Implementing CQI projects in hospitals

BACKGROUND: Quality improvement approaches such as continuous quality improvement (CQI) and total quality management are widely used, but little is known about how much it costs to use the principles and techniques required to implement CQI processes. In the Robert Wood Johnson Foundation's Improving the Quality of Hospital Care (IQHC) program, four consortia of hospitals were funded in the early 1990s. Interviews with quality managers at 38 of the consortia hospitals were conducted in 1995 to determine the costs of conducting CQI projects to allow an estimation of the marginal cost of using CQI processes (particularly cross-disciplinary teams) to improve quality of care. CQI PROJECTS: Quality managers described 69% of project outcomes as critical to clinical services. Team members identified the issues their teams addressed and selected the project 64% of the time, the methods of analysis 87% of the time, and the approaches to resolving the problem or issue 97% of the time. Most of the respondents agreed that the team members had the authority to resolve the problem without appealing to higher levels of management. Costs for hospitals' most recently completed projects varied widely, from $148 for the entire project to $18,590. The length or duration of the projects also varied widely, from 1 month to 66 months. DISCUSSION: In the hospitals included in this sample, all of which were highly self-selected (evidenced by their participation in a voluntary consortium of hospitals focused on quality of care), knowledge of CQI processes appeared to be fairly thorough. Teams appeared to have a reasonable amount of autonomy. New CQI projects should be subjected to scrutiny in terms of their likely contribution to quality of care, as distinct from other positive outcomes.     

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.     

Developing a quality measurement tool and reporting format for long- term care

BACKGROUND: Quality measurement in long term care (LTC) presents many challenges: the lack of a uniform definition of quality, the existence of multiple domains for measurement, a multitude of potential perspectives, and regulatory influences that emphasize measurement only of poor quality. Research efforts have yet to solve the issues of measurement; however, operators of long term care facilities must use the current state of the art in quality measurement as the basis for their quality improvement efforts. A project was commissioned by management of a large integrated delivery system with a robust network of LTC facilities who wished to implement a continuous quality improvement process on the basis of a measurement tool that provides a comprehensive resident-centered assessment of quality. The objectives of this project, therefore, were to identify domains of quality, to select and adapt validated instruments for measurement within each domain, to pilot test a data collection process, and to develop an operational quality profiling report format for LTC facilities. DESIGN AND METHODS: Using an expert panel and the LTC research literature, an operational measurement tool was developed, consisting of four domains of quality: organizational, clinical, environmental, and social. DISCUSSION: A pilot study conducted in two nursing facilities demonstrated that the data collection process could be operationalized within tight resource and budgetary constraints. The development of an operational quality assessment tool enables management to take a consistent view of diverse institutions, focusing in detail on quality of care as it is perceived by residents. The tool allows evaluation of trends over time and comparison to external norms.     

Reducing injuries among Native Americans: five cost-outcome analyses

This paper presents cost-outcome analyses of five injury prevention efforts in Native American jurisdictions: a safety-belt program, a streetlight project, a livestock control project, a drowning prevention program, and a suicide prevention and intervention program. Pre- and post-intervention data were analyzed to estimate projects' impact on injury reduction. Projects' costs were amortized over the time period covered by the evaluation or over the useful life of physical capital invested. Projects' savings were calculated based on estimated reduction in medical and public program expenses, on estimated decrease in lost productivity, and on estimated quality adjusted life years saved.All projects yielded positive benefit-cost ratios. The net cost per quality adjusted life years was less than zero (i.e. the monetary savings exceeded project costs) for all but one of the projects.     

