Key issues in transforming health care organizations for quality: the case of advanced access

Advanced Access Scheduling in Primary Care: A Synthesis of Evidence

EXECUTIVE SUMMARY

Advanced access (AA) scheduling aims to improve primary care throughput by decreasing appointment scheduling wait time for patients. The primary objective of this article is to provide a review and analysis of the evidence comparing AA scheduling in primary care with traditional scheduling. A comprehensive search of electronic databases (PubMed, Cochrane, CINAHL, Web of Science, PsychINFO) from 1999 through 2018 was completed to identify all studies that compared practice and patient outcomes before implementation of AA scheduling and after implementation in primary care. PRISMA-P 2015 protocol guidelines for systematic review were used. Of the 177 studies eligible for inclusion, 18 satisfied all inclusion criteria. Findings suggest that AA scheduling may reduce appointment scheduling wait time (83%) and no-show rates (67%), increase patient volume (50%) and productivity of providers (83%), and decrease emergency and urgent care visits (75%). Patient and staff satisfaction, continuity of care, revenue, and quality of care outcomes were mixed in terms of improvement. This author investigated definition controversies, implication to stakeholders, differences in scheduling implementation, and measures and outcomes of AA in primary care. The analysis found that AA scheduling promises to improve access in primary care. Further research must be conducted to better inform healthcare stakeholders on how, where, and with whom AA scheduling systems can be best implemented.

Interventions to reduce wait times for primary care appointments: a systematic review

Background

Accessibility and availability are important characteristics of efficient and effective primary healthcare systems. Currently, timely access to a family physician is a concern in Canada. Adverse outcomes are associated with longer wait times for primary care appointments and often leave individuals to rely on urgent care. When wait times for appointments are too long patients may experience worse health outcomes and are often left to use emergency department resources. The primary objective of our study was to systematically review the literature to identify interventions designed to reduce wait times for primary care appointments. Secondary objectives were to assess patient satisfaction and reduction of no-show rates.

Methods

We searched multiple databases, including: Medline via Ovid SP (1947 to present), Embase (from 1980 to present), PsychINFO (from 1806 to present), Cochrane Central Register of Controlled Trials (CENTRAL; all dates), Cumulative Index to Nursing and Allied Health (CINAHL; 1937 to present), and Pubmed (all dates) to identify studies that reported outcomes associated with interventions designed to reduce wait times for primary care appointments. Two independent reviewers assessed all identified studies for inclusion using pre-defined inclusion/exclusion criteria and a multi-level screening approach. Our study methods were guided by the Cochrane Handbook for Systematic Reviews of Interventions.

Results

Our search identified 3,960 articles that were eligible for inclusion, eleven of which satisfied all inclusion/exclusion criteria. Data abstraction of included studies revealed that open access scheduling is the most commonly used intervention to reduce wait times for primary care appointments. Additionally, included studies demonstrated that dedicated telephone calls for follow-up consultation, presence of nurse practitioners on staff, nurse and general practitioner triage, and email consultations were effective at reducing wait times.

Conclusions

To our knowledge, this is the first study to systematically review and identify interventions designed to reduce wait times for primary care appointments. Our findings suggest that open access scheduling and other patient-centred interventions may reduce wait times for primary care appointments. Our review may inform policy makers and family healthcare providers about interventions that are effective in offering timely access to primary healthcare.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2219-y) contains supplementary material, which is available to authorized users.

Transforming community prevention systems for sustained impact: embedding active implementation and scaling functions

Traditional efforts to translate evidence-based prevention strategies to communities, at scale, have not often produced socially significant outcomes or the local capacity needed to sustain them. A key gap in many efforts is the transformation of community prevention systems to support and sustain local infrastructure for the active implementation, scaling, and continuous improvement of effective prevention strategies. In this paper, we discuss (1) the emergence of applied implementation science as an important type 3-5 translational extension of traditional type 2 translational prevention science, (2) active implementation and scaling functions to support the full and effective use of evidence-based prevention strategies in practice, (3) the organization and alignment of local infrastructure to embed active implementation and scaling functions within community prevention systems, and (4) policy and practice implications for greater social impact and sustainable use of effective prevention strategies.

