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Di Fazio N, Scopetti M, Delogu G, La Russa R, Foti F, Grassi VM, Vetrugno G, De Micco F, De Benedictis A, Tambone V, Rinaldi R, Frati P, Fineschi V. Analysis of Medico-Legal Complaint Data: A Retrospective Study of Three Large Italian University Hospitals. Healthcare (Basel) 2023; 11:healthcare11101406. [PMID: 37239691 DOI: 10.3390/healthcare11101406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 05/01/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023] Open
Abstract
(1) Background: Identifying hospital-related critical, and excellent, areas represents the main goal of this paper, in both a national and local setting. Information was collected and organized for an internal company's reports, regarding civil litigation that has been affecting the hospital, to relate the obtained results with the phenomenon of medical malpractice on a national scale. This is for the development of targeted improvement strategies, and for investing available resources in a proficient way. (2) Methods: In the present study, data from claims management in Umberto I General Hospital, Agostino Gemelli University Hospital Foundation and Campus Bio-Medico University Hospital Foundation, from 2013 to 2020 were collected. A total of 2098 files were examined, and a set of 13 outcome indicators in the assessment of "quality of care" was proposed. (3) Results: From the total number, only 779 records (37.1%) were attributable to the categories indexable for the present analysis. This data highlights how, following a correct and rigorous categorization of hospital events, it is possible to analyze these medico-legal aspects using a small number of indicators. Furthermore, it is important to consider how a consistent percentage of remaining events was difficult to index, and was also of poor scientific interest. (4) Conclusions: The proposed indicators do not require standards to be compared to, but provide a useful instrument for comparative purposes. In fact, in addition to comparative assessment between different business realities distributed throughout the territory, the use of outcome indicators allows for a longitudinal analysis evaluating the performance of an individual structure over time.
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Affiliation(s)
- Nicola Di Fazio
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00128 Rome, Italy
| | - Matteo Scopetti
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00128 Rome, Italy
| | - Giuseppe Delogu
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00128 Rome, Italy
| | - Raffaele La Russa
- Department of Clinical and Experimental Medicine, University of Foggia, 71122 Foggia, Italy
| | - Federica Foti
- Risk Management Unit, Fondazione Policlinico Universitario "A Gemelli" IRCCS-Legal Medicine, Department of Health Surveillance and Bioethics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Vincenzo M Grassi
- Risk Management Unit, Fondazione Policlinico Universitario "A Gemelli" IRCCS-Legal Medicine, Department of Health Surveillance and Bioethics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giuseppe Vetrugno
- Risk Management Unit, Fondazione Policlinico Universitario "A Gemelli" IRCCS-Legal Medicine, Department of Health Surveillance and Bioethics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Francesco De Micco
- Research Unit of Bioethics and Humanities, Department of Medicine and Surgery, Università Campus 12 Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Anna De Benedictis
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Nursing Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Vittoradolfo Tambone
- Research Unit of Bioethics and Humanities, Department of Medicine and Surgery, Università Campus 12 Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Raffaella Rinaldi
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00128 Rome, Italy
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00128 Rome, Italy
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00128 Rome, Italy
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2
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Davis MM, Schneider JL, Petrik AF, Miech EJ, Younger B, Escaron AL, Rivelli JS, Thompson JH, Nyongesa D, Coronado GD. Clinic Factors Associated With Mailed Fecal Immunochemical Test (FIT) Completion: The Difference-Making Role of Support Staff. Ann Fam Med 2022; 20:123-129. [PMID: 35346927 PMCID: PMC8959740 DOI: 10.1370/afm.2772] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 07/22/2021] [Accepted: 08/17/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Mailed fecal immunochemical test (FIT) programs can facilitate colorectal cancer (CRC) screening. We sought to identify modifiable, clinic-level factors that distinguish primary care clinics with higher vs lower FIT completion rates in response to a centralized mailed FIT program. METHODS We used baseline observational data from 15 clinics within a single urban federally qualified health center participating in a pragmatic trial to optimize a mailed FIT program. Clinic-level data included interviews with leadership using a guide informed by the Consolidated Framework for Implementation Research (CFIR) and FIT completion rates. We used template analysis to identify explanatory factors and configurational comparative methods to identify specific combinations of clinic-level conditions that uniquely distinguished clinics with higher and lower FIT completion rates. RESULTS We interviewed 39 clinic leaders and identified 58 potential explanatory factors representing clinic workflows and the CFIR inner setting domain. Clinic-level FIT completion rates ranged from 30% to 56%. The configurational model for clinics with higher rates (≥37%) featured any 1 of the following 3 factors related to support staff: (1) adding back- or front-office staff in past 12 months, (2) having staff help patients resolve barriers to CRC screening, and (3) having staff hand out FITs/educate patients. The model for clinics with lower rates involved the combined absence of these same 3 factors. CONCLUSIONS Three factors related to support staff differentiated clinics with higher and lower FIT completion rates. Adding nonphysician support staff and having those staff provide enabling services might help clinics optimize mailed FIT screening programs.
