Creating a culture of medication administration safety: laying the foundation for computerized provider order entry

BACKGROUND: Computerized provider order entry (CPOE) systems are recognized as an effective tool for reducing preventable adverse drug events; however, implementation is a complex process that involves much more than installing new software. The literature addresses the use of these systems in large tertiary care hospitals and university settings; yet there is little information on their implementation and use in smaller hospitals. Beaver Dam Community Hospital, a small, rural hospital, set about laying the foundation for implementing CPOE. Actions were taken in terms of context (the culture and attitude, acceptance, and importance regarding the change), process (roles, workflow, and policies relating to the change), and content (how-to, such as procedural steps and rules). USE OF THE RAPID-CYCLE IMPROVEMENT PROCESS: The team elected to use the rapid-cycle improvement process for implementation to allow it to move ahead quickly, adjusting changes as necessary for maximum success. Each change was considered an individual Plan-Do-Check-Act cycle, with its own action plan and measurement for successful implementation. PLANNING ACTUAL IMPLEMENTATION: The Patient Safety Committee has begun the planning of actual implementation--Phase II. Issues addressed include how to phase in the system--in which units to bring up first, how to structure the transitional period, how to redesign workflow, and how to plan role changes. SUMMARY: The changes already implemented contribute to medication safety and are important from that perspective alone, without the use of CPOE. The addition of an electronic system will enhance the organization's ability to provide safe, accurate medication administration.     

Comparing physician and administrator responses to cesarean section guidelines and actual practice

BACKGROUND: A cross-sectional study was conducted in 1996 to determine to what extent hospitals have adopted guidelines to improve the appropriate use of cesarean section (C-section); discover attitudes of obstetricians toward C-section guidelines; and explore how physician attitudes toward guidelines interact with organizational features. METHODS: The study consisted of two components: (1) Telephone interviews with hospital administrators from Michigan hospitals providing obstetric care (response rate: 100%); these interviews were intended to determine whether guidelines were in use and the processes for their development and implementation. (2) A self-administered mail survey assessing the attitudes of 266 Michigan obstetricians (response rate: 57%), intended to assess their attitudes toward the content and effects of C-section guidelines. RESULTS: Twenty-nine percent of hospitals were using C-section guidelines, according to reports from hospital administrators. Mean C-section rates were not significantly different between hospitals using guidelines and those not using guidelines (23.2% and 22.4%, p = 0.49). More than 80% of physicians felt that the guidelines were supported by the literature and were applicable in daily practice, and agreed with their ideas about C-section performance, and 67% reported that guidelines would have no or minimal effect on their practice. However, only 55% of physicians and administrators agreed on the presence or absence of guidelines at their hospital (kappa = 0.09). DISCUSSION: Physicians appear to agree with guidelines and believe they are already following them, despite high C-section rates. Physicians' attitudes toward guidelines are not necessarily a reflection of actual practice. If C-section guidelines are to decrease excessive C-section rates, stronger, more integrated implementation strategies are needed.     

A quality improvement approach to reducing use of meperidine

BACKGROUND: In 1991 the University of Wisconsin Hospital and Clinics formed a pain management QI team whose goal was to improve pain management through education, outcome monitoring, and the development of programs intended to improve clinical practice. Longitudinal monitoring mechanisms were established to audit medical records and survey patients to examine both staff practice patterns and patient outcomes. The QI team targeted use of meperidine, one of the most widely used opioid analgesics for the treatment of moderate to severe pain, which is now discouraged as a first-line agent for most painful conditions. IMPLEMENTING THE QI PROCESS: A QI process was implemented using a traditional plan-do-check-act (PDCA) model, resulting in a successful and sustained reduction of inappropriate meperidine use. A cause-and-effect diagram helped highlight the multiple factors contributing to the drug's overuse and was used to prioritize targets for action. A flow chart helped to uncover some of the interrelationships between the myths about meperidine and the resultant customary prescribing and administration practices. While most of the strategies were implemented in 1996 (formulary guideline release, change in stock supply and physician orders, staff education and feedback), a significant impact in practice was not seen until late 1997. Ongoing tracking and feedback loops were established to ensure continued low use of meperidine. CONCLUSION: Use of a QI approach in pain management has been shown to affect the visibility of pain as a clinical priority, enhance interdisciplinary collaboration, facilitate the implementation of clinical guidelines at the bedside, and improve the quality of care for patients.     

