Continuous quality improvement in primary care: what's happening?

OBJECTIVES

Despite much health care interest in quality and Continuous Quality Improvement, there is little quantitative information about it. The purpose of this study was to measure the attitudes, activities, and organizational cultures concerning Continuous Quality Improvement in a group of Midwestern primary care clinics.

METHODS

Three surveys of the clinicians, nurses, and other staff in 44 primary care clinics in the metropolitan area of Minneapolis and St. Paul were conducted. These surveys assessed: (1) attitudes about quality improvement, (2) previous efforts in these clinics to use process improvement teams, and (3) the extent to which the clinics' organizational cultures were perceived as supporting quality. The Provider Attitude Survey was completed by clinicians and nurses; the Process Improvement Progress was completed by members of the best Continuous Quality Improvement teams, if any; and the Quality Systems Inventory was completed by all personnel.

RESULTS

Most of the clinical personnel reported support for various Continuous Quality Improvement concepts, but their understanding and experience were limited. Only 20 (45%) clinics had had at least one Continuous Quality Improvement team in the past, only five of the 12 teams with adequate information had completed an improvement cycle, and only seven reported improving a process with it. The mean clinic scores for quality culture were no better than those in other types of organizations.

CONCLUSIONS

Despite relatively favorable attitudes and some Continuous Quality Improvement activities, there appears to be a need to help clinics build skill and experience for the required care improvements.

The state of research within managed care plans: 1997 survey

The growing need for information about managed care and for the use of managed care organization (MCO) members in clinical and health services research requires research capability within MCOs. To learn the extent to which such capability exists, we conducted a survey of readily identifiable MCO research programs. Responses were obtained from twenty of twenty-three eligible organizations. Although there is great variability in size, these organizations have a collective budget of $93 million, more than 158 career researchers, and extensive research infrastructure and applied research activities.

Using continuous quality improvement to improve diabetes care in populations: the IDEAL model. Improving care for Diabetics through Empowerment Active collaboration and Leadership

BACKGROUND

The care of patients with chronic diseases, especially those with diabetes mellitus, has been less than ideal. However, despite clear national guidelines, various examples of better care models, and multiple attempts to improve care, an effective process for facilitating and replicating diabetes care improvements in typical primary care practices has been elusive.

METHODS

On the basis of the approach and lessons from developmental work at the Minnesota Diabetes Control Program and a trial of continuous quality improvement for clinical preventive services (IMPROVE), a clinic-based intervention processes (IDEAL) has been developed to improve the system and process of care for patients with diabetes as a model for all chronic diseases. The intervention incorporates facilitation of leadership actions in support of change, training for the leader and facilitator of an intraclinic multidisciplinary continuous quality improvement (CQI) team, and consultative and networking support of the change process. Each element of this intervention emphasizes a seven-step process improvement approach and a system for care of patients with diabetes. This model is being developed and tested in a unique partnership between the Minnesota Department of Health and HealthPartners, a large managed care organization (MCO).

RESULTS

A prepilot demonstration has succeeded in improving glycemic control, three primary care clinics affiliated with HealthPartners have succeeded in a pilot of the intervention, and an additional 13 clinics are participating in a randomized controlled trial of a refined intervention.

CONCLUSIONS

The IDEAL model holds promise for substantial improvements in care, not only for diabetes but for all chronic diseases and for other settings.

Primary care, process improvement, and turmoil

The current health care environment in the United States is in turmoil, especially in regions that are further ahead in the transition from free-for-service to managed care. This article examines turmoil within primary care during a health-maintenance-organization-sponsored and federally funded randomized trial of using continuous quality improvement for adult clinical preventive services. The external and internal changes in structure and leadership occurring in primary care clinics are profound and prevalent. The sponsors of the project have responded to the turmoil by encouraging greater leadership involvement within the clinic and by supporting more skill building for change management.

