Quality improvement in primary care clinics

BACKGROUND: Case studies from Project IMPROVE, the first randomized controlled trial to evaluate the effectiveness of continuous quality improvement (CQI) in primary care, were subjected to a qualitative analysis. Three questions were addressed: How does change in the health care environment affect a quality improvement (QI) process? How does clinic organization influence a QI process? and What is the impact of a QI process on clinic organization? METHOD: Case studies were conducted in 6 clinics that had been randomly selected from the 22 clinics participating in the IMPROVE intervention. The case study data consisted of observations of CQI team meetings, open-ended interviews with 30 informants (team members plus others in the clinics), interviews with IMPROVE consultants, and documentation from the project. The data were analyzed to identify themes and generate concepts, assess and compare the informants' experiences, and develop a conceptual framework stimulated by research and theory literature. RESULTS: Change and uncertainty in the health care environment both complicated the QI process and motivated participation in improvement. The smaller clinics appeared to have more difficulty with the QI process because of limited resources and lack of compatibility between the QI approach and their clinic organization. Project IMPROVE had two qualitative effects on clinics: increased awareness of preventive services and application of the CQI method to other problems and issues. CONCLUSION: QI initiatives can help clinics adapt to a changing health care environment and create functioning teams or groups that can address a variety of organization problems and tasks. The process should be flexible to accommodate varying organization structures and cultures.     

Occupational stress and health care use

This study investigated the relationship between health care use and (a) stressful work events; (b) strain; (c) social support; (d) type of job and industry; and (e) the individual characteristics of control, commitment, and length of time in position. A sample of 260 individuals (95 men, 165 women) from two different industries was used. Correlational analyses suggested that health care claims and costs were positively related to stressful work events and strain and negatively related to employees' length of time in position. Industry type also played a role in predicting the health care variables. Multivariate analyses suggested that environmental, stressor, and strain variables accounted for up to 16% of the variance in health care costs and 21.5% of the variance in number of health care claims.     

Cooperative health care clinics: a group approach to individual care

In cooperative health care clinics (CHCC), health care is provided to older patients in a group setting. The CHCC concept, which was developed under a research grant by Kaiser Permanente in Colorado in 1991, showed improvement in patient and provider satisfaction, as well as improved quality of care and cost effectiveness. CHCC are being replicated in other sites under a research grant from the Robert Wood Johnson Foundation. In addition to formal findings from research studies, much has been learned about factors that have promoted the success of the program.     

Medical records audit in primary care clinics of the Israel Navy

The primary care clinics of the Israeli Defense Forces are similar to those of the civilian health system, yet some characteristics are unique: Soldiers are a young, healthy population; their physicians are either serving in the reserves for short periods, or are primary care physicians of the regular army; and during military service the soldier is usually treated in several different primary care clinics. A detailed medical record facilitates communication between the various primary care physicians. As part of a 2-year quality assurance project all naval clinics in Israel were surveyed at 6-month intervals. From the clinic records, 685 encounters involving the 7 most common problems were randomly chosen. We evaluated the quality of the medical records of these encounters scoring them according to subjective, objective assessment and therapeutic and evaluative plan (SOAP) Each record was evaluated by 2 physicians and scored from 0 to 100, using fixed criteria. The score for the therapeutic and evaluative plan was significantly higher than that of the other parts of the medical record (80% vs. 55-59%, p < 0.001). The score of the primary care physicians was significantly higher than that of physicians of the reserves (73% vs. 63%, p < 0.001). Encounters involving upper respiratory tract infections and abdominal pain scored higher than those involving other common problems. The medical recording process has a fundamental role in medical care. Our findings suggest that the subjective, objective and assessment parts of naval medical records need improvement. Further studies might help improve the quality of primary medical care.     

Occupational asthma due to latex in health care workers

Immediate hypersensitivity reactions ranging from mild urticaria to life threatening anaphylaxis after exposure to natural rubber latex have been reported frequently in health care workers while occupational asthma due to latex exposure is less well studied. The results of specific challenge tests and immunological tests in four health care workers with work related respiratory and skin disorders induced by the use of latex gloves are described. Occupational asthma was confirmed in three subjects by specific challenge tests. All had a positive skin test reaction to the latex extract; specific IgE antibodies were detected in only one subject. The fourth subject had a negative specific inhalation and skin test reaction to the latex extract. Peak expiratory flow monitoring at work and away from work showed a pattern consistent with work related asthma. These findings confirm that latex is a cause of occupational asthma in health care workers.     

Mental health facilitators in primary care

In the context of the National Primary Care Facilitation Programme, the Sainsbury Centre for Mental Health has reviewed the membership of the Mental Health in Primary Care Network, and explored members' roles; the findings of the review are reported in this article. Researchers examined the activities undertaken by network members, and identified the proportion working directly with primary health care teams and those working strategically within health authorities. Education and training, health promotion, and liaison and linkworking were undertaken by many staff, while a few worked at a more strategic level. In order to increase the effectiveness of this model, a more focused approach is recommended, targeting those with responsibility for implementing changes and developing mental health care in primary care settings. Learning sets which involve primary care and mental health teams, and strategic work with health authorities, are also recommended.     

