There is a continued need to improve the quality of health care services and the health outcomes associated with that care. Quality improvement model and the Learning Health System framework have emerged as potential methods to achieve the goals of better care and enhanced outcomes. Few practical tools and approaches have been developed to assist with the initiation of quality improvement and development of a Learning Health System. The Department of Veterans Affairs developed and deployed a national system to assist and organize improvement projects and serve as a database for learning. During its first 5 years of use, 7397 quality improvement projects were completed using the electronic tool. National implementation of a structured tool for quality improvement is possible.
References
Baker A. Book: crossing the quality chasm: a new health system for the 21st century. BMJ. 2001;323:1192���1192.
Medicine I of, America C on Q of HC in. To Err is Human: Building a Safer Health System. National Academies Press; 2000.
Bates DW, Singh H. Two decades since to Err Is Human : an assessment of progress and emerging priorities in patient safety. Health Aff (Millwood). 2018;37:1736���1743.
Clancy CM. Where we are a decade after to Err is Human. J Patient Saf. 2009;5:199���200.
Bates DW, Levine DM, Salmasian H, et al. The safety of inpatient health care. N Engl J Med. 2023;388:142���153.
Taylor MJ, McNicholas C, Nicolay C, et al. Systematic review of the application of the plan���do���study���act method to improve quality in healthcare. BMJ Qual Saf. 2014;23:290���298.
Glasgow JM, Scott-Caziewell JR, Kaboli PJ. Guiding inpatient quality improvement: a systematic review of lean and six sigma. Jt Comm J Qual Patient Saf. 2010;36:533���540.
Boggan JC, Shekelle PG, Mak S, et al. Continuous Quality Improvement (CQI) for Clinical Teams: A Systematic Review of Reviews. Department of Veterans Affairs (US); 2022. Accessed March 19, 2024. http://www.ncbi.nlm.nih.gov/books/NBK579403/ .
Nelson EC, Godfrey MM, Batalden PB, et al. Clinical microsystems, part 1. The building blocks of health systems. Jt Comm J Qual Patient Saf. 2008;34:367���378.
Greene SM, Reid RJ, Larson EB. Implementing the learning health system: from concept to action. Ann Intern Med. 2012;157:207���210.
Etheredge LM. A rapid-learning health system. Health Aff (Millwood). 2007;26:w107���w118.
Garvin DA. Building a learning organization. Harv Bus Rev. 1993;71:78���91.
Forliti M. Platform Revolution: Curing More People, Reaching More Lives, Anytime, Anywhere. Mayo Clinic News Network; 2020.
Ojo B, Feldman R, Rampersad S. Lean methodology in quality improvement. Paediatr Anaesth. 2022;32:1209���1215.
Karhade AV, Larsen AMG, Cote DJ, et al. National databases for neurosurgical outcomes research: options, strengths, and limitations. Neurosurgery. 2018;83:333���344.
Perotti V, Sheridan MMP. Root cause analysis of critical events in neurosurgery, N ew S outh W ales. ANZ J Surg. 2015;85:626���630.
Taitz J, Genn K, Brooks V, et al.; NSW RCA Review Committee. System-wide learning from root cause analysis: a report from the New South Wales Root Cause Analysis Review Committee. Qual Saf Health Care. 2010;19:e63���e63.
Bagian JP, Gosbee J, Lee CZ, et al. The Veterans Affairs root cause analysis system in action. Jt Comm J Qual Improv. 2002;28:531���545.
Riblet N, Shiner B, Mills P, et al. Systematic and organizational issues implicated in post-hospitalization suicides of medically hospitalized patients: a study of root-cause analysis reports. Gen Hosp Psychiatry. 2017;46:68���73.
