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Perry CK, Lindner S, Hall J, Solberg LI, Baron A, Cohen DJ. How Type of Practice Ownership Affects Participation with Quality Improvement External Facilitation: Findings from EvidenceNOW. J Gen Intern Med 2022; 37:793-801. [PMID: 34981342 PMCID: PMC8904707 DOI: 10.1007/s11606-021-07204-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 10/08/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Facilitation is an implementation strategy that can help primary care practices improve healthcare quality and build quality improvement (QI) capacity when delivered in a flexible manner by trained professionals. Practice ownership is associated with use of QI. However, little is known about how practices of different ownership participate in external facilitation, and this could inform future initiatives. OBJECTIVE Using data from EvidenceNOW, we examined how practice ownership influences participation in external facilitation. STUDY DESIGN We used an iterative mixed-methods design. PARTICIPANTS, APPROACH, AND MEASURES We collected data from practices on practice characteristics (e.g., location, size, payer mix) and ownership type via surveys and from facilitators on the number of hours, encounters, and months each practice had with a facilitator via facilitation logs. Using multivariable linear regression, we examined the association between facilitation and ownership (n = 1117 practices). We conducted semi-structured interviews with EvidenceNOW leadership (n = 12) and facilitators (n = 51) and observed facilitators in a subset of practices (n = 64); we analyzed this qualitative data for patterns of facilitation. KEY RESULTS In the fully adjusted model, differences by ownership were non-significant; FQHCs, however, had significantly less participation in facilitation than clinician-owned practices across two measures (unadjusted difference: - 2.83, p < 0.01 for number of encounters, and - 2.04, p < 0.01 for number of months with encounters). Qualitative data showed that Health System and FQHC ownership influenced types of practices enrolled in EvidenceNOW, and suggested that in these practices lower autonomy and greater complexity compared to clinician-owned ownership influenced facilitation participation patterns. CONCLUSIONS Practice ownership shaped how but not how much practices participated in external facilitation. This finding highlights the importance of tailoring facilitation approaches based on ownership-related characteristics in future QI initiatives.
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Affiliation(s)
- Cynthia K Perry
- School of Nursing, Oregon Health & Science University, Portland, OR, USA.
| | - Stephan Lindner
- Center for Health System Effectiveness, Oregon Health & Science University, Portland, OR, USA
| | - Jennifer Hall
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | | | - Andrea Baron
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
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Leeman J, Rohweder C, Lee M, Brenner A, Dwyer A, Ko LK, O'Leary MC, Ryan G, Vu T, Ramanadhan S. Aligning implementation science with improvement practice: a call to action. Implement Sci Commun 2021; 2:99. [PMID: 34496978 PMCID: PMC8424169 DOI: 10.1186/s43058-021-00201-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 08/25/2021] [Indexed: 12/24/2022] Open
Abstract
Background In several recent articles, authors have called for aligning the fields of implementation and improvement science. In this paper, we call for implementation science to also align with improvement practice. Multiple implementation scholars have highlighted the importance of designing implementation strategies to fit the existing culture, infrastructure, and practice of a healthcare system. Worldwide, healthcare systems are adopting improvement models as their primary approach to improving healthcare delivery and outcomes. The prevalence of improvement models raises the question of how implementation scientists might best align their efforts with healthcare systems’ existing improvement infrastructure and practice. Main body We describe three challenges and five benefits to aligning implementation science and improvement practice. Challenges include (1) use of different models, terminology, and methods, (2) a focus on generalizable versus local knowledge, and (3) limited evidence in support of the effectiveness of improvement tools and methods. We contend that implementation science needs to move beyond these challenges and work toward greater alignment with improvement practice. Aligning with improvement practice would benefit implementation science by (1) strengthening research/practice partnerships, (2) fostering local ownership of implementation, (3) generating practice-based evidence, (4) developing context-specific implementation strategies, and (5) building practice-level capacity to implement interventions and improve care. Each of these potential benefits is illustrated in a case study from the Centers for Disease Control and Prevention’s Cancer Prevention and Control Research Network. Conclusion To effectively integrate evidence-based interventions into routine practice, implementation scientists need to align their efforts with the improvement culture and practice that is driving change within healthcare systems worldwide. This paper provides concrete examples of how researchers have aligned implementation science with improvement practice across five implementation projects. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00201-1.