Strategies for Aligning Physicians to System Redesign Goals at Eight Safety-Net Systems

BACKGROUND

Facing recent economic and regulatory pressures, safety-net systems (SNSs) are redesigning their organizations to improve care delivery, remain financially viable, and maintain competitive positions. Aligning physicians with redesign goals is a priority, particularly as many SNSs shift toward patient-centered, population health-focused models. No previous work has examined efforts to align physicians to safety net redesign efforts.

METHODS

This qualitative study, conducted at eight SNSs, examined challenges faced in a changing health care environment, as well as strategies and resources to address them.

RESULTS

Strategies clustered in two categories: physician role definition and organizational infrastructure. Physician role definition strategies were (1) changing payment and employment arrangements, (2) changing clinical roles, (3) increasing physician involvement in quality improvement, and (4) strengthening physician leadership in clinical and quality roles. Organizational infrastructure strategies were (1) ensuring medical center leadership support and integration, (2) utilizing data to drive physician behavior, and (3) addressing competing allegiances with academia. All sites reported multifaceted approaches but differed in specific strategies employed, facilitators noted, and challenges encountered.

DISCUSSION

The findings highlight the need to implement multiple strategies to align physicians in redesign efforts. They suggest that all health systems, whether SNSs or not, can capitalize on qualities of physicians and existing infrastructural and leadership elements to achieve physician alignment. However, they must contend with and address challenges of competing allegiance (for example, academic, physician organization, hospital), as well as resistance to changing clinical roles and payment structures.

Improving inpatient postnatal services: midwives views and perspectives of engagement in a quality improvement initiative

BACKGROUND

Despite major policy initiatives in the United Kingdom to enhance women's experiences of maternity care, improving in-patient postnatal care remains a low priority, although it is an aspect of care consistently rated as poor by women. As part of a systems and process approach to improving care at one maternity unit in the South of England, the views and perspectives of midwives responsible for implementing change were sought.

METHODS

A Continuous Quality Improvement (CQI) approach was adopted to support a systems and process change to in-patient care and care on transfer home in a large district general hospital with around 6000 births a year. The CQI approach included an initial assessment to identify where revisions to routine systems and processes were required, developing, implementing and evaluating revisions to the content and documentation of care in hospital and on transfer home, and training workshops for midwives and other maternity staff responsible for implementing changes. To assess midwifery views of the quality improvement process and their engagement with this, questionnaires were sent to those who had participated at the outset.

RESULTS

Questionnaires were received from 68 (46%) of the estimated 149 midwives eligible to complete the questionnaire. All midwives were aware of the revisions introduced, and two-thirds felt these were more appropriate to meet the women's physical and emotional health, information and support needs. Some midwives considered that the introduction of new maternal postnatal records increased their workload, mainly as a consequence of colleagues not completing documentation as required.

CONCLUSIONS

This was the first UK study to undertake a review of in-patient postnatal services. Involvement of midwives at the outset was essential to the success of the initiative. Midwives play a lead role in the planning and organisation of in-patient postnatal care and it was important to obtain their feedback on whether revisions were pragmatic and achieved anticipated improvements in care quality. Their initial involvement ensured priority areas for change were identified and implemented. Their subsequent feedback highlighted further important areas to address as part of CQI to ensure best quality care continues to be implemented. Our findings could support other maternity service organisations to optimise in-patient postnatal services.

Does open access improve the process and outcome of podiatric care?

Background

Open access to clinics is a management strategy to improve healthcare delivery. Providers are sometimes hesitant to adopt open access because of fear of increased visits for potentially trivial complaints. We hypothesized open access clinics would result in decreased wait times, increased number of podiatry visits, fewer “no shows”, higher rates of acute care visits, and lower minor amputation rates over control clinics without open access.

Methods

This study was a national retrospective case-control study of VHA (Veterans Hospital Administration) podiatry clinics in 2008. Eight case facilities reported to have open podiatry clinic access for at least one year were identified from an email survey. Sixteen control facilities with similar structural features (e.g., full time podiatrists, health tech, residency program, reconstructive foot surgery, vascular, and orthopedic surgery) were identified in the same geographic region as the case facilities.

Results

Twenty-two percent of facilities responded to the survey. Fifty-four percent reported open access and 46% did not. There were no differences in facility or podiatry panel size, podiatry visits, or visit frequency between the cases and controls. Podiatry visits trended higher for control facilities but didn’t reach statistical significance. Case facilities had more new consults seen within 30 days (96%, 89%; P = 0.050) and lower minor amputation rates (0.62/1,000, 1.0/1,000; P = 0.041).

Conclusions

The VHA is the world’s largest managed care organization and it relies on clinical efficiencies as one mechanism to improve the quality of care. Open access clinics had more timely access for new patients and lower rates of minor amputations.

Keywords

Health care; Quality; Access; Evaluation; Delivery of health care; Amputation; Amputation prevention

Towards an organisation-wide process-oriented organisation of care: a literature review

BACKGROUND

Many hospitals have taken actions to make care delivery for specific patient groups more process-oriented, but struggle with the question how to deal with process orientation at hospital level. The aim of this study is to report and discuss the experiences of hospitals with implementing process-oriented organisation designs in order to derive lessons for future transitions and research.

METHODS

A literature review of English language articles on organisation-wide process-oriented redesigns, published between January 1998 and May 2009, was performed.

RESULTS

Of 329 abstracts identified, 10 articles were included in the study. These articles described process-oriented redesigns of five hospitals. Four hospitals tried to become process-oriented by the implementation of coordination measures, and one by organisational restructuring. The adoption of the coordination mechanism approach was particularly constrained by the functional structure of hospitals. Other factors that hampered the redesigns in general were the limited applicability of and unfamiliarity with process improvement techniques.

CONCLUSIONS

Due to the limitations of the evidence, it is not known which approach, implementation of coordination measures or organisational restructuring (with additional coordination measures), produces the best results in which situation. Therefore, more research is needed. For this research, the use of qualitative methods in addition to quantitative measures is recommended to contribute to a better understanding of preconditions and contingencies for an effective application of approaches to become process-oriented. Hospitals are advised to take the factors for failure described into account and to take suitable actions to counteract these obstacles on their way to become process-oriented organisations.

Summary of the National Demonstration Project and recommendations for the patient-centered medical home

This article summarizes findings from the National Demonstration Project (NDP) and makes recommendations for policy makers and those implementing patient-centered medical homes (PCMHs) based on these findings and an understanding of diverse efforts to transform primary care. The NDP was launched in June 2006 as the first national test of a particular PCMH model in a diverse sample of 36 family practices, randomized to facilitated or self-directed groups. An independent evaluation team used a multimethod evaluation strategy, analyzing data from direct observation, depth interviews, e-mail streams, medical record audits, and patient and clinical staff surveys. Peer-reviewed manuscripts from the NDP provide answers to 4 key questions: (1) Can the NDP model be built? (2) What does it take to build the NDP model? (3) Does the NDP model make a difference in quality of care? and (4) Can the NDP model be widely disseminated? We find that although it is feasible to transform independent practices into the NDP conceptualization of a PCMH, this transformation requires tremendous effort and motivation, and benefits from external support. Most practices will need additional resources for this magnitude of transformation. Recommendations focus on the need for the PCMH model to continue to evolve, for delivery system reform, and for sufficient resources for implementing personal and practice development plans. In the meantime, we find that much can be done before larger health system reform.

A four phase development model for integrated care services in the Netherlands

BACKGROUND

Multidisciplinary and interorganizational arrangements for the delivery of coherent integrated care are being developed in a large number of countries. Although there are many integrated care programs worldwide, the process of developing these programs and interorganizational collaboration is described in the literature only to a limited extent. The purpose of this study is to explore how local integrated care services are developed in the Netherlands, and to conceptualize and operationalize a development model of integrated care.