Towards patient‐centered packaging design: An industry perspective on processes,functions, and constraints

Medication packaging is essential to provide patients with guidance and correct use of their medicines for effective treatment. This research aims to increase knowledge about the medication packaging innovation process and its uptake towards patient‐centered packaging design. The study applied a qualitative research approach based on data from 25 in‐depth interviews with stakeholders involved in medication packaging design. The empirical data analysis revealed four themes that can improve and advance user‐centered packaging design: medication packaging innovation process, medication packaging functions and features, medication packaging design constraints, and patient‐centered medication packaging design. The findings suggest that medication packaging design is strongly affected by an emphasis on protective and safety packaging functions rather than on patients' needs. Packaging innovation usually is constrained by rigid incremental development processes, where compliance with regulations, extensive documentation, avoidance of manufacturing complexity, and considerations on cost prevail. These findings are discussed in relation to the three most evident trade‐offs for patient‐centered design: protection versus openability, utility versus cost, and complexity of manufacturability versus complexity of use. This research contributes with valuable input and additional evidence about the necessary shift to a user‐centered approach in a field that has not been design driven. This input complements previous research and provides an opportunity for industry decision makers and policy makers to lead patient‐centered packaging design that can benefit patients and relieve overloaded health care systems.     

A simulation based approach to analyse the effects of job release on the performance of a multi-stage job-shop with processing flexibility

Workload control concepts are advocated as one of the new production planning and control methods. In its elaborated form, workload control includes three major decision levels: job entry, job release and priority dispatching. In each decision level, several decision points which have significant impact on the effectiveness of the production planning and control are defined (i.e., acceptance/rejection, due date assignment, etc.). Workload control systems should consider all of these decision points simultaneously in order to improve the effectiveness of production planning and control. In addition to these decision levels, flexibility of the shop can also be included as the fourth decision level which allows the shop capacity to be adjusted as new orders enter the system and as they are released to the shop floor. In this study, simulation models which enable the effect of each decision level within a workload control concept to be explored are developed and tested. The results reveal that simultaneous consideration of decision levels is critical and can improve the effectiveness of production planning and control.     

The utility of decision support, clinical guidelines, and financial incentives as tools to achieve improved clinical performance

BACKGROUND: Whether one seeks to reduce inappropriate utilization of resources, improve diagnostic accuracy, increase utilization of effective therapies, or reduce the incidence of complications, the key to change is physician involvement in change. Unfortunately, a simple approach to the problem of inducing change in physician behavior is not available. COMPREHENSIVE CLINICAL GUIDELINES: There is a generally accepted view that expert, best-practice guidelines will improve clinical performance. However, there may be a bias to report positive results and a lack of careful analysis of guideline usage in routine practice in a "postmarketing" study akin to that seen in the pharmaceutical industry. FINANCIAL INCENTIVES: Systems that allow the reliable assessment of quality of outcomes, efficiency of resource utilization, and accurate assessment of the risks associated with the care of given patient populations must be widely available before deciding whether an incentive-based system for providing the full range of medical care is feasible. DECISION SUPPORT: Decision support focuses on providing information, ideally at the "point of service" and in the context of a particular clinical situation. Rules are self-imposed by physicians and are therefore much more likely to be adopted. CONCLUSION: As health care becomes corporatized, with increasing numbers of physicians employed by large organizations with the capacity to provide detailed information on the nature and quality of clinical care, it is possible that properly constructed guidelines, appropriate financial incentives, and robust forms of decision support will lead to a physician-led, process improvement approach to more rational and affordable health care.     

Physicians taking the lead to improve patient care

BACKGROUND: "Quality: putting clinicians in the Cockpit"--a conference about producing measurable, clinically important improvement in the quality and cost of health care--was sponsored by the Institute for Clinical Systems Integration, based in Minneapolis, and the Institute for Healthcare Improvement, in Boston. More than 200 persons, including clinicians engaged in clinical improvement activities, medical directors, medical group administrators, and quality improvement staff and researchers, attended the Minneapolis meeting, held October 1-3, 1997. PHYSICIANS AS LEADERS: According to James Reinertsen, MD, who described the strategies that physician leaders can use, the leader's main role is to "establish an environment in which quality can thrive" by removing obstacles to quality improvement. DATA: IMPROVING CESAREAN SECTION RATES: Robert DeMott, MD, reported an initiative conducted in a region in which physicians had strongly held beliefs and long-held approaches to obstetric care. DATA LEADS TO DECISION SUPPORT TOOLS FOR CARDIAC CARE: William Nugent, MD, described the impact of the Northern New England Cardiovascular Disease Study Group, a voluntary regional initiative to improve outcomes in patients undergoing coronary bypass grafting. EVIDENCE-BASED IMPROVEMENT--THE GROUP HEALTH EXPERIENCE: Michael Stuart, MD, commented on Group Health's efforts to develop clinical guidelines so that clinical decisions are based on the best available evidence. SHARING INFORMATION IN A COMPETITIVE ENVIRONMENT: Gordon Mosser, MD, and Donald Berwick, MD, discussed the challenges clinicians face in sharing information in a competitive environment. In a session on making sense of information, Paul Batalden, MD, noted, "There is lots of information; if it were only clear who to send it to for the improvement of health care."     