A process IMPROVEment approach to preventive services: case studies of CQI demonstration projects in two primary care clinics

The IMPROVE Project is a 4-year randomized controlled trial to test the hypothesis that HMOs can improve preventive services in their contracted primary clinics by assisting clinics to implement continuous quality improvement (CQI) and an organized system for preventive services. This paper describes findings from case studies of CQI teams in two demonstration sites where the CQI approach was tested. The case study analysis is based on interviews and observations conducted about 10 to 12 months after the CQI teams began. Initial responses of clinic staff to the IMPROVE Project included a mixture of interest in CQI, enthusiasm for prevention-oriented care, concern about the burden the project might impose, and skepticism. There were two formidable barriers to change: time and inertia. Environmental changes in the parent organizations also complicated and impeded the CQI process within the clinics. The thematic analysis identified four factors that appear to be important in implementing a CQI process in a clinic setting: awareness, momentum, ownership, and communication.

Will patient satisfaction set the preventive services implementation agenda?

BACKGROUND

Patient satisfaction has become a measure of the quality of health care, and in highly competitive markets like the Twin Cities metropolitan area of Minnesota, it has become a health plan marketing tool. The purpose of this analysis is to examine whether the known association between preventive services and patient satisfaction might spontaneously lead clinicians to recommend preventive services at greater rates.

DESIGN

We conducted a mail survey of a stratified random sample (n = 6,830) of adult patients who had recently visited a physician in one of 44 clinics in and around Minneapolis-St. Paul, Minnesota. The main outcome measures are patient-reported rates of being advised to have eight preventive services, patient satisfaction with preventive services, patient satisfaction with overall health care, and correlations among these variables.

RESULTS

Self-reports of being advised to have a preventive service when due were correlated with higher levels of satisfaction with that specific service only at levels of r = 0.16 to r = 0.35. They were correlated at levels of r = 0.01 to r = 0.27 with the Group Health Association of America satisfaction index.

CONCLUSIONS

Although there is a positive association between being advised to have a preventive service on the one hand and reporting satisfaction with care on the other, this association appears too weak to spontaneously stimulate physicians to recommend preventive services to their patients. This suggests that, if preventive services are to be delivered at higher rates, they must become an explicit component of quality evaluations.

Delivery rates for preventive services in 44 midwestern clinics

OBJECTIVE

To determine the rates at which private primary-care clinics are recommending blood pressure and cholesterol measurement, smoking cessation, clinical breast examination, screening mammography, Papanicolaou testing, and influenza and pneumococcus immunizations.

MATERIAL AND METHODS

We conducted a mail survey of 7,997 randomly selected patients from 44 primary-care clinics in and around Minneapolis-St. Paul, Minnesota, of whom 6,830 (85.4%) completed the questionnaire on preventive services delivery rates. The responses were analyzed statistically, including stratification by reason for the clinic visit.

RESULTS

On the average, about two-thirds of the patients in each clinic reported being up-to-date on preventive services before their clinic visit; an exception was pneumococcus immunization (mean rate, 33%). Except for blood pressure and smoking cessation advice, less than 30% of patients who were not up-to-date on a preventive service were offered it if the clinic visit was for a reason other than a checkup or physical examination. For patients who said that they saw their physician for a checkup or physical examination, the rate was more than 50% only for Papanicolaou smear. In contrast, nearly all responding practitioners agreed that each of the eight preventive services was very important or important.

CONCLUSION

Preventive services consensus goals are not being met, even for patients who report that their clinic visit was for a checkup or physical examination. This finding suggests that it may be necessary to develop clinical systems that support and enable the delivery of preventive services.

How important are clinician and nurse attitudes to the delivery of clinical preventive services?

BACKGROUND

The purpose of this study was to determine the relation between primary care clinic physician and nurse attitudes toward preventive services and the rates at which their clinics provide these services to their adult patients.