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Affiliation(s)
- Melinda M Davis
- Oregon Rural Practice-Based Research Network, Department of Family Medicine, and School of Public Health, Oregon Health & Science University, Portland, Oregon
| | | | - Amanda F Petrik
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Edward J Miech
- Regenstrief Institute, Center for Health Services Research, Indianapolis, Indiana
| | - Brittany Younger
- AltaMed Institute for Health Equity, AltaMed Health Services Corporation, Los Angeles, California
| | - Anne L Escaron
- AltaMed Institute for Health Equity, AltaMed Health Services Corporation, Los Angeles, California
| | - Jennifer S Rivelli
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Jamie H Thompson
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Denis Nyongesa
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Gloria D Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
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3
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Mold JW, Walsh M, Chou AF, Homco JB. The Alarming Rate of Major Disruptive Events in Primary Care Practices in Oklahoma. Ann Fam Med 2018; 16:S52-S57. [PMID: 29632226 PMCID: PMC5891314 DOI: 10.1370/afm.2201] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 11/16/2017] [Accepted: 11/28/2017] [Indexed: 11/09/2022] Open
Abstract
PURPOSE In primary care practices, sustainability of performance improvements and ability to deliver continuity of care to patients can be adversely affected by major disruptive events, such as relocations and changes in ownership, clinicians, and key staff. This study documented the rates of major disruptive events in a cohort of primary care practices in Oklahoma. METHODS Practices were included if they had existed for 1 year before enrollment and remained in the project for at least 1 year after enrollment. Practice characteristics for 208 practices and major disruptive events during the preenrollment year were collected by survey. Postenrollment major disruptive events were prospectively collected by practice facilitators. We compiled frequency statistics and conducted bivariate analyses for each data set. RESULTS Of 208 eligible practices, 81 (39%) were clinician owned, and 51 (25%) were health system owned. One hundred nine practices (52%) were in nonmetropolitan counties. One hundred seventy-five major disruptive events occurred in 120 (58%) practices during the preenrollment year, with 42 practices having experienced multiple events. During the first year of the project, 89 major disruptive events occurred in 67 (32%) practices, with 20 practices experiencing multiple events. The major disruptive events reported most often during both periods were loss of personnel and implementation of electronic health records and billing systems. Practice size was associated with occurrence of these events. CONCLUSIONS During a 2-year period, major disruptive events occurred at an alarming rate, adversely affecting quality improvement efforts. Most reported events involved losses of clinicians and staff. More research is needed to identify and address the root causes of these events.
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Affiliation(s)
- James W Mold
- Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma .,University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Margaret Walsh
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Ann F Chou
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Juell B Homco
- University of Oklahoma School of Community Medicine, Tulsa, Oklahoma
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4
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Länsisalmi H, Kivimäki M, Aalto P, Ruoranen R. Innovation in Healthcare: A Systematic Review of Recent Research. Nurs Sci Q 2016; 19:66-72; discussion 65. [PMID: 16407603 DOI: 10.1177/0894318405284129] [Citation(s) in RCA: 134] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Research on innovations in healthcare organizations published between 1994 and 2004 are here reviewed and summarized. The majority of the 31 identified studies dealt with the adoption of innovations and new practices and were cross-sectional designs applying quantitative methods, or multiple case studies applying qualitative methods. Five pathways for future research are recommended: (a) Multilevel approaches studying innovation simultaneously on individual, group, and organizational levels; (b) a combination of quantitative and qualitative data; (c) use of longitudinal designs (innovation both as the dependent and independent variable); (d) application of experimental designs in interventions; and (e) exploration of innovation generation and structural innovations.