The Safety of Intravenous Ferric Gluconate Self Administered During Routine Home Hemodialysis

Home hemodialysis (HHD) patients are often inconvenienced when intravenous iron preparations are administered. Formerly, these patients received their medication in the clinic on an off-dialysis day or during in-center hemodialysis (HD). For the last 2 years, 5 patients in our HHD program have been receiving intravenous ferric gluconate during their routine HD session.
Procedure:  All patients were trained in the proper administration of ferric gluconate in-center. No test dose was administered. Ferric gluconate was infused via the heparin infusion pump on their HD machine at a rate of 31.25 mg/h. Doses were of either 62.5 mg or 125 mg per session. K/DOQI guidelines for intravenous iron use were adhered to. TSATs greater than 25%, ferritin greater than 100 ng/mL and less than 800 ng/mL, and hemoglobin between 11 and 12 g% were the goals of therapy. Both loading doses (8 doses during sequential HD sessions) and maintenance doses every week or every other week were employed.
Results:  Over the last 2 years, 223 doses were administered at home. No serious reactions occurred during the course of therapy. One patient experienced minor nausea and vomiting during one dose, which was thought to be possibly related to the iron infusion. This patient subsequently received ferric gluconate again without difficulty.
Conclusion:  Ferric gluconate can be safely administered at home during HHD.     

A multidisciplinary team approach to reducing medication variance

BACKGROUND: In March 2000 a multidisciplinary team was formed at Williamsburg Community Hospital (Williamsburg, Virginia) to address medication-related patient safety initiatives. MEDICATION SAFETY TEAM: The team focused on promoting a nonpunitive reporting environment, developing a collaborative medication administration policy, and designing an education and communication plan that promoted safe medication practices. In creating a nonpunitive environment, the first step was to revise the medication variance reporting policy. The team focused on process improvement and removed all references to corrective action from the policy. It launched an extensive educational effort throughout the hospital to raise awareness of the change in policy and to increase the focus on patient safety initiatives. The team also oversaw development of a comprehensive medication administration policy, which consolidated nursing, physician, and pharmacy practices. The team implemented a number of quick fixes that generated momentum and provided some immediate successes. RESULTS: Within a 9-month period (May 2001-January 2002), the number of reports doubled. As the number of variance reports increased, a subcommittee formed, with the specific responsibility of reviewing the reports on a weekly basis. DISCUSSION: The team sought to change the environment and attitudes related to medication variances and reporting. This was an organization wide change that required employees to change their perceptions regarding the purpose of reporting. Implementing the changes in small bites to realize immediate successes helped provide the impetus to keep the team focused and energized in tackling this huge endeavor. The team provided the ability to solve problems and recommend changes quickly and effectively from a variety of perspectives.     

Evidence-based medicine: is translating evidence into practice a solution to the cost-quality challenges facing medicine?

BACKGROUND: Evidence-based medicine (EBM) and practice guidelines have been embraced by increasing numbers of scholars, administrators, and medical journalists as an intellectually attractive solution to the dilemma of improving health care quality while reducing costs. However, certain factors have thus far limited the role that EBM might play in resolving cost-quality trade-offs. FACTORS FOR SUCCESS OF EBM RECOMMENDATIONS AND GUIDELINES: Beyond the quality of the guideline and the evidence base itself, critical factors for success include local clinician involvement, a unified or closed medical staff, protocols that minimize use of clinical judgment and that call for involvement of so-called physician extenders (such as nurse practitioners and physician assistants), and financial incentive. TROUBLESOME ISSUES RELATED TO COST-QUALITY TRADE-OFFS: Rationing presents many dilemmas, but for physicians one critical problem is determining what is the physician's responsibility. Is the physician to be the patient's advocate, or should the physician be the advocate of all patients (the patients' advocate)? How do we get physicians out of potentially conflicted roles? EBM guidelines are needed to help minimize the number of instances physicians are asked to ration care at the bedside. If the public can decide to share and limit resources--presumably based on shared priorities--physicians would have a basis to act as advocates for all patients. CONCLUSIONS: Although EBM alone is not a simple solution to the problems of increasing costs and public expectations, it can be an important source of input and information in relating the value of service and medical technology to public priorities.     

