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Identifying the Problem Is Key to Quality Improvement in Cancer Care

January 2019, Vol 9, No 1

“There are a number of ways to go wrong when you’re trying to improve something,” said Kaveh G. Shojania, MD, Director, Centre for Quality Improvement and Patient Safety, University of Toronto, Canada, and Editor-in-Chief, BMJ Quality & Safety, who delivered the keynote address at the 2018 ASCO Quality Care Symposium. When it comes to improving quality in cancer care, there are no magic bullets. Many approaches have little to no impact. But recognizing and avoiding the most common pitfalls in quality improvement efforts can improve the chances for success, according to Dr Shojania.

Understanding the Problem

Dr Shojania cited the main reasons why quality improvement interventions often yield disappointing results.

First is jumping to a solution before understanding the problem, which would be like looking at a patient and saying, “You look ill. I’m going to give you a red pill,” when you have no idea of the pill’s ingredients or what the illness is, Dr Shojania said.

Similarly, premature evaluation (ie, rushing to a randomized controlled trial before optimizing an intervention) and “pilot projects” with no attention to sustainability can significantly contribute to intervention failure.

“It is a very complex system in which we operate. And if we don’t take the time to understand the processes on which we’re trying to intervene, we can, without realizing it, contribute to the complexity,” he said.

According to Dr Shojania, messy clinical practice settings make it hard to understand target problems. Unlike in the setting of clinical trials, implementing solutions in the real world involves many challenges, which can lead to unintended consequences. “That makes having a theory to guide you very valuable,” he said.

He presented an example of a quality improvement report addressing hand hygiene in the workplace. The report stated that hospital infections affect thousands of people each year, and hospital staff fail to wash their hands consistently. To address this issue and improve quality, that particular institution implemented a multifaceted strategy.

“How many times have we seen that phrase: ‘multifaceted strategy’?” Dr Shojania asked. “That includes staff education, which is almost always a placebo, clinical champions, whatever those are, and empowering patients to ask staff if they’ve washed their hands, which is embarrassing to providers.”

What’s missing in that particular intervention is understanding how these strategies address the main causes of poor hand hygiene compliance—in other words, a connection between the problem and the solution. Similarly, if people know that colorectal cancer screening is important, then why don’t people get screened?

The key to a good quality improvement initiative lies in characterizing the problem, identifying the cause, and describing how the intervention can address those problems, he said.

Identifying the Cause

One study looked at the issue of unnecessary antibiotic use for upper respiratory infections, showing that patient expectations were the major actor in antibiotic overprescribing. Yet, many interventions aimed at reducing antibiotic use for such infections only target clinicians with guidelines and educational material, and do not target patients.

“This is why you want to make sure you understand the cause, or why people are behaving the way they are,” he noted.

Another study examining the reasons for 30-day hospital readmissions after surgery showed that surgical-site infections and ileus accounted for 50% of all readmissions.1 “If you were tackling readmissions in the abstract, you might go down all kinds of pathways,” he said. “But when you see that surgical-site infections and ileus are the concrete problems accounting for a lot of these readmissions, those are things you can deal with. This is just another strategy for trying to understand the causes of the problems, and to flesh out a theory for whatever intervention you pursue.”

According to Dr Shojania, thinking through a theory enhances patient (or provider) selection, by sharpening one’s thinking about who will benefit most from an intervention. It enhances the recognition of key ingredients and contextual factors (you may realize you’re missing one), and helps with anticipating implementation challenges.

Finally, articulating a theory will facilitate choice of outcomes and implementation.

Understanding context is vital to successful quality improvement. Context refers to the features of a setting that may not be a part of the intervention, but may explain why it did or did not work. In a clinical study, researchers intuitively know what context is relevant to the study, such as cancer stage, comorbid conditions, or previous treatments. “Articulating your theory can help,” he said.


Although clinical sustainability issues can be attributed to poorly designed interventions, other interventions simply stop working. For example, pay-for-performance incentives eventually erode the intrinsic motivation behind providers’ actions. “You want to make the right thing to do the easy thing to do,” he said. “That’s the key to sustainability.”

Keep sustainability in mind. If the intervention works, will it require ongoing care? Choose projects that stand out, and that your colleagues will want to see succeed. “You may have an intervention that seems convenient,” he said. “But if so-and-so taking the lead is, essentially, the intervention, that’s going to be short-lived.”

Avoid Burnout

Avoid constant change and burnout by tackling problems at which you will likely succeed, and will make everyone’s job easier.

“Build resilience instead of burnout,” said Dr Shojania. “Once people are feeling burnt out, you can’t ever take enough away to make them feel less so. But if you give them something they feel good about, that makes a big difference.”


  1. Merkow RP, Ju MH, Chung JW, et al. Underlying reasons associated with hospital readmission following surgery in the United States. JAMA. 2015;313:483-495.

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