Appreciative Inquiry for quality improvement in primary care practices

Leveraging learning systems to improve quality and patient safety in allergen immunotherapy

Adverse events occur in all fields of medicine, including allergy-immunology, in which allergen immunotherapy medical errors can cause significant harm. Although difficult to experience, such errors constitute opportunities for improvement. Identifying system vulnerabilities can allow resolution of latent errors before they become active problems. We review key aspects and frameworks of the medical error response, acknowledging the fundamental responsibility of clinical teams to learn from harm. Adverse event response comprises 4 major phases: (1) event recognition and reporting, (2) investigation (for which root cause analysis can be helpful), (3) improvement (inclusive of the plan-do-study-act cycle), and (4) communication and resolution. Throughout the process, clinician wellness must be maintained. Adverse event prevention should be prioritized, and a human factors engineering approach can be useful. Quality improvement tools and approaches complement one another and together offer a meaningful avenue for error recovery and prevention.

Implementation strategies for large scale quality improvement initiatives in primary care settings: a qualitative assessment

BACKGROUND AND OBJECTIVES

The EvidenceNOW: Advancing Heart Health in Primary Care was designed to assist primary care practices in the US in implementing evidence-based practices in cardiovascular care and building capacity for quality improvement. EvidenceNOW, NCT03054090, was registered with ClinicalTrials.gov on 15/02/2017. The goals of this study were to gain a comprehensive understanding of perspectives from research participants and research team members on the value of implementation strategies and factors that influenced the EvidenceNOW initiative in Virginia.

METHODS

In 2018, we conducted 25 focus groups with clinicians and staff at participating practices, including 80 physicians, advanced practice clinicians, practice managers and other practice staff. We also conducted face-to-face and telephone interviews with 22 research team members, including lead investigators, practice facilitators, physician expert consultants, and evaluators. We used the integrated-Promoting Action on Research Implementation in the Health Services (i-PARIHS) framework in our qualitative data analysis and organization of themes.

RESULTS

Implementation strategies valued by both practice representatives and research team members included the kick-off event, on-site practice facilitation, and interaction with physician expert consultants. Remote practice facilitation and web-based tools were used less frequently. Contextual factors that influence quality improvement efforts include leadership support, access to resources, previous quality improvement experience, and practice ownership type (independent compared to health system owned). Many clinicians and staff were overwhelmed by day-to-day activities and experience initiative fatigue, which hindered their ability to fully participate in the EvidenceNOW initiative.

CONCLUSIONS

This study provides details on how the practice environment plays an essential role in the implementation of evidence-based practices in primary care. Future efforts to improve quality in primary care practices should consider the context and environment of individual practices, with targeted implementation strategies to meet the needs of independent and health system owned practices. Future efforts to improve quality in primary care practices require strategies to address initiative fatigue among clinicians and practice staff. External support for building capacity for quality improvement could help primary care practices implement and sustain evidence-based practices and improve quality of care.

TRIAL REGISTRATION

This project was registered with ClinicalTrials.gov on 15/02/2017 and the identifier is NCT03054090.

Systematic review and narrative synthesis of the impact of Appreciative Inquiry in healthcare

BACKGROUND

Appreciative Inquiry is a motivational, organisational change intervention, which can be used to improve the quality and safety of healthcare. It encourages organisations to focus on the positive and investigate the best of 'what is' before thinking of 'what might be', deciding 'what should be' and experiencing 'what can be'. Its effects in healthcare are poorly understood. This review seeks to evaluate whether Appreciative Inquiry can improve healthcare.

METHODS

Major electronic databases and grey literature were searched. Two authors identified reports of Appreciative Inquiry in clinical settings by screening study titles, abstracts and full texts. Data extraction, in duplicate, grouped outcomes into an adapted Kirkpatrick model: participant reaction, attitudes, knowledge/skills, behaviour change, organisational change and patient outcomes.

RESULTS

We included 33 studies. One randomised controlled trial, 9 controlled observational studies, 4 qualitative studies and 19 non-controlled observational reports. Study quality was generally poor, with most having significant risk of bias. Studies report that Appreciative Inquiry impacts outcomes at all Kirkpatrick levels. Participant reaction was positive in the 16 studies reporting it. Attitudes changed in the seventeen studies that reported them. Knowledge/skills changed in the 14 studies that reported it, although in one it was not universal. Behaviour change occurred in 12 of the 13 studies reporting it. Organisational change occurred in all 23 studies that reported it. Patient outcomes were reported in eight studies, six of which reported positive changes and two of which showed no change.

CONCLUSION

There is minimal empirical evidence to support the effectiveness of Appreciative Inquiry in improving healthcare. However, the qualitative and observational evidence suggests that Appreciative Inquiry may have a positive impact on clinical care, leading to improved patient and organisational outcomes. It is, therefore, worthy of consideration when trying to deliver improvements in care. However, high-quality studies are needed to prove its effects.

PROSPERO REGISTRATION NUMBER

CRD42015014485.

Building Positive Organizations: A Typology of Positive Psychology Interventions

Research indicates that Positive Psychology Interventions (PPIs) in the work context have a small positive impