Designing an ambulatory clinical practice for outcomes improvement: from vision to reality--the Spine Center at Dartmouth-Hitchcock, year one

The clinical microsystems approach: Does it really work? A systematic review of organizational theories of health care practices

OBJECTIVES

Faced with increased expectations regarding the quality and safety of health care delivery systems, a number of stakeholders are increasingly looking for more efficient ways to deliver care. This study was conducted to provide a critical appraisal and synthesize the best available evidence on the impact of implementing clinical microsystems (CMS) on the quality of care and safety of the health care delivery.

DATA SOURCES

A comprehensive and systematic search of 6 electronic databases, from 1998 to 2018, was conducted to identify empirical literature published in both English and French, evaluating the impact of implementing CMS in health care settings.

STUDY SELECTION

We included all study designs that evaluate the impact of implementing CMS in health care settings.

DATA EXTRACTION

Independent reviewers screened abstracts, read full texts, extracted data from the included studies, and appraised the methodological quality.

RESULTS

Of the 1907 records retrieved, 35 studies met the inclusion criteria. The settings included general practice clinics (n = 18), specialized care units (n = 14), and emergency and ambulatory units (n = 3). The implementation of CMS helped to develop the patient-centered approach, promote interdisciplinarity and quality improvement skills, increase the fluidity of the clinical acts performed, and increase patient safety. It contributed to increasing patients' and clinicians' satisfaction, as well as reducing hospital length of stay and reducing hospital-acquired infections. The implementation of CMS also contributed to the development and refinement of diagnostic tools and measurement instruments.

CONCLUSION

The CMS approach is unique because of the primacy given to the quality of care offered and the safety of patients over any other consideration, and its ability to redesign health care delivery systems. Efforts still need to be made to legitimize the approach in various health care settings worldwide.

A qualitative study of design stakeholders' views of developing and implementing a registry-based learning health system

BACKGROUND

New opportunities to record, collate, and analyze routine patient data have prompted optimism about the potential of learning health systems. However, real-life examples of such systems remain rare and few have been exposed to study. We aimed to examine the views of design stakeholders on designing and implementing a US-based registry-enabled care and learning system for cystic fibrosis (RCLS-CF).

METHODS

We conducted a two-phase qualitative study with stakeholders involved in designing, implementing, and using the RCLS-CF. First, we conducted semi-structured interviews with 19 program personnels involved in design and delivery of the program. We then undertook 11 follow-up interviews. Analysis of interviews was based on the constant comparative method, supported by NVivo software.

RESULTS

The organizing principle for the RCLS-CF was a shift to more partnership-based relationships between patients and clinicians, founded in values of co-production, and facilitated by technology-enabled data sharing. Participants proposed that, for the system to be successful, the data it collects must be both clinically useful and meaningful to patients and clinicians. They suggested that the prerequisites included a technological infrastructure capable of supporting data entry and joint decision-making in an accessible way, and a set of social conditions, including willingness from patients and clinicians alike to work together in new ways that build on the expertise of both parties. Follow-up interviews highlighted some of the obstacles, including technical challenges and practical constraints on refiguring relationships between clinicians and patients.

CONCLUSIONS

The values and vision underlying the RCLS-CF were shared and clearly and consistently articulated by design stakeholders. The challenges to realization were often not at the level of principle, but were both practical and social in character. Lessons from this study may be useful to other systems looking to harness the power of "big data" registries, including patient-reported data, for care, research, and quality improvement.

Quality Improvement in Athletic Health Care

CONTEXT

  Quality improvement (QI) is a health care concept that ensures patients receive high-quality (safe, timely, effective, efficient, equitable, patient-centered) and affordable care. Despite its importance, the application of QI in athletic health care has been limited.

OBJECTIVES

  To describe the need for and define QI in health care, to describe how to measure quality in health care, and to present a QI case in athletic training.

DESCRIPTION

  As the athletic training profession continues to grow, a widespread engagement in QI efforts is necessary to establish the value of athletic training services for the patients that we serve. A review of the importance of QI in health care, historical perspectives of QI, tools to drive QI efforts, and examples of common QI initiatives is presented to assist clinicians in better understanding the value of QI for advancing athletic health care and the profession. Clinical and Research Advantages:  By engaging clinicians in strategies to measure outcomes and improve their patient care services, QI practice can help athletic trainers provide high-quality and affordable care to patients.