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Affiliation(s)
- Jennifer Leeman
- School of Nursing, The University of North Carolina at Chapel Hill, CB #7460, Chapel Hill, NC, 27599, USA.
| | - Catherine Rohweder
- Center for Health Promotion & Disease Prevention, The University of North Carolina at Chapel Hill, CB #7424, Carrboro, NC, 27510, USA
| | - Matthew Lee
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Ave, 8th Floor, New York, NY, 10016, USA
| | - Alison Brenner
- Department of General Medicine & Clinical Epidemiology, UNC School of Medicine, The University of North Carolina at Chapel Hill, CB #7293, Carrboro, NC, 27510, USA
| | - Andrea Dwyer
- University of Colorado Cancer Center, 13001 East 17th Avenue, Aurora, CO, 80045, USA
| | - Linda K Ko
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, USA.,Department of Cancer Prevention, Fred Hutchinson Cancer Research Center, Hans Rosling Center for Public Health, 3980 15th Avenue NE, 4th Floor, Seattle, WA, 98195, USA
| | - Meghan C O'Leary
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, CB #7400, Chapel Hill, NC, 27599, USA
| | - Grace Ryan
- The University of Iowa, 145 N. Riverside Drive, N475 CPHB, Iowa City, IA, 52242, USA
| | - Thuy Vu
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, USA
| | - Shoba Ramanadhan
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
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Effects of 2 Forms of Practice Facilitation on Cardiovascular Prevention in Primary Care: A Practice-randomized, Comparative Effectiveness Trial. Med Care 2020; 58:344-351. [PMID: 31876643 DOI: 10.1097/mlr.0000000000001260] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Effective quality improvement (QI) strategies are needed for small practices. OBJECTIVE The objective of this study was to compare practice facilitation implementing point-of-care (POC) QI strategies alone versus facilitation implementing point-of-care plus population management (POC+PM) strategies on preventive cardiovascular care. DESIGN Two arm, practice-randomized, comparative effectiveness study. PARTICIPANTS Small and mid-sized primary care practices. INTERVENTIONS Practices worked with facilitators on QI for 12 months to implement POC or POC+PM strategies. MEASURES Proportion of eligible patients in a practice meeting "ABCS" measures: (Aspirin) Aspirin/antiplatelet therapy for ischemic vascular disease, (Blood pressure) Controlling High Blood Pressure, (Cholesterol) Statin Therapy for the Prevention and Treatment of Cardiovascular Disease, and (Smoking) Tobacco Use: Screening and Cessation Intervention, and the Change Process Capability Questionnaire. Measurements were performed at baseline, 12, and 18 months. RESULTS A total of 226 practices were randomized, 179 contributed follow-up data. The mean proportion of patients meeting each performance measure was greater at 12 months compared with baseline: Aspirin 0.04 (95% confidence interval: 0.02-0.06), Blood pressure 0.04 (0.02-0.06), Cholesterol 0.05 (0.03-0.07), Smoking 0.05 (0.02-0.07); P<0.001 for each. Improvements were sustained at 18 months. At 12 months, baseline-adjusted difference-in-differences in proportions for the POC+PM arm versus POC was: Aspirin 0.02 (-0.02 to 0.05), Blood pressure -0.01 (-0.04 to 0.03), Cholesterol 0.03 (0.00-0.07), and Smoking 0.02 (-0.02 to 0.06); P>0.05 for all. Change Process Capability Questionnaire improved slightly, mean change 0.30 (0.09-0.51) but did not significantly differ across arms. CONCLUSION Facilitator-led QI promoting population management approaches plus POC improvement strategies was not clearly superior to POC strategies alone.
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Price DW, Biernacki H, Nora LM. Can Maintenance of Certification Work? Associations of MOC and Improvements in Physicians' Knowledge and Practice. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:1872-1881. [PMID: 29952770 DOI: 10.1097/acm.0000000000002338] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE To summarize the findings of studies, conducted by individuals both internal and external to the American Board of Medical Specialties (ABMS) Member Boards, of the associations of Maintenance of Certification (MOC) and improvements in physicians' knowledge and patient care processes or outcomes. METHOD The authors conducted a narrative review of studies identified by searching PubMed and Web of Science for English-language articles from the United States published between 2000 and May 2017. To be included, articles had to examine the relationship of MOC to physician knowledge, clinical practice processes, or patient care outcomes. The initial search yielded 811 articles. After two rounds of review and excluding those articles that did not fit the study criteria, 39 articles were included for analysis. RESULTS The 39 included studies were conducted by or included diplomates of 12 ABMS Member Boards. Twenty-two studies examined MOC processes that were developed by an ABMS Board; 17 examined interventions that were developed by nonboard entities but accepted for MOC credit by an ABMS Board. Thirty-eight studies examined a single component of MOC; 24 studied the improvement in medical practice component. Thirty-seven studies reported at least one positive outcome. CONCLUSIONS Most of the studies included in this review highlighted circumstances in which MOC was associated with positive impacts on physician knowledge and patient care processes or outcomes. Future collaborative research is needed to improve the relevance, helpfulness, and generalizability of continuing certification to different physicians across specialties and practice settings.
