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

Does comparison of performance lead to better care? A pilot observational study in patients admitted for hip fracture in three French public hospitals

OBJECTIVE

To assess whether comparison of quality of hip fracture care among three teams located in different hospitals is associated with improvement in process and outcomes.

DESIGN

A baseline assessment was performed using quality indicators selected by professionals.

RESULTS

were discussed among the three teams followed by a post-comparison assessment of the same indicators.

SETTING

Three hospitals in North Western France.

PARTICIPANTS

Professionals caring for patients operated on for a low-impact hip fracture.

INTERVENTION

Review and discussion of comparative performance results by three teams followed by implementation of quality improvement as deemed necessary by each team.

MAIN OUTCOME MEASURES

Fifteen quality indicators of health care during orthopedic and rehabilitation stay, mobility, dependence and place of residence before hip fracture and 3 months after discharge, 3 month post-surgery mortality and readmission rates.

RESULTS

Major differences were observed among hospitals throughout the care process during baseline period. Comparison of performance and discussion among the three teams were followed by corrective action in 11 areas. After comparison, a significant improvement was observed in 10 areas, seven of which corresponded to quality improvement areas chosen for improvement action by professionals. A significant decrease in readmission rate (6.7% vs. 15.7%, P < 0.001) was observed but there was no change in mortality, functional outcome or length of stay.

CONCLUSIONS

Comparison of performance among voluntary teams, on fields selected by health-care professionals, was associated with improvement in the care process and with improvement of some related outcomes.

Improving medical practice: a conceptual framework

PURPOSE

The purpose of this article is to produce a relatively simple conceptual framework for guiding and studying practice improvement.

METHODS

I summarize the lessons from my experience with a variety of quality improvement research studies during the last 30 years, supplemented with relevant literature from both medicine and other industries about the issues associated with successful quality improvement.

RESULTS

My experience suggests that organizational leadership with an urgent vision for change, ability to manage the change process, and selection of systematic changes capable of fulfilling the vision are each critical for successful quality improvement. Published literature from other industries emphasizes the importance of a goal-directed change process managed by leaders who recognize the need to engage their employees and other leaders in a disciplined but flexible way that accommodates external and internal factors and uses teams and group learning. It also suggests the importance of organizational context and the level of external and internal barriers and facilitators for change. The resulting model proposes that priority, change process, and care process content are necessary for measurable improvements in quality of care and patient outcomes, although internal and external barriers must also be attended to and addressed.

CONCLUSION

This framework may provide a guide to those in the front lines of care who would like to make the care transformations that are needed to greatly improve care. It may also be helpful to those who are developing or testing interventions and recruiting medical practices for such change efforts.

What motivates managers to coordinate the learning experience of interprofessional student teams in service delivery settings?

This article addresses the realities of providing interdisciplinary student team placements (i.e., experiential team learning for students) in healthcare settings. Three site coordinators from different clinical settings in Alberta (a geriatric assessment unit, a geriatric dementia care unit, and a primary healthcare centre), who facilitated Student Team Placements from the University of Alberta (UofA) in 2004, comment on their experiences and incentives for participating in interdisciplinary teamwork with students. The coordinators suggest that students provide input into the sites' continuous quality improvement cycle, contribute to host organizations, and confer benefits for the student preceptors, the staff and the patients who participate. The site coordinators also recognize and accept the responsibility common to all service providers, to model a unique site culture that promotes learning/teaching of team skills for health science students. The experience of others in the literature supports our findings that two systems--the system to educate health professionals and the system that influences the health of the community--can interact so that each realizes a mutual benefit.

Randomized trial of quality improvement intervention to improve diabetes care in primary care settings

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 = 0.04), used patient registries more often (P = 0.03), and had better test rates for HbA(1c) (A1C), LDL, and blood pressure (P = 0.02). Other processes of diabetes care were unchanged. The intervention did not improve A1C (P = 0.54), LDL (P = 0.46), or blood pressure (P = 0.69) levels or a composite of these outcomes (P = 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.

Understanding variation in chronic disease outcomes

We propose an explanation for variation in disease outcomes based on patient adaptation to the conditions of chronic disease. We develop a model of patient adaptation using the example of Type 2 diabetes mellitus and assumptions about the process entailed in transforming self-care behaviors of compliance with treatment, compliance with glucose monitoring, and patient's knowledge seeking behavior into health outcomes of glycemic control and patient satisfaction. Using data from 609 adults with diagnosed Type 2 diabetes we develop an efficiency (fitness) frontier in order to identify best practice (maximally adapted) patients and forms (archetypes) of patient inefficiency. Outcomes of frontier patients are partitioned by categories of returns to scale. Outcomes for off-frontier patients are associated with disease severity and patient archetype. The model implicates strategies for improved health outcomes based on fitness and self-care behaviors.

Improving diabetes care in a large health care system: an enhanced primary care approach

OBJECTIVE

The objective of this study was to evaluate the impact of a multifaceted improvement strategy on diabetes quality of care in a defined population of patients.

STUDY DESIGN

A multifaceted improvement strategy to enhance diabetes care was deployed to 18 primary care clinics serving 170,000 adults. Interventions empowered patient self-management, supported care team decision making, redesigned office systems, and maximized use of available information technology. Specific goals were to improve glycemic control and reduce cardiovascular risk in all adult diabetes patients. DATA SOURCE AND COLLECTION: Diabetes was identified through pharmacy and diagnostic data (estimated sensitivity 0.91, positive predictive value 0.94), and the target population ranged from 6,542 to 7,037 members over time. Trends in glycosylated hemoglobin (HbA1c) and low-density lipid LDL-cholesterol were analyzed monthly throughout 1999 in both cohorts and serial cross-sections.

RESULTS

During 12 months, mean HbA1c improved from 7.86% to 7.47%, and the proportion of patients with HbA1c levels < 8% rose from 60.5% to 68.3%, and the proportion with HbA1c > 10% fell from 10.3% to 7.2%. The LDL test rate rose from 47.4% to 57.4%, and mean LDL fell from 120 mg/dl to 116 mg/dl. The proportion with acceptable lipid control (LDL < 130 mg/dl, or < 100 mg/dl with coronary artery disease) rose from 48.9% to 57.7%. All changes were significant at p < 0.01 or less.

CONCLUSION

Clinically significant population-based improvements in diabetes care were observed during a 1-year period using a multifaceted "enhanced primary care" strategy.

Five giant leaps toward integrating health care delivery and ways to drive organizations to leap or get out of the way

The article argues that incremental improvement of, or "tinkering" with, health care delivery is taking too long and leaves unacceptable gaps in health care quality and service. It lists five common types of quality improvement "leaps" that have proven across studies to improve the integration of care during hospital and emergency department discharge, to bring mental health and substance abuse treatment into primary care, and to allow better management of chronic diseases. It also lists five key tasks that organizations need to accomplish in order to make such leaps and then describes four ways that consumers, employers, consumer advocates, and investors force the stubborn "bullfrogs" to take a big jump forward.

Systems change resulting from HIV/AIDS education and training. A cross-cutting evaluation of nine innovative projects

An evaluation of nine diverse HIV/AIDS training programs assessed the degree to which the programs produced changes in the ways that health care systems deliver HIV/AIDS care. Participants were interviewed an average of 8 months following completion of training and asked for specific examples of a resulting change in their health care system. More than half of the trainees gave at least one example of a systems change. The examples included the way patient referrals are made, the manner in which agency collaborations are organized, and the way care is delivered.