Balancing accountability and improvement: a case study from Massachusetts

BACKGROUND: The Massachusetts Health Quality Partnership (MHQP), a coalition of health care providers and insurers, and business and government organizations, conducted a voluntary statewide survey about patients' experiences with inpatient care at Massachusetts hospitals in 1998, and made the results public. METHODS: MHQP contracted with The Picker Institute (Boston) to conduct the statewide survey about seven dimensions of care for adult medical, surgical, and maternity patients at 58 hospitals across Massachusetts. The communications strategy for public report release was designed to promote fair reporting by the news media and emphasize the improvement goals of performance measurement above evaluation. Along with critical agreements on report design, trial surveys, advertising, and commitments from coalition members about the use of survey results, these measures sought to drive out fear of participation and unfair evaluation. RESULTS: Statewide news media coverage reflected the project's communications goals. Editorial praise for the report was widespread. The project stimulated numerous hospital quality improvement efforts and focused hospital leaders on the need to improve patients' experiences with hospital care. All participating hospitals voluntarily renewed their enrollment for a third survey and public report cycle, and new hospitals joined the project. DISCUSSION: Voluntary public release of performance information by health care providers is possible when the risks, motivations, rewards, and penalties of measurement and public reporting are understood and carefully managed. The goals of public accountability reporting will be realized sooner when it is wedded to the spirit of continuous quality improvement and when providers are engaged as partners at every step of the measurement and reporting 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."     

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.     

Developing a patient complaint tracking system to improve performance

BACKGROUND: Assessing patient satisfaction exclusively through close-ended scaled survey questions may not provide a complete picture of patients' concerns. Only recently has the role of complaint data as a management tool received attention. FORMATION OF THE TEAM AND THE DATABASE: The Complaint Management Team was created in January 1997 at Hartford Hospital (Conn) to develop a coding and reporting mechanism for complaints (negative comments) gathered from patient surveys. Developing the codebook was an evolutionary process. A database was designed to collect three separate complaints and the verbatim text associated with the code. REPORTING: Department-specific, location-specific, and organization wide reports are generated. Quarterly department-specific reports are used to trend the incidence of complaint themes, identify specific locations with problems, and initiate improvement efforts. OVERALL FINDINGS: Since March 1997, most complaints have fallen into five major categories--accommodations (environment), quality of care (care and treatment), respect and caring (humaneness or attitudes and behaviors), timeliness, and communication. The hospital's real estate department has completed a project focused on increasing patient satisfaction with parking. Two projects are still in progress; one is focused on increasing patient satisfaction with respect and staff caring attitude/behaviors, and one on improving satisfaction with the level of noise on the units. DISCUSSION: Approximately 4,000 survey complaints are coded every year. One limitation of the database is that all sources of complaints received throughout the organization are not yet captured. Another limitation is that the outcomes measurement section has exclusive access to the database. CONCLUSIONS: The patient complaint tracking system enables staff, managers, teams, and departments to develop improvement efforts based on quantitative and qualitative data.     

Integrating patient satisfaction into performance measurement to meet improvement challenges

BACKGROUND: A Value Compass has been proposed to guide health care data collection. The "compass corners" represent the four types of data needed to meet health care customer expectations: appropriate clinical outcomes, improved functional status, patient satisfaction, and appropriate costs. Collection of all four types of data is necessary to select processes in need of improvement, guide improvement teams, and monitor the success of improvement efforts. INTEGRATED DATA AT BRYANLGH: BryanLGH Medical Center in Lincoln, Nebraska, has adopted multiple performance measurement systems to collect clinical outcome, financial, and patient satisfaction data into integrated databases. Data integration allows quality professionals at BryanLGH to identify quality issues from multiple perspectives and track the interrelated effects of improvement efforts. A CASE EXAMPLE: Data from the fourth quarter of 1997 indicated the need to improve processes related to cesarean section (C-section) deliveries. An interdisciplinary team was formed, which focused on educating nurses, physicians, and the community about labor support measures. Physicians were given their own rates of C-section deliveries. RESULTS: The C-section rate decreased from 27% to 19%, but per-case cost increased. PickerPLUS+ results indicated that BryanLGH obstetric patients reported fewer problems with receiving information than the Picker norm, but they reported more problems with the involvement of family members and friends. CONCLUSIONS: The data collected so far have indicated a decrease in the C-section rate and a need to continue to work on cost and psychosocial issues. A complete analysis of results was facilitated by integrated performance management systems. Successes have been easily tracked over time, and the need for further work on related processes has been clearly identified.     