Building a learning health system using clinical registers: a non-technical introduction

Purpose The purpose of this paper is to describe how clinical registers were designed and used to serve multiple purposes in three health systems, in order to contribute practical experience for building learning healthcare systems. Design/methodology/approach Case description and comparison of the development and use of clinical registries, drawing on participants' experience and published and unpublished research. Findings Clinical registers and new software systems enable fact-based decisions by patients, clinicians, and managers about better care, as well as new and more economical research. Designing systems to present the data for users' daily work appears to be the key to effective use of the potential afforded by digital data. Research limitations/implications The case descriptions draw on the experience of the authors who were involved in the development of the registers, as well as on published and unpublished research. There is limited data about outcomes for patients or cost-effectiveness. Practical implications The cases show the significant investments which are needed to make effective use of clinical register data. There are limited skills to design and apply the digital systems to make the best use of the systems and to reduce their disadvantages. More use can be made of digital data for quality improvement, patient empowerment and support, and for research. Social implications Patients can use their data combined with other data to self-manage their chronic conditions. There are challenges in designing and using systems so that those with lower health and computer literacy and incomes also benefit from these systems, otherwise the digital revolution may increase health inequalities. Originality/value The paper shows three real examples of clinical registers which have been developed as part of their host health systems' strategies to develop learning healthcare systems. The paper gives a simple non-technical introduction and overview for clinicians, managers, policy-advisors and improvers of what is possible and the challenges, and highlights the need to shape the design and implementation of digital infrastructures in healthcare services to serve users.

Integrating Patient-Reported Outcomes into Spine Surgical Care through Visual Dashboards: Lessons Learned from Human-Centered Design

Introduction:

The collection of patient-reported outcomes (PROs) draws attention to issues of importance to patients—physical function and quality of life. The integration of PRO data into clinical decisions and discussions with patients requires thoughtful design of user-friendly interfaces that consider user experience and present data in personalized ways to enhance patient care. Whereas most prior work on PROs focuses on capturing data from patients, little research details how to design effective user interfaces that facilitate use of this data in clinical practice. We share lessons learned from engaging health care professionals to inform design of visual dashboards, an emerging type of health information technology (HIT).

Methods:

We employed human-centered design (HCD) methods to create visual displays of PROs to support patient care and quality improvement. HCD aims to optimize the design of interactive systems through iterative input from representative users who are likely to use the system in the future. Through three major steps, we engaged health care professionals in targeted, iterative design activities to inform the development of a PRO Dashboard that visually displays patient-reported pain and disability outcomes following spine surgery.

Findings:

Design activities to engage health care administrators, providers, and staff guided our work from design concept to specifications for dashboard implementation. Stakeholder feedback from these health care professionals shaped user interface design features, including predefined overviews that illustrate at-a-glance trends and quarterly snapshots, granular data filters that enable users to dive into detailed PRO analytics, and user-defined views to share and reuse. Feedback also revealed important considerations for quality indicators and privacy-preserving sharing and use of PROs.

Conclusion:

Our work illustrates a range of engagement methods guided by human-centered principles and design recommendations for optimizing PRO Dashboards for patient care and quality improvement. Engaging health care professionals as stakeholders is a critical step toward the design of user-friendly HIT that is accepted, usable, and has the potential to enhance quality of care and patient outcomes.

Surgeon specialty and outcomes after elective spine surgery

STUDY DESIGN

Retrospective cohort analysis of prospectively collected clinical data.

OBJECTIVE

To compare outcomes of elective spine fusion and laminectomy when performed by neurological and orthopedic surgeons.

SUMMARY OF BACKGROUND DATA

The relationship between primary specialty training and outcome of spinal surgery is unknown.

METHODS

We analyzed the 2006 to 2012 American College of Surgeons National Surgical Quality Improvement Project database of 50,361 patients, 33,235 (66%) of which were operated on by a neurosurgeon. We eliminated all differences in preoperative and intraoperative risk factors between surgical specialties by matching 17,126 patients who underwent orthopedic surgery (OS) to 17,126 patients who underwent neurosurgery (NS) on propensity scores. Regular and conditional logistic regressions were used to predict adverse postoperative outcomes in the full sample and matched sample, respectively. The effect of perioperative transfusion on outcomes was further assessed in the matched sample.