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Affiliation(s)
- David W Price
- D.W. Price is senior vice president, Research and Education Foundation, and executive director, Multispecialty Portfolio Program, American Board of Medical Specialties, Chicago, Illinois, and professor, Department of Family Medicine, University of Colorado School of Medicine, Denver, Colorado; ORCID: https://orcid.org/0000-0002-7645-0126. H. Biernacki is manager, Research Operations, American Board of Medical Specialties, Chicago, Illinois. L.M. Nora is immediate past president and chief executive officer, American Board of Medical Specialties, Chicago, Illinois
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Wang A, Pollack T, Kadziel LA, Ross SM, McHugh M, Jordan N, Kho AN. Impact of Practice Facilitation in Primary Care on Chronic Disease Care Processes and Outcomes: a Systematic Review. J Gen Intern Med 2018; 33:1968-1977. [PMID: 30066117 PMCID: PMC6206351 DOI: 10.1007/s11606-018-4581-9] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/08/2018] [Accepted: 07/06/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND More than 100 million individuals in the USA have been diagnosed with a chronic disease, yet chronic disease care has remained fragmented and of inconsistent quality. Improving chronic disease management has been challenging for primary care and internal medicine practitioners. Practice facilitation provides a comprehensive approach to chronic disease care. The objective is to evaluate the impact of practice facilitation on chronic disease outcomes in the primary care setting. METHODS This systematic review examined North American studies from PubMed, EMBASE, and Web of Science (database inception to August 2017). Investigators independently extracted and assessed the quality of the data on chronic disease process and clinical outcome measures. Studies implemented practice facilitation and reported quantifiable care processes and patient outcomes for chronic disease. Each study and their evidence were assessed for risk of bias and quality according to the Cochrane Collaboration and the Grade Collaboration tool. RESULTS This systematic review included 25 studies: 12 randomized control trials and 13 prospective cohort studies. Across all studies, practices and their clinicians were aware of the implementation of practice facilitation. Improvements were observed in most studies for chronic diseases including asthma, cancer (breast, cervical, and colorectal), cardiovascular disease (cerebrovascular disease, coronary artery disease, dyslipidemia, hypertension, myocardial infarction, and peripheral vascular disease), and type 2 diabetes. Mixed results were observed for chronic kidney disease and chronic illness care. DISCUSSION Overall, the results suggest that practice facilitation may improve chronic disease care measures. Across all studies, practices were aware of practice facilitation. These findings lend support for the potential expansion of practice facilitation in primary care. Future work will need to investigate potential opportunities for practice facilitation to improve chronic disease outcomes in other health care settings (e.g., specialty and multi-specialty practices) with standardized measures.
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Affiliation(s)
- Andrew Wang
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Teresa Pollack
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lauren A Kadziel
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Samuel M Ross
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Megan McHugh
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Neil Jordan
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Departments of Psychiatry & Behavioral Sciences and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL, USA
| | - Abel N Kho
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Leeman J, Birken SA, Powell BJ, Rohweder C, Shea CM. Beyond "implementation strategies": classifying the full range of strategies used in implementation science and practice. Implement Sci 2017; 12:125. [PMID: 29100551 PMCID: PMC5670723 DOI: 10.1186/s13012-017-0657-x] [Citation(s) in RCA: 233] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 10/18/2017] [Indexed: 01/17/2023] Open
Abstract
Background Strategies are central to the National Institutes of Health’s definition of implementation research as “the study of strategies to integrate evidence-based interventions into specific settings.” Multiple scholars have proposed lists of the strategies used in implementation research and practice, which they increasingly are classifying under the single term “implementation strategies.” We contend that classifying all strategies under a single term leads to confusion, impedes synthesis across studies, and limits advancement of the full range of strategies of importance to implementation. To address this concern, we offer a system for classifying implementation strategies that builds on Proctor and colleagues’ (2013) reporting guidelines, which recommend that authors not only name and define their implementation strategies but also specify who enacted the strategy (i.e., the actor) and the level and determinants that were targeted (i.e., the action targets). Main body We build on Wandersman and colleagues’ Interactive Systems Framework to distinguish strategies based on whether they are enacted by actors functioning as part of a Delivery, Support, or Synthesis and Translation System. We build on Damschroder and colleague’s Consolidated Framework for Implementation Research to distinguish the levels that strategies target (intervention, inner setting, outer setting, individual, and process). We then draw on numerous resources to identify determinants, which are conceptualized as modifiable factors that prevent or enable the adoption and implementation of evidence-based interventions. Identifying actors and targets resulted in five conceptually distinct classes of implementation strategies: dissemination, implementation process, integration, capacity-building, and scale-up. In our descriptions of each class, we identify the level of the Interactive System Framework at which the strategy is enacted (actors), level and determinants targeted (action targets), and outcomes used to assess strategy effectiveness. We illustrate how each class would apply to efforts to improve colorectal cancer screening rates in Federally Qualified Health Centers. Conclusions Structuring strategies into classes will aid reporting of implementation research findings, alignment of strategies with relevant theories, synthesis of findings across studies, and identification of potential gaps in current strategy listings. Organizing strategies into classes also will assist users in locating the strategies that best match their needs.
