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.     

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.     

Using clinical practice analysis to improve care

BACKGROUND: Improving clinical outcomes requires that physicians examine and change their clinical practice. Sustaining outcome improvements requires a dedicated and dynamic program of analyzing and improving patient care. In 1992 North Mississippi Health Services (NMHS) implemented a program to improve physicians' clinical efficiency. CLINICAL PRACTICE ANALYSIS ( CPA): CPA uses evidenced-based guidelines and examines each physician's resource utilization, processes, and outcomes for a diagnosis or procedure. Clinical practice profiles are developed, and individual performance is compared to local and national benchmarks and presented to physicians. The CPA process is used on its own or as a component of more comprehensive performance improvements projects. Physicians have been engaged in outcome improvement by more than 55 CPA projects. RESULTS: NHMS has progressively reduced its Medicare loss and its length of stay (LOS) to 4.9 days. Mortality and readmission rates have been reduced in specific diagnoses. The community-acquired pneumonia project reduced the LOS from 7.7 to 5.1 days, decreaesed the mortality rate from 8.9% to 5.0%, and decreased the cost of care from $4,269 to $3,834. The ischemic stroke project reduced the aspiration pneumonia rate from 6.4% to 0% and mortality from 11.0% to 4.6%. Patients' average LOS decreased from 10.7 days to 6.5 days, and their cost of care was reduced by $1,100 per patient. DISCUSSION: Providing individualized data has engaged physicians in improving outcomes. The program has evolved from improving efficiency to managing outcomes and from simple CPA projects to integrated performance improvement projects; however, the CPA process remains the cornerstone of the current process.     

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."     

Patient safety and computerized medication ordering at Brigham and Women's Hospital

BACKGROUND: Medications are important therapeutic tools in health care, yet creating safe medication processes is challenging for many reasons. Computerized physician order entry (CPOE), one important way that technology can be used to improve the medication process, has been in place at Brigham and Women's Hospital (BWH; Boston) since 1993. CPOE AT BWH: The CPOE application, designed and developed internally by the BWH information systems team, allows physicians and other clinicians to enter all patient orders into the computer. Physicians enter 85% of orders, with the remainder entered electronically by other clinicians. CPOE AND SAFE MEDICATION USE: The CPOE application at BWH includes several features designed to improve medication safety--structural features (for example, required fields, use of pick lists), enhanced workflow features (order sets, standard scales for insulin and potassium), alerts and reminders (drug-drug and drug-allergy interaction checking), and adjunct features (the pharmacy system, access to online reference information). RESULTS AT BWH: Studies of the impact of CPOE on physician decision making and patient safety at BWH include assessment of CPOE's impact on the serious medication error and the preventable adverse drug event rate, the impact of computer guidelines on the use of vancomycin, the impact of guidelines on the use of heparin in patients at bed rest, and the impact of dosing suggestions on excessive dosing. CONCLUSION: CPOE and several forms of clinical decision support targeted at increasing patient safety have substantially decreased the frequency of serious medication errors and have had an even bigger impact on the overall medication error rate.     

Integrating clinical performance improvement across physician organizations: the PhyCor experience

BACKGROUND: There is a paucity of literature describing the implementation of clinical performance improvement (CPI) efforts across geographically dispersed multispecialty group practices and independent practice associations. PhyCor, a physician management company based in Nashville, Tennessee, has integrated CPI initiatives into its operating infrastructure. PhyCor CPI INITIATIVES: The strategic framework guiding PhyCor's CPI initiatives is built around a physician-driven, patient-centered model. Physician/administrator leadership teams develop and implement a clinical and financial strategic plan for performance improvement; adopt local clinical and operational performance indicators; and agree on and gain consensus with local physician champions to engage in CPI initiatives. The area/regional leadership councils integrate and coordinate regional medical management and CPI initiatives among local groups and independent practice associations. In addition to these councils and a national leadership council, condition-specific care management councils have also been established. These councils develop condition-specific protocols and outcome measures and lead the implementation of CPI initiatives at their own clinics. RESOURCES: Key resources supporting CPI initiatives include information/knowledge management, education and training, and patient education and consumer decision support. PRELIMINARY RESULTS AND OBSERVATIONS: Localized efforts in both the asthma care and diabetes management initiatives have led to some preliminary improvements in quality of care indicators. CRITICAL SUCCESS FACTORS AND CHALLENGES: Physician leadership and strategic vision, CPI-oriented organizational infrastructure, broad-based physician involvement in CPI, providing access to performance data, parallel incentives, and creating a sense of urgency for accelerated change are all critical success factors to the implementation of CPI strategies at the local, regional, and national levels.     