METHODS

The research is based on an expert panel study followed by a two-part questionnaire, designed to identify the development process of integrated care. Essential elements of integrated care, which were developed in a previous Delphi and Concept Mapping Study, were analyzed in relation to development process of integrated care.

RESULTS

Integrated care development can be characterized by four developmental phases: the initiative and design phase; the experimental and execution phase; the expansion and monitoring phase; and the consolidation and transformation phase. Different elements of integrated care have been identified in the various developmental phases.

CONCLUSION

The findings provide a descriptive model of the development process that integrated care services can undergo in the Netherlands. The findings have important implications for integrated care services, which can use the model as an instrument to reflect on their current practices. The model can be used to help to identify improvement areas in practice. The model provides a framework for developing evaluation designs for integrated care arrangements. Further research is recommended to test the developed model in practice and to add international experiences.

Implementing open-access scheduling of visits in primary care practices: a cautionary tale

BACKGROUND

Open-access scheduling (also known as advanced access or same-day access) is a popular tool for improving patient access to primary care appointments.

OBJECTIVE

To assess the effect of open-access scheduling and describe the barriers to implementing the open-access scheduling model in primary care.

DESIGN

Case series.

SETTING

Boston, Massachusetts, metropolitan area.

PARTICIPANTS

6 primary care practices studied from October 2003 through June 2006.

INTERVENTION

Implementation of open-access scheduling.

MEASUREMENTS

Time to third available appointments, no-show rates, and patient and staff satisfaction with appointment availability.

RESULTS

5 of 6 practices were able to implement open-access scheduling. Within 4 months of implementation, these 5 practices substantially reduced their mean wait for third available appointments from 21 to 8 days for 15-minute visits and from 39 to 14 days for 30-minute visits. However, none of the 5 practices attained the goal of same-day access, and waits for third available appointments increased during 2 years of follow-up. No consistent changes in patient or staff satisfaction or patient no-show rates were found. Barriers to implementation included decreases in appointment supply from provider leaves of absence and departures and increases in appointment demand when practices reopened to new patients after initial implementation of open-access scheduling.

LIMITATIONS

The study lacked control practices. The small number of practices and providers precluded formal statistical comparisons.

CONCLUSION

In 5 of 6 primary care practices, implementation of open-access scheduling improved appointment access in some practices. However, none was able to achieve same-day access and patient and staff satisfaction and patient no-show rates were unchanged. Broader evaluation of open-access scheduling in primary care is needed.

Evaluating follow-up of positive fecal occult blood test results: lessons learned

The objective of this study was to assess the effectiveness of a follow-up system for positive fecal occult blood test (FOBT) results in a single tertiary care hospital. The system consisted of a designated nurse who reviewed records of all positive FOBT cases for appropriate follow-up testing and notified clinic managers if no follow-up occurred. This system identified 63/423 (15%) of positive FOBT cases with inadequate follow-up in a 10-month period, but it was unsuccessful in ensuring subsequent follow-up in 24% of these cases. Primary care providers often lacked knowledge regarding appropriate follow-up testing. More direct follow-up of positive FOBT results is recommended.

Measuring organizational attributes of primary care practices: development of a new instrument

OBJECTIVE

To develop an instrument to measure organizational attributes relevant for family practices using the perspectives of clinicians, nurses, and staff.

DATA SOURCES/STUDY SETTING

Clinicians, nurses, and office staff (n=640) from 51 community family medicine practices.

DESIGN

A survey, designed to measure a practices' internal resources for change, for use in family medicine practices was created by a multidisciplinary panel of experts in primary care research and health care organizational performance. This survey was administered in a cross-sectional study to a sample of diverse practices participating in an intervention trial. A factor analysis identified groups of questions relating to latent constructs of practices' internal resources for capacity to change. ANOVA methods were used to confirm that the factors differentiated practices.