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Affiliation(s)
- Jennifer Leeman
- School of Nursing, University of North Carolina at Chapel Hill, CB #7460, Chapel Hill, NC, 27599, USA.
| | - Sarah A Birken
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Byron J Powell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Catherine Rohweder
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Christopher M Shea
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
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DeVoe JE, Likumahuwa-Ackman S, Shannon J, Steiner Hayward E. Creating 21st-Century Laboratories and Classrooms for Improving Population Health: A Call to Action for Academic Medical Centers. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017; 92:475-482. [PMID: 27655058 DOI: 10.1097/acm.0000000000001385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Academic medical centers (AMCs) in the United States built world-class infrastructure to successfully combat disease in the 20th century, which is inadequate for the complexity of sustaining and improving population health. AMCs must now build first-rate 21st-century infrastructure to connect combating disease and promoting health. This infrastructure must acknowledge the bio-psycho-social-environmental factors impacting health and will need to reach far beyond the AMC walls to foster community "laboratories" that support the "science of health," complementary to those supporting the "science of medicine"; cultivate community "classrooms" to stimulate learning and discovery in the places where people live, work, and play; and strengthen bridges between academic centers and these community laboratories and classrooms to facilitate bidirectional teaching, learning, innovation, and discovery.Private and public entities made deep financial investments that contributed to the AMC disease-centered approach to clinical care, education, and research in the 20th century. Many of these same funders now recognize the need to transform U.S. health care into a system that is accountable for population health and the need for a medical workforce equipped with the skills to measure and improve health. Innovative ideas about communities as centers of learning, the importance of social factors as major determinants of health, and the need for multidisciplinary perspectives to solve complex problems are not new; many are 20th-century ideas still waiting to be fully implemented. The window of opportunity is now. The authors articulate how AMCs must take bigger and bolder steps to become leaders in population health.
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Affiliation(s)
- Jennifer E DeVoe
- J.E. DeVoe is professor and chair, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, and senior research advisor, OCHIN, Inc., Portland, Oregon. S. Likumahuwa-Ackman is research program manager, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon. J. Shannon is associate professor, School of Public Health, director, Knight Community Engaged Research Program, Knight Cancer Institute, and associate director, Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland, Oregon. E. Steiner Hayward is adjunct associate professor, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, and senator, Oregon State Legislature, Salem, Oregon
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Abstract
This paper discusses the UK’s National Programme for IT (NPfIT), which was an ambitious programme launched in 2002 with an initial budget of some £6.2 billion. It attempted to implement a top-down digitization of healthcare in England’s National Health Service (NHS). The core aim of the NPfIT was to bring the NHS’ use of information technology into the 21st century, through the introduction of an integrated electronic patient record systems, and reforming the way that the NHS uses information, and hence to improve services and the quality of patient care. The initiative was not trusted by doctors and appeared to have no impact on patient safety. The project was marred by resistance due to the inappropriateness of a centralized authority making top-down decisions on behalf of local organizations. The NPfIT was officially dismantled in September 2011. Deemed the world’s largest civil IT programme, its failure and ultimate demise sparked a lot of interest as to the reasons why. This paper summarises the underlying causes that lead to dismantling the NPfIT. At the forefront of those circumstances were the lack of adequate end user engagement, the absence of a phased change management approach, and underestimating the scale of the project.
