Balancing participation and expertise: a comparison of locally and centrally managed health care quality improvement within primary care practices.

In a longitudinal qualitative study, the authors evaluated two health care quality improvement (QI) methods that emphasized either participation (local approach) or expertise (central approach). They followed teams using these approaches to develop depression care QI programs for primary care practices over several years, observing their processes and outcomes and learning about participants' perceptions, beliefs, and experiences. Concordant with the literature, most participants preferred the local approach, but some were willing to relinquish some decision making to experts. Participants identified unique advantages of both the local (e.g., maximizes buy-in and local fit) and central (e.g., maximizes efficiency, reduces burden) approaches. The authors propose a hybrid model in which experts make strategic decisions about what practices to adopt and local site personal make tactical decisions about implementation. They believe that balancing participation and expertise provides the best formula for producing lasting QI for health care organizations across a wide variety of circumstances.