First do no harm: integrating patient safety and quality improvement

BACKGROUND: Lehigh Valley Hospital's (LVH's; Allentown, Penn) interdisciplinary quality improvement program Primum Non Nocere (PNN), or First Do No Harm, is composed of 12 quality improvement (QI) projects that are a combination of ongoing operations improvement projects and new projects in patient safety. The projects stress delivery of cost-effective medical care while reducing preventable adverse events through improved communication, process redesign, and evidence-based protocol use. EXAMPLE: WRONG-SITE SURGERY: In response to an initial alert warning in 1998, LVH developed a policy of marking "yes" on the surgical site and "no" on the other side. However, several near misses occurred, and a root cause analysis indicated that the policy was not always followed for some very specific reasons. For example, the operative record included no prompt to address laterality, and the procedures in which laterality should be addressed were never specified. Interventions to address these issues were quickly developed that were in keeping with the recommendations outlined in a second alert warning on the issue in December 2001. A year after these stepwise changes, compliance with the policy is almost 100%, and there have been no further near misses. DISCUSSION: Specific project barriers included the initial challenge of changing the mindset in the institution from gradual change on a grand scale to smaller, more rapid changes, analyses, and actions. Another issue identified early in the initiative was the tendency of project groups to outline elaborate process improvements without determining how to measure and monitor success. A project sustainability is inherently linked to its initial strengths and the successful solutions to barriers that are encountered.     

Lessons from Europe on quality improvement: report on the Velen Castle WHO meeting.

BACKGROUND: In conjunction with the German Ministry of Health, the European Regional Office of the World Health Organization (WHO/EURO) held a workshop, "Experiences with Quality Management in an International Context," at Velen Castle, Velen (Nordrhein-Westfalen), Germany, January 15-17, 1998. The approximately 50 participants were selected in part on the basis of recommendations of their respective countries' health ministries. IMPLEMENTATION AND EVALUATION OF QUALITY MANAGEMENT: Possible ways to introduce quality management ranged from introduction of specific process control projects to total quality management (TQM) and reengineering. STRATEGIES FOR IMPLEMENTING QUALITY MANAGEMENT: Working group sessions identified specific strategies for high-level managers, health care providers, and various kinds of consumers to facilitate quality management. For example, managers need to transmit a vision, create a quality management infrastructure, develop reporting structures, establish a system of incentives, and manage the hospital according to the principles of continuous improvement. QUALITY MANAGEMENT MODELS AND TOOLS: Hospitals and other health care providers in Sweden are testing various methods and systems to assess and improve their organizations' ability to meet patients' demands. Benchmarking is being used as a tool for quality management of diabetes care (DiabCare-France). The benchmarking data are processed centrally and made available to the health care providers in a user-friendly format for application to their own quality improvement processes. Clinical databases-registries containing process and outcome data for a well-defined patient population-can be used for quality and technology assessment, to answer questions of treatment effectiveness, and as an information tool. PRINCIPLES AND STRATEGIES FOR QUALITY MANAGEMENT AND DEVELOPMENT: Successful implementation of quality improvement benefits from local, professional, and national policies and objectives. A balance of incentives can reward efficiency or specific activities. Laws, rules, and regulations can be useful, especially if used sparingly. More education is needed at all levels of the health care system about how to understand and use information and information systems. Research is needed on what processes result in favorable outcomes. Despite optimism about the cost-saving potential of quality improvement efforts, many interventions are likely to be cost-effective without actually saving costs. Public release of performance data requires careful consideration, with participation of the professions.     

Dynamic Lean Management of the Naval Construction Process

Abstract:

The naval and private construction industries face shared problems in regard to cost over-runs and delays that may be addressed in part through improvements to the construction process. The scope of this study is to examine the naval construction process from design to implementation, with special emphasis on the role of design sharing and constructability. We use the System Dynamics methodology to model the construction process and conduct simulations to examine the impact of project management decisions. We conclude that increased constructability efforts and design sharing mitigate the impact of cost over-runs and project completion delays, and that when limited resources exist it is best to focus improvement efforts early rather than later.     

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.     