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Affiliation(s)
- Taghreed Justinia
- King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
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McHugh M, Harvey J, Hamil J, Verevkina NI, Alexander J, Scanlon DP. The Impact of the Affordable Care Act on Health Care Alliances' Quality Improvement Efforts in Targeted Communities: Perceptions of Health Care Alliance Leaders. Jt Comm J Qual Patient Saf 2016; 42:137-45. [PMID: 26892703 DOI: 10.1016/s1553-7250(16)42017-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Megan McHugh
- Center for Healthcare Studies and Department of Emergency Medicine, Northwestern University, Feinberg School of Medicine, Chicago, USA
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McHugh M, Shi Y, Ramsay PP, Harvey JB, Casalino LP, Shortell SM, Alexander JA. Patient-Centered Medical Home Adoption: Results From Aligning Forces For Quality. Health Aff (Millwood) 2016; 35:141-9. [DOI: 10.1377/hlthaff.2015.0495] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Megan McHugh
- Megan McHugh ( ) is a research assistant professor in the Center for Healthcare Studies and Department of Emergency Medicine, Feinberg School of Medicine, at Northwestern University, in Chicago, Illinois
| | - Yunfeng Shi
- Yunfeng Shi is an assistant professor in the Department of Health Policy and Administration at Pennsylvania State University, in University Park
| | - Patricia P. Ramsay
- Patricia P. Ramsay is a policy analyst in the School of Public Health and administrative director of the Center for Healthcare Organizational and Innovation Research at the University of California, Berkeley
| | - Jillian B. Harvey
- Jillian B. Harvey is an assistant professor of healthcare leadership and management at the Medical University of South Carolina, in Charleston
| | - Lawrence P. Casalino
- Lawrence P. Casalino is the Livingston Farrand Professor and chief of the Division of Health Policy and Research at Weill Cornell Medical College, in New York City
| | - Stephen M. Shortell
- Stephen M. Shortell is dean emeritus of the School of Public Health, the Blue Cross of California Distinguished Professor of Health Policy and Management in both the School of Public Health and the Haas School of Business, and faculty director of the Center for Healthcare Organizational and Innovation Research, all at the University of California, Berkeley
| | - Jeffrey A. Alexander
- Jeffrey A. Alexander is a professor emeritus of health management and policy at the University of Michigan, in Ann Arbor
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Newton WP, Lefebvre A. Is a strategy focused on super-utilizers equal to the task of health care system transformation? No. Ann Fam Med 2015; 13:8-9. [PMID: 25583885 PMCID: PMC4291258 DOI: 10.1370/afm.1747] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Warren Polk Newton
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina North Carolina Area Health Education Centers, University of North Carolina, Chapel Hill, North Carolina
| | - Ann Lefebvre
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina North Carolina Area Health Education Centers, University of North Carolina, Chapel Hill, North Carolina
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Oxendine V, Meyer A, Reid PV, Adams A, Sabol V. Evaluating Diabetes Outcomes and Costs Within an Ambulatory Setting: A Strategic Approach Utilizing a Clinical Decision Support System. Clin Diabetes 2014; 32:113-20. [PMID: 26246682 PMCID: PMC4521435 DOI: 10.2337/diaclin.32.3.113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Peterson LE, Blackburn B, Phillips RL, Puffer JC. Improving quality of care for diabetes through a maintenance of certification activity: family physicians' use of the chronic care model. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2014; 34:47-55. [PMID: 24648363 DOI: 10.1002/chp.21216] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Improving the care of patients with diabetes is a health care priority. Through Part 4 of Maintenance of Certification for Family Physicians (MC-FP), American Board of Family Medicine (ABFM) diplomates participate in quality improvement (QI) modules for diabetes. Our objective was to determine associations between physician characteristics and actions taken during Part 4 diabetes modules with quality of care outcomes. METHODS The study sample was all Part 4 modules completed by family physicians from 2005 to 2012. Descriptive statistics were used to characterize the physicians and their behavior in the module. We used linear regression to test for associations between choice of intervention, mode of intervention, and chronic care model domain with improvement in quality measures. RESULTS There were 7924 modules completed by family physicians, whose mean age was 48.2 years; 61.9% were male, and 76.9% lived in urban areas. All physician and patient quality measures improved over the course of the Part 4 module. Regression models found that only baseline performance was consistently associated with quality outcomes. No other consistent association was seen between intervention type, mode, or chronic care model domain and greater likelihood of improvements; however, every quality measure improved. DISCUSSION Through MC-FP, family physicians improved the quality of care they delivered to diabetic patients. Improvement of care across nearly all measures, despite no consistent associations between processes of care or physician characteristics with improvement, suggests that participation in QI itself may lead to higher quality health care and this may be achieved through MC-FP.
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Halladay JR, DeWalt DA, Wise A, Qaqish B, Reiter K, Lee SY, Lefebvre A, Ward K, Mitchell CM, Donahue KE. More extensive implementation of the chronic care model is associated with better lipid control in diabetes. J Am Board Fam Med 2014; 27:34-41. [PMID: 24390884 PMCID: PMC4096824 DOI: 10.3122/jabfm.2014.01.130070] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Chronic disease collaboratives help practices redesign care delivery. The North Carolina Improving Performance in Practice program provides coaches to guide implementation of 4 key practice changes: registries, planned care templates, protocols, and self-management support. Coaches rate progress using the Key Drivers Implementation Scales (KDIS). This study examines whether higher KDIS scores are associated with improved diabetes outcomes. METHODS We analyzed clinical and KDIS data from 42 practices. We modeled whether higher implementation scores at year 1 of participation were associated with improved diabetes measures during year 2. Improvement was defined as an increase in the proportion of patients with hemoglobin A1C values <9%, blood pressure values <130/80 mmHg, and low-density lipoprotein (LDL) levels <100 mg/dL. RESULTS Statistically significant improvements in the proportion of patients who met the LDL threshold were noted with higher "registry" and "protocol" KDIS scores. For hemoglobin A1C and blood pressure values, none of the odds ratios were statistically significant. CONCLUSIONS Practices that implement key changes may achieve improved patient outcomes in LDL control among their patients with diabetes. Our data confirm the importance of registry implementation and protocol use as key elements of improving patient care. The KDIS tool is a pragmatic option for measuring practice changes that are rooted in the Chronic Care Model.