RESULTS

Diagnosis and procedure were the only factors that were found to be significantly different between surgical subspecialties in the full sample. We found that compared with patients who underwent NS, patients who underwent OS were more than twice as likely to experience prolonged length of stay (LOS) (odds ratio: 2.6, 95% confidence interval: 2.4-2.8), and significantly more likely to receive a transfusion perioperatively, have complications, and to require discharge with continued care. After matching, patients who underwent OS continued to have slightly higher odds for prolonged LOS, and twice the odds for receiving perioperative transfusion compared with patients who underwent NS. Taking into account perioperative transfusion did not eliminate the difference in LOS between patients who underwent OS and those who underwent NS.

CONCLUSION

Patients operated on by OS have twice the odds for undergoing perioperative transfusion and slightly increased odds for prolonged LOS. Other differences between surgical specialties in 30-day postoperative outcomes were minimal. Analysis of a large, multi-institutional sample of prospectively collected clinical data suggests that surgeon specialty has limited influence on short-term outcomes after elective spine surgery.

LEVEL OF EVIDENCE

3.

Technical report: an ePRO patient reported outcome program for the evaluation of patients with irritable bowel syndrome

BACKGROUND

Patient reported outcome (PRO) is an important healthcare concept that describes patient's participation in their care by self-evaluation, usually in the form of questionnaires. This report describes an unique computerized technique, electronic PRO (ePRO), for following the progress of patients with irritable bowel syndrome (IBS).

METHODS

Patients first completed a series of questionnaires, including questions about their illness history, symptom severity, and, in this application, psychological and relationship issues. The symptom severity and psychological questionnaires were then completed at intervals by the patients on their own computers. The ePRO was constructed to allow scores to be automatically summed and placed on a time-line graph for review at the time of the next office visit.

KEY RESULTS

Of the 32 patients who completed the initial set of questionnaires, 20 maintained participation in the program for a 6-month period. Of those 20 patients, median number of submissions was 7.0; median interval between questionnaire submissions was 3.0 weeks, whereas median interval between office visits was 5.9 weeks. On average, questionnaire completion took less than 5 min and was positively experienced by the patients.

CONCLUSIONS & INFERENCES

The ePRO program proved to be technically feasible, clinically useful, and positively experienced by the patients. It provides a focus on a collaborative conversation between physician and patient. It has significant potential as a technique for evaluating outcome in response to various therapies.

Value-based shoulder surgery: practicing outcomes-driven, cost-conscious care

BACKGROUND

Pathology of the shoulder contributes significantly to the increasing burden of musculoskeletal disease. Currently, there exists high variability in the nature and quality of shoulder care, and outcomes and cost reporting are not uniform. Value-based practice aims to simultaneously maximize outcomes and minimize costs for given disease processes.

METHODS

The current state of the shoulder care literature was examined with regards to cost and outcomes data, initiatives in streamlining care delivery, and evidence-based practice improvements. This was synthesized with value-based care theory to propose new avenues to improve shoulder care in the future.

CONCLUSION

The treatment of shoulder disorders is ideal for the value-based model but has been slow to adopt its principles thus far. We can begin to advance value-based practices through (1) the universal reporting of outcomes and costs, (2) integrating shoulder care across provider specialties, and (3) critically analyzing data to formulate best practices.

Deciphering the crystal ball in spine care: can preoperative patient variables predict postoperative functional outcomes and risks?

Meredith DS, Huang RC, Nguyen J, Lyman S. Obesity increases the risk of recurrent herniated nucleus pulposus after lumbar microdiscectomy. Spine J 2010;10:575-580 (in this issue). Yadla S, Malone J, Campbell PG, et al. Obesity and spine surgery: reassessment based on a prospective evaluation of perioperative complications in elective degenerative thoracolumbar procedures. Spine J 2010;10:581-587 (in this issue).

Feed forward systems for patient participation and provider support: adoption results from the original US context to Sweden and beyond

BACKGROUND

This is a study of 2 clinical feed forward systems (FFSs) situated in different contexts: in the United States, where the system was developed, and in Swedish clinical settings, where it was first adopted. Both systems were identified as clinically successful despite differing contexts, and the objective of this study is to understand what essential properties determined their success.

METHODS

In our search for essential properties of the FFS, we used acceptance, use, and utility as indicators in questionnaires and interviews of patients and providers. Properties were identified as essential if they enabled reinforcing loops favorable for patients, providers, or both at clinical encounters.