A Web-based diabetes care management support system

BACKGROUND: Because of the often asymptomatic nature of diabetes and the long period between sustained hyperglycemia and observable complications, appropriate diabetes care relies on a long-term program of secondary prevention. Yet routine monitoring and screening among patients with diabetes is less than optimal. To support the provision of routine care to patients with diabetes, the Center for Health Services Research, Henry Ford Health System (Detroit), developed a Web-based Diabetes Care Management Support System (DCMSS). A nonrandomized, longitudinal study was conducted (January 1, 1998-October 31, 1999) with 13,325 health maintenance organization patients with diabetes who were aligned to 190 primary care providers practicing in 31 primary care clinics. RESULTS: Three DCMSS features--clinical practice guidelines, patient registries, and performance reports--were made available via a corporate intranet within an existing electronic medical record. The effect of DCMSS usage frequency was evaluated on the likelihood of a patient's receipt of glycated hemoglobin testing, lipid profile testing, and retinal examinations. Logistic regression models controlling for patient sociodemographic and clinical characteristics, and the testing history of the patient, the primary care physician, and the primary care clinic, were fit using generalized estimating equation methods. The more often a physician used DCMSS, the more likely his or her patients were to receive lipid profile testing (OR [odds ratio] = 1.01, 95% CI [confidence interval] = 1.01-1.02). Compared with patients of physicians who never used the system, patients of physicians who initiated 12 sessions were an estimated 19% more likely (95% CI = 7%-33%) to receive lipid profile testing. The analyses also suggested that the likelihood of a patient receiving a retinal exam was associated with system usage (OR = 1.01, 95% CI = 1.01-1.01). No relationship was found between system use and glycated hemoglobin testing. CONCLUSIONS: Computerized systems of clinical practice guidelines, patient registries, and performance feedback may help improve the rate of routine testing among patients with diabetes.     

A Web-based program for implementing evidence-based patient safety recommendations

BACKGROUND: In response to increasing national concerns about medical safety, product developers from a health services research and software group recently created a commercial Web-based program to address a wide variety of patient safety issues in the acute care setting. They also wanted to provide a program with credible, referenced, and up-to-date content, not just a technology infrastructure for reporting errors. SAFETY OPTIMIZER: This Web-based program, which has evolved over time, now features seven modules for assessing organizational risk and for implementing strategies to reduce risk. The Literature Module features detailed synopses that are graded and organized into summary statements to provide recommendations for improving patient safety. The Implementation/Tracking Module includes numerous risk-reduction strategies. The Incident Reporting Module enables the collection of data at the point of care on a variety of incidents, using either paper-based or on-line forms. Other modules offer opportunities to assess adherence to JCAHO patient safety standards, forecast the benefits of certain evidence-based guidelines, evaluate staff competency, and obtain information from a variety of key safety Web sites. EXPERIENCE TO DATE: The program is in use at more than 30 health care organization facilities and systems. It is still too early to provide quantitative data on the impact of this program on patient safety. CONCLUSIONS: It is hoped that vendor solutions such as the one described in this article will help organizations develop a practical and effective framework for addressing the wide range of issues in patient safety.     

Taking the national guideline for care of acute myocardial infarction to the bedside: developing the guideline applied in practice (GAP) initiative in Southeast Michigan.

BACKGROUND: The Guideline Applied in Practice (GAP) program was developed in 2000 to improve the quality of care by improving adherence to clinical practice guidelines. For the first GAP project, the American College of Cardiology (ACC) partnered with the Southeast Michigan Quality Forum Cardiovascular Subgroup and the Michigan Peer Review Organization (MPRO) to develop interventions that might facilitate the use of the ACC/AHA Acute Myocardial Infarction (AMI) guideline in the practice setting. Ten Michigan hospitals participated in implementing the project, which began in March 2000. DESIGNING THE PROJECT: The project developed a multifaceted intervention aimed at key players in the care delivery triangle: the physician, nurse, and patient. Intervention components included a project kick-off presentation and dinner, creation and implementation of a customized tool kit, identification and assignment of local nurse and physician opinion leaders, grand rounds site visits, and measurement before and after the intervention. IMPLEMENTING THE PROJECT: The GAP project experience suggests that hospitals are enthusiastic about partnering with ACC to improve quality of care; partners can work together to develop a program for guideline implementation; rapid-cycle implementation is possible with the GAP model; guidelines and quality indicators for AMI are well accepted; and hospitals can adapt the national guideline for care into usable tools focused on physicians, nurses, and patients. DISCUSSION: Important structure and process changes--both of which are required for successful QI efforts--have been demonstrated in this project. Ultimately, the failure or success of this initiative will depend on an indication that the demonstrated improvement in the quality indicators is sustained over time.     

