Pursuing perfection: an interview with Don Berwick and Michael Rothman. Interview by Andrea Kabcenell and Jane Roessner

Don Berwick and Michael Rothman discuss the Pursuing Perfection initiative, which is intended to help health care organizations integrate improvement work into day-to-day life, with systemwide changes in infrastructure, project management, care, and leadership.     

Expanding a performance improvement initiative in critical care from hospital to system

BACKGROUND: Concern about the expense and effects of intensive care prompted the development and implementation of a hospital-based performance improvement initiative in critical care at North Shore University Hospital, Manhasset, New York, a 730-bed acute care teaching hospital. THE HOSPITAL-BASED PERFORMANCE IMPROVEMENT INITIATIVE IN CRITICAL CARE: The initiative was intended to use a uniform set of measurements and guidelines to improve patient care and resource utilization in the intensive care units (ICUs), to establish and implement best practices (regarding admission and discharge criteria, nursing competency, unplanned extubations, and end-of-life care), and to improve performance in the other hospitals in the North Shore-Long Island Jewish Health System. In the medical ICU, the percentage of low-risk (low-acuity) patients was reduced from 42% to 22%. ICU length of stay was reduced from 4.6 days to 4.1 days. IMPLEMENTING THE CRITICAL CARE PROJECT SYSTEMWIDE: A system-level critical care committee was convened in 1996 and charged with replicating the initiative. By and large, system efforts to integrate and implement policies have been successful. The critical care initiative has provided important comparative data and information from which to gauge individual hospital performance. DISCUSSION: Changing the critical care delivered on multiple units at multiple hospitals required sensitivity to existing organizational cultures and leadership styles. Merging organizational cultures is most successful when senior leadership set clear expectations that support the need for change. The process of collecting, trending, and communicating quality data has been instrumental in improving care practices and fostering a culture of safety throughout the health care system.     

The organizational costs of preventable medical errors

BACKGROUND: Preventable medical errors are associated with additional costs that tend to be borne by patients, but little is known about organizational costs associated with such errors. Two composite case studies (a fall and a delay in diagnosis) were used to identify the organizational costs of preventable medical errors. ANALYSIS: Legal, marketing, and organizational costs--direct, indirect, and long term--were associated with each of the preventable medical errors. A model was generated to examine the theoretical relationship between the costs and four determinants of corporate performance--price, wages, cost of capital, and efficiency. DISCUSSION: Organizations may also have a financial incentive to improve patient safety, for beyond patient and societal costs, preventable medical errors appear to account for significant legal, marketing, and operational costs for the organizations that deliver health care. Some of these costs are not so much the cost of the error but the costs of organizational responses to the error. Three broad areas of inquiry could be used to test the model and improve our understanding of the organizational costs of errors: market response to patient safety interventions, before/after studies of interventions, and case-control studies. SUMMARY AND CONCLUSION: Health care leaders have a moral imperative to implement systems that reduce medical errors and improve patient safety. An understanding of the costs associated with medical errors may help leaders understand the importance of patient safety from a financial perspective, develop measures to evaluate the impact of patient safety initiatives, and efficiently allocate resources to address this important health concern.     

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.     

Developing partnerships among patients, families, and staff at the Medical College of Georgia Hospital and Clinics

BACKGROUND: The initiative of the Medical College of Georgia (MCG) Hospital and Clinics in patient/family-centeredness began with the inpatient pediatric units. As plans were being made for a separate, dedicated children's medical center, patient/family-centered care was chosen as the new model of care delivery. MCG began to adopt the model for the adult hospital and the other clinical sites in 1996. USE OF PATIENT FEEDBACK: Multiple strategies were developed, including the formation of advisory councils, to elicit information from and build relationships with patients and families. Since 1996 patients and family members have been involved in facility design planning for various adult services. A broad-based community advisory committee helped in the planning for a freestanding community-based Center for Senior Health. Patients and family members were also involved in the planning of the redesign process for the preoperative evaluation and ambulatory surgery waiting areas. More recently, focus groups of patients and families were convened to address the design and facility planning for two additional areas of the hospital: the family waiting areas for the specialized care centers (four of the critical care areas) and the outpatient cardiology services area. Patient and family input has also been used to evaluate and change care practices, for example, in the unit and bed assignments made for living-related kidney transplant donors and recipients. FUTURE DIRECTIONS: MCG Hospital and Clinics continue to use the patient satisfaction survey process and multiple advisory groups. The next phase of implementation will focus on further education and training of staff.     