RESULTS

A total of 44 patients participated in each context, along with 13 providers from the United States and 6 providers from the Swedish clinics. In the patient questionnaire, a majority of patients rated their impression of the FFS as excellent to good (United States: 84%, Sweden: 96%, P < .001). Interviews with both patients and providers indicated that the FFS patient overview displaying structured data previous to the clinical encounter is favorable. These essential properties enabled patient involvement through engagement, education, and communication with the provider, who appreciated them as time-saving for managing data and as decision support.

DISCUSSION

Despite distinctly different contexts and locally adapted content, essential properties that induced successful patient participation and provider support were identified as universal in the FFSs. Thus, further spread of the FFS may be enabled to accomplish patient-centered care and improved clinical information and quality management.

Analysis of Means Used to Compare Providers' Referral Patterns

OBJECTIVES

The objective of this study was to demonstrate through a case study how an analysis of means (ANOM) chart can be used to compare groups and to advocate the usefulness of this method in improvement work.

METHODS

The ANOM technique was used to compare referral rates among providers at the Dartmouth-Hitchcock Medical Center's Spine Center. The purpose was to see whether there were any differences across providers in referral rates to Behavioral Medicine services for patients who scored low on their mental health score and whether referral rates were any different among the patient characteristics. ANOM charts were also used to determine whether patient characteristics were different among the providers.

RESULTS

Six of the 17 providers had significantly different referral rates compared to the overall referral rate of 38%. Seven patients' characteristics had a significantly different referral rate compared to the system's rate. The additional ANOM charts used to compare providers relative to specific patient characteristics demonstrated several special causes and revealed characteristic referral patterns for some of the providers analyzed.

CONCLUSION

The ANOM chart may be underutilized in health care improvement work. The ANOM procedure of analyzing patient characteristics to determine differences among providers could be explored in other patient populations and settings.

Understanding the complexity of redesigning care around the clinical microsystem

The microsystem is an organizing design construct in which social systems cut across traditional discipline boundaries. Because of its interdisciplinary focus, the clinical microsystem provides a conceptual and practical framework for simplifying complex organizations that deliver care. It also provides an important opportunity for organizational learning. Process mapping and microworld simulation may be especially useful for redesigning care around the microsystem concept. Process mapping, in which the core processes of the microsystem are delineated and assessed from the perspective of how the individual interacts with the system, is an important element of the continuous learning cycle of the microsystem and the healthcare organization. Microworld simulations are interactive computer based models that can be used as an experimental platform to test basic questions about decision making misperceptions, cause-effect inferences, and learning within the clinical microsystem. Together these tools offer the user and organization the ability to understand the complexity of healthcare systems and to facilitate the redesign of optimal outcomes.

Patient preferences regarding spine surgical decision making

STUDY DESIGN

Patient surveys to determine preferences in surgical decision making.

OBJECTIVE

To evaluate spine patient preferences regarding physician and patient roles in surgical decision making and to discuss the ethical considerations that arise.

SUMMARY OF BACKGROUND DATA

Since the 1980s, there has been a push toward increasing patient autonomy and self-determination, and away from the paternalism of the past. Commensurate with this shift, patients have been encouraged to take the primary active role in surgical decision making. To date, there is little empirical evidence regarding how deeply patients want to be involved in this decision-making process.

METHODS

A total of 200 consecutive patients seen at our academic spine center were administered 1 of 2 questionnaires (previously validated) aimed at determining patient preferences about how clinical decision making should take place.

RESULTS

Patients felt strongly that complete risk information be provided. The majority of patients felt that the physician, rather than the patient, should make the basic treatment decision, and the great majority felt that the physician should make the technical decisions regarding treatment.

CONCLUSIONS

Spine surgical patients often prefer to defer surgical decision making to their surgeons. In clinical scenarios where there is little controversy and the evidence is clear, this results in little consequence, assuming that the surgeon aims to provide evidence-based care. In scenarios with greater controversy and less clear evidence, the choice of treatment offered by the surgeon may be based on factors outside of the available science, and, accordingly, efforts should be made to educate fully the patient and to help the patient make his/her own decision based on personal values regarding outcomes.