Benefits of a mobile,point-of-care anticoagulation therapy management program

BACKGROUND: Current guidelines recommend anticoagulation therapy for a number of medical conditions, but this therapy also has the potential for serious complications, particularly bleeding complications. Maintenance of anticoagulation within a narrow therapeutic window usually entails frequent monitoring with a blood test called the international normalized ratio (INR). Anticoagulation therapy management (ATM) clinics lead to improvements in quality of care, in terms of improved INR control and reduced complications. This study examined the impact of a mobile multisite, office-based ATM program that operated in seven cardiology offices in all three counties in Delaware. ATM PROGRAM: The ATM program was managed by a trained nurse who rotated among all seven offices. Patients made office visits to the nurse and received patient education, point-of-care INR testing, and medication adjustment based on a physician-approved algorithm. METHODS: This retrospective cohort study compared INR levels in the year before (May 1998-Apr 1999) and the year after (Aug 1999-Jul 2000) the start of the ATM program. RESULTS: From the year before to the year after implementation of the ATM program, the percentage of in-range INRs increased from 40.7% to 58.5% (p < 0.001). The percentage in the modified target range also increased (50.0% to 62.9%, p < 0.001). DISCUSSION: This study demonstrates the positive impact of a statewide office-based ATM program. If similar programs could be implemented in other networks of specialty offices or primary care offices, they could have a significant benefit to quality of care for patients who require anticoagulation therapy.     

Justification: how to get referring physicians involved

Barriers to involvement of clinicians in the process of justification include an already overloaded knowledge base, lack of time, inconsistent guidance and disproportionate patient expectations. Strategies to improve referring physicians' input include education, use of imaging referral guidelines, clinical audit and regulation. This article discusses and reviews evidence for approaches to encourage greater participation in justification by clinicians. Approaches are best summarised by 'Awareness, appropriateness and audit'.     

Using a new method of gathering patient satisfaction data to assess the effects of organizational factors on primary care quality

BACKGROUND: As health care in the United States evolves increasingly toward managed care, there are continuing concerns about maintaining the quality of the physician-patient interaction, of which patient satisfaction is one measure. A quality assessment tool that measures both patient satisfaction with care and the ways organizational factors affect satisfaction will enable clinicians and administrators to redesign the care process accordingly. SURVEY METHODOLOGY: The measure of the quality of a physician office visit includes both the administration of a standardized satisfaction instrument and direct observation of the patient throughout the care process. This methodology was tested in 1997-1998 on an initial sample of 291 patients at a large multispecialty medical group in northern California. The surveyor recorded objective characteristics of the visit, surveyed patients about their impression of certain aspects of the visit related to satisfaction, and administered a standardized visit satisfaction survey. A second set of control patients who visited the same physician on the same day was contacted by phone and given the satisfaction survey two to four weeks later. PRINCIPAL FINDINGS: Patients readily accepted the presence of a surveyor during their visit, with an overall response rate of 78%. While patients contacted retrospectively gave lower satisfaction ratings, the presence of a surveyor did not affect patients' satisfaction responses. Data obtained by using the concurrent methodology provides significant information about organizational factors influencing patient satisfaction. CONCLUSIONS: Measuring patient satisfaction concurrently during a physician office visit offers an attractive alternative to other methods of measuring this key aspect of quality.     

