RE:

To the editors and authors,

The recent publication by K. Coleman et al. is the latest in a series describing outcomes from a randomized trial of external support strategies for cardiovascular care quality improvement in small and medium-sized primary care practices. This paper describes how the change in a measure of quality improvement capacity or QICA (i.e., activities, processes, and skills) from baseline to follow-up was associated with changes in clinical quality process measures (aspirin use, blood pressure control, and smoking). Previous work by these authors (Parchman et al., BMC Fam Practice (2019) 20:103) described baseline correlations between the QICA and clinical quality process measures. The novelty and importance of this current paper is topical to practices and healthcare organizations seeking to measure and invest in quality improvement (QI) capacity. While historic focus has been on capturing the downstream results of quality improvement activities via clinical outcomes and process measures, little work outside of the QICA has gone into developing tools to help smaller practices build and evaluate their abilities to conduct quality improvement. The QICA serves this purpose, and this paper provides a much-needed confirmation that investment in and use of the QICA has dividends clinically.

Several implications of this paper deserve note. First, the QICA domains could be conceptualized as practice standards in order to target activities and process related to specific clinical areas. However, as pointed out in this article, disparate clinical areas may not universally benefit from QI capacity development, and uneven, nonlinear, progress should be expected. As clear from this paper and prior work, growth in the QICA was intertwined with the clinical topic of achieving blood pressure (BP) control for these practices. This was likely related to initially higher focus on BP as a key clinical quality domain (as briefly noted by the authors). The association between the change in QICA and change in BP control makes sense; Practice baseline QICA scores were most strongly validated for the domains associated with BP control (i.e., having a QI process, self-management support, and linking patients to resources), while baseline performance for aspirin use and smoking cessation were less consistently associated (i.e., only through identification of at-risk patients and utilization of data respectively). The baseline data submitted by practices was also worse (less valid) for aspirin and smoking than for BP, suggesting BP data may have had existing infrastructure support.

Second, while it was not conceptually explored in this paper, a previous analysis I completed with this group (Schuttner et al., Health Care Management Review (2021) 46:2) explored the nuances of the development of capacity for change as a function of both internal (e.g., higher order learning within the practice and resilience for the change process) and external (e.g., external resources or alignment within a larger health system) capacity. We concluded that these dimensions of internal capacity for the change process may be a prerequisite to actualized processes and activities for QI as captured in the QICA, and may subsequently be a cornerstone of clinical process changes. The contributions from external capacity and infrastructure to QI capacity development and to clinical performance measures were less clear (of practices in our analysis, 40% were aligned with larger health systems and 46% reported centralized QI support structures). Additionally, external influences such as the CMS Innovation project, the Million Hearts Initiative (2012-2016), may have also led to differential growth in performance on clinical measures.

In summary, the current publication further supports the use of an instrument like the QICA to both guide and evaluate QI capacity development. While more investigation is needed into translating that capacity into clinical process and outcome measure change, this study is a promising step in strengthening the argument for investing in QI capacity in order to make an appreciable impact on primary care quality for small and medium-sized practices.