Improving health care, Part 5: Applying the Dartmouth clinical improvement model to community health

BACKGROUND: Traditional approaches to community health initiatives provide guidance on community mobilization, health assessment, planning, and intervention. Yet direction in how to frame the action steps to implement and measure results is often missing. Many community health initiatives find implementation overwhelming and ineffectual. FRAMEWORK FOR COMMUNITY HEALTH-THE CLINICAL IMPROVEMENT MODEL: The process--outcome methodology of continuous quality improvement (CQI) can translate large community aims into manageable projects. The sequential application of the clinical improvement model and the Community Health Value Compass for measuring outcomes-in state of health, quality of life, satisfaction, and costs-provides a link between data and action, thereby producing accountability for the community health initiative. USING THE CLINICAL IMPROVEMENT MODEL IN TWIN FALLS: Healthy Magic Valley (Twin Falls, Idaho) is the vision for long-term improvement in health status and reduction of health risks for the Southcentral Idaho Health Network. Since 1996 the Twin Falls Community Health Collaborative and SAFE KIDS Coalition have used the Value Compass model and CQI methods to decrease the rate of motor vehicle collisions, serious injuries, and deaths involving teens, while reducing the health, educational, legal, and financial consequences associated with teen-involved motor vehicle collisions. In 1993 the Twin Falls collaborative convened to apply CQI methods to the health of the community. The team has since met periodically to address the issues of community health, using the Dartmouth value compass model since 1996. Each sequential application of the process-outcome CQI framework exposes a blueprint for action and the unfolding of a health improvement strategy. The interventions should affect one or more dimensions of the value compass for teenage driving and motor vehicle collisions. CASE STUDY OF THE CLINICAL IMPROVEMENT MODEL: The motor vehicle death in October 1997 of a high school football player, who was not wearing a seat belt, led to a call to action for injury prevention. Implementation of a local community health initiative on seat belt use started in 1998. A strategy was developed to address implementation of the project among high school teens (for immediate impact) and elementary school children (for long-term impact) and to promote collaboration between the school and the rest of the community. RESULTS: Observed use of seat belts increased from January to September 1998. Data on fatality rates; injury rates; percentages of teens in crashes, of teens injured, and of teen collisions involving use of alcohol; and comprehensive costs are also monitored. DISCUSSION: Once coalitions are built and priorities set, the Dartmouth clinical improvement model presents a method that emphasizes measuring the benefits to the individual members of the community. A portfolio composed of a value compass for each health improvement initiative provides ongoing feedback for guiding subsequent strategic planning by the governing community health network.