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Warner G, Drainoni ML, Parker V, Agins BD, Eldred L. Factors Associated with the Successful Implementation of a Quality Improvement Project in Human Immunodeficiency Virus Ambulatory Care Clinics. Am J Med Qual 2016; 19:75-82. [PMID: 15115278 DOI: 10.1177/106286060401900205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We examined a quality improvement (QI) program, offered to ambulatory care clinics (N = 82) serving human immunodeficiency virus-positive clients, to determine what factors predicted the clinic independently implementing QI processes without their program consultant's help. Initial analyses examined clinics at 4 levels of involvement: withdrew from the project, initial QI proficiency, advanced QI proficiency, and consultant independent. The initial and advanced stages were collapsed into 1 group (consultant dependent) and compared with consultant-independent clinics for multivariate logistic regression. In the multivariate models, 3 factors significantly predicted the clinic being consultant independent: staffing level (odds ratio [OR] = 1.6, 95% confidence interval [CI] = 1.2-2.2), the number of participating months (OR = 1.4, 95% CI = 1.0-2.0), and baseline QI readiness (OR = 1.1, 95% CI = 1.0-1.3). Receiver operator curves were calculated for significant predictors; the strongest predictor was staffing (c statistic = .79). Clinics that are organizationally prepared for QI, allow adequate time to adopt QI methods into their organization, and provide adequate QI staffing are more likely to independently apply QI methods.
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Affiliation(s)
- Grace Warner
- Center for Health Quality, Outcomes, and Economic Research, VAMC, Bedford, Mass, USA.
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Korom-Djakovic D, Canamucio A, Lempa M, Yano EM, Long JA. Organization Complexity and Primary Care Providers' Perceptions of Quality Improvement Culture Within the Veterans Health Administration. Am J Med Qual 2014; 31:139-46. [PMID: 25414376 DOI: 10.1177/1062860614559743] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study examined how aspects of quality improvement (QI) culture changed during the introduction of the Veterans Health Administration (VHA) patient-centered medical home initiative and how they were influenced by existing organizational factors, including VHA facility complexity and practice location. A voluntary survey, measuring primary care providers' (PCPs') perspectives on QI culture at their primary care clinics, was administered in 2010 and 2012. Participants were 320 PCPs from hospital- and community-based primary care practices in Pennsylvania, West Virginia, Delaware, New Jersey, New York, and Ohio. PCPs in community-based outpatient clinics reported an improvement in established processes for QI, and communication and cooperation from 2010 to 2012. However, their peers in hospital-based clinics did not report any significant improvements in QI culture. In both years, compared with high-complexity facilities, medium- and low-complexity facilities had better scores on the scales assessing established processes for QI, and communication and cooperation.
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Affiliation(s)
- Danijela Korom-Djakovic
- Philadelphia VA Medical Center, Philadelphia, PA University of Pennsylvania, Philadelphia, PA
| | | | | | - Elizabeth M Yano
- VA Greater Los Angeles Healthcare System, Sepulveda, CA UCLA Fielding School of Public Health, Los Angeles, CA
| | - Judith A Long
- Philadelphia VA Medical Center, Philadelphia, PA University of Pennsylvania, Philadelphia, PA
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Brennan SE, Bosch M, Buchan H, Green SE. Measuring organizational and individual factors thought to influence the success of quality improvement in primary care: a systematic review of instruments. Implement Sci 2012; 7:121. [PMID: 23241168 PMCID: PMC3573896 DOI: 10.1186/1748-5908-7-121] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 11/05/2012] [Indexed: 12/19/2022] Open
Abstract
Background Continuous quality improvement (CQI) methods are widely used in healthcare; however, the effectiveness of the methods is variable, and evidence about the extent to which contextual and other factors modify effects is limited. Investigating the relationship between these factors and CQI outcomes poses challenges for those evaluating CQI, among the most complex of which relate to the measurement of modifying factors. We aimed to provide guidance to support the selection of measurement instruments by systematically collating, categorising, and reviewing quantitative self-report instruments. Methods Data sources: We searched MEDLINE, PsycINFO, and Health and Psychosocial Instruments, reference lists of systematic reviews, and citations and references of the main report of instruments. Study selection: The scope of the review was determined by a conceptual framework developed to capture factors relevant to evaluating CQI in primary care (the InQuIRe framework). Papers reporting development or use of an instrument measuring a construct encompassed by the framework were included. Data extracted included instrument purpose; theoretical basis, constructs measured and definitions; development methods and assessment of measurement properties. Analysis and synthesis: We used qualitative analysis of instrument content and our initial framework to develop a taxonomy for summarising and comparing instruments. Instrument content was categorised using the taxonomy, illustrating coverage of the InQuIRe framework. Methods of development and evidence of measurement properties were reviewed for instruments with potential for use in primary care. Results We identified 186 potentially relevant instruments, 152 of which were analysed to develop the taxonomy. Eighty-four instruments measured constructs relevant to primary care, with content measuring CQI implementation and use (19 instruments), organizational context (51 instruments), and individual factors (21 instruments). Forty-one instruments were included for full review. Development methods were often pragmatic, rather than systematic and theory-based, and evidence supporting measurement properties was limited. Conclusions Many instruments are available for evaluating CQI, but most require further use and testing to establish their measurement properties. Further development and use of these measures in evaluations should increase the contribution made by individual studies to our understanding of CQI and enhance our ability to synthesise evidence for informing policy and practice.