METHODS

Forty-four private primary care clinics contracting with the sponsoring health maintenance organizations were recruited for a randomized controlled trial of an intervention consisting of training and consultation in continuous quality improvement and office prevention systems. Before the intervention began, 647 clinic physicians, midlevel practitioners, and nurses in the 44 participating clinics completed a questionnaire addressing their attitudes toward prevention, and 6830 patients visiting those clinics completed a questionnaire about their own up-to-date preventive care status as well as clinic actions to provide eight important preventive services during the visit. Scales were developed from significantly intercorrelated sets of attitude questions. Correlations were calculated by clinic for the relation between mean provider scores on those scales and specific service rates.

RESULTS

The questionnaire provided three scales with high internal consistency reliabilities that appear to measure generally favorable attitudes toward preventive services and toward improving them in an organized way. There was little association between these attitudes and rates of providing preventive services.

CONCLUSIONS

While favorable attitudes may be helpful, they are clearly insufficient to affect the actual delivery of preventive services. There is reason to believe that preventive services rates could be improved more effectively by targeting factors related to the provision of preventive services, particularly those that shape the clinical environment in which clinicians work.

Are physicians less likely to recommend preventive services to low-SES patients?

BACKGROUND

Do low-SES adult patients visiting private primary care clinics differ from higher SES adult patients in their need for eight preventive services or in receiving either a recommendation for or the needed services?

METHODS

Randomly identified adult patients were surveyed within 2 weeks of a visit to 22 clinics in the Minneapolis-St. Paul area. Questions assessed patient recollection of the latest receipt of eight services and whether needed services had been recommended during the visit or received then soon after.

RESULTS

Of those surveyed, 4,245 patients (1,650 low SES) responded (84.3%), showing that low SES patients were less likely to be up to date for cholesterol measurement, Pap smear, mammography, breast exam, and flu or pneumonia shots (P < 0.004), but not for blood pressure measurement. Low-SES patients needing services received recommendations to have them and actually received them at the same rate as higher SES patients.

CONCLUSIONS

The 22 primary care clinics studied appear to be recommending and providing needed preventive services to visiting patients at the same rate regardless of income or insurance status. The reasons for differences in prevention status by SES are complex but the low proportion of all patients receiving recommendations for needed services suggests the need to take advantage of all visits for updating prevention needs.

The GAINS project: outcome of smoking cessation strategies in four urban Native American clinics. Giving American Indians No-smoking Strategies

This study was designed to assess the capability of the Doctors Helping Smokers (DHS) model to produce an increase in smoking cessation over controls within four urban Indian Health clinics. A total of 601 Native American smokers were enrolled, surveyed, and measured for cardiovascular risk factors. Of those present in treatment clinics at 1-year follow-up, 7.1% reported being abstinent vs. 4.9% in the control group. Of those who made at least one visit to the clinic during the treatment year, 9.4% self-reported being abstinent in the treatment sites vs. 3.9% in the control group (p = .04). Cotinine validated quits for all enrollees, regardless of whether they attended the clinic during the intervention, are 6.7% (intervention) and 6.8% (control). Number of quit attempts and future quit intentions were greater in the intervention group. Recommendations for future intervention efforts include earlier contact with clinicians, clinic involvement in preplanning, developing the program around the principles and realities of each site, building in more extensive components, and utilizing additional community resources.

Smoking screening and management in primary care practices

OBJECTIVES

To describe the screening and management of patients who smoke by primary care physicians and to review practice factors associated with smoking services.

DESIGN AND METHODS

A descriptive study based on physician and patient questionnaires and medical record retrospective reviews.

SETTING AND SUBJECTS

Forty-five nonacademic primary care practices, including 160 physicians (whose subspecialty is family practice, internal medicine, or general practice) in 4 Midwest states and 4879 adult patients who completed questionnaires and consented for medical record review.

MAIN OUTCOME MEASURES

The a priori hypothesis was that screening by physicians would detect most persons who smoke, but that the lack of systematic methods to screen, intervene, or follow-up would limit the provision of smoking cessation services.