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Affiliation(s)
- Jacqueline R Halladay
- the Department of Family Medicine and the Division of General Medicine and Clinical Epidemiology, Cecil G. Sheps Center for Health Services Research, and the Departments of Biostatistics and Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill; the Department of Health Policy and Management, University of Michigan School of Public Health, Ann Arbor; and the North Carolina Area Health Education Centers, Chapel Hill
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Ryan AM, Bishop TF, Shih S, Casalino LP. Small physician practices in new york needed sustained help to realize gains in quality from use of electronic health records. Health Aff (Millwood) 2013; 32:53-62. [PMID: 23297271 DOI: 10.1377/hlthaff.2012.0742] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The 2009 American Recovery and Reinvestment Act spurred adoption of electronic health records (EHRs) in the United States, through such measures as financial incentives to providers through Medicare and Medicaid and regional extension centers, which provide ongoing technical assistance to practices. Yet the relationship between EHR adoption and quality of care remains poorly understood. We evaluated the early effects on quality of the Primary Care Information Project, which provides subsidized EHRs and technical assistance to primary care practices in underserved neighborhoods in New York City, using the regional extension center model. We found that just general participation in, or exposure to, the project was not enough to improve quality of care. It took sustained exposure on the part of these practices and technical assistance to them before they demonstrated improvement on measures of care most likely to be affected by the use of electronic health records, such as cancer screenings and care for patients with diabetes. Participating in the Primary Care Information Project for nine or more months was associated with significantly improved quality, but only for this limited group of quality measures and only for physicians receiving extensive technical assistance.
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Affiliation(s)
- Andrew M Ryan
- Weill Cornell Medical College, New York City, NY, USA.
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16
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Fraher EP, Ricketts TC, Lefebvre A, Newton WP. The role of academic health centers and their partners in reconfiguring and retooling the existing workforce to practice in a transformed health system. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2013; 88:1812-1816. [PMID: 24128624 DOI: 10.1097/acm.0000000000000024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Inspired by the Affordable Care Act and health care payment models that reward value over volume, health care delivery systems are redefining the work of the health professionals they employ. Existing workers are taking on new roles, new types of health professionals are emerging, and the health workforce is shifting from practicing in higher-cost acute settings to lower-cost community settings, including patients' homes. The authors believe that although the pace of health system transformation has accelerated, a shortage of workers trained to function in the new models of care is hampering progress. In this Perspective, they argue that urgent attention must be paid to retraining the 18 million workers already employed in the system who will actually implement system change.Their view is shaped by work they have conducted in helping practices transform care, by extensive consultations with stakeholders attempting to understand the workforce implications of health system redesign, and by a thorough review of the peer-reviewed and gray literature. Through this work, the authors have become increasingly convinced that academic health centers (AHCs)-organizations at the forefront of innovations in health care delivery and health workforce training-are uniquely situated to proactively lead efforts to retrain the existing workforce. They recommend a set of specific actions (i.e., discovering and disseminating best practices; developing new partnerships; focusing on systems engineering approaches; planning for sustainability; and revising credentialing, accreditation, and continuing education) that AHC leaders can undertake to develop a more coherent workforce development strategy that supports practice transformation.