Treatment decisions about lumbar herniated disk in a shared decision-making program

BACKGROUND: An explicit process of collaborative (shared) decision making involving the patient and physician has been recommended for discretionary surgical procedures in which small-area analysis demonstrates high variation not attributable to differences in the patient population in the area. One such example is laminectomy for lumbar herniated disk (HD). An observational study was undertaken to evaluate the impact of an HD videodisk program on patient satisfaction, decision making, and treatment preferences. METHODS: Enrollment occurred in the outpatient offices of surgeons treating Kaiser Permanente (Colorado Region) patients with HD who had indications for surgery. Enrollment took place from May 1993 to December 1995, and follow-up surveys of patients were completed by January 1997. RESULTS: A 6.0% decrease in the undecided group and a 1.3% decrease in the group preferring nonsurgical treatment drove a shift of patients toward laminectomy, from 26.7% to 35.8% (Wilcoxon signed rank test = 349.5, p = .017). Postviewing preference (74.0%) was a better aggregate predictor of the ultimate treatment than previewing preference (70.0%) for laminectomy. DISCUSSION: Viewing the videodisk increased the preference for laminectomy. However, limitations in the data prevented us from determining whether this change in preference was actually reflected in patients' ultimate decisions. The fact that the strongest predictor of choosing surgery was the patient's valuation of his or her condition supports shared decision making, with its emphasis on patient's values. Participation in other videodisk programs has been low; perhaps physicians should ask patients to view these videodisks before their visits.     

Manufacturers' compliance with the US Food and Drug Administration's Over‐the‐counter Human Drugs: Labeling Requirements

The use of over‐the‐counter (OTC) medications is increasing every year among consumers for symptomatic relief of ailments. Consumers have difficulties in reading and comprehending information on the OTC medication packages. A standardized format to present information on OTC medication packages was necessary; hence the FDA announced guidelines, Over‐the‐counter Human Drugs: Labeling Requirements, on 11 March 1999. Manufacturers have been given 6 years since 1999 to comply with the FDA guidelines. The objective of our study was to evaluate marketed OTC medication packages to determine the extent of adoption of the FDA guidelines by manufacturers. Packages (n ± 104) of OTC medication products from three different categories, viz. pain relievers, cough and cold remedies and stomach remedies, were evaluated for general information, written information and product claims. The Compugraphic point system scale was used to measure the font size of written information. In addition variables recommended by the FDA, such as bullets, paragraphs and hyphenations, were also evaluated. All the variables were coded in a database and analysed using the SAS (Version 8.2) statistical package. The study found that some manufacturers have adopted the FDA guidelines. However, many manufacturers did not implement several aspects of the guidelines. Although manufacturers still have a few more years to adhere to the guidelines, early implementation could benefit the consumers. Copyright © 2003 John Wiley & Sons, Ltd.     

Clinical performance improvement series. Classic CQI integrated with comprehensive disease management as a model for performance improvement.

BACKGROUND: In recent years, health and disease management has emerged as an effective means of delivering, integrating, and improving care through a population-based approach. Since 1997 the University of Pennsylvania Health System (UPHS) has utilized the key principles and components of continuous quality improvement (CQI) and disease management to form a model for health care improvement that focuses on designing best practices, using best practices to influence clinical decision making, changing processes and systems to deploy and deliver best practices, and measuring outcomes to improve the process. Experience with 28 programs and more than 14,000 patients indicates significant improvement in outcomes, including high physician satisfaction, increased patient satisfaction, reduced costs, and improved clinical process and outcome measures across multiple diseases. DIABETES DISEASE MANAGEMENT: In three months a UPHS multidisciplinary diabetes disease management team developed a best practice approach for the treatment of all patients with diabetes in the UPHS. After the program was pilot tested in three primary care physician sites, it was then introduced progressively to additional practice sites throughout the health system. The establishment of the role of the diabetes nurse care managers (certified diabetes educators) was central to successful program deployment. Office-based coordinators ensure incorporation of the best practice protocols into routine flow processes. A disease management intranet disseminates programs electronically. Outcomes of the UPHS health and disease management programs so far demonstrate success across multiple dimensions of performance-service, clinical quality, access, and value. DISCUSSION: The task of health care leadership today is to remove barriers and enable effective implementation of key strategies, such as health and disease management. Substantial effort and resources must be dedicated to gain physician buy-in and achieve compliance. The challenge is to provide leadership support, to reward and recognize best practice performers, and to emphasize the use of data for feedback and improvement. As these processes are implemented successfully, and evidence of improved outcomes is documented, it is likely that this approach will be more widely embraced and that organizationwide performance improvement will increase significantly. CONCLUSIONS: Health care has traditionally invested extraordinary resources in developing best practice approaches, including guidelines, education programs, or other tangible products and services. Comparatively little time, effort, and resources have been targeted to implementation and use, the stage at which most efforts fail. CQI's emphasis on data, rapid diffusion of innovative programs, and rapid cycle improvements enhance the implementation and effectiveness of disease management.