DATA COLLECTION

The survey was administered to all staff from 51 practices.

PRINCIPAL FINDINGS

The factor analysis resulted in four stable and internally consistent factors. Three of these factors, "communication,""decision-making," and "stress/chaos," describe resources for change in primary care practices. One factor, labeled "history of change," may be useful in assessing the success of interventions.

CONCLUSIONS

A 21-item questionnaire can reliably measure four important organizational attributes relevant to family practices. These attributes can be used both as outcome measures as well as important features for targeting system interventions.

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.

Challenges of change: a qualitative study of chronic care model implementation

PURPOSE

The Chronic Care Model (CCM) provides a conceptual framework for transforming health care for patients with chronic conditions; however, little is known about how to best design and implement its specifics. One large health care organization that tried to implement the CCM in primary care provided an opportunity to study these issues.

METHODS

We conducted a qualitative, comparative case study of 5 of 18 group clinics 18 to 23 months after the implementation began. Built on knowledge of the clinics from a previous study of advanced access implementation, data included in-depth interviews with organizational leaders and varied clinic personnel, observation of clinic care processes, and review of written materials.

RESULTS

Relatively small and highly variable care process changes were made during the study period. The change process underwent several marked shifts in strategy when initial efforts failed to achieve much and bore little resemblance to the change process used in the previously successful large-scale implementation of advanced access scheduling. Many barriers were identified, including too many competing priorities, a lack of specificity and agreement about the care process changes desired, and little engagement of physicians.

CONCLUSION

These findings highlight specific organizational challenges with health care transformation in the absence of a blueprint more specific than the CCM. Effective models of organizational change and detailed examples of proven, feasible care changes still need to be demonstrated if we are to transform care as called for by the Institute of Medicine.

Productivity measures associated with a patient access initiative

OBJECTIVE

To assess financial performance associated with a patient 7-day access initiative.

BACKGROUND DATA

Patient access to clinical services is frequently an obstacle at academic medical centers. Conflicting surgeon priorities among academic, clinical, educational, and leadership duties often create difficulties for patient entry into the "system."

METHODS

The scope and objectives were identified to be: design of a standard, simple new patient appointment process, design of a standard process in cases where an appointment is not available in 7 days, use subspecialty team search capabilities, minimize/eliminate prescheduling requirements, centralize appointment scheduling, and creation and reporting of 7-day access metrics. Following maturation of the process, the 7-day access metrics from the period July 2004 to December 2004 and January 2005 to June 2005 were compared with corresponding time periods from calendar years 2001, 2002, and 2003.

RESULTS

Payor mix was unaltered. The median waiting time for a new patient appointment decreased from 21 days to 10 days. When compared with calendar years 2001, 2002, and 2003, respectively, the 2 periods of the 7-day access initiative in calendar years 2004 and 2005 were associated with significantly increased visits, new patients, operative procedures, hospital charges, and physician charges.

CONCLUSIONS

Implementation of a 7-day access initiative can significantly increase financial productivity of general surgery groups in academic medical centers. We conclude that simplifying access to services can benefit academic surgical practices. Sustaining this level of productivity will continue to prove challenging.

Advanced access: more than just GP waiting times?

BACKGROUND

Advanced access has been forwarded as a strategy for reducing waiting times in primary care; however, previous evaluations have raised important issues regarding its appropriateness.

OBJECTIVES

The objectives of this paper are to assess the impact of advanced access on patient access to primary care services, and its broader effects on stakeholders.

METHODS

A quantitative analysis of appointment data on 462 practices implementing advanced access, together with qualitative analysis of open survey responses and interviews with 28 practice staff. Appointment data recorded time to third available appointment for GP and practice nurse, together with the percentage of patients seen on their day of choice. Themes were identified from the interviews and survey responses and related to issues identified in previous research.