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Affiliation(s)
- Erin P Fraher
- Dr. Fraher is director, Program on Health Workforce Research and Policy, Cecil G. Sheps Center, and assistant professor, Department of Family Medicine and Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Dr. Ricketts is professor, Department of Health Policy and Management and Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Ms. Lefebvre is associate director, North Carolina Area Health Education Centers Program, and adjunct assistant professor, Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Dr. Newton is vice dean, North Carolina Area Health Education Centers Program of the School of Medicine, and William B. Aycock Professor and Chair, Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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17
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Okelo SO, Butz AM, Sharma R, Diette GB, Pitts SI, King TM, Linn ST, Reuben M, Chelladurai Y, Robinson KA. Interventions to modify health care provider adherence to asthma guidelines: a systematic review. Pediatrics 2013; 132:517-34. [PMID: 23979092 PMCID: PMC4079294 DOI: 10.1542/peds.2013-0779] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Health care provider adherence to asthma guidelines is poor. The objective of this study was to assess the effect of interventions to improve health care providers' adherence to asthma guidelines on health care process and clinical outcomes. METHODS Data sources included Medline, Embase, Cochrane CENTRAL Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Educational Resources Information Center, PsycINFO, and Research and Development Resource Base in Continuing Medical Education up to July 2012. Paired investigators independently assessed study eligibility. Investigators abstracted data sequentially and independently graded the evidence. RESULTS Sixty-eight eligible studies were classified by intervention: decision support, organizational change, feedback and audit, clinical pharmacy support, education only, quality improvement/pay-for-performance, multicomponent, and information only. Half were randomized trials (n = 35). There was moderate evidence for increased prescriptions of controller medications for decision support, feedback and audit, and clinical pharmacy support and low-grade evidence for organizational change and multicomponent interventions. Moderate evidence supports the use of decision support and clinical pharmacy interventions to increase provision of patient self-education/asthma action plans. Moderate evidence supports use of decision support tools to reduce emergency department visits, and low-grade evidence suggests there is no benefit for this outcome with organizational change, education only, and quality improvement/pay-for-performance. CONCLUSIONS Decision support tools, feedback and audit, and clinical pharmacy support were most likely to improve provider adherence to asthma guidelines, as measured through health care process outcomes. There is a need to evaluate health care provider-targeted interventions with standardized outcomes.
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Affiliation(s)
- Sande O. Okelo
- David Geffen School of Medicine and Mattel Children’s Hospital, University of California at Los Angeles, Los Angeles, California; and
| | | | - Ritu Sharma
- Bloomberg School of Public Health Baltimore, Johns Hopkins University, Baltimore, Maryland
| | | | | | | | - Shauna T. Linn
- Bloomberg School of Public Health Baltimore, Johns Hopkins University, Baltimore, Maryland
| | - Manisha Reuben
- Bloomberg School of Public Health Baltimore, Johns Hopkins University, Baltimore, Maryland
| | | | - Karen A. Robinson
- School of Medicine and,Bloomberg School of Public Health Baltimore, Johns Hopkins University, Baltimore, Maryland
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18
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Donahue KE, Newton WP, Lefebvre A, Plescia M. Natural history of practice transformation: development and initial testing of an outcomes-based model. Ann Fam Med 2013; 11:212-9. [PMID: 23690320 PMCID: PMC3659137 DOI: 10.1370/afm.1497] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 08/31/2012] [Accepted: 09/19/2012] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Practice transformation is the cornerstone of the future of family medicine and health care reform, but little is known about how the process occurs. We sought to develop and test a model of the natural history of practice transformation. METHODS We developed an outcomes-based model of how a practice moves through practice transformation in 2 phases: (1) initial model created through meetings with collaborative experts and practice facilitators, and (2) clinical and practice systems change reports examined from the first group of participating North Carolina Improving Performance In Practice practices to test and further refine the model. RESULTS The resultant model described motivators and supports to transformation. Three emerging practice patterns were identified with the model: transformed practices experiencing robust improvement, activated practices with moderate change, and engaged practices with minimal change in measured quality over a 2-year period. Transformed practices showed broad-based improvement; some reached a threshold and others continued to improve. These practices had highly engaged leadership and used data to drive decisions. Activated practices had a slower improvement trajectory, usually encountering a barrier that took time to overcome (eg, extracting population data, spreading practice changes). Engaged practices did not improve or were unable to sustain change; despite good intentions, multiple competing distractions interfered with practice transformation. CONCLUSIONS Practice transformation is a continuous and long-term process. Internal and external practice motivations and specific practice supports provided by a community-based quality improvement program appear to have an impact on engagement, rate of quality improvement, and long-term sustainability. Early successes play a key role as practices learn how to change their performance.
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Affiliation(s)
- Katrina E Donahue
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA.
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19
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Donahue KE, Halladay JR, Wise A, Reiter K, Lee SYD, Ward K, Mitchell M, Qaqish B. Facilitators of transforming primary care: a look under the hood at practice leadership. Ann Fam Med 2013; 11 Suppl 1:S27-33. [PMID: 23690383 PMCID: PMC3707244 DOI: 10.1370/afm.1492] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE This study examined how characteristics of practice leadership affect the change process in a statewide initiative to improve the quality of diabetes and asthma care. METHODS We used a mixed methods approach, involving analyses of existing quality improvement data on 76 practices with at least 1 year of participation and focus groups with clinicians and staff in a 12-practice subsample. Existing data included monthly diabetes or asthma measures (clinical measures) and monthly practice implementation, leadership, and practice engagement scores rated by an external practice coach. RESULTS Of the 76 practices, 51 focused on diabetes and 25 on asthma. In aggregate, 50% to 78% made improvements within in each clinical measure in the first year. The odds of making practice changes were greater for practices with higher leadership scores (odds ratios = 2.41-4.20). Among practices focused on diabetes, those with higher leadership scores had higher odds of performing nephropathy screening (odds ratio = 1.37, 95% CI, 1.08-1.74); no significant associations were seen for the intermediate outcome measures of hemoglobin A1c, blood pressure, and cholesterol. Focus groups revealed the importance of a leader, typically a physician, who believed in the transformation work (ie, a visionary leader) and promoted practice engagement through education and cross-training. Practices with greater change implementation also mentioned the importance of a midlevel operational leader who helped to create and sustain practice changes. This person communicated and interacted well with, and was respected by both clinicians and staff. CONCLUSIONS In the presence of a vision for transformation, operational leaders within practices can facilitate practice changes that are associated with clinical improvement.