Diabetes-related foot care at 10 Veterans Affairs medical centers: must do's associated with successful microsystems

BACKGROUND

Well-coordinated interdisciplinary preventive foot care has been reported to significantly reduce diabetes-related foot ulcers, amputations, and hospitalization. However, the contribution of the specific components leading to these "successes" is not fully characterized. The microsystem conceptual framework was adapted to foot care to determine which of the microsystem success characteristics were associated with decreased major lower-limb amputation rates at 10 Veterans Affairs (VA) medical centers.

METHODS

Two-day site visits were conducted using standardized interviews at the 10 VA medical centers.

RESULTS

Six "must do's" for foot care in microsystems were correlated at > or = (-.30) with amputation rates: (1) addressing all foot care needs, (2) appropriate referrals, (3) ease in recruiting staff, (4) confidence in staff, (5) available stand alone specialized diabetic foot care services, and (6) providers attending diabetic foot care education in the past three years. Using multiple linear regression, the sum of these items described 59% of the variance (p = 0.006).

DISCUSSION

Clinicians and managers may want to include the must-do's in system modifications to improve foot care for people with diabetes. Many of the sites displayed exemplary features in foot care, such as providing a formal orientation to the foot care clinics.

Screening for depressive symptoms in patients with chronic spinal pain using the SF-36 Health Survey

BACKGROUND DATA

Depression is a common co-morbidity for patients with complaints of spinal pain, yet often goes undiagnosed in clinical practice. Depressed patients who are not identified do not receive a referral or recommendation for treatments that may help ease their total illness burden. Relative to the total outcomes of spine care this may increase costs, decrease overall functional outcomes, and limit patient satisfaction. Some spine care settings track functional outcomes using a general health status survey. Although a specific and reliable survey to detect depression could be employed, an additional survey would unnecessarily increase responder and analyst burdens if the general health status survey could be used instead.

OBJECTIVE

To identify the Mental Component Summary (MCS) cutoff score from the Short Form 36-item Health Survey (SF-36) that best predicts a positive depression score as measured by the Center for Epidemiological Study-Depression Survey (CES-D).

STUDY DESIGN

An analysis of the diagnostic properties of the SF-36 MCS Scale as a predictor of depressive symptoms as measured by the CES-D.

OUTCOME MEASURES

The SF-36 is a general health survey that contains a MCS score that represents the psychological well-being and general health perception of the respondent. This composite score is norm-based (mean = 50, SD = 10) with lower scores representing poorer health. The CES-D has been well-studied in patients with chronic pain complaints and was used as the gold standard for determining the MCS cutoff score. A CES-D score of 19 or greater was considered positive for depressive symptoms.

PATIENT SAMPLE

All patients entering our facility routinely complete the SF-36. Between February 2002 and October 2002, all patients scoring 30 or less on the MCS (MCS < or = 30) also completed the CES-D. Patients who scored 2 standard deviations below the mean (MCS = 30 or less) were considered most at risk for depression. Patients scoring above 30 on their MCS (MCS > 30) were considered less likely to have depressive symptoms and were randomly chosen to complete the CES-D. There were 420 patients who completed both surveys of which there were 99 MCS < or = 30 patients and 321 MCS > 30 patients.

METHODS

Receiver operating characteristic (ROC) curves were used to assess the sensitivity and specificity of the SF-36 as a screening tool for detecting depressive symptoms.

RESULTS

An MCS score of 35 has a sensitivity of 80% (76-83; 95% confidence interval), a specificity of 90% (87-93), an ROC area of 0.8517 (0.81-0.89), and correctly identified 87% of the sample.

CONCLUSION

The SF-36 provides the benefits of a general functional health status measure and additionally appears to provide a screening tool for depressive symptoms. A cutoff score of 35 or less on the MCS scale has a high degree of sensitivity and specificity and is able to identify depressive symptoms in patients with back pain, which can help identify patients who will benefit from mental health treatments.

Publicly Reporting Comprehensive Quality and Cost Data: A Health Care System’s Transparency Initiative

BACKGROUND

Transparency in health care, including the public reporting of health care results, is an expanding and unstoppable phenomenon. Health care systems have an opportunity to: (1) be proactive and accountable for the care they provide, (2) help patients learn more about their condition as a supplement to understanding the performance measures, and (3) use public reporting to foster process of care and outcome improvement initiatives. An overview is provided of the first 22 months of a transparency initiative at Dartmouth-Hitchcock Medical Center (DHMC).

