The many barriers described in the previous section can be translated into areas of opportunity for quality improvement research. As Scott Young of Kaiser’s Care Management Institute noted, future quality improvement efforts will need to take into account improvements in care for those with multiple chronic conditions, transitions in care, new technologies, robust evidence-based medicine, and innovative care environments.

There are a number of concrete actions that can be taken to make quality improvement and quality improvement studies better in the short term. One area of focus, for example, is the development of an evidence base. And as Frank Davidoff of the Institute for Healthcare Improvement said, managing the heterogeneity of research will require that the goals of quality improvement projects be more focused. Heterogeneity cannot be ignored, but there are ways to control it within the constraints of the real world. Adapting a lesson from randomized trial advocate Tom Chalmers, Davidoff proposed quality improvement interventions be assessed using the most rigorous methods possible immediately after the intervention has been introduced. In this way, the strength of study results may increase due to the ability to randomize.

Additionally, randomized controlled trials should build on previous work that characterized context and intervention development, Batalden said. The gap between technical knowledge limits and the needs of the particular applications of knowledge must be bridged.

The focus of quality improvement projects should also be clarified, suggested Davidoff. Projects often do not distinguish between the goals of determining the efficacy of the clinical intervention itself and of assessing the effectiveness of the care system in delivering the intervention. Different types of evidence may be required for the different goals, Davidoff noted. With a greater emphasis on clearly defining the focus of studies, the field could produce useful, generalizable knowledge that is actually needed, Grimshaw said.

Understanding the ethical issues is also an important, tangible change that can help improve the state of quality improvement research, Davidoff said.

One long-term solution to improving quality improvement and quality improvement research would be to provide training in research methods to people doing work in quality improvement, Davidoff suggested. This could help fix the aforementioned mismatch between training and practice. Davidoff also noted that changes should be made to professional education. Examples of such changes would include teaching collaborative skills, training physicians in the manner that health care should be delivered, and encouraging provider partnerships.

Academic and editorial cultures also need to change in order for quality improvement and quality improvement research to develop. These stakeholders need to recognize the social and intellectual values of quality improvement work, Davidoff said. Other opportunities include learning more about experiential learning and leveraging other research disciplines. Davidoff noted that other research disciplines, such as social sciences and economics, could be useful in moving forward. One important step in achieving this could be recognizing that quality improvement research, as an interdisciplinary field, will require special attention, Pincus noted.

Strategies should be developed to take action on these opportunities, Pincus said. He proposed six strategies to help advance

quality improvement research: an infusion of new dollars, diversification of funding sources, creation of institutional homes for quality improvement research, recognition of the need for diverse strategies for different audiences, exposure to future researchers at multiple and early points in academic development, and enhancement of data about what strategies are most effective in engaging investigators and developing substantial programs. While these strategies are all important, a prioritization was not offered. Indeed, as Titler noted, because of the complexity of the health care system and the often conflicting needs of various stakeholders, it is extremely difficult to prioritize among strategies to develop quality improvement and quality improvement research.