The AMA clinical quality improvement forum on addressing patient safety

BACKGROUND: More than 200 health care policy makers and researchers, clinicians, quality professionals, and other representatives of health care organizations, government, and academia attended the Division of American Medical Association Clinical Quality Improvement's conference, "Addressing Patient Safety," April 28, 2000, in Chicago--the first national conference to respond to the recent Institute of Medicine (IOM) report, To Err Is Human: Building a Safer Health System. ADDRESSING PATIENT SAFETY--PUBLIC AND PRIVATE PERSPECTIVES: John M. Eisenberg, MD, stated that research on errors is needed to describe the scope and nature of the problem, understand the barriers to and benefits of improvement, and develop and test strategies for improvement. Kenneth W. Kizer, MD, MPH, stated that the National Quality Forum will develop a compendium of best practices and will develop core measures for serious adverse events, and health care organizations and government health programs should act now to make a clear organizational commitment to patient safety, create a nonpunitive health care culture of safety, and implement known safe medication practices. Alan R. Nelson, MD, stated that the IOM report places its emphasis on continuous quality improvement and technology that can be used to mitigate the risks in a complex health system. HOSPITAL AND ACCREDITATION AGENCY ACTIVITIES ON PATIENT SAFETY ISSUES: Donald M. Nielsen, MD, discussed the American Hospital Association's (AHA's) Medication Safety Initiative, which promised to provide its members with successful practices, tools, and resources and to track progress of implementation of the recommended successful practices. Dennis S. O'Leary, MD, stated that when a hospital reports a sentinel event, the hospital is expected to implement improvements to reduce risk and monitor their effectiveness. The National Committee for Quality Assurance is considering changes to its accreditation standards to further address patient safety.     

Developing a systemwide approach to patient safety: the first year

BACKGROUND: Health care organizations face an imperative to ensure that care is provided to patients in the safest manner possible. In 2000 INTEGRIS Health, an Oklahoma City-based health system including ten acute care organizations, developed a patient safety framework that was built on the foundation of a culture of patient safety and began implementation in January 2001. IMPORTANCE OF LEADERSHIP IN PATIENT SAFETY: The first step in establishing a culture of safety was to ensure that leadership and the entire organization understand the rationale for a focus on patient safety. The traditional blaming approach will not prevent human error; staff need to speak freely, to talk about errors that happen and those that almost happen, and to identify where mistakes are likely and where systems allow mistakes to get through. Systems and processes should make it difficult for staff to make mistakes and easy for them to do things correctly. EXPERIENCE TO DATE: Since our efforts began, staff have helped identify multiple accidents waiting to happen. For example, an anesthesiologist, the service chief at one of our large hospitals, prepared a list of safety issues immediately after hearing a presentation to the Medical Executive Committee. Many system flaws have been identified as a result of our discussions; some of the solutions are easy and some much more complex. CHALLENGES: Challenges include keeping patient safety highly visible and demonstrating progress in our implementation, developing effective mechanisms for communicating safety solutions and ensuring that they are implemented in all the facilities, and figuring out how to measure success in a meaningful way.     

Effecting and leading change in health care organizations

BACKGROUND: Understanding change is crucial to implementing quality improvement (QI) initiatives. Widespread change will be required to correct what many consider to be outmoded and deficient systems of care. This article summarizes the current literature--within both health care and the fields of business and management--regarding how change occurs at the individual and organizational levels. Part 1 focuses on changing clinician behavior, which is instrumental to any effort directed in the health care setting. Part 2 examines the culture of change. Part 3 addresses issues of leadership, along with the necessary steps to guide change in an organization. Part 4 summarizes key elements of change. Finally, Part 5 provides three case examples of QI initiatives reported in the recent literature to illustrate how the application of the knowledge of change management can assist in the successful implementation of QI programs. KEY ELEMENTS OF CHANGE: The knowledge base regarding successful change in health care organizations can be summarized in eight crucial strategies or principles: (1) develop a vision for change, (2) focus on the change process, (3) analyze which individuals in the organization must respond to the proposed change and what barriers exist, (4) build partnerships between physicians and the administration, (5) create a culture of continuous commitment to change, (6) ensure that change begins with leadership, (7) ensure that change is well communicated, and (8) build in accountability for change. CONCLUSION: A knowledge of change management can help leaders of QI programs in health care organizations successfully apply these concepts to bring about much-needed transformations in health care.     