RESULTS

Eighty-one percent of all patients and 93% of patients who smoked in the past 2 years reported being asked if they smoked. Patients who smoked reported being told to quit (78%), discussing a quit data (60%), receiving a nicotine prescription (20%) or referral (25%) at higher rates than prior reports. Patients with coronary heart disease (CHD) or CHD risk factors, who smoked more, visited the physician more, or who wanted help were more likely to receive smoking cessation services. Few practices had developed systems to routinely provide services, and a lack of systems was associated with fewer interventions.

CONCLUSIONS

Physician screening and management of their practice patients is higher than reported in population surveys. Most patients who smoke report that they were asked whether they smoke, but smoking status is not routinely documented or updated. Significant variability is noted between physicians in smoking-related screening and interventions, and proved methods to improve services are infrequently used.

The three faces of performance measurement: improvement, accountability, and research

In the current climate of public accountability, many clinicians have become uncomfortable with any efforts to create measurement systems. That is unfortunate because measurements are absolutely essential to efforts for improving the processes of medical care. In their guideline implementation and measurement efforts, ISCI and the IMPROVE Project in Minnesota have gradually learned how to distinguish between measurement for improvement and that for accountability. Both approaches are different from the approach that physicians are used to in their encounters with medical research. Understanding these differences and respecting the confidentiality of individual medical groups has been crucial to moving past confusion and suspicion to genuine improvement actions involving multiple medical groups and their contracting managed care plans.

Mechanism of action and impact of a cystitis clinical practice guideline on outcomes and costs of care in an HMO

BACKGROUND

A study was conducted in 1995 at five primary care clinics of a staff-model health maintenance organization in the Midwest to assess the impact of a cystitis clinical guideline and to help elucidate the guideline implementation process.

METHODOLOGY

Two hundred one eligible women with uncomplicated cystitis were treated in a three-month period before the guideline, and 241 similar cases were treated in a three-month period after the guideline. Nursing supervisors and clinic managers at each clinic were interviewed about how the cystitis guideline was implemented at each clinic.

RESULTS

Use of a recommended three-day antibiotic treatment increased from 28% to 52% of cases (chi-square = 25.01, p < 0.001). Use of urine cultures decreased from 70% to 37% of cases (chi-square = 48.19, p < 0.001). The proportion of eligible cystitis cases coordinated primarily by the nurse increased from 21% to 78% (chi-square = 142.93, p < 0.001). However, desired changes in use of antibiotics and urine cultures were limited to nurse-coordinated cases. There was no increase in hospital admissions, emergency room visits, repeat office visits (p > 0.05), or repeat antibiotic courses (p > 0.05) after cystitis guideline implementation. Cost of cystitis care delivered after guideline implementation was 35% lower than before guideline implementation.

CONCLUSIONS

Use of the guideline was associated with desirable changes in antibiotic use, nurse coordination of care, costs of care, and comparable clinical outcomes. Clinics that used clinical systems and tools to support nurse-coordinated cystitis care had greater guideline adherence than clinics that did not support nurse-coordinated care.

Recruitment of private practices for primary care research: experience in a preventive services clinical trial

BACKGROUND

Recruitment of community primary care practices for studies to improve health service delivery is important to many health care organizations. Prior studies have focused on individual physician recruitment or academic settings.

METHODS

This descriptive study evaluated the efficiency and utility of three different recruitment methods to encourage community practice participation in a preventive services research trial. Primary care practices in four midwestern states were recruited using different sources for initial mailings (physician lists, practice lists, and a managed care organization's primary care network) and different recruiting methods. Outcome measures included response rates, participation rates, and comparative costs of each method.

RESULTS

Of the 86 eligible practices contacted, 52 (60%) consented to participate. Mailing to individual physicians was the most cumbersome and expensive method and had the lowest response rate. Initial contacts with practice medical directors increased the participation rate substantially, and practice recruitment meetings improved both study participation and practice-project communication.

CONCLUSIONS

Experience with these three methods suggests that the most efficient way to recruit practices for participation in a preventive services research trial involves targeted mailings and phone calls to medical directors, followed by on-site practice meetings.

