Key Issues in Transforming Health Care Organizations for Quality: The Case of Advanced Access

Solberg, Leif I.; Hroscikoski, Mary C.; Sperl-Hillen, JoAnn M.; O’Connor, Patrick J.; Crabtree, Benjamin F.

doi:10.1016/s1549-3741(04)30002-x

Cited by 33 publications

(27 citation statements)

References 8 publications

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“…This suggestion is consistent with several current intervention approaches being studied. [26][27][28][29][30] What organizational features support clinical preventive services? Having a physician champion and making strategic economic choices were important features shared by many practices with higher clinical preventive service delivery rates.…”

Section: Discussionmentioning

confidence: 99%

Delivery of Clinical Preventive Services in Family Medicine Offices

Crabtree¹

2005

The Annals of Family Medicine

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BACKGROUND This study aimed to elucidate how clinical preventive services are delivered in family practices and how this information might inform improvement efforts. METHODSWe used a comparative case study design to observe clinical preventive service delivery in 18 purposefully selected Midwestern family medicine offi ces from 1997 to 1999. Medical records, observation of outpatient encounters, and patient exit cards were used to calculate practice-level rates of delivery of clinical preventive services. Field notes from direct observation of clinical encounters and prolonged observation of the practice and transcripts from in-depth interviews of practice staff and physicians were systematically examined to identify approaches to delivering clinical preventive services recommended by the US Preventive Services Task Force. RESULTSPractices developed individualized approaches for delivering clinical preventive services, with no one approach being successful across practices. Clinicians acknowledged a 3-fold mission of providing acute care, managing chronic problems, and prevention, but only some made prevention a priority. The clinical encounter was a central focus for preventive service delivery in all practices. Preventive services delivery rates often appeared to be infl uenced by competing demands within the clinical encounter (including between different preventive services), having a physician champion who prioritized prevention, and economic concerns.CONCLUSIONS Practice quality improvement efforts that assume there is an optimal approach for delivering clinical preventive services fail to account for practices' propensity to optimize care processes to meet local contexts. Interventions to enhance clinical preventive service delivery should be tailored to meet the local needs of practices and their patient populations. INTRODUCTIONT he Healthy People 2010 report calls for a major effort to improve rates of preventive service delivery by primary care clinicians.1 Despite prevention being a core component of primary care practice, 2 studies show that clinical preventive service delivery rates are low.3,4 A range of interventions to enhance the delivery of clinical preventive services have been tried with varying degrees of success, including the use of continuing medical education, audit and feedback, computerized reminder systems, the involvement of nursing staff, the use of chart-based algorithms, and the implementation of continuous quality improvement programs. [5][6][7][8][9][10] Efforts to improve clinical preventive services delivery are limited by our understanding of how clinicians and practices actually incorporate and deliver preventive services within the competing demands of care. [11][12][13] Although recent research provides insight into the emergent nature of practices as human organizations, 14,15 much remains to be understood about how the specifi cs of patients, their families, communities, clinicians, and health systems affect the approaches used in practices to provide clinical...

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Section: Discussionmentioning

confidence: 99%

Delivery of Clinical Preventive Services in Family Medicine Offices

Crabtree¹

2005

The Annals of Family Medicine

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“…The importance of external accountability, external incentives, and sophisticated information systems to sustain care improvement in medical groups has been recently emphasized (3,29). Our QI intervention strategy introduced substantial external accountability by providing active participation in periodic meetings with other clinics and by requiring preparation for clinic site visits from research team members.…”

Section: Changes In Process and Intermediate Outcomes Of Diabetes Carementioning

confidence: 99%

“…This intervention focused on clinic leaders as the principal vector for change, but some reports suggest that change strategies driven by medical group leaders may be more effective than those driven by clinic leaders (6,28,29). Some may argue that insufficient time elapsed between the completion of training and the measure of A1C concentrations.…”