LAUNCHING THE TRANSPARENCY INITIATIVE

An interdisciplinary operations group works with the various clinical programs--both providers and patients--to identify what quality and cost measures are most desired by patients and what measures are the focus of the clinical program's internal measurement and reporting processes. The measures are presented on the DHMC Web site, with access to additional resources, such as clinical decision aids.

DISCUSSION

A variety of factors are important to the transparency initiative--senior leaders' perceptions, risk management issues, resources required for the design and maintenance of the initiative, and developing both methodological protocols and technical systems.

The rate and variation of referrals to behavioral medicine services for patients reporting poor mental health in the national spine network

STUDY DESIGN

Descriptive analysis of cross-sectional data collected prospectively in 20 National Spine Network (NSN) centers.

OBJECTIVES

First, to summarize clinical and demographic characteristics of patients likely to need servicesfor psychosocial concerns. Second, to determine the rate and variability of referrals for behavioral medicine interventions (BMED) across the NSN.

SUMMARY OF BACKGROUND DATA

The prevalence of mental distress resulting from or coexisting with spinal pain is unclear. There is evidence that psychological treatments, particularly BMED, can aid the recovery of patients with symptoms of mental distress.

METHODS

From 1998 to 2001, 28,349 patients presenting to NSN centers completed the SF-36 General Health Survey. Patients were dichotomized by the mental component summary (MCS) score into two groups: 1) those scoring <or=35 on the MCS scale (patients self-reporting significant signs of mental distress) and 2) those scoring >35. Clinicians recorded a "treatment plan" comprised of a standard array of treatment options. For patients scoring <or=35 on the MCS, the rate and variation of referrals to BMED was assessed.

RESULTS

Baseline health status scores were lower across all SF-36 scales for the patients scoring an MCS <or= 35. For mentally distressed patients, the overall average referral rate for any BMED service for patients scoring MCS <or= 35 was 11.8%. The rate varied across NSN sites from 0 to 41%.

CONCLUSION

With only 11.8% of mentally distressed NSN patients receiving a referral for any form of BMED, it appears that a large proportion of eligible patients are not receiving a potentially beneficial treatment. Wide variation across centers may indicate an inability to adequately assess mental distress via the usual clinical interview and examination for spinal conditions or a lack of consensus regarding BMED's availability and utility.

Medication reviews in the community: results of a randomized, controlled effectiveness trial

AIMS

To examine the effectiveness of a multidisciplinary service model delivering medication review to patients at risk of medication misadventure in the community.

METHODS

The study was carried out in three Australian states; Queensland, New South Wales and Western Australia, and conducted as a randomized, controlled effectiveness trial with the general practitioner (GP) as the unit of randomization. In total, 92 GPs, 53 pharmacists and 400 patients enrolled in the study. The multidisciplinary service model consisted of GP education, patient home visits, pharmacist medication reviews, primary healthcare team conferences, GP implementation of action plans in consultation with patients, and follow-up surgery visits for monitoring. Effectiveness was assessed using the four clinical value compass domains of (i) functional status, (ii) clinical outcomes, (iii) satisfaction and (iv) costs. The domains of functional status (assessed by the health-related quality of life measure SF-36 subscales) and clinical outcomes (as assessed by adverse drug events (ADEs), number of GP visits, hospital services and severity of illness) were measured at baseline and endpoint. Satisfaction was measured by success in implementation and by participant satisfaction at endpoint, and costs (as assessed using medication and healthcare service costs, less intervention costs) were measured preintervention and during the trial. In addition, process evaluation was conducted for intervention patients, in which problems and recommendations from the medication reviews were described.

RESULTS

The model was successfully implemented with 92% of intervention GPs suggesting that the model had improved the care of participating patients, a view shared by 94% of pharmacists. In addition, positive trends in clinical outcomes (ADEs and severity of illness) and costs (an ongoing trend towards reduction in healthcare service costs) were evident, although the trial was limited to a 6-month intervention time. No differences between intervention and control groups were identified for the health-related quality of life domain. The cost-effectiveness ratio for the intervention based on cost savings, reduced adverse events and improved health outcomes was small. The most common problems identified in the medication reviews were potential adverse drug reactions, suboptimal monitoring and adherence/lack of concordance issues. In total, 54.4% of recommendations were enacted, and 23.9% were implemented precisely as recommended in the medication review. Follow-up evaluation showed that 70.9% of actions had a positive outcome, 15.7% no effect and 3.7% had a negative outcome.