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5
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Zapka J, Goins KV, Pbert L, Ockene JK. Translating Efficacy Research to Effectiveness Studies in Practice: Lessons From Research to Promote Smoking Cessation in Community Health Centers. Health Promot Pract 2016; 5:245-55. [PMID: 15228779 DOI: 10.1177/1524839904263713] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Researchers and their community partners have been challenged by funders and political entities to translate what is learned in research into practice. Such translation is more challenging than it appears, and it is important to systematically make use of opportunities available to learn about facilitators and barriers to the implementation of effectiveness research in real-world settings. This article presents a case study of the process evaluation undertaken as part of Quit Together, a randomized trial of the effectiveness of an intervention to improve smoking cessation and relapse prevention among low-income pregnant and postpartum women who receive care at community health centers (CHCs). The analysis considers areas of program implementation failure that may need critical rethinking. The article demonstrates the importance of process-monitoring methods to examine context factors of collaborative research, outlines lessons learned and the challenges of research carried out in CHCs, and summarizes implications for researchers and for practitioners.
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Affiliation(s)
- Jane Zapka
- Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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6
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Ackermann RT. Description of an integrated framework for building linkages among primary care clinics and community organizations for the prevention of type 2 diabetes: emerging themes from the CC-Link study. Chronic Illn 2010; 6:89-100. [PMID: 20484325 DOI: 10.1177/1742395310364857] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Strong clinic-community linkages are pivotal for the success of preventive services that combine clinical and community resources. Unfortunately, there has been limited guidance for how clinical and community groups can partner to improve self-care and prevention for chronic conditions. This manuscript describes the development and implementation of an integrated framework to guide clinic-community linkages for the prevention of type 2 diabetes in an ongoing randomized effectiveness trial known as Clinical-Community Linkages to Prevent Diabetes (CC-Link) study. This study involves 10 primary care practices in a metropolitan area of the Midwest US. The study provided each practice location with technical assistance to select, implement, evaluate and refine different strategies to identify and address pre-diabetes using a clinic-community linkage. Sites were also randomized to receive either direct or indirect involvement by a community liaison/expert from the YMCA of Greater Indianapolis. Early implementation of the CC-Link Framework has underscored the importance of strong leadership and partnership synergy, and it uncovered several examples of how linkages can be designed to make the most of partner strengths. This success is promising, and an evaluation of the effectiveness of these efforts to improve lifestyle behaviours of adults with prediabetes is now underway.
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Affiliation(s)
- Ronald T Ackermann
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
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7
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Close K, Rozier RG, Zeldin LP, Gilbert AR. Barriers to the adoption and implementation of preventive dental services in primary medical care. Pediatrics 2010; 125:509-17. [PMID: 20123767 DOI: 10.1542/peds.2009-1008] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine the barriers to adopting preventive oral health procedures in medical primary care. METHODS Medical providers who participated in a Medicaid demonstration in North Carolina completed questionnaires reporting their experiences with providing preventive dental services for children from birth to 3 years of age. Eleven factors were established as possible obstacles to the adoption of an oral health program. After 12 months of participation in the Into the Mouths of Babes training program, providers (N = 231) from 49 pediatric practices and 28 family physician practices reported if any of the 11 factors had been an obstacle to adoption and, if so, whether these obstacles were overcome. Program adoption and implementation, defined as providing all of the services on a regular basis, were predicted by using logistic regression to analyze the responses from providers who reported 1 or more barriers, the number of barriers identified (knowledge, attitudes, and external factors), and the number that were overcome. RESULTS Program-adoption rates were high, with 70.3% of the participants providing dental services on a routine basis. Attitude and external factors were positively associated with adoption, particularly with difficulty in applying the varnish, integration of the dental procedures into practice, resistance among staff and colleagues, and dentist referral difficulties. From 40.4% to 61.5% of providers overcame these 4 most common barriers. Those who reported external barriers and were unable to overcome them were less likely to provide the services, compared with those providers who reported no barriers (odds ratio: 0.08 [95% confidence interval: 0.01-0.44]). CONCLUSIONS The number of barriers to adopting preventive dental procedures in primary care medical practices is associated with implementation. A large proportion of these barriers can be overcome, leading to high adoption rates in a short amount of time. The barriers to adoption are similar to those identified in the literature on changing patient care, with the unique aspects of fluoride application to teeth. Interventions to promote preventive dental care in medical settings should rely heavily on empirical literature. Training physicians in preventive dentistry should identify and target potential barriers with information and options for introducing office-based systems to improve the chances of adoption.