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Affiliation(s)
- Sue E Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
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Continuous quality improvement: effects on professional practice and healthcare outcomes. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [DOI: 10.1002/14651858.cd003319.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Faria C, Wenzel M, Lee KW, Coderre K, Nichols J, Belletti DA. A narrative review of clinical inertia: focus on hypertension. ACTA ACUST UNITED AC 2009; 3:267-76. [DOI: 10.1016/j.jash.2009.03.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Revised: 02/26/2009] [Accepted: 03/01/2009] [Indexed: 11/15/2022]
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Solberg LI, Asche SE, Margolis KL, Whitebird RR. Measuring an organization's ability to manage change: the change process capability questionnaire and its use for improving depression care. Am J Med Qual 2008; 23:193-200. [PMID: 18539980 DOI: 10.1177/1062860608314942] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To describe a new survey tool for assessing medical group capability to improve care and to test the relationship between survey scores and other factors among 41 medical groups. METHODS The 30 factors and strategies that experienced quality improvement leaders ranked as most important for successful implementation were incorporated in a questionnaire. The scores from 41 medical directors on this Change Process Capability Questionnaire (CPCQ) in relation to depression improvement were correlated with organizational factors. RESULTS On a 5-point response scale, there was high variation on nearly all CPCQ items (standard deviation, 0.59-1.63) and for overall scores for factors and strategies. The total CPCQ score also correlated highly with organizational priority for depression improvement as well as with the presence of overall systems for depression care. CONCLUSIONS This measure appears to distinguish among medical groups and to demonstrate an association with both change priorities and implemented systems for depression.
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Affiliation(s)
- Leif I Solberg
- HealthPartners Research Foundation, Minneapolis, Minnesota 55440-1524, USA.
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Abatemarco DJ, Kairys SW, Gubernick RS, Kairys JA. Expanding the Pediatrician’s Black Bag: A Psychosocial Care Improvement Model to Address the “New Morbidities”. Jt Comm J Qual Patient Saf 2008; 34:106-15. [DOI: 10.1016/s1553-7250(08)34013-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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8
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Quality-Directed Activities and Barriers to Quality in Social Service Organizations. ACTA ACUST UNITED AC 2007. [DOI: 10.1300/j147v31n02_05] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Sciamanna CN, Alvarez K, Miller J, Gary T, Bowen M. Attitudes toward nurse practitioner-led chronic disease management to improve outpatient quality of care. Am J Med Qual 2006; 21:375-81. [PMID: 17077419 DOI: 10.1177/1062860606293075] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To understand the acceptability for a model of chronic disease management, in which primary care patients see nurse practitioners for structured visits using an evidence-based encounter form, the authors sent a mailed survey to primary care physicians and nurse practitioners. A total of 212 subjects completed the survey, for a total response rate of 53% (physicians, 44%; nurse practitioners, 61%). Most physicians (79.5%) reported that nurse practitioners saw patients in their practice. Most physicians (80.0%) and nurse practitioners (95.7%) believed that the proposed model of care would improve the control of chronic illnesses. In addition, most physicians (73.8%) and nurse practitioners (87.6%) believed that the model of care would be of interest to similar providers. Overall, the high level of support for the model and the presence of nurse practitioners in most physician offices suggests that future studies are warranted to understand how best to implement this.