CONCLUSIONS

Most studies emphasize efficacy and the best achievable clinical outcomes rather than whether an intervention will be effective in practice. The current trial showed that three of the four domains in the clinical value compass showed trends of improvement or were indeed improved in the relatively short follow-up period of the trial, suggesting that a service based on this model could achieve similar benefits in practice. A domiciliary medication review programme similar to this model has now been implemented into national Australian practice, where GPs and pharmacists are reimbursed by the Australian government for the provision of these services.

A Conceptual Idea to Improve Access in a Complex Health Care System

OBJECTIVE

The purpose of this article was to briefly describe the Open Access model, a method of improving access to a health care organization, and a conceptual idea is proposed for complex organizations that want to engage in this improvement work. The target audience is health care organizations that want to improve access to their services but are challenged by the complexity of their processes.

METHODS

A case study presents an organization's experience with the Open Access assessment process. This process starts with quantifying an organization's supply and demand and then deciding how to reshape its capacity and implement other strategies. A high-leverage area to improve access is a standardized or predictable process that is streamlined or implemented for a specific group of patients.

RESULTS

Health care organizations are complex and have processes of care that are not explicit, in which services are rendered uniquely for each individual patient and it is difficult to see the harmony or patterns in how the work is done.

CONCLUSION

The underlying principles of the Open Access model can be adopted in a complex organization, if it is acceptable to do more exploratory work and create or increase opportunities for the right things to happen.

"Best practice" in inflammatory bowel disease: an international survey and audit

Background: An observational study was conducted at eight university and four district hospitals in eight countries collaborating in clinical and epidemiological research in inflammatory bowel disease (IBD) to compare European health care facilities and to define current "best practice" with regard to IBD. Methods: The approach used in this multi-national survey was unique. Existing quality norms, developed for total hospital care by a specialized organization, were restricted to IBD-specific care and adapted to the frame of reference of the study group. In each center, these norms were surveyed by means of questionnaires and professional audits in all participating centers. The collected data were reported to the center, compared to data from other hospitals, and used to benchmark. Group consensus was reached with regard to defining current "best practice". Results: The observations in each center involved patient-oriented processes, technical and patient safety, and quality of the medical standard. Several findings could be directly implemented to improve IBD care in another hospital (benchmarks). These included a confidential relationship between health care worker(s) and patients, and availability of patient data. Conclusions: The observed benchmarks, in combination with other subjectively chosen "positive" procedures, have been defined as current "best practice in IBD", representing practical guidelines towards better quality of care in IBD.

Good measurement for good improvement work

PURPOSE

To provide guidance on using measurement to support the conduct of local quality improvement projects that will strengthen the evaluation of results and increase their potential for publication.

TARGET GROUP

Individuals leading quality improvement efforts who wish to enhance their use of measurement.

PROCEDURES TO PROMOTE GOOD MEASUREMENT

Eleven procedures are offered to promote intelligent measurement in quality improvement research that may become publishable: 1. Start with an important topic 2. Develop a clear aim statement 3. Turn the aim statement into key questions 4. Develop a theory about causes and effects, process changes and predictable sources of variation 5. Construct a research design and accompanying dummy data displays to answer your primary research questions 6. Develop and use operational definitions for each variable needed to make your dummy data displays 7. Design a data collection plan to gather information on each variable that will enable you to generate reliable, valid, and sensitive measures related to each research question 8. Pilot test the data collection plan, construct preliminary data displays, and revise your methods based on what you learn 9. Stay close to the data collection process as the data plan goes from idea to execution 10. Perform data analysis and display results in a way that answers your key questions. 11. Review and document the strengths and limitations of your measurement work and use this knowledge to guide intelligent interpretation of the observed results.

Study designs for PDSA quality improvement research

OBJECTIVE

The purpose of this article is to discuss strengths and weaknesses of quasi-experimental designs used in health care quality improvement research. The target groups for this article are investigators in plan-do-study-act (PDSA) quality improvement initiatives who wish to improve the rigor of their methodology and publish their work and reviewers who evaluate the quality of research proposals or published work.