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Affiliation(s)
- Kelly Close
- MSUP, University of North Carolina, Gillings School of Global Public Health, Department of Health Policy and Management, 1105-F McGavran-Greenberg Hall, 135 Dauer Dr, CB 7411, Chapel Hill, NC 27499, USA
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8
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Zapka JG, White MJ, Reed G, Ockene JK, List E, Pbert L, Jolicoeur D, Reiff-Hekking S. Organizational systems to support publicly funded tobacco treatment services. Am J Prev Med 2005; 28:338-45. [PMID: 15831338 PMCID: PMC1635789 DOI: 10.1016/j.amepre.2005.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Professional societies and government organizations have promoted guidelines and best practices that encourage clinicians to routinely integrate cessation counseling into patient encounters. While research in health maintenance organizations has demonstrated that the development and maintenance of office systems do enable clinicians' smoking-cessation services, little is known about the adoption of system strategies in diverse organizations serving disadvantaged populations. METHODS Data were collected via face-to-face interviews from November 2001 to October 2002 using a standardized systems assessment checklist at service delivery sites of 83 funded community health service agencies, which included hospitals, community health centers, and other organizations (e.g., substance abuse, mental health, and multiservice). The content of the structured assessment reflected system elements with proven effectiveness that have been included in guidelines and best practices recommendations. Detailed information was collected on the implementation strategies. RESULTS This study found considerable attention to systems that support cessation services in diverse healthcare organizations, but much remains to be done. There is a wide diversity of implementation strategies employed, with varied degrees of sophistication. CONCLUSIONS A major challenge is to develop systems capable of providing population-based feedback to, and between, providers, which will enable further quality improvement efforts.
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Affiliation(s)
- Jane G Zapka
- Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01655, USA.
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9
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Abstract
Clinicians and the organizations within which they practice play a major role in enabling patient participation in cancer screening and ensuring quality services. Guided by an ecologic framework, the authors summarize previous literature reviews and exemplary studies of breast, cervical, and colorectal cancer screening intervention studies conducted in health care settings. Lessons learned regarding interventions to maximize the potential of cancer screening are distilled. Four broad lessons learned emphasize that multiple levels of factors-public policy, organizational systems and practice settings, clinicians, and patients-influence cancer screening; that a diverse set of intervention strategies targeted at each of these levels can improve cancer screening rates; that the synergistic effects of multiple strategies often are most effective; and that targeting all components of the screening continuum is important. Recommendations are made for future research and practice, including priorities for intervention research specific to health care settings, the need to take research phases into consideration, the need for studies of health services delivery trends, and methods and measurement issues.
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Affiliation(s)
- Jane G Zapka
- Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01655, USA.
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Speroff T, James BC, Nelson EC, Headrick LA, Brommels M. Guidelines for Appraisal and Publication of PDSA Quality Improvement. Qual Manag Health Care 2004; 13:33-9. [PMID: 14976905 DOI: 10.1097/00019514-200401000-00003] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Plan-do-study-act (PDSA) quality improvement is the application of the scientific method to implement and test the effects of change ideas on the performance of the health care system. Users of quality improvement could benefit with markers to gauge the "best" science. Four core questions can determine the value of a quality improvement study: Is the quality improvement study pertinent and relevant? Are the results valid? Are appropriate criteria used to interpret the results? Will the study help you with your practice or organization of care? A set of guidelines is provided to help answer these questions. Similar guidelines exist for randomized clinical trials and clinical-epidemiologic observational studies. Analogous to these existing research guidelines, the PDSA quality improvement guidelines will provide researchers and reviewers with succinct standards of methodological rigor to assist in critical appraisal of quality improvement protocols and publications.
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Affiliation(s)
- Theodore Speroff
- Departments of Medicine and Preventive Medicine, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tenn. 37232, USA.
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11
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Abstract
OBJECTIVE The aim of this study was to assess knowledge, beliefs, and practices of primary care clinicians regarding colorectal cancer screening. METHODS We surveyed 77 primary care providers in six clinics in central Massachusetts to evaluate several factors related to colorectal cancer screening. RESULTS Most agreed with guidelines for fecal occult blood test (97%) and sigmoidoscopy (87%), which were reported commonly as usual practice. Although the majority (86%) recommended colonoscopy as a colorectal cancer screening test, it was infrequently reported as usual practice. Also, 36% considered barium enema a colorectal cancer screening option, and it was rarely reported as usual practice. Despite lack of evidence supporting effectiveness, digital rectal examinations and in-office fecal occult blood test were commonly reported as usual practice. However, these were usually reported in combination with a guideline-endorsed testing option. Although only 10% reported that fecal occult blood test/home was frequently refused, 60% reported sigmoidoscopy was. Frequently cited patient barriers to sigmoidoscopy compliance included fear the procedure would hurt and that patients assume symptoms occur if there is a problem. Perceptions of health systems barriers to sigmoidoscopy were less strong. CONCLUSIONS Most providers recommended guideline-endorsed colorectal cancer screening. However, patient refusal for sigmoidoscopy was common. Results indicate that multiple levels of intervention, including patient and provider education and systems strategies, may help increase prevalence.
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Affiliation(s)
- Stephenie C Lemon
- Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01655, USA
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12
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Bonollo DP, Zapka JG, Stoddard AM, Ma Y, Pbert L, Ockene JK. Treating nicotine dependence during pregnancy and postpartum: understanding clinician knowledge and performance. PATIENT EDUCATION AND COUNSELING 2002; 48:265-274. [PMID: 12477611 DOI: 10.1016/s0738-3991(02)00023-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
This study investigated the relationship of clinicians' knowledge of treatments for nicotine dependence during pregnancy and postpartum and explored what provider characteristics are associated with knowledge levels. Survey data from community health center (CHC)-based prenatal, pediatric (PED), and WIC program (Special Supplemental Nutrition Program for Women, Infants, and Children) providers participating in a randomized clinical study were used. Providers reported low awareness of the health risks of smoking to the developing fetus/child of pregnant and postpartum women and of the effectiveness of nicotine replacement therapy (NRT) for doubling quit rates. Obstetric (OB) and WIC providers were more aware than PED providers that provider-delivered interventions are effective. Confidence in using counseling steps was significantly associated with general and NRT-related knowledge. NRT-related knowledge, but not general knowledge, was associated with higher performance of intervention steps. Educational programs targeting OB, WIC, and PED providers' knowledge about effective smoking cessation counseling strategies and their confidence in being effective with patients are needed.
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Affiliation(s)
- Debra P Bonollo
- Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, MA, USA.
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13
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Abstract
BACKGROUND Developing effective programs to promote colorectal cancer (CRC) screening requires understanding of the effect of healthcare system factors on access to screening and adherence to guidelines. METHODS This study assessed the role of insurance status, type of plan, the frequency of preventive health visits, and provider recommendation on utilization of CRC screening tests using a cross-sectional, random-digit-dial survey of 1002 Massachusetts residents aged > or =50. RESULTS A broad definition of CRC screening status included colonoscopy or barium enema (screening or diagnostic) within 10 years, flexible sigmoidoscopy (FSIG) within 5 years, and fecal occult blood testing (FOBT) in the past year as options; 51.7% of subjects aged 50 to 64 and 61.5% of older subjects were current. The uninsured had the lowest current testing rate. Among insured participants, type of insurance had little impact on CRC testing; older subjects enrolled in HMOs had marginally higher rates, although not statistically significant. Increased frequency of preventive health visits and ever receiving a physician's recommendation for FSIG or ever receiving FOBT cards were associated with higher rates of CRC screening among both age groups. CONCLUSIONS Even when broad criteria are used to define current CRC screening status, a substantial proportion of the age-eligible population remains underscreened. Obtaining regular preventive care and receiving a physician's recommendation for screening appear to be potent facilitators of screening that should be considered in designing promotional efforts.
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Affiliation(s)
- Jane G Zapka
- Medical School, University of Massachusetts, Worcester 01655, USA.
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14
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Abstract
STUDY OBJECTIVES Although the interest in and promulgation of clinical practice guidelines have significantly increased in the past 2 decades, concern exists about their actual implementation. This article focuses on one strategy to encourage guideline implementation at the clinician level: clinician education. The objectives of the article are to review educational strategies, to consider them within the context of complementary strategies carried out at the organizational and clinic setting levels, and to outline challenges and recommendations for clinicians' continuing education. METHODS Experience and data from relevant randomized clinical trials within an educational framework are reviewed. OBSERVATIONS Implementation of clinical practice guidelines requires a variety of skills, including assessment, appropriate delineation of a treatment and monitoring plan, patient tracking, and patient counseling and education skills. Continuing education strategies must reflect the content and teaching methods that best match the learning objectives. The pressures of current-day practices place limits on the resources, particularly clinician time, that are available for continuing education. Organizational resources must be committed to build the complementary supportive systems necessary for improved clinician practice. In addition to physicians, education must be directed at nonphysician clinicians, office staff, and administrators who also are responsible for guideline implementation. CONCLUSIONS To meet the challenges of developing clinician motivation, balancing competing demands, and treating patients with complex medical conditions, all within time constraints, clinical leaders need to design education activities that have leadership support, reflect compelling evidence, use multiple strategies and teaching techniques, and engage learners in skill building and problem solving.
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Affiliation(s)
- J K Ockene
- Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, North Worcester, MA 01655, USA.
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15
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Solberg LI, Brekke ML, Fazio CJ, Fowles J, Jacobsen DN, Kottke TE, Mosser G, O'Connor PJ, Ohnsorg KA, Rolnick SJ. Lessons from experienced guideline implementers: attend to many factors and use multiple strategies. THE JOINT COMMISSION JOURNAL ON QUALITY IMPROVEMENT 2000; 26:171-88. [PMID: 10749003 DOI: 10.1016/s1070-3241(00)26013-6] [Citation(s) in RCA: 129] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Studies of clinical guideline implementation have focused almost entirely on changing individual clinician behavior with single intervention strategies and without much attention to the situational context. The goal of this project was to learn from clinic leaders, seasoned in the guideline implementation process, what contextual variables they viewed as important and whether implementation success could be expected if only a single implementation strategy was used. METHODS In 1998, 12 people with extensive experience in leading clinical guideline implementation were identified who were thought to have particularly keen insight into the process. They were interviewed to generate variables they considered important, as well as strategies they considered effective when used appropriately. A modified nominal group/Delphi process was then used for rating these variables and strategies, and the reactions of international experts were obtained to add perspective to this information. RESULTS Eighty-seven variables and 25 strategies were identified, clustering in 6 categories (ranked in order of importance by the panel): organizational capabilities for change, infrastructure for implementation, implementation strategies, medical group characteristics, guideline characteristics, and external environment. All six categories were considered to be important, key, or essential by the experienced implementers, although variables within a medical group that directly affect its ability to undertake planned change were rated as much more important than either guideline characteristics or the external environment. DISCUSSION Although the opinions of those experienced in the process of guideline implementation are primarily of value for generating hypotheses, panel members believe that implementation efforts focusing on the individual physician with a single strategy are unlikely to be successful. Rather, implementation efforts must use multiple strategies that take account of multiple characteristics of the guideline, practice organization, and external environment.
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Affiliation(s)
- L I Solberg
- HealthPartners Research Foundation, Minneapolis, MN 55440-1524, USA.
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Coleman EA, Grothaus LC, Sandhu N, Wagner EH. Chronic care clinics: a randomized controlled trial of a new model of primary care for frail older adults. J Am Geriatr Soc 1999; 47:775-83. [PMID: 10404919 DOI: 10.1111/j.1532-5415.1999.tb03832.x] [Citation(s) in RCA: 144] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine whether a new model of primary care, Chronic Care Clinics, can improve outcomes of common geriatric syndromes (urinary incontinence, falls, depressive symptoms, high risk medications, functional impairment) in frail older adults. DESIGN Randomized controlled trial with 24 months of follow-up. Physician practices were randomized either to the Chronic Care Clinics intervention or to usual care. SETTING Nine primary care physician practices that comprise an ambulatory clinic in a large staff-model HMO in western Washington State. PARTICIPANTS Those patients aged 65 and older in each practice with the highest risk for being hospitalized or experiencing functional decline. INTERVENTION Intervention practices (5 physicians, 96 patients) held half-day Chronic Care Clinics every 3 to 4 months. These clinics included an extended visit with the physician and nurse dedicated to planning chronic disease management; a pharmacist visit that emphasized reduction of polypharmacy and high-risk medications; and a patient self-management/support group. Control practices (4 physicians, 73 patients) received usual care. MEASUREMENTS Changes in self-reported urinary incontinence, frequency of falls, depressive symptoms, physical function, and satisfaction were analyzed using an intention-to-treat analysis adjusted for baseline differences, covariates, and practice-level variation. Prescriptions for high-risk medications and cost/utilization data obtained from administrative data were similarly analyzed. RESULTS After 24 months, no significant improvements in frequency of incontinence, proportion with falls, depression scores, physical function scores, or prescriptions for high risk medications were demonstrated. Costs of medical care including frequency of hospitalization, hospital days, emergency and ambulatory visits, and total costs of care were not significantly different between intervention and control groups. A higher proportion of intervention patients rated the overall quality of their medical care as excellent compared with control patients (40.0% vs 25.3%, P = .10). CONCLUSIONS Although intervention patients expressed high levels of satisfaction with Chronic Care Clinics, improved outcomes for selected geriatric syndromes were not demonstrated. These findings suggest the need for developing greater system-wide support for managing geriatric syndromes in primary care and illustrate the challenges of conducting practice improvement research in a rapidly changing delivery system.
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Affiliation(s)
- E A Coleman
- Division of Geriatric Medicine, University of Colorado Health Sciences Center, Denver 80206, USA
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Abstract
As part of a randomized control trial to improve the delivery of preventive services, the authors studied the effect on clinic nurses in the roles of team leaders or facilitators of multidisciplinary, continuous quality improvement (CQI) teams. Our goal was to learn how these nurses felt about their experience with this project, specifically their satisfaction with process improvement, acquired knowledge and skills, and the impact on their nursing role. Overall, the nurses involved in this study reported significant gains in all three areas. This study suggests that CQI can be a valuable vehicle for improving and expanding the nursing role for clinic nurses.
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Magnan S, Solberg LI, Kottke TE, Nelson AF, Amundson GM, Richards S, Reed MK. IMPROVE: bridge over troubled waters. THE JOINT COMMISSION JOURNAL ON QUALITY IMPROVEMENT 1998; 24:566-78. [PMID: 9801954 DOI: 10.1016/s1070-3241(16)30404-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The original collaborative project was described in a 1995 Journal article titled "Competing HMOs Collaborate to Improve Preventive Services." IMPROVE (IMproving PRevention through Organization, Vision, and Empowerment) was a large randomized controlled trial using continuous quality improvement to implement clinical systems to improve the delivery of adult preventive services in primary care settings. The project was funded by the Agency for Health Care Policy and Research and initiated as a collaboration between two health maintenance organizations (HMOs) in the Twin Cities: Health Partners and Blue Plus. METHODOLOGY Forty-four clinics were recruited for the study. Initially the 22 intervention clinics received the multifaceted intervention of leadership support, training on CQI and prevention systems, and consultation and networking opportunities. Next, the comparison clinics received similar assistance, and other clinics were invited into the collaboration. Ultimately, 57 clinics were involved in the project. Multiple collaborations--among clinics, leaders, and HMOs--developed during the project. STATUS Despite turmoil in the environment during the project, many benefits have been described, including enhanced leadership, growth of systems thinking, better change management skills, and collaboration of competing organizations. SUMMARY The IMPROVE collaboration survived and flourished in a very competitive market. It was viewed positively by clinicians, medical clinics, and HMOs, and its benefits have extended into the community.
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Affiliation(s)
- S Magnan
- Blue Cross and Blue Shield of Minnesota and Blue Plus, St Paul 55164-0179, USA.
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Fischer LR, Solberg LI, Kottke TE. Quality improvement in primary care clinics. THE JOINT COMMISSION JOURNAL ON QUALITY IMPROVEMENT 1998; 24:361-70. [PMID: 9689569 DOI: 10.1016/s1070-3241(16)30387-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Case studies from Project IMPROVE, the first randomized controlled trial to evaluate the effectiveness of continuous quality improvement (CQI) in primary care, were subjected to a qualitative analysis. Three questions were addressed: How does change in the health care environment affect a quality improvement (QI) process? How does clinic organization influence a QI process? and What is the impact of a QI process on clinic organization? METHOD Case studies were conducted in 6 clinics that had been randomly selected from the 22 clinics participating in the IMPROVE intervention. The case study data consisted of observations of CQI team meetings, open-ended interviews with 30 informants (team members plus others in the clinics), interviews with IMPROVE consultants, and documentation from the project. The data were analyzed to identify themes and generate concepts, assess and compare the informants' experiences, and develop a conceptual framework stimulated by research and theory literature. RESULTS Change and uncertainty in the health care environment both complicated the QI process and motivated participation in improvement. The smaller clinics appeared to have more difficulty with the QI process because of limited resources and lack of compatibility between the QI approach and their clinic organization. Project IMPROVE had two qualitative effects on clinics: increased awareness of preventive services and application of the CQI method to other problems and issues. CONCLUSION QI initiatives can help clinics adapt to a changing health care environment and create functioning teams or groups that can address a variety of organization problems and tasks. The process should be flexible to accommodate varying organization structures and cultures.
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Affiliation(s)
- L R Fischer
- HealthPartners Research Foundation, Minneapolis, MN 55440, USA.
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Solberg LI, Kottke TE, Brekke ML. Will primary care clinics organize themselves to improve the delivery of preventive services? A randomized controlled trial. Prev Med 1998; 27:623-31. [PMID: 9672958 DOI: 10.1006/pmed.1998.0337] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND There is increasing evidence that the most effective way to improve delivery of preventive services in primary care is to establish organized preventive service systems. This study tests the hypothesis that a managed care organization (MCO) can help its contracted private primary care clinics to develop such systems. METHODS Forty-four primary care clinics contracting with two large MCOs were randomized to a comparison (C) or an intervention (I) group. Group (I) clinic team leaders received training plus ongoing consultation and networking. Personnel at all 44 clinics completed surveys prior to and at the end of the intervention to measure adoption of the improvement process and the prevention system. RESULTS All 22 (I) clinics identified teams that appeared to follow the seven-step improvement process. The mean numbers of system processes were identical at baseline, 11.2 (I) vs 12.1 (C), while after the intervention this had changed to 25.8 in (I) clinics vs 11.3 in (C) (P = 0.022). CONCLUSIONS With training and assistance, interested primary care clinic teams will establish functioning CQI teams that will produce a substantial increase in the presence of functional prevention system processes. Whether this change is sufficient to increase the rates of preventive services remains to be documented.
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Affiliation(s)
- L I Solberg
- Health Partners Research Foundation, Minneapolis, Minnesota 55440, USA.
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Solberg LI, Reger LA, Pearson TL, Cherney LM, O'Connor PJ, Freemen SL, Lasch SL, Bishop DB. Using continuous quality improvement to improve diabetes care in populations: the IDEAL model. Improving care for Diabetics through Empowerment Active collaboration and Leadership. THE JOINT COMMISSION JOURNAL ON QUALITY IMPROVEMENT 1997; 23:581-92. [PMID: 9407262 DOI: 10.1016/s1070-3241(16)30341-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The care of patients with chronic diseases, especially those with diabetes mellitus, has been less than ideal. However, despite clear national guidelines, various examples of better care models, and multiple attempts to improve care, an effective process for facilitating and replicating diabetes care improvements in typical primary care practices has been elusive. METHODS On the basis of the approach and lessons from developmental work at the Minnesota Diabetes Control Program and a trial of continuous quality improvement for clinical preventive services (IMPROVE), a clinic-based intervention processes (IDEAL) has been developed to improve the system and process of care for patients with diabetes as a model for all chronic diseases. The intervention incorporates facilitation of leadership actions in support of change, training for the leader and facilitator of an intraclinic multidisciplinary continuous quality improvement (CQI) team, and consultative and networking support of the change process. Each element of this intervention emphasizes a seven-step process improvement approach and a system for care of patients with diabetes. This model is being developed and tested in a unique partnership between the Minnesota Department of Health and HealthPartners, a large managed care organization (MCO). RESULTS A prepilot demonstration has succeeded in improving glycemic control, three primary care clinics affiliated with HealthPartners have succeeded in a pilot of the intervention, and an additional 13 clinics are participating in a randomized controlled trial of a refined intervention. CONCLUSIONS The IDEAL model holds promise for substantial improvements in care, not only for diabetes but for all chronic diseases and for other settings.
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Affiliation(s)
- L I Solberg
- Group Health Foundation/HealthPartners, Minneapolis, MN, USA.
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