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Affiliation(s)
- Christopher N Sciamanna
- Department of Health Policy, Jefferson Medical College, 1015 Walnut Street, Suite 115, Philadelphia, PA 19107, USA.
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Litaker D, Tomolo A, Liberatore V, Stange KC, Aron D. Using complexity theory to build interventions that improve health care delivery in primary care. J Gen Intern Med 2006; 21 Suppl 2:S30-4. [PMID: 16637958 PMCID: PMC2557133 DOI: 10.1111/j.1525-1497.2006.00360.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Previous observational research confirms abundant variation in primary care practice. While variation is sometimes viewed as problematic, its presence may also be highly informative in uncovering ways to enhance health care delivery when it represents unique adaptations to the values and needs of people within the practice and interactions with the local community and health care system. We describe a theoretical perspective for use in developing interventions to improve care that acknowledges the uniqueness of primary care practices and encourages flexibility in the form of intervention implementation, while maintaining fidelity to its essential functions.
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Affiliation(s)
- David Litaker
- VA HSR&D Center for Quality Improvement Research, Louis Stokes Cleveland Department of Veterans Affairs Medical Center and Department of Medicine, Case Western Reserve University, OH 44106, USA
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Stroebel CK, McDaniel RR, Crabtree BF, Miller WL, Nutting PA, Stange KC. How complexity science can inform a reflective process for improvement in primary care practices. Jt Comm J Qual Patient Saf 2005; 31:438-46. [PMID: 16156191 DOI: 10.1016/s1553-7250(05)31057-9] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Quality improvement processes have sometimes met with limited success in small, independent primary care settings. The theoretical framework for these processes uses an implied understanding of organizations as predictable with potentially controllable components. However, most organizations are not accurately described using this framework. Complexity science provides a better fit for understanding small primary care practices. METHODS The Multimethod Assessment Process (MAP)/Reflective Adaptive Process (RAP) is informed by complexity science. This process was developed in a series of studies designed to understand and improve primary care practice. A case example illustrates the application and impact of the MAP/RAP process. RESULTS Guiding principles for a reflective change process include the following: an understanding of practices' vision and mission is useful in guiding change, learning and reflection helps organizations adapt to and plan change, tension and discomfort are essential and normal during change, and diverse perspectives foster adaptability and new insights for positive change. DISCUSSION A reflective change process that treats organizations as complex adaptive systems may help practices make sustainable improvements.
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Solberg LI, O'Connor PJ, Christianson JB, Whitebird RR, Rush WA, Amundson GM. The QUEST for Quality: What Are Medical Groups Doing About It? Jt Comm J Qual Patient Saf 2005; 31:211-9. [PMID: 15913128 DOI: 10.1016/s1553-7250(05)31027-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND It is important to know whether medical groups have quality improvement (QI) priorities, approaches, activities, and congruence that will allow them to achieve major improvements in quality of care. METHODS Simultaneous surveys were sent to medical and administrative leaders of 18 medical groups, 84 of their constituent clinics, and their primary care physicians providing the majority of the primary care in the Minneapolis/St. Paul metropolitan area. RESULTS Of the 18 medical groups, 17 have an overall physician leader for QI and 11 have the same at each of their constituent clinics. Nearly 100% of clinic leaders report their group leaders see QI as important and expect clinics to improve care, while 69%-84% of their physicians report the clinic leaders are committed to QI for diabetes and heart disease. Diabetes and coronary heart disease are the priorities for improvement by 14 and 12 medical groups respectively. Only seven groups report adequate QI resources and only three report that incentives are aligned with quality. Intermediate groups generally appear to be just as active and supportive of QI as large ones. DISCUSSION These medical groups and their constituent clinics and physicians appear ready to work on the issues raised by the Institute of Medicine (IOM). However, they believe that limited resources and financial incentives that are not aligned with quality constrain their ability to help America cross the quality chasm.