Section: Quality Improvement In Diabetes Carementioning

confidence: 99%

Randomized Trial of Quality Improvement Intervention to Improve Diabetes Care in Primary Care Settings

et al. 2005

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OBJECTIVE -To assess the impact of a quality improvement (QI) intervention on the quality of diabetes care at primary care clinics.RESEARCH DESIGN AND METHODS -Twelve primary care medical practices were matched by size and location and randomized to intervention or control conditions. Intervention clinic staff were trained in a seven-step QI change process to improve diabetes care. Surveys and medical record reviews of 754 patients, surveys of 329 clinic staff, interviews with clinic leaders, and analysis of training session videotapes evaluated compliance with and impact of the intervention. Mixed-model nested analyses compared differences in the quality of diabetes care before and after intervention.RESULTS -All intervention clinics completed at least six steps of the seven-step QI change process in an 18-month period and, compared with control clinics, had broader staff participation in QI activities (P ϭ 0.04), used patient registries more often (P ϭ 0.03), and had better test rates for HbA 1c (A1C), LDL, and blood pressure (P ϭ 0.02). Other processes of diabetes care were unchanged. The intervention did not improve A1C (P ϭ 0.54), LDL (P ϭ 0.46), or blood pressure (P ϭ 0.69) levels or a composite of these outcomes (P ϭ 0.35).CONCLUSIONS -This QI change process was successfully implemented but failed to improve A1C, LDL, or blood pressure levels. Data suggest that to be successful, such a QI change process should direct more attention to specific clinical actions, such as drug intensification and patient activation.

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“…Health systems spend greatly on delivering care-both on its administration and on competition for patients-but they spend relatively little on the important system redesigns that are essential to deliver care well. Although progressive institutions-exemplifi ed by the Veterans Administration, 8 "breakthrough collaboratives," 9,10 and leading health systems 11 -have enacted bold system redesigns and achieved notable success in delivering the right care at the right time, most health systems and private practices have moved less boldly. 12,13 Unlike the leaders of other industries who have committed themselves to quality, managers in health care have not embraced the need for system restructuring and have not committed resources to optimize service to their clients.…”

Section: Society's Prioritiesmentioning

confidence: 99%

The Break-Even Point: When Medical Advances Are Less Important Than Improving the Fidelity With Which They Are Delivered

Woolf

Johnson²

2005

The Annals of Family Medicine

182

121

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Society invests billions of dollars in the development of new drugs and technologies but comparatively little in the fi delity of health care, that is, improving systems to ensure the delivery of care to all patients in need. Using mathematical arguments and a nomogram, we demonstrate that technological advances must yield dramatic, often unrealistic increases in effi cacy to do more good than could be accomplished by improving fi delity. In 2 examples (the development of antiplatelet agents and statins), we show that enhanced effi cacy failed to achieve the health gains that would have occurred by delivering older agents to all eligible patients. Society's huge investment in technological innovations that only modestly improve effi cacy, by consuming resources needed for improved delivery of care, may cost more lives than it saves. The misalignment of priorities is driven partly by the commercial interests of industry and by the public's appetite for technological breakthroughs, but health outcomes ultimately suffer. Health, economic, and moral arguments make the case for spending less on technological advances and more on improving systems for delivering care. INTRODUCTIONA lthough modern medicine can be proud of its successes in the prevention and treatment of disease, much more can be done to alleviate morbidity and premature mortality. Two transcendent problems predominate. First, available care is not delivered well: Americans do not always obtain the interventions that would improve their health or prevent illness. By one account, Americans receive only 55% of recommended health care services.1 Gaps in delivery are even greater for the poor and for racial and ethnic minorities.2 Second, the interventions that Americans do receive have limited effi cacy in improving outcomes. More lives could be saved by developing better drugs, technologies, and procedures. In effect, society faces a choice between these 2 strategies for bettering health and must strike a prudent balance in how many resources it allocates to each endeavor. FidelityThe fi rst endeavor addresses what might be described as the fi delity of health care. Independent of the effi cacy or effectiveness of interventions, fi delity is the extent to which the system provides patients the precise interventions they need, delivered properly, precisely when they need them. Fidelity is lacking when patients cannot make known their need for care (eg, there are barriers in access or communication), when clinicians cannot recognize that an intervention is indicated (eg, there is a lack of time, knowledge, attention, or memory), and when the intervention cannot be delivered properly (eg, there is inadequate infrastructure, procedures, safety, coordination, or information). Fidelity has less to do with the properties of interventions than with the functionality of the system that delivers them. It requires systems of care (eg, practice groups, hospitals) to have intelligent designs, skilled professionals, coordinated teams, adequate resources, compe...

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Key Issues in Transforming Health Care Organizations for Quality: The Case of Advanced Access

Cited by 33 publications

References 8 publications

Delivery of Clinical Preventive Services in Family Medicine Offices

Delivery of Clinical Preventive Services in Family Medicine Offices

Randomized Trial of Quality Improvement Intervention to Improve Diabetes Care in Primary Care Settings

The Break-Even Point: When Medical Advances Are Less Important Than Improving the Fidelity With Which They Are Delivered

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