The impact of quality practices and employee empowerment in the performance of hospital units

Healthcare is a unique services environment with increasing demand for services coupled with widely diverse patient needs. In addition, hospitals are under increased pressure to provide quality care yet simultaneously decrease associated costs. This study examines how the use of quality practices and employee empowerment impact hospital unit outcomes. Specifically, the sociotechnical theory is used to explain the relationship of quality practices and employee empowerment in respiratory care services. Utilising data from 101 different hospital units, survey responses from managers and physicians within the same hospital units are used to test the impact on quality and cost of care performance metrics via path modelling. The results show the social side of improvement programs, i.e. employee empowerment, may be a critical component to true quality improvement in hospital units. Furthermore, while respiratory care managers feel that employee empowerment reduces costs of patient care, physicians felt that there was no impact on costs. The implications of these findings and differing perspectives are discussed.     

Inheritance and Innovation of Engineering Management Informatization

In the life-cycle of large projects, the operational phase lasts the longest, costs the most and substantially benefits the project. During the whole phase, energy, material and human resources may cost a lot. Effective control of such costs is one of the main targets of engineering management informatization. How to lower the organization collaboration cost in project management and how to support effective collaboration among different areas, organizations and departments in the ways of technology and management are major goals in engineering management informatization. In the phase of project operation, project owners, partners and customers are the stakeholders of engineering management informatization. Through the case of airport management informatization, inherited and innovation of engineering management informatization will be discussed. It is illustrated that airport informatization is the innovation of business model and technology applications through the analysis and study on cases of airport informatization.     

Beyond the classroom: integrating improvement learning into health professions education in Norway.

BACKGROUND: Students in the health professions must internalize the subject matter--professional knowledge--to acquire the necessary skills to serve as practitioners. Yet the ability to engage in continuous improvement is attainable only when combining professional knowledge with improvement knowledge. It is a challenge to strike a balance between theoretical teaching and practical training when working with personal quality improvement (QI), observing processes, and employing new methods and tools for problem solving and improvement work. EVOLUTION OF EFFORTS TO INTEGRATE IMPROVEMENT KNOWLEDGE INTO HEALTH PROFESSIONS EDUCATION: In February 1995 A National Strategy for Quality Improvement in Health Care stipulated that training in quality improvement be an integral part of the education of health care personnel. A program was developed at Bergen College in 1998 to integrate the philosophy and methodology of quality improvement (improvement knowledge) into students' learning of professional knowledge. This program involves a variety of pilot projects in personal improvement, practice-related instruction on training wards, observation practice, clinical studies, cross-education student projects, and thesis writing. PERSONAL IMPROVEMENT PROJECTS: With the starting point "quality is personal," students can work on personal change and improvement. If students learn methods and tools for improvement in their personal realm, they can transfer and use this knowledge in their professional work. Problems experienced by students in relation to their studies can be addressed by the Plan-Do-Check-Act problem-solving method. DISCUSSION: A longitudinal, personal-then-clinical, approach enables students to learn techniques and tools they can use as professionals, both in the care for patients and in contributing to organizational improvement.     

Improving the care of patients with community-acquired pneumonia: a multihospital collaborative QI project

BACKGROUND: Performance of several processes of care was measured in eight acute care hospitals in Connecticut which provided inpatient treatment to 713 elderly patients with community-acquired pneumonia (CAP). BASELINE DATA ABSTRACTION AND FEEDBACK: Chart review feedback was provided, and the hospitals were requested to design their own quality improvement (QI) interventions, after which reexamination of process of care performance was conducted. HOSPITAL QI INTERVENTIONS: Six of the eight hospitals had submitted QI plans. The quality indicators dealing with timeliness of antibiotic delivery were specifically addressed by five hospitals. However, each hospital also picked one or two other processes of care for intervention. RESULTS: The mean time to antibiotic administration decreased from 5.5 hours (+/- 0.2) to 4.7 hours (+/- 0.3; p < 0.0001), and the percentage of patients who received antibiotics within four hours increased from 41.5% to 61.8% (p < 0.0001). DISCUSSION: This project called for obtaining buy-in from both the clinician and administrative representatives of each hospital early in the process. In this way, the targeted processes of care were likely to have relevance for each of the participating hospitals. Education of practicing physicians and other health professionals, as the method chosen by each hospital to address delays in antibiotic administration, appears to have been successful in this project as part of a multifaceted intervention. The project also helped establish a collegial environment that has served as the basis for more ambitious pneumonia QI projects. SUMMARY AND CONCLUSIONS: Widespread improvements in process of care performance can result from hospitals' participation in Quality Improvement Organization collaboration.     