SUMMARY

A primary purpose of PDSA quality improvement research is to establish a functional relationship between process changes in systems of health care and variation in outcomes. The time series design is the fundamental paradigm for demonstrating such functional relationships. The rigor of a PDSA quality improvement study design is strengthened using replication schemes and research methodology to address extraneous factors that weaken validity of observational studies.

CONCLUSION

The design of PDSA quality improvement research should follow from the purpose and context of the project. Improving the rigor of the quality improvement literature will build a stronger foundation and more convincing justification for the study and practice of quality improvement in health care.

Emergency department structure and operations

The purpose of this article is to explore some of the tools and technologies available in operations management in health care in general and in emergency medicine in particular. The intent is to stimulate the reader to explore some of these approaches and tools in further detail. Various theories are noted, but the intent of this article is to be eclectic so as to give the reader a feel for the rich variety of approaches available.

Policy Support For Patient-Centered Care: The Need For Measurable Improvements In Decision Quality

The phenomenon of practice variation draws attention to the need for better management of clinical decision making as a means of ensuring quality. Different policies to address variations, including guidelines and measures of appropriateness, have had little demonstrable impact on variation itself or on the underlying quality problems. Variations in rates of interventions raise questions about the patient-centeredness of decisions that determine what care is provided to whom. Policies that support the development and routine use of measures of decision quality will provide opportunities to measurably improve the quality of decisions, thereby leading to more patient-centered and efficient health care.

Trends And Geographic Variations In Major Surgery For Degenerative Diseases Of The Hip, Knee, And Spine

Although Medicare rates for surgery to treat degenerative diseases of the hip, knee, and spine are highly variable among hospital referral regions (HRRs), the relative risk for surgery within a region is constant from year to year-a large majority of the variation in surgery in 2000--01 is "explained" by the variation in rates in 1992--93. The within-region constancy in rates for highly variable procedures (the "surgical signature") is illustrated for South Florida HRRs. Involving the patient in choice of treatments (shared decision making) and outcomes research are promising strategies for reducing unwarranted regional variation and local constancy in surgery risk.

Microsystems in health care: Part 2. Creating a rich information environment

BACKGROUND

A rich information environment supports the functioning of the small, functional, frontline units--the microsystems--that provide most health care to most people. Three settings represent case examples of how clinical microsystems use data in everyday practice to provide high-quality and cost-effective care.

CASES

At The Spine Center at Dartmouth, Lebanon, New Hampshire, a patient value compass, a one-page health status report, is used to determine if the provided care and services are meeting the patient's needs. In Summit, New Jersey, Overlook Hospital's emergency department (ED) uses uses real-time process monitoring on patient care cycle times, quality and productivity indicator tracking, and patient and customer satisfaction tracking. These data streams create an information pool that is actively used in this ED icrosystem--minute by minute, hourly, daily, weekly, and annually--to analyze performance patterns and spot flaws that require action. The Shock Trauma Intensive Care Unit (STRICU), Intermountain Health Care, Salt Lake City, uses a data system to monitor the "wired" patient remotely and share information at any time in real time. Staff can complete shift reports in 10 minutes.

DISCUSSION

Information exchange is the interface that connects staff to patients and staff to staff within the microsystem; microsystem to microsystem; and microsystem to macro-organization.

Microsystems in health care: Part 1. Learning from high-performing front-line clinical units

BACKGROUND

Clinical microsystems are the small, functional, front-line units that provide most health care to most people. They are the essential building blocks of larger organizations and of the health system. They are the place where patients and providers meet. The quality and value of care produced by a large health system can be no better than the services generated by the small systems of which it is composed.

METHODS

A wide net was cast to identify and study a sampling of the best-quality, best-value small clinical units in North America. Twenty microsystems, representing different component parts of the health system, were examined from December 2000 through June 2001, using qualitative methods supplemented by medical record and finance reviews.

RESULTS

The study of the 20 high-performing sites generated many best practice ideas (processes and methods) that microsystems use to accomplish their goals. Nine success characteristics were related to high performance: leadership, culture, macro-organizational support of microsystems, patient focus, staff focus, interdependence of care team, information and information technology, process improvement, and performance patterns. These success factors were interrelated and together contributed to the microsystem's ability to provide superior, cost-effective care and at the same time create a positive and attractive working environment.

CONCLUSIONS

A seamless, patient-centered, high-quality, safe, and efficient health system cannot be realized without the transformation of the essential building blocks that combine to form the care continuum.