RESULTS

The implementation of advanced access was associated with reductions in time to see practice nurses as well as GPs, and increases in the proportion of patients being seen on their day of choice. Interviewee and survey responses suggested that practice population characteristics may impact on the model, and some patient groups may be disadvantaged from the changes in the appointment systems seen in this study. Whilst experiences were mixed, the potential for broader changes to working practices of all practice staff was evident.

CONCLUSIONS

In general, these results suggest that advanced access can have a positive impact across several aspects of primary care services, and not just the availability of GP appointments. However, it also highlights some problems, in that waiting times worsened in some practices and there were concerns that some vulnerable groups may be disadvantaged.

Patient and physician perceptions of timely access to care

BACKGROUND

Timeliness of care is 1 of 6 dimensions of quality identified in Crossing the Quality Chasm. We compared patient and physician perceptions of appropriate timing of visits for common medical problems.

METHODS

This study was conducted at 2 internal medicine clinics at the University of Colorado Health Sciences Center. Adult patients and companions, and outpatient General Internists were surveyed. The survey contained 11 clinical scenarios of varying urgency. Respondents indicated how soon the patient in each scenario should be seen. Responses ranged from that day to 1 to 3 months. Responses were analyzed using the Mann-Whitney U test.

RESULTS

Two hundred and sixty-two patients and 46 of 61 physicians responded. For 8 of the 11 scenarios patients felt they should be seen significantly earlier than physicians. Scenarios involving chronic knee and stomach pain, routine diabetes care, and hyperlipidemia generated the greatest differences. Patients and physicians agreed on the urgency of scenarios concerning wheezing in an asthmatic, an ankle injury, and acute pharyngitis.

CONCLUSIONS

Patients expected to be seen sooner than physicians thought necessary for many common chronic medical conditions, but are in agreement about timeliness for some acute problems. Understanding patient expectations may help physicians respond to requests for urgent evaluation of chronic conditions.

Effect of improved primary care access on quality of depression care

PURPOSE

We wanted to determine whether a major improvement in access to primary care during 2000 was associated with changes in the quality of care for patients with depression.

METHODS

Health plan administrative data were analyzed by multilevel regression to compare the quality of care received by patients with depression between 1999 and 2001, a time without major changes in depression care guidelines. Approximately 6,000 patients with depression who received all care in a large multispecialty medical group during any single year were subjects for this study. Thirteen different quality measures assessed process quality under the dimensions of effectiveness, timeliness, safety, and patient-centeredness.

RESULTS

The largest change was a reduction in the proportion of depressed patients with no follow-up visit in primary care after starting a new antidepressant medication: from 33.0% before a change in access to care to 15.4% afterward, P =.001. During the same period, continuity of care in primary care improved (>50% of primary care visits to 1 doctor increased from 67.3% to 74.0%, P = or <.001), as did persistence of 6-month antidepressant medication (from 46.2% to 50.8%, P = or <.001). Further analyses found that the latter change was primarily associated with the change in continuity of care. Measures of subspecialty mental health care worsened during this time.

CONCLUSION

Marked improvement in access to primary care for 1 year was associated with some improvement in primary care for patients with depression, but the mechanism appeared to be improved continuity. Those planning to implement advanced access to care need to do so in such a way that continuity of care is enhanced rather than harmed by the change.

The break-even point: when medical advances are less important than improving the fidelity with which they are delivered

Society invests billions of dollars in the development of new drugs and technologies but comparatively little in the fidelity of health care, that is, improving systems to ensure the delivery of care to all patients in need. Using mathematical arguments and a nomogram, we demonstrate that technological advances must yield dramatic, often unrealistic increases in efficacy to do more good than could be accomplished by improving fidelity. In 2 examples (the development of anti-platelet agents and statins), we show that enhanced efficacy failed to achieve the health gains that would have occurred by delivering older agents to all eligible patients. Society's huge investment in technological innovations that only modestly improve efficacy, by consuming resources needed for improved delivery of care, may cost more lives than it saves. The misalignment of priorities is driven partly by the commercial interests of industry and by the public's appetite for technological breakthroughs, but health outcomes ultimately suffer. Health, economic, and moral arguments make the case for spending less on technological advances and more on improving systems for delivering care.