Primary care physicians perceptions and practices regarding fall prevention in adult's 65 years and over

Background

Falls are the leading cause of injury deaths and the most common cause of disability, premature nursing home admissions, medical costs, and hospitalizations among people 65 years and over. Interventions targeting multiple fall risk factors can reduce fall rates by 30–40%. Yet, national studies show that screening conducted by physicians for older adult falls is short of acceptable standards. Tri-County Health Department (TCHD) in Colorado conducted a study to examine fall prevention practices among primary care physicians in our jurisdiction.

Methods

TCHD randomly sampled primary care physicians (n = 100) obtained from a statewide healthcare provider database and surveyed them about fall prevention screening practices and perceived barriers to screening. Data were examined using single and multiple logistic regression analysis.

Results

The response rate was 67.6%. Only 8% of responding physicians based their fall prevention practices on clinical guidelines from any recognized organizations. Frequently reported barriers included a lack of time during visits, more pressing issues, and a lack of educational materials. Physicians who did not accept Medicare (OR 0.163 [CI 0.03–0.84]) remained significantly less likely to refer patients for home safety assessments than those who did, on multivariate analysis.

Conclusions

This study reveals certain physicians require targeted interventions to improve fall prevention practices and use of clinical guidelines. Recommendations include providing physicians with trainings, screening guides, educational materials, environmental/home safety checklists, and referral resources.     

The 1999 ICSI/IHI colloquium on clinical quality improvement--"quality: settling the frontier"

BACKGROUND: A Colloquium on Clinical Quality Improvement, "Quality: Setting the Frontier," held in May 1999, covered methods and programs in clinical quality improvement. Leadership and organizational behavior were the main themes of the breakout sessions; specific topics included implementing guidelines, applying continuous quality improvement (CQI) methods in preventive services and primary care, and using systems thinking to improve clinical outcomes. Three keynote addresses were presented. LEADERSHIP FOR QUALITY: James L. Reinertsen, MD (CareGroup, Boston), characterized the financial challenges faced by many health care organizations as a "clarion call" for leadership on quality. "The leadership imperative is to establish an environment in which quality can thrive, despite unprecedented, severe economic pressures on our health systems." LINKING GROUP AND ORGANIZATIONAL KNOWLEDGE TO IMPROVEMENT STRATEGIES: How do we make improvement more effective? G. Ross Baker, PhD (University of Toronto), reviewed what organizational literature says about making teams more effective, understanding the organizational context to enable improvement work, and augmenting existing methods for creating sustainable improvement. For example, he noted the increasing interest among may organizations in rapid-cycle improvement but cautioned that such efforts may work best where problems can be addressed by existing clinical teams (not cross-functional work groups) and where there are available solutions that have worked in other settings. IMPROVING THE ENVIRONMENT FOR QUALITY: Mark Chassin, MD (Mount Sinai School of Medicine, New York), stated that critical tasks for improving quality include increasing public awareness, engaging clinicians in improvement, increasing the investment in producing measures and improvement tools, and reinventing health care delivery, clinical education and training, and QI.     