Epidemiology and primary health care

University departments of epidemiology and primary medical care have tended to develop separately because they require very different skills. The Department of Community Medicine at St. Thomas's Hospital Medical School, London, is an example of a harmonious, combined development of the two disciplines. Working as a multidisciplinary team, the department has conducted studies initiated by epidemiologists, primary physicians and the interaction of the two. Examples are given from past and current research of the department. Through mutual cooperation the scientific knowledge of the epidemiologist and the down-to-earth practical knowledge of the clinician have complemented each other to produce valid research of practical relevance. The association has also provided educational facilities for medical students for whom, as physicians, protocol thinking, analysis and questioning of accepted "facts" will become increasingly important.     

Automatic data processing in primary health care

Norwegian general practitioners are installing computers in their offices at an increasing rate. More than half of them now run their practice using electronic journals and electronic exchange of information with hospitals, pharmacies etc. There is wide interest among colleagues in the development of new software approaches and packages for running the office. At present, this development is marked by creativity and competitiveness. In fact, Norway has become a market leader within GP-software exporting as far as to Australia. In this article, the seven packages currently available are described by experienced users, and compared from a technical point of view.     

Work satisfaction of health personnel in primary care

OBJECTIVE: To determine the level of work satisfaction of health professionals working in Primary Care and to establish the social, demographic and professional factors which determine it. DESIGN: An observational, crossover study using a self-administered questionnaire. SETTING: Primary Care. PARTICIPANTS: All the doctors and nurses working in the Primary Care teams in the Albacete Health Area (468 in all). MEASUREMENTS AND MAIN RESULTS: The scale of work satisfaction of health professionals in Primary Care teams was used. Social, demographic and professional data were collected. 9 dimensions or components of work satisfaction were identified through a factorial analysis. The lowest scores were for motivation, opportunities for professional development and coordination with specialists. CONCLUSIONS: The findings show, in general, indifference as to work satisfaction or lack of it in areas such as motivation and opportunities for professional development. The differences observed in those polled relate to their job and work-place, and also, in the case of doctors, to specialist training.     

Training of surgeons for primary health care

It has been the view of the Association of Surgeons of East Africa (ASEA) that, like primary health care, there is primary surgery. The unit of provision of primary surgery is the district hospital. The training of surgeons for district hospitals starts at the undergraduate level, leading to the attainment of Bachelor of Medicine and Bachelor of Surgery (M.B. Ch.B.) degree. After internship the doctor works in a district or provincial hospital for 2-3 years, then trains for the degree of Master of Medicine (M. Med. (Surg.)) for a period of 3 years. The training involves rotation through all branches of surgery, so that the surgeon should be able to handle all aspects of routine surgery in a district hospital. To equip the surgeon further, a period in an outside setting is considered advisable. There are arrangements for regional surgical colleges to standardise the form of surgical training in the ASEA region. To keep surgeons in touch with the outside world, specialist training is done outside the region, but arrangements are being made for localised specialised units to offer this training.     

Facilitating practice changes in mental health clinics: A guide for implementation development in health care systems.

For more than a decade, health care systems have attempted to implement evidence-based practices and guidelines. These efforts have demonstrated the difficulty in making practice changes in complex systems of care. Many health care systems, including the Department of Veterans Affairs (VA) and state community mental health systems, have made adoption of evidence-based treatments, especially psychotherapies, a priority. Psychologists, as behavioral change experts and clinical leaders, are positioned to aid local implementation efforts but may have limited knowledge of the “implementation science” literature. This article provides a brief introduction to the implementation literature and offers a guide for developing an implementation plan to adopt evidence-based psychotherapies in local health care settings illustrated by a hypothetical example. Challenges to implementation are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Prevalence of hypertension in patients with type II diabetes in referral versus primary care clinics

We report our clinical experience in managing a 59-year-old Italian male with Churg-Strauss syndrome (CSS) whose first clinical manifestation was a persistent dysphonia; the patient worked as a mechanic. Video-laryngostroboscopic examination revealed paresis of the right vocal fold with a reduction in adduction together with incomplete glottal closure. Spectrographic and spirometric tests both showed abnormal changes. Laryngeal electromyography revealed neurogenic damage of the right thyroarytenoid and crycoarytenoid muscles. Due to the appearance of typical signs of systemic involvement of CSS as a necrotizing vasculitis, the patient was admitted to the Rheumatology Unit of the University of Pisa. Histologic analysis of a skin lesion on the patient's foot confirmed the diagnosis. Treatment with 6-methylprednisolone quickly brought remission from systemic and laryngeal symptoms, as well as improvement in the results of video-laryngostroboscopic, spectrographic and laryngeal myographic tests.     

Continuity of care and delivery of ambulatory services to children in community health clinics

This study assesses how continuity of care influences receipt of preventive care and overall levels of ambulatory care among children and adolescents in community health clinics (CHCs). It is a secondary data analysis of the 1988 Child Health Supplement to the National Health Interview Survey. Of 17,110 children in the sample population, the 1465 who identified CHCs as their routine source of care formed the study population. Continuity of site was defined as identification of a CHC as a source of both routine and sick care, and continuity with a clinician was defined as identification of a specific clinician for sick visits. In bivariate analyses both continuity with the CHC and with a specific clinician were associated with increased levels of preventive care and overall ambulatory care. In logistic regression models, continuity of care was associated with nearly a two-fold increase in the odds of receiving age-appropriate preventive care. Alternatively, insurance status was a better predictor of receipt of overall levels of ambulatory care. We conclude that expanding financial access alone is unlikely to sufficiently improve low-income children's access to Community Health Clinics. Additional emphasis on localizing the delivery of both routine and sick care services in a single site or with a specific clinician may be needed to achieve higher levels of both preventive care and overall ambulatory care.