Change, Lack of Change, and Creating Optimal Change Out of Chaos

Abstract

Once again, we consider how to effect practice change at the local and national levels. This issue includes several articles that relate to quality improvement. Some physician actions seem resistant to change, as do the underlying social determinants and processes that lead to what are thought to be avoidable hospitalizations, but we also find that concerted effort, along with standardized orders sets and other avenues, can make a difference. Sometimes, however, our attempts at change can lead to more distraction then efficacy. Here we include articles that place the quality issues in context, report interventions, and advance the types of specific knowledge that allow interventional trials. We also have several articles about cancer screening and follow-up, a subset of quality improvement. Quality ImprovementBaird 1 provides us with a fascinating historic and nuanced reflection of how and whether medical homes represent something new or otherwise different from former attempts at reform in family medicine, specifically managed care. In light of previous inflated expectations of the ways in which reforms can change medical care, he says, "no villains allowed."Information chaos is clearly one of the reasons that we struggle to improve quality to a desired level. Beasley and colleagues 2 provide a structure to consider the information chaos, the negative outcomes of the chaos, and some direction for future research. This construct also relates to our tonguein-cheek, yet provocative, selection from Baxley et al.3 who suggests that we sometimes act as if we have attention deficit disorder as we attempt to implement multiple concurrent Plan-Do-StudyAct practice improvement projects. It is a variant of a "quality improvement disorder." Therefore, some remedies are in order. However, the answer is not to just take a pill daily and hope it will go away. Hopefully, we can improve the quality of our quality improvement activities.In one major attempt to improve health care nationally, the Affordable Care Act mandates that the Centers for Medicaid and Medicare Services (CMS) implement a 10% payment increase for primary care. CMS criteria defining primary care are unfortunately currently inadequate to the task because they exclude many family physicians, particularly those in more rural settings or those who provide a broader range of services, as documented by research from the Robert Graham Center. 4 On to specific examples from the articles in this issue. We know that preventable hospitalizations vary by location, but just how easy are these to avert? Sumner et al 5 determined that the differences in preventable hospitalizations between the counties in Kentucky persisted over time. This suggests that underlying problems or processes are not readily changed, and that needed health care improvements will be relatively resistant to transformation.Another specific quality improvement item that seems resistant to change is the ordering of urine cultures for women with urinary tract infection symptoms. Obtaining urine culture...