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Affiliation(s)
- Katrina E Donahue
- University of North Carolina, Department of Family Medicine, Chapel Hill, North Carolina 27599, USA.
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20
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Harvey JB, Beich J, Alexander JA, Scanlon D. Building The Scaffold To Improve Health Care Quality In Western New York. Health Aff (Millwood) 2012; 31:636-41. [DOI: 10.1377/hlthaff.2011.0761] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jillian B. Harvey
- Jillian B. Harvey ( ) is a doctoral candidate in the Program in Health Policy and Administration, College of Health and Human Development, at the Pennsylvania State University, in University Park
| | - Jeff Beich
- Jeff Beich is a consultant in health services research, in Grand Island, New York
| | - Jeffrey A. Alexander
- Jeffrey A. Alexander is the Richard Carl Jelinek Professor of Health Management and Policy at the School of Public Health, University of Michigan, in Ann Arbor
| | - Dennis Scanlon
- Dennis Scanlon is a professor of health policy and administration at Penn State
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Margolis PA, DeWalt DA, Simon JE, Horowitz S, Scoville R, Kahn N, Perelman R, Bagley B, Miles P. Designing a large-scale multilevel improvement initiative: the improving performance in practice program. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2010; 30:187-196. [PMID: 20872774 DOI: 10.1002/chp.20080] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Improving Performance in Practice (IPIP) is a large system intervention designed to align efforts and motivate the creation of a tiered system of improvement at the national, state, practice, and patient levels, assisting primary-care physicians and their practice teams to assess and measurably improve the quality of care for chronic illness and preventive services using a common approach across specialties. The long-term goal of IPIP is to create an ongoing, sustained system across multiple levels of the health care system to accelerate improvement. IPIP core program components include alignment of leadership and leadership accountability, promotion of partnerships to promote health care quality, development of attractive incentives and motivators, regular measurement and transparent sharing of performance data, participation in organized quality improvement efforts using a standardized model, development of enduring collaborative improvement networks, and practice-level support. A prototype of the program was tested in 2 states from March 2006 to February 2008. In 2008, IPIP began to spread to 5 additional states. IPIP uses the leadership of the medical profession to align efforts to achieve large-scale change and to catalyze the development of an infrastructure capable of testing, evaluating, and disseminating effective approaches directly into practice.
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Affiliation(s)
- Peter A Margolis
- James A. Anderson Center for Health System Excellence, Division of Health Policy and Clinical Effectiveness, Cincinnati Children's Hospital Medical Center, MLC 7014, 3333 Burnet Avenue, Cincinnati, OH 45299, USA.
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Weaver SJ, Rosen MA, Salas E, Baum KD, King HB. Integrating the science of team training: guidelines for continuing education. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2010; 30:208-220. [PMID: 21171026 DOI: 10.1002/chp.20085] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The provision of high-quality, efficient care results from the coordinated, cooperative efforts of multiple technically competent health care providers working in concert over time, spanning disciplinary and professional boundaries. Accordingly, the role of medical education must include the development of providers who are both expert clinicians and expert team members. However, the competencies underlying effective teamwork are only just beginning to be integrated into medical school curricula and residency programs. Therefore, continuing education (CE) is a vital mechanism for practitioners already in the field to develop the attitudes, behaviors (skills), and cognitive knowledge necessary for highly reliable and effective team performance.The present article provides an overview of more than 30 years of evidence regarding team performance and team training in order to guide, shape, and build CE activities that focus on developing team competencies. Recognizing that even the most comprehensive and well-designed team-oriented CE programs will fail unless they are supported by an organizational and professional culture that values collaborative behavior, ten evidence-based lessons for practice are offered in order to facilitate the use of the science of team-training in efforts to foster continuous quality improvement and enhance patient safety.
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Affiliation(s)
- Sallie J Weaver
- Doctoral Candidate, Department of Psychology, and Institute for Simulation and Training, University of Central Florida, Orlando, Florida 32826, USA
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