The morbidity and cost implications of hemodialysis clinical performance measures

Clinical performance measures, including dialysis dose, hemoglobin, albumin, and vascular access, are the focus of monitoring and quality improvement activities. However, little is known about the implications of clinical performance measures for hospital utilization and health care costs. We obtained clinical performance measures and hospitalization records for a national random sample of 10,650 hemodialysis patients and analyzed the relationship between changes in clinical performance measures and hospital utilization after adjustment for patient demographic and medical characteristics. Higher hemoglobin, higher albumin, and fistula or graft use were independently associated with fewer hospitalizations, fewer hospital days, and decreased Medicare inpatient reimbursement. For example, a 0.5 g/dL higher hemoglobin, a 0.25 g/dL higher albumin, fistula use, and graft use were associated with hospitalization rate ratios of 0.90 (95% confidence interval 0.85, 0.96), 0.64 (0.53, 0.77), 0.60 (0.52, 0.69), and 0.79 (0.71, 0.89), respectively. Moreover, there was a 2-3-fold variation in hospital utilization across end-stage renal disease networks that was still evident after adjustment for patient characteristics and clinical performance measures. Clinical performance measures, especially albumin and vascular access, are strongly associated with hospital utilization and health care costs. These results highlight the importance of targeting nutrition and vascular access in quality improvement efforts. The marked variation in hospital utilization across networks deserves further examination.     

A survey of 92 quality improvement projects.

BACKGROUND: Studies focusing on the impact of improvement efforts on the organization have yielded mixed results, which has increased interest in comparing the processes of improvement used. Data for a convenience sample of 92 quality improvement (QI) projects in 32 organizations were gathered from interviews and self-reported surveys from 1998 to 2000. A self-administered questionnaire was developed to measure 70 characteristics of improvement projects. RESULTS: Most (80%) of the improvement projects were conducted by hospitals or clinics affiliated with hospitals. The projects took an average of 13 months from the team's first meeting to the end of the pilot study. Project teams met 14 times (approximately once a month) and spent 1.5 hours per meeting. Some projects did not measure the impact, others did not intend to have a specific impact, and still others measured but did not achieve the planned impact. DISCUSSION: Patients and employees may be benefitting from improvement projects, but organizations may not be leveraging these improvements to reduce cost of delivery or increase market share. Considerable variation in the projects' impact raises the question of the need to improve the improvement methods. Generalization from this study should be made with caution, as data were based on a self-selected convenience sample of organizations. Furthermore, respondents did not complete all items, and missing information may affect the conclusions. The data on current improvement practices that are provided in this study can serve as baseline data against which rapid improvement efforts can be judged.     

Federal efforts to improve quality of care: the Quality Interagency Coordination Task Force (QuIC)

FORMATION OF THE QUIC: The Quality Interagency Coordination Task Force (QuIC) was established in 1998 to enable the participating federal agencies to coordinate their activities to study, measure, and improve the quality of care delivered by federal health programs; provide people with information to help them in making more informed choices about their care; and develop the research base and infrastructure needed to improve the health care system, including knowledgeable and empowered workers, well-designed systems of care, and useful information systems. STUDY, MEASURE, AND IMPROVE CARE: The QuIC's initial efforts to improve the care delivered in federal health care programs have focused on diabetes, depression, and the effect of working conditions on quality of care. More recently, patient safety efforts are under way to establish a coordinating center that will enable those who are testing methods of reducing errors to share information across their projects and with experts in error reduction. DEVELOP A RESEARCH BASE AND INFRASTRUCTURE: The QuIC has coordinated efforts in credentialing, information on measures of quality, a taxonomy of quality improvement methods, and errors data collection. PROVIDE INFORMATION TO AMERICANS ABOUT HEALTH CARE QUALITY: The QuIC agencies are developing products that will enhance their ability to communicate with the American people about their health care choices: improved gateways for consumer information available from federal agencies, a glossary of commonly used terms, and guidance for producing report cards on quality of care. MOVING THE QUALITY IMPROVEMENT AGENDA FORWARD: Federal efforts to improve quality of care are moving forward in a more integrated fashion on a wide number of fronts.