Implementing evidence-based recommendations for health care: a roundtable comparing European and American experiences

BACKGROUND: A roundtable held October 5-6 1999, in Maidstone, Kent, United Kingdom, was convened to identify current strategies and ongoing challenges in implementing evidence-based practice guidelines in health care. Despite numerous new medical research findings for improving health care and despite the dissemination of many practice guidelines, the recommendations from these efforts are not being uniformly adopted. Overuse, underuse, and misuse plague the practice of medicine today. IMPLEMENTING GUIDELINES: Multiple implementation strategies are more likely to succeed that a single implementation method; local selection and adaptation of guidelines are critical; and reminders, educational outreach (for prescribing), and interactive educational workshops are generally effective. EXPERIENCE IN EUROPE: In most countries, guideline development has progressed from consensus conference, to evidence-based statements, and finally to evidence-based guidelines that also consider cost-effectiveness. Guideline development is the most advanced in The Netherlands, where physicians have coordinated their efforts with the government to achieve more uniformity than is found elsewhere. EXPERIENCE IN THE UNITED STATES: Designing systems that will facilitate change--not changing physician behavior--should be the focus. The concern for effecting improvement in health care is now more acute because of the increased attention being given to medical errors and patient safety. SUMMARY STATEMENT: Multifaceted approaches are clearly the most important method for improving care. Such approaches may include many improvement methods, none of which work well alone most of the time or any of the time.     

A longitudinal study of performance of physicians' office practices: data from the Peer Assessment Program in Ontario, Canada.

BACKGROUND: The College of Physicians and Surgeons of Ontario has conducted a Peer Assessment Program since 1980. All physicians who turn 70 years of age in a given year are automatically selected for assessment, and the program assesses a random selection of physicians within specific practice and specialty areas. Each assessor--a physician who practices in the same area of medicine as the physician undergoing assessment--reviews the physical facilities, the system of record keeping and the content of approximately 20-30 medical records, and the quality of care provided, as determined by the medical record content and discussions with the physician. The assessed physician is then assigned a grade. In 1998, program records for 109 nonspecialist physicians who had undergone two assessments more than 10 years apart (first assessment, 1981 to 1987; second, 1991 to 1997) were examined to determine possible changes in performance. RESULTS: The mean time between assessments was 12.2 years. Seventy (64.2%) of the 109 physicians showed a decline in grade, whereas 35 (32.1%) received the same grade, and only 4 (3.7%) had an improvement in grade. CONCLUSIONS: This report is consistent with previous observations that performance changes with age. In contrast to previous studies, this report is based on longitudinal rather than cross-sectional data.     

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.     

Physician-hospital partnerships: incentive alignment through shared governance within a performance improvement structure

BACKGROUND: Producing accessible, appropriate, and accountable medical care that improves the health of the populations served requires collaborative physician-organization relationships within which performance measurement across the continuum of care occurs. Governance and shared responsibility for performance improvement (PI) through organizational structure and process have proven to be particularly complex challenges. REDESIGN OF THE PI SYSTEM: The Health Alliance of Central New York, based in Syracuse, New York, which consists in part of Crouse Hospital; ambulatory medical care sites and physicians; a physician organization, a physician-hospital organization, and an independent practice association; in February 1997 established a plan for a redesign of the PI system. IMPLEMENTING THE MODEL: In April 1998 the development of joint performance indicators, the Family of Measures, was undertaken. Recommendations for improvements necessary to correct process failures are referred to the medical staff executive committee and/or the appropriate coordinating committee, which then charges the appropriate service-line PI Council(s) with the responsibility for making those improvements. DISCUSSION: Systemwide PI with collaborative decision making by process stakeholders has been a major cultural transition requiring a degree of organizational readiness. Support of the most senior levels of management is critical. Institutional silos do not support shared, participatory decision making and cannot be overcome without strong support from senior management and in many cases the direct support and involvement of the CEO. Integrating information systems represents a considerable challenge: to find hardware and software that will interface properly to produce desired results, to successfully interface computer support personnel into the PI process, and to ensure the commitment to the financial resources to meet the information system requirements. In addition, meaningful and material reengineering requires substantial physician input. Simply reducing length of stay or cost per case is not an outcome that is by and large a strong motivator for physicians. Projects must have meaning at the level of the individual physician to raise interest and create buy-in. Enduring success will be achieved only through achievement of material and salient improvements (for both physicians and the institution) in combination with careful alignment of physician and institutional incentives.     