A qualitative study of the impact of the implementation of advanced access in primary healthcare on the working lives of general practice staff

Background

The North American model of 'advanced access' has been emulated by the National Primary Care Collaborative in the UK as a way of improving patients' access in primary care. The aim of this study was to explore the impact of the implementation of advanced access on the working lives of general practice staff.

Methods

A qualitative study design, using semi-structured interviews, was conducted with 18 general practice staff: 6 GPs, 6 practice managers and 6 receptionists. Two neighbouring boroughs in southeast England were used as the study sites. NUD*IST computer software assisted in data management to identify concepts, categories and themes of the data. A framework approach was used to analyse the data.

Results

Whilst practice managers and receptionists saw advanced access as having a positive effect on their working lives, the responses of general practitioners (GPs) were more ambivalent. Receptionists reported improvements in their working lives with a change in their role from gatekeepers for appointments to providing access to appointments, fewer confrontations with patients, and greater job satisfaction. Practice managers perceived reductions in work stress from fewer patient complaints, better use of time, and greater flexibility for contingency planning. GPs recognised benefits in terms of improved consultations, but had concerns about the impact on workload and continuity of care.

Conclusion

AA has improved working conditions for receptionists, converting their perceived role from gatekeeper to access facilitator, and for practice managers as patients were more satisfied. GP responses were more ambivalent, as they experienced both positive and negative effects.

Delivery of clinical preventive services in family medicine offices

BACKGROUND

This study aimed to elucidate how clinical preventive services are delivered in family practices and how this information might inform improvement efforts.

METHODS

We used a comparative case study design to observe clinical preventive service delivery in 18 purposefully selected Midwestern family medicine offices from 1997 to 1999. Medical records, observation of outpatient encounters, and patient exit cards were used to calculate practice-level rates of delivery of clinical preventive services. Field notes from direct observation of clinical encounters and prolonged observation of the practice and transcripts from in-depth interviews of practice staff and physicians were systematically examined to identify approaches to delivering clinical preventive services recommended by the US Preventive Services Task Force.

RESULTS

Practices developed individualized approaches for delivering clinical preventive services, with no one approach being successful across practices. Clinicians acknowledged a 3-fold mission of providing acute care, managing chronic problems, and prevention, but only some made prevention a priority. The clinical encounter was a central focus for preventive service delivery in all practices. Preventive services delivery rates often appeared to be influenced by competing demands within the clinical encounter (including between different preventive services), having a physician champion who prioritized prevention, and economic concerns.

CONCLUSIONS

Practice quality improvement efforts that assume there is an optimal approach for delivering clinical preventive services fail to account for practices' propensity to optimize care processes to meet local contexts. Interventions to enhance clinical preventive service delivery should be tailored to meet the local needs of practices and their patient populations.

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.

What are the facilitators and barriers in physician organizations' use of care management processes?

BACKGROUND

Care management processes (CMPs) such as disease registries, reminder systems, performance feedback, case management, and self-management education can improve chronic illness care, yet 50% of physician organizations have instituted few if any CMPs.

METHODS

Site-visit interviews were conducted with 158 leaders at 15 physician organizations, with 3 organizations (1 large medical group, 1 small medical group, and 1 independent practice association [IPA]) chosen randomly in most cases in each of five communities.

RESULTS

Seven of the 15 organizations had implemented CMPs minimally or not at all. CMPs were most common for diabetes and least common for depression; no IPAs had achieved significant CMP implementation for any of the conditions. The two most commonly mentioned facilitators were strong leadership and organizational culture valuing quality. The top five barriers were poor financial situation, reimbursement that does not reward high quality, inadequate information technology, physician resistance, and physicians being too busy.

DISCUSSION

Strong leadership and a quality-valuing culture are important facilitators of improved chronic care, but if insurers do not reward chronic care improvement, it is unlikely that CMPs will become permanently institutionalized in physician organizations.