Using continuous quality improvement to increase preventive services in clinical practice--going beyond guidelines

BACKGROUND

Even the most uniformly accepted prevention guidelines do not by themselves lead to implementation or to adequate rates of preventive services in medical practice. Although much has been learned about the office systems that seem to be needed for major change in a busy clinical practice, there are still no examples of a model for developing, implementing, and sustaining those office systems in a nonacademic practice.

METHODS

IMPROVE, the first large randomized controlled trial of CQI (continuous quality improvement) in any industry, is providing a scientific test of the hypothesis that HMO sponsorship of a CQI-based intervention can lead to sustained organizational change, implementation and maintenance of office systems, and improved rates of adult preventive services in contracted private primary care clinics. The 22 clinics assigned to the intervention arm of the study are receiving training, consultation, networking, and reinforcement for internal multidisciplinary teams as they work through a structured process to understand and improve their clinic's process for providing preventive services. Rates and quality of eight preventive services in these clinics are being compared over time with those in 22 matched comparison clinics.

RESULTS

The 44 clinics needed for the trial have been recruited and randomized, and baseline comparisons show no significant differences between the two groups. Nine months into the trial, 21 of 22 intervention clinics have completed training and are pursuing a systematic improvement process for preventive services.

CONCLUSIONS

With external training and consultation, many private primary care clinics will voluntarily engage in a lengthy multidisciplinary team effort to use CQI techniques to study and systematically improve their entire process for providing preventive services.

Competing HMOs collaborate to improve preventive services

BACKGROUND

In July 1993, an unusual collaboration developed between competing managed care plans and with competing primary care clinics as part of a federally funded research grant (IMPROVE from the Agency for Health Care Policy and Research). The goal of this collaboration is to scientifically test the ability of an health maintenance organization (HMO) to improve the delivery of eight adult preventive services by training and facilitating the use of continuous quality improvement and prevention systems by contracted private primary clinics.

METHODOLOGY

In order to conduct this effectiveness study, it was necessary for two HMOs to come to a structural and functional understanding of how to operate jointly. Investigators recruited 44 private clinics for a randomized controlled trial in which 22 are being assisted in improving the process used to deliver these preventive services and 22 are being left alone as comparison clinics. The intervention is a train-the-trainer and consultation approach focused on clinics as collaborating customers. The comparison will be based on repeated surveys of patients and clinic personnel as well as chart audits to measure changes in systems and prevention rates.

SUMMARY

Although this project was made possible by a number of unusual favorable factors, it can serve as a model for support of the clinician leadership that is essential to true health care delivery reform.

Health plans helping smokers

Tobacco use is the leading cause of preventable mortality in the United States. Therefore, health care organizations have an important role to play in the control of tobacco use both among their plan members and in the communities that they serve. To be effective, they need to adopt a policy that all tobacco users will be identified and provided with advice to quit smoking (or chewing) at each contact with a health care professional. This same policy ought to be adopted for parents of pediatric patients. The policy can be implemented by defining tobacco use as a "vital sign" and periodically assessing implementation rates with a chart review. Patients who express an interest in quitting should be supported through individual or group follow-up. To make clinical interventions more effective, to counteract tobacco promotion that is directed at youth, and to protect the health of non-smokers, HMOs will want to support local and regional tobacco control coalitions that are taking action against tobacco promotion and are promoting smoke-free public areas.

Making "time" for preventive services

Although the implementation of clinical preventive services is a high priority on the national agenda and physicians acknowledge the importance of these services, implementation rates remain far below the target years after the recommendations have been released. Physicians repeatedly report that the reason for not providing preventive services is that they do not have "time." In this article, we identify attributes of the health-services system that create this phenomenon. We present evidence that formal delivery systems for preventive services must be developed if the "time" problem is to be solved, and we review why preventive-services systems need to be integrated into the current health-services system. Finally, we list the attributes that we believe a preventive-services system must have if it is to be successful. The success of clinical trials of such systems indicates that our goals of preventive services can be achieved if all persons who have an investment in clinical preventive services commit themselves to developing and supporting these systems.