Assessing clinical pathways use in a community hospital: it depends on what "use" means

BACKGROUND: Many benefits have been associated with the use of clinical pathways, yet developing them can be costly, and implementing them is not always successful. A 300-bed Midwestern community hospital began a clinical pathways program in 1995, and by fall 1998, 15 pathways were in various stages of implementation, with 3 under development. Many challenges had been encountered, but hospital leaders were eager to find ways to increase pathway use. METHODS: A qualitative case study design was used to investigate four clinical pathways, two perceived as being "used" and two that were perceived as "not used". Each pathway was analyzed as a separate case, followed by cross-case analysis. Qualitative data were collected in 65 semistructured interviews with administrators, physicians, physicians' office staff, nurses, and allied health professionals at the hospital. Data were also collected through observation and document analysis. RESULTS: The two used pathways had been introduced as part of a larger change in care, whereas the two pathways not used had been introduced as stand-alone innovations. Confusing and inadequately developed aspects of the hospital's clinical pathways program included its purposes, the definition of pathway use, pathway procedures, accountability, education, and incentives. A new case management department, ongoing administrative support, and a sophisticated medical information system were viewed as supports for continued growth in the program. CONCLUSIONS: Implementation of clinical pathways was delayed and complicated by the varied perceptions of the program among stakeholders. Lack of clarity and consistency in how information about the program was communicated made it difficult for clinicians to develop a shared understanding of clinical pathways.     

Designing an intervention to improve the management of Helicobacter pylori infection

BACKGROUND: An intervention to improve the testing and treatment of Helicobacter pylori (HP) in patients receiving chronic acid suppression (AS) therapy was developed at Harvard Pilgrim Health Care (HPHC), a mixed-model not-for-profit health maintenance organization. METHODS: Ten full-time primary care physicians (4 staff model and 6 group practice) were interviewed in 1999 about their knowledge, attitudes, and practice regarding dyspepsia, the use of chronic AS drugs, and approaches to HP infection, as well as about the feasibility and acceptability of various potential interventions that might be used in a quality improvement program. RESULTS: Self-reported practice regarding dyspepsia and HP infection were relatively uniform, and physicians were generally aware of current recommendations. Three common misperceptions acted as barriers to optimal HP management: Untreated HP was not considered an important problem; patients who used drugs for chronic AS rarely had HP infection; and chronic use of AS drugs was considered effective and without adverse consequence. All physicians wanted brief educational materials with explicit guidelines, preferably locally adapted and endorsed by local experts. All informants agreed that the main barrier to successful QI interventions was the requirement for any extra time or effort, particularly when directed at populations of patients who do not have symptomatic complaints. DISCUSSION: The interviews revealed the many barriers to improving the management of HP infection and to targeting educational messages and tailoring different methods for facilitating practice change across different managed care settings. Evidence-based components of the intervention program include physician education, a notification/reminder system, and practice-based tools to facilitate change and minimize workload.     