Safety culture and accident analysis--a socio-management approach based on organizational safety social capital

One of the biggest challenges for organizations in today's competitive business environment is to create and preserve a self-sustaining safety culture. Typically, the key drivers of safety culture in many organizations are regulation, audits, safety training, various types of employee exhortations to comply with safety norms, etc. However, less evident factors like networking relationships and social trust amongst employees, as also extended networking relationships and social trust of organizations with external stakeholders like government, suppliers, regulators, etc., which constitute the safety social capital in the Organization—seem to also influence the sustenance of organizational safety culture. Can erosion in safety social capital cause deterioration in safety culture and contribute to accidents? If so, how does it contribute? As existing accident analysis models do not provide answers to these questions, CAMSoC (Curtailing Accidents by Managing Social Capital), an accident analysis model, is proposed. As an illustration, five accidents: Bhopal (India), Hyatt Regency (USA), Tenerife (Canary Islands), Westray (Canada) and Exxon Valdez (USA) have been analyzed using CAMSoC. This limited cross-industry analysis provides two key socio-management insights: the biggest source of motivation that causes deviant behavior leading to accidents is ‘Faulty Value Systems’. The second biggest source is ‘Enforceable Trust’. From a management control perspective, deterioration in safety culture and resultant accidents is more due to the ‘action controls’ rather than explicit ‘cultural controls’. Future research directions to enhance the model's utility through layering are addressed briefly.     

Microsystems in health care: Part 1. Learning from high-performing front-line clinical units

BACKGROUND: Clinical microsystems are the small, functional, front-line units that provide most health care to most people. They are the essential building blocks of larger organizations and of the health system. They are the place where patients and providers meet. The quality and value of care produced by a large health system can be no better than the services generated by the small systems of which it is composed. METHODS: A wide net was cast to identify and study a sampling of the best-quality, best-value small clinical units in North America. Twenty microsystems, representing different component parts of the health system, were examined from December 2000 through June 2001, using qualitative methods supplemented by medical record and finance reviews. RESULTS: The study of the 20 high-performing sites generated many best practice ideas (processes and methods) that microsystems use to accomplish their goals. Nine success characteristics were related to high performance: leadership, culture, macro-organizational support of microsystems, patient focus, staff focus, interdependence of care team, information and information technology, process improvement, and performance patterns. These success factors were interrelated and together contributed to the microsystem's ability to provide superior, cost-effective care and at the same time create a positive and attractive working environment. CONCLUSIONS: A seamless, patient-centered, high-quality, safe, and efficient health system cannot be realized without the transformation of the essential building blocks that combine to form the care continuum.     

Applying quality improvement principles to achieve healthy work organizations

BACKGROUND: Health care has used total quality management (TQM)/quality improvement (QI) methods to improve quality of care and patient safety. Research on healthy work organizations (HWOs) shows that some of the same work organization factors that affect employee outcomes such as quality of life and safety can also affect organizational outcomes such as profits and performance. An HWO is an organization that has both financial success and a healthy workforce. For a health care organization to have financial success it must provide high-quality care with efficient use of scarce resources. To have a healthy workforce, the workplace must be safe, provide good ergonomic design, and provide working conditions that help to mitigate the stress of health care work. INTEGRATING TQM/QI INTO THE HWO PARADIGM: If properly implemented and institutionalized, TQM/QI can serve as the mechanism by which to transform a health care organization into an HWO. To guide future research, a framework is proposed that links research on QI with research on HWOs in the belief that QI methods and interventions might be an effective means by which to create an HWO. Specific areas of research should focus on identifying the work organization, cultural, technological, and environmental factors that affect care processes; affect patient health, safety, and satisfaction; and indirectly affect patient health, safety, and satisfaction through their effects on staff and care process variables. SUMMARY: Integrating QI techniques within the paradigm of the HWO paradigm will make it possible to achieve greater improvements in the health of health care organizations and the populations they serve.     