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Affiliation(s)
- Leif I Solberg
- Care Improvement Research, HealthPartners Medical Group, Minneapolis, USA.
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Shortell SM, Marsteller JA, Lin M, Pearson ML, Wu SY, Mendel P, Cretin S, Rosen M. The role of perceived team effectiveness in improving chronic illness care. Med Care 2005; 42:1040-8. [PMID: 15586830 DOI: 10.1097/00005650-200411000-00002] [Citation(s) in RCA: 235] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND/OBJECTIVES The importance of teams for improving quality of care has received increased attention. We examine both the correlates of self-assessed or perceived team effectiveness and its consequences for actually making changes to improve care for people with chronic illness. STUDY SETTING AND METHODS: Data were obtained from 40 teams participating in the national evaluation of the Improving Chronic Illness Care Program. Based on current theory and literature, measures were derived of organizational culture, a focus on patient satisfaction, presence of a team champion, team composition, perceived team effectiveness, and the actual number and depth of changes made to improve chronic illness care. RESULTS A focus on patient satisfaction, the presence of a team champion, and the involvement of the physicians on the team were each consistently and positively associated with greater perceived team effectiveness. Maintaining a balance among culture values of participation, achievement, openness to innovation, and adherence to rules and accountability also appeared to be important. Perceived team effectiveness, in turn, was consistently associated with both a greater number and depth of changes made to improve chronic illness care. The variables examined explain between 24 and 40% of the variance in different dimensions of perceived team effectiveness; between 13% and 26% in number of changes made; and between 20% and 42% in depth of changes made. CONCLUSIONS The data suggest the importance of developing effective teams for improving the quality of care for patients with chronic illness.
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Abstract
BACKGROUND Counseling to effect lasting change in health behaviors has proven only moderately effective. The Torah, or Five Books of Moses, conveys many of the key messages regularly promulgated by prevention professionals. The promise of synergy with the behavioral messages of preventive medicine among devout Scripture-based adherents led to the development of a SCripture Oriented Preventive Education (SCOPE) tool. METHODS Forty-eight SCOPE articles were written to complement the weekly Torah portion read throughout the year in Orthodox Jewish synagogues. These were disseminated via newsletter within a modern Orthodox Jewish community in Israel. Two articles are included. An age-stratified, 25% random sample (120/471) of community readership was surveyed to ascertain receptivity to SCOPE and to gauge support for future implementation. RESULTS Response rate was 76% (92/120). Lifestyle behavior-related articles were most popular (77% found them interesting) and injury prevention the least (41%). Knowledge gained was the most common benefit reported (55% of respondents), followed by attitude change (24%). Those aged 30 to 49 years were significantly more likely than others to report behavior change (p=0.002) and health improvement (p=0.005) secondary to SCOPE. Clinical prevention (p=0.007) and environmental health (p=0.03) articles were significantly more popular in people aged > or =30 and 30 to 49, respectively. Between 69% and 84% supported the implementation of SCOPE in secondary schools, by physicians, and/or rabbis. CONCLUSIONS SCOPE was designed to deliver prevention materials to faith communities via a Scripture-based vehicle. A postexposure readership survey in an Israeli Orthodox Jewish community demonstrated its effectiveness. SCOPE's ultimate utility as a counseling adjunct in Scripture-adherent communities awaits broader assessment.
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Affiliation(s)
- Elliot Rosenberg
- National Geriatics Council, Israeli Ministry of Health, Tel-Aviv, Israel.
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Williams K, Cobb AK, Nowak J, Domian EW, Hicks V, Starling C. Faculty-Agency Partnering for Improved Client Outcomes. J Nurs Educ 2002; 41:531-4. [PMID: 12530565 DOI: 10.3928/0148-4834-20021201-06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Implications for practice and education include recognition of the value of clinical outcome studies to clinicians and administrators in clinical agencies, as well as to nursing education. This project provides an example of the opportunity for mutually beneficial education and practice partnerships. Faculty, staff, and students demonstrated their ability to use the basic model for outcome studies developed by the United Way of America (1996). Teams of staff, faculty, and students were able to design small scale outcome studies that provided valuable information for clinicians and administrators about evaluating and improving the quality of clinical services, as well as for seeking continued funding. It is anticipated that further benefits may be discovered when faculty work with agencies to target program outcomes that will yield the most powerful effect for these agencies.