Medical Outcomes Trust Conference presents dramatic advances in patient-based outcomes assessment and potential applications in accreditation

BACKGROUND: At its fourth annual State-of-the-Art Health Outcomes Conference, November 2, 1998, the Medical Outcomes Trust (Boston) convened experts to review advances in outcomes assessment technology and potential applications in clinical trials, clinical practice, and accreditation. KEYNOTE ADDRESS: "Future Directions in Health Status Assessment" identified what needs to happen next in order to put patient-defined outcomes into the databases used in medical decision making. Advances include a major recalibration of the SF-36 and SF-12 instruments from the Medical Outcomes Study (MOS) offering new norm-based scoring and the new methodology known as Dynamic Health Assessment (DynHA), which uses a computerized interactive process to select questions to produce a briefer but more precise assessment. CHOOSING COMPUTER SOFTWARE: A detailed needs assessment should be made and submitted to vendors to identify the best software for outcomes management in a particular organization. OUTCOMES IN CLINICAL TRIALS: Scientific and regulatory requirements differ between clinical trials and clinical practice, as seen in health status measurement of pain (migraine and osteoarthritis) and in antiretroviral therapies for patients with HIV (human immunodeficiency virus) disease. OUTCOMES ASSESSMENT IN SPECIFIC DISEASES: Similarities and distinctive challenges are identified in outcomes measurement of depression, low back pain, and congestive heart failure. OUTCOMES IN ACCREDITATION: Efforts are ongoing in integrating outcomes measures into the accreditation process for physicians, health care organizations, and health care plans. HEALTH OF SENIORS/MEDICARE HEALTH OUTCOMES SURVEY (HOS): The Health Care Financing Administration is unrolling the first patient-based outcomes measure to assess the quality of care provided to the Medicare population in managed care organizations.     

A practical approach to evidence grading

BACKGROUND: The Institute for Clinical Systems Improvement (ICSI) is a collaboration of 17 Minnesota medical groups. Among other activities, ICSI develops health care guidelines and technology assessment reports. To maintain focus on the underlying evidence, ICSI has developed an evidence and conclusion grading system for use by the practicing clinicians who write the documents and use them in making decisions about patient care. THE EVIDENCE GRADING SYSTEM IN DETAIL: The centerpiece of the evidence grading system is the conclusion grading worksheet, which calls for statement of a conclusion, summarization of research reports that support or dispute the conclusion, assignment of classes and quality markers to the research reports, and assignment of a grade to the conclusion. EXPERIENCE AND RESULTS: The system has been used in the writing of more than 40 guidelines and numerous technology assessment reports. An example of a worksheet from the congestive heart failure guideline is presented. The system has helped the drafting groups to attend to the evidence. The methods have proven to be well accepted by practicing physicians and to be practical, although staff expertise in epidemiology is needed to support the system. Grading of conclusions appears to be reliable, although this characteristic of the system has not been rigorously tested. The outputs are valued by users of the documents. DISCUSSION: Although some residual problems remain to be solved, the system appears to be successful in overcoming the complexity of some published systems for grading evidence while still yielding a defensible classification of conclusions based on the strength of the underlying evidence.     

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.     

Using performance measures to identify plans of action to improve care.

BACKGROUND: Health care organizations dedicate enormous time and resources collecting data to measure the performance of physicians, hospitals, and other medical facilities. These measures may reflect outcomes, processes of care, patient perceptions of the quality of care, and resource utilization and cost. However, less thought is given to how the performance data should be used to improve care. The data must be translated into clinically relevant terms that assess the decisions of the clinical staff and the functioning of the systems that support the delivery of care. The processes of care are identified through record review, analysis of the system of care delivery, and patient interview, and are then further assessed to determine the underlying causes. EXAMPLES: Examples, drawn from case studies, are provided to illustrate how to identify and address components of care requiring improvement. DISCUSSION: Physician behavior is an important component of care in all performance measures. Modification of some patterns of behavior, including those of nursing and other support staff, may be needed to reduce some types of error. For this reason it is important to involve physicians in the process of discovering root causes. When the root cause involves the medical care system, an interdisciplinary approach will be needed. This may involve administrators, nurses, pharmacists, home care and discharge planners, and office personnel. One recommended approach to QI is to identify system errors and then design changes in the system to reduce that type of error. CONCLUSION: Performance measures must be translated into the components(s) of care that are implicated in the measure. Once this component has been identified as the reason behind the suboptimal measure, its root cause should be used to structure the most effective intervention.     

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.