational Context: Peer Review Committee Challenges and Appreciative Inquiry Team Origin Our organization is an integrated health system that oper- ates more than 30 hospitals and more than 200 outpatient health centers across six states in the United States. The or- ganization's medical group employs more than 2,000 physi- cians 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 re- view committee in 2014. In 2019 this committee consisted of 16 physicians and one advanced practice provider, en- compassing 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

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