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Affiliation(s)
- Kristine Williams
- University of Kansas School of Nursing, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA.
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Meurer SJ, Rubio DM, Counte MA, Burroughs T. Development of a healthcare quality improvement measurement tool: results of a content validity study. Hosp Top 2002; 80:7-13. [PMID: 12238232 DOI: 10.1080/00185860209597989] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Current methods of measuring continuous quality improvement (CQI) implementation are too long and not comprehensive. A new survey for CQI implementation was developed and tested for content validity using a panel of 8 experts--7 from the United States and 1 from England. The survey was reduced from 70 items to 22. The resultant survey had a clarity interrater agreement (IR) of .91, a representativeness IR of .93, a clarity content validity index (CVI) of .73, and a representativeness CVI of .91. Content validity served as an excellent data reduction method in building a valid, concise, and comprehensive measure of CQI implementation.
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Hill A, Gwadry-Sridhar F, Armstrong T, Sibbald WJ. Development of the continuous quality improvement questionnaire (CQIQ). J Crit Care 2001; 16:150-60. [PMID: 11815900 DOI: 10.1053/jcrc.2001.30165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE Increasingly, hospitals are engaging in continuous quality improvement (CQI) endeavors, aimed at optimizing patient care. Physician involvement is critical to the success of such initiatives. Little is known about any mediating factors that affect physician participation in these projects, though such knowledge may be potentially important for targeting approaches to maximize physician involvement. The purpose of this study was to develop a reliable and valid instrument to assess physicians' knowledge of and attitudes toward CQI. MATERIALS AND METHODS Items for the questionnaire were generated by using interviews and literature re-view and covered areas of knowledge, attitude, and facilitators and barriers to involvement in CQI projects. Five physicians participated in the interviews, 64 participated in the survey, and 9 participated in the assessment of test-retest reliability. Main outcomes were reliability and validity. RESULTS The CQI questionnaire (CQIQ) had acceptable internal consistency and Cronbach's alpha correlation coefficient exceeded.70 for all scales. Item-total correlation ranged from.30 to.63 for all scales except for 1 item. Pearson's correlation coefficient for test-retest reliability was 0.85 (P =.02). A 76% response rate was achieved. CONCLUSIONS There appears to be complex interactions among psychologic and environmental mediators that influence physician participation in hospital quality initiatives. The CQIQ shows reasonable measurement properties and our findings should be generalizable to physicians in other academic institutions. The CQIQ provides additional information on the implementation of programs and processes that should be validated in other institutional settings to enhance the interpretability of the instrument.
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Affiliation(s)
- A Hill
- Critical Care Research Network, London Health Sciences Centre, London, Ontario, Canada
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Sheahan SL, Simpson C, Rayens MK. Nurse practitioner peer review: process and evaluation. JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 2001; 13:140-5. [PMID: 11930586 DOI: 10.1111/j.1745-7599.2001.tb00235.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To describe the initiation and evaluation of a nurse practitioner (NP) peer review program for a group of 15 NPs practicing at a Veteran's Affairs Medical Center. DATA SOURCES Using a standardized review form, 15 NPs performed a peer review on a total of 163 medical records; each review was re-reviewed by 2 researchers who were also NPs. To determine the congruency of the reviews among the 15 NPs, the data were analyzed with Intraclass correlations (ICC) and ANOVA. CONCLUSIONS A relatively low ICC (r = 0.37) was found for the 15 NPs. The ANOVA indicated that there were significant differences among the NPs (F = 11.92, p < .0001). IMPLICATIONS FOR PRACTICE The outcome of a peer review process depends upon the motivation and values of the NPs, practice sites, and standardization of the format, as well as the degree of collective participation. Peer review can reveal charting deficiencies as well as identify topics for continuing education and risk management programs.
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Affiliation(s)
- S L Sheahan
- University of Kentucky College of Nursing, Lexington, Kentucky, USA
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Meyer GS. Balancing the quality cycle: tackling the measurement-improvement gap in health care. Part II. Nutrition 2001; 17:271-3. [PMID: 11312078 DOI: 10.1016/s0899-9007(00)00558-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- G S Meyer
- Center for Quality Measurement and Improvement, Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, Maryland 20852, USA.
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Wilkinson EK, McColl A, Exworthy M, Roderick P, Smith H, Moore M, Gabbay J. Reactions to the use of evidence-based performance indicators in primary care: a qualitative study. Qual Health Care 2000; 9:166-74. [PMID: 10980077 PMCID: PMC1743530 DOI: 10.1136/qhc.9.3.166] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To investigate reactions to the use of evidence-based cardiovascular and stroke performance indicators within one primary care group. DESIGN Qualitative analysis of semi-structured interviews. SETTING Fifteen practices from a primary care group in southern England. PARTICIPANTS Fifty two primary health care professionals including 29 general practitioners, 11 practice managers, and 12 practice nurses. MAIN OUTCOME MEASURES Participants' perceptions towards and actions made in response to these indicators. The barriers and facilitators in using these indicators to change practice. RESULTS Barriers to the use of the indicators were their data quality and their technical specifications, including definitions of diseases such as heart failure and the threshold for interventions such as blood pressure control. Nevertheless, the indicators were sufficiently credible to prompt most of those in primary care teams to reflect on some aspect of their performance. The most common response was to improve data quality through increased or improved accuracy of recording. There was a lack of a coordinated team approach to decision making. Primary care teams placed little importance on the potential for performance indicators to identify and address inequalities in services between practices. The most common barrier to change was a lack of time and resources to act upon indicators. CONCLUSION For the effective implementation of national performance indicators there are many barriers to overcome at individual, practice, and primary care group levels. Additional training and resources are required for improvements in data quality and collection, further education of all members of primary care teams, and measures to foster organisational development within practices. Unless these barriers are addressed, performance indicators could initially increase apparent variation between practices.
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Affiliation(s)
- E K Wilkinson
- Wessex Institute for Health Research & Development, University of Southampton, Southampton General Hospital, UK
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Miller DK, Coe RM. Physician participation in TQM in geriatric medicine. THE JOINT COMMISSION JOURNAL ON QUALITY IMPROVEMENT 2000; 26:466-75. [PMID: 10934637 DOI: 10.1016/s1070-3241(00)26039-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Quality improvement (QI) approaches such as total quality management (TQM) and continuous quality improvement (CQI) have great potential for improving the care provided to older people. Geriatricians have the necessary experience and skills to initiate and lead these QI efforts. A national sample of practicing geriatricians was surveyed in 1998 regarding involvement in, satisfaction with, and insights regarding TQM processes in four care settings. RESULTS Of 537 questionnaires returned in time for analysis, 497 were included for analysis after omitting questionnaires that were undeliverable or unusable (n = 25) and those from respondents who worked fewer than 20 hours per week (n = 15). More than one-third of the respondents (37.1%) reported no TQM activity at all. For the remainder, the primary site for TQM activity was the nursing home (33.0%), the hospital (22.5%), the office (11.4%), and the patient's home (3.7%). A majority of the respondents spent two hours per week or less on TQM projects. Planning an intervention and acting to maintain it in practice after its evaluation were the two stages of the improvement cycle these respondents engaged in most frequently. DISCUSSION More geriatricians should be encouraged to participate in TQM training and in specific projects to improve systems of care for older people. Incentives to increase participation should be made available. Rapid-cycle improvement may fit better with physicians' culture of working for outcomes that have relatively short turnaround times.
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Affiliation(s)
- D K Miller
- Department of Internal Medicine, Saint Louis University School of Medicine, MO 63104, USA.
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Goldberg HI, Horowitz CR. Musings on using evidence to guide CQI efforts toward success: the computerized firm system as primary care microunit. THE JOINT COMMISSION JOURNAL ON QUALITY IMPROVEMENT 1999; 25:529-38. [PMID: 10522234 DOI: 10.1016/s1070-3241(16)30467-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The attempt to transfer classic industrial CQI (continuous quality improvement) theory into the clinical arena has proved to be more difficult than originally promised. A new "computerized firm system" approach to incorporating CQI efforts into mainstream practice settings, which has been able to obviate many of these shortcomings, is described. METHODS To make it easier for CQI efforts to be successful, the scope of activities undertaken in completing the Shewhart cycle popularly referred to as PDSA (plan change, do change, study results, act on results) was delimited. Rather than plan the intervention themselves, staff worked with experts on tailoring a preselected change idea with already established efficacy--a computerized reminder system. Because the clinic was divided into two small group practices known as firms, a controlled time-series trial (CTST) design was used by initially turning the reminders on for one firm but not the other. The clinic was thereby also relieved of the responsibility of conducting a study to determine whether the intended improvement in quality had been achieved. In essence, one clinic was asked to do just DA (that is, do-act). RESULTS This approach engendered the successful completion of a streamlined Shewhart cycle in a busy clinic setting at remarkably low cost. The compelling nature of controlled evaluation results aided leadership in rapidly disseminating the reminder system to the remaining 11 primary care clinics associated with the university's 2 academic medical centers. CONCLUSION Computerized firm systems can be developed to conduct CTSTs as part of streamlined CQI cycles guided by both published and local evidence, and they are worth developing.
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Glasgow RE, Boles SM, Calder D, Dreyer L, Bagdade J. Diabetes care practices in primary care: results from two samples and three measurement sets. DIABETES EDUCATOR 1999; 25:755-63. [PMID: 10646472 DOI: 10.1177/014572179902500508] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE There has been substantial recent interest in diabetes disease management interventions, guidelines, and care practices. As the vast majority of diabetes care occurs in primary care settings, it makes sense to evaluate current levels of recommended practices in different primary care settings. METHODS We report on two separate studies that included a combined total of 389 patients seen by over 30 different providers. Three different sets of recommended practices were assessed: (1) the ADA provider recognition measures, (2) the proposed Diabetes Quality Improvement Project measures, and (3) the state of Oregon Population-Based Guidelines for Diabetes. RESULTS In general, there was only a moderate level of adherence to recommended practices, and adherence was much lower for behavioral or patient-focused practices as contrasted with laboratory tests. There was considerable variability across providers and across different guidelines activities. CONCLUSIONS Policy and quality improvement implications and future research issues are discussed, including the need for studying different measurement approaches for evaluating guidelines adherence.
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Affiliation(s)
- R E Glasgow
- The AMC Cancer Research Center, Denver, Colorado (Dr Glasgow)
| | - S M Boles
- The Oregon Research Institute, Eugene (Dr Boles)
| | - D Calder
- The Oregon Medical Group, Sacred Heart Hospital, Eugene (Drs Calder and Bagdade)
| | - L Dreyer
- The Oregon Health Division, Portland (Ms Dreyer)
| | - J Bagdade
- The Oregon Medical Group, Sacred Heart Hospital, Eugene (Drs Calder and Bagdade)
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Nolan P, Murray E, Dallender J. Practice nurses' perceptions of services for clients with psychological problems in primary care. Int J Nurs Stud 1999; 36:97-104. [PMID: 10376219 DOI: 10.1016/s0020-7489(99)00015-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Over a third of people presenting in primary care in the United Kingdom (UK) have a mental health problem causing some degree of disruption in their lives. Approximately 90% of these are treated and managed by primary care staff without any support from mental health services. Following the White Paper published by the UK Department of Health in 1997 (Department of Health, 1997. The New NHS--Modern and Dependable, HMSO, London), the influence of primary care both in the commissioning and provision of mental health services is likely to increase. By far the largest professional group currently involved in mental health in primary care are practice nurses. Although their numbers have increased dramatically during this decade, little is known of the work they do or of their perceptions of it. The present questionnaire-based study sought to elicit the types of mental health problems encountered by practice nurses in primary care, the interventions they provide and the skills they utilise. The data indicates that practice nurses care for people with a wide variety of mental health problems ranging from mild to severe. Many feel unprepared for this type of work and are reluctant to get too involved with clients in case they uncover problems they are not able to cope with. Lack of access to appropriate educational support is identified as the main problem currently faced by practice nurses alongside poor inter-professional relationships with mental health personnel. This paper discusses ways of meeting the needs of practice nurses and of improving collaboration in primary care settings.
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Affiliation(s)
- P Nolan
- School of Health Sciences, University of Birmingham, Edgbaston, UK.
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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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