John M. Eisenberg Patient Safety Awards. System innovation: Concord Hospital

BACKGROUND: The Cardiac Surgery Program at Concord Hospital (Concord, NH) restructured clinical teamwork for improved safety and effectiveness on the basis of theory and practice from human factors science, aviation safety, and high-reliability organization theory. A team-based, collaborative rounds process--the Concord Collaborative Care Model--that involved use of a structured communications protocol was conducted daily at each patient's bedside. METHODS: The entire care team agreed to meet at the same time each day (8:45 AM to 9:30 AM) to share information and develop a plan of care for each patient, with patient and family members as active participants. The cardiac surgery team developed a structured communications protocol adapted from human factors science. To provide a forum for discussion of team goals and progress and to address system-level concerns, a biweekly system rounds process was established. RESULTS: Following implementation of collaborative rounds, mortality of Concord Hospital's cardiac surgery patients declined significantly from expected rates. Satisfaction rates of open heart patients scores were consistently in the 97th-99th percentile nationally. A quality of work life survey indicated that in every category, providers expressed greater satisfaction with the collaborative care process than with the traditional rounds process. Practice patterns in the Cardiac Surgery Program at Concord Hospital have changed to a much more collaborative and participatory process, with improved outcomes, happier patients, and more satisfied practitioners. A culture of continuous program improvement has been implemented that continues to evolve and produce benefits.     

Reducing adverse drug events: lessons from a breakthrough series collaborative

BACKGROUND: In January 1996, 38 hospitals and health care organizations (for a total of 40 hospitals) in the United States came together in an Institute for Healthcare Improvement (IHI; Boston) Breakthrough Series collaborative to reduce adverse drug events-injuries related to the use or nonuse of medications. METHODS: The participants were taught the Model for Improvement, a method for rapid-cycle change and evaluation, and were then coached on how to identify their own problem areas and develop changes in practice for rapid-cycle testing. These changes could be implementation of one or more known medication error prevention practices or new practices developed. RESULTS: During a 15-month period the 40 hospitals conducted a total of 739 tests of changes. Process changes accounted for 63% of the cycles; the remainder consisted of preliminary data gathering, consensus-building, or education cycles. Eight types of changes were implemented by seven or more hospitals, with a success rate of 70%. These changes included non-punitive reporting, ensuring documentation of allergy information, standardizing medication administration times, and implementing chemotherapy protocols. DISCUSSION: Success in making significant changes was associated with strong leadership, effective processes, and appropriate choice of intervention. Successful teams were able to define, clearly state, and relentlessly pursue their aims, and then chose practical interventions and moved early into changing a process. They did not spend months collecting data before beginning a change. Changes that were most successful were those that attempted to change processes, not people. Health care organizations committed to patient safety need not regard current performance limits as inevitable.     

Information technology strategy for a patient-oriented,lean, and agile integration of hospital pharmacy and medical equipment supply chains

Both public and private hospitals are increasingly under pressure to reduce costs while improving patient care across all medical disciplines and departments. Hospitals must become patient-oriented, lean, and agile in order to properly realign and integrate health care processes, helping to reconcile efficiency imperatives with patient needs and hospital mission. One of the highest potential for improvement can be found in supply chain management (SCM) practices for medical supplies, which often represent more than 40% of a hospital’s operating budget. We report on 3 case studies of business process management and reengineering projects, relying on advanced information technology, focused on the supply chains of two major urban hospitals, involving $2 million in minimum stocks for drug inventory. Case study 1 deals with an in-depth analysis of SCM practices around a key medical asset in pharmaceutical supply, i.e. infusion pumps. Case study 2 builds upon the findings of case 1, and proposes an radio-frequency identification solution to support a new hospital-wide asset location process and system, aiming for just-in-time availability of infusion pumps for critical drugs administration. Case study 3 complements cases 1 and 2 by analysing the feasibility of integrating the various components of the hospital pharmacy inventories, which in turn could be integrated to asset location systems. Our 3 case studies lead us to a number of conclusions on how hospitals can develop a patient-oriented, agile, and lean perspectives and practices, as well as ensure the proper integration of patient needs within optimised supply chains.     

Conference report. Measuring and improving the quality of care in health plans.

BACKGROUND: More than 200 health care policymakers and researchers, clinicians, quality professionals, and other representatives of managed care organizations, government, and academia, attended the fifth annual Building Bridges conference, "The Health Care Puzzle: Using Research to Bridge the Gap Between Perception and Reality," in Chicago, April 11-13, 1999. Sponsored by the American Association of Health Plans and the Agency for Health Care Policy and Research--and now, the Centers for Disease Control and Prevention--these annual conferences are intended to promote research in measuring the quality and effectiveness of the services health plans provide. Selected plenary sessions from the conference are represented in this report. KEYNOTE ADDRESS: "Three worthy objectives" for managed care-harmonize practice guidelines, develop evidence-based copays or price structure for drugs, and demystify medical necessity--were discussed. PLENARY: A POPULATION HEALTH PERSPECTIVE: Population-based care is designed to identify effective clinical and service interventions and ensure their efficient delivery, identify ineffective interventions and minimize their use, and monitor outcomes and change practice if outcomes are suboptimal. Yet certain questions need to be asked about how to put this strategy in place, especially Why should any individual or potential patient be willing to be treated in a population-based delivery system? THE FINANCIAL AND SCIENTIFIC EVIDENCE BEHIND PREVENTION: The concepts of scientific evidence and financial evidence for prevention were reviewed and applied in scenarios of the effectiveness and cost-effectiveness of selected preventive care services. Education efforts are needed to promote the use of effective interventions and encourage questioning of interventions with unproven or less important effectiveness and poor cost-effectiveness.     

Quality improvement initiatives in Brazil: a progress report.

BACKGROUND: In 1994 Brazil's Ministry of Health (MOH) introduced a program to provide a supporting environment for quality improvement (QI) initiatives. Yet the five-track QI strategy, which included moving toward outcome indicators, establishing a national accreditation program, emphasizing QI tools, establishing basic clinical guidelines, and enhancing community control, was discontinued in 1998, following the dismissal of the minister of health. The QI program retained only its accreditation activities. ACCREDITATION: The Consortium for Brazilian Accreditation (CBA) began in 1994 to establish an accreditation process compatible with international initiatives. Both the MOH and the CBA have developed standards for hospitals. The Brazilian Manual for the Accreditation of Hospitals is available on the Internet. The CBA has developed a set of standards by adapting the 1996 hospital standards from the Joint Commission on Accreditation of Healthcare Organizations. To developing CBA's role as an accrediting organization, administrative and technical supporting structures were created within the Cesgranrio Foundation and a Joint Commission for Accreditation was established. QUALITY MANAGEMENT INITIATIVES: A growing number of hospitals, clinical laboratories, blood banks, health plans, and other health care services and organizations are seeking International Organization for Standardization (Geneva) certification. Consulting firms in the field of quality management continue to increase the number of their clients in the health sector. CONCLUDING REMARKS: Current QI initiatives represent only a minority of health care services and organizations in the country. Strong efforts need to be made by both the private and public sectors to expand such initiatives throughout Brazil.     

The failure of a controlled trial to improve depression care: a qualitative study.

BACKGROUND: The DIAMOND Project (Depression Is A MANageable Disorder), a nonrandomized controlled effectiveness trial, was intended to improve the long-term management of depression in primary care medical clinics. The project tested whether a quality improvement (QI) intervention could implement a systems approach-so that there would be more reliable and effective monitoring of patients with depression, leading to better outcomes. THE QUALITATIVE STUDY: A study was conducted in 1998-2000 to determine why a quality improvement intervention to improve depression care did not have a significant impact. Data consisted of detailed notes from observations of 12 project-related events (for example, team meetings and presentations) and open-ended interviews with a purposive sampling of 17 key informants. Thematic analytic methods were used to identify themes in the contextual data. PRINCIPAL FINDINGS: Overall, the project implementation was very limited. Five themes emerged: (1) The project received only lukewarm support from clinic and medical group leadership. (2) Clinicians did not perceive an urgent need for the new care system, and therefore there was a lack of impetus to change. (3) The improvement initiative was perceived as too complex by the physicians. (4) There was an inherent disconnect between the commitment of the improvement team and the unresponsiveness of most other clinic staff. (5) The doctor focus in clinic culture created a catch-22 dilemma-the involvement and noninvolvement of physicians were both problematic. CONCLUSION: Problems in both predisposing and enabling factors accounted for the ultimate failure of the DIAMOND quality improvement effort.     

Providing the right infrastructure to lead the culture change for patient safety

BACKGROUND: In early 2000 the hospital leadership of Good Samaritan Hospital (GSH), a community teaching hospital in Dayton, Ohio, made patient safety a strategic priority and devoted resources to incorporate safety as a part of the hospital's culture and care processes. The vice president of clinical effectiveness and performance improvement, as a champion for safety, led a consensus-building effort to enlist the support of key physician and hospital leaders to a safety program. GSH added a Safety Board to its administrative infrastructure, which was to serve as an oversight body to ensure the advance of the safety program and to produce policies and procedures that are associated with safety. ADDRESSING PATIENT SAFETY AIMS: To assess GSH's progress toward achieving three aims--demonstrate patient safety as a top leadership priority, promote a nonpunitive culture for sharing information and lessons learned, and implement an integrated patient safety program throughout the organization--the Safety Board evaluates GSH's performance bimonthly, using a 5-point-scaled self-assessment tool. For example, for the third aim, the Safety Board oversaw the formation of three subcommittees, which were to test ideas and achieve improvements in three areas--medication, clinical, and environmental. DISCUSSION: The administrative structure provides the leadership and momentum necessary to fuel a cultural change in the way that patient safety issues are perceived and acted on throughout the organization. "To err" may be human, but so is the ability to increase patient safety awareness, to promote cultural change within existing systems, and to improve the patient care processes and outcomes.     

Inherent safety, ethics and human error

A patient is to have the damaged left kidney removed. To safeguard correctness of action several layers of expert checks have been performed prior to the operation, which results in the removal of the fully functional right kidney. Nobody asked the patient. The patient did not volunteer providing “unnecessary” information. The experts know everything …

An untidy house made out of flammable materials. A careless smoker left his lit cigarette unattended. A blow of wind and the house comes in flames. Would better construction materials have prevented the accident in spite of the carelessness of the inhabitant

A tricky medical condition which is expected to provoke a patient's fast health deterioration and their slow death. The doctor takes the initiative and responsibility of performing a risky operation. The patient's life is saved and their health is re-established.

This work is not, as initially intended, the result of a thorough investigation of accidents, neither contains a systematic collection of data that can support the conclusions or the suggestions made. It is in the main a compilation of personal views. These views have been established from the correlation of the results of numerous accident investigation reports with the causes of small and insignificant incidents. These incidents are related with the education of university students, regulations within an academic environment and from independent personal experience working in different countries and with people of different cultures. The analysis that follows, however, should not be perceived as a mere reference to university students and/or to a university environment. University is the place where the fundamental scientific and engineering principles are germinated while current and past university students are the future and current production and design engineers, respectively. The places where the presented incidents have occurred are not always relevant with the conclusions, thus they are not stated. The reason this article is presented here is that I believe that often, complex accidents, similarly to insignificant ones, often demonstrate an attitude which can be characterized as “inherently unsafe”. I take the view that the enormous human potential and the human ability to minimize accidents needs to become a focal point towards inherent safety. Restricting ourselves to human limitations and how we could “treat” or prevent humans from not making accidents needs to be re-addressed.

The purpose of this presentation is to highlight observations and provoke a discussion on how we could possibly improve the understanding of safety related issues. I do not intent to reject or criticize existing methodologies. (The entire presentation is strongly influenced by Trevor Kletz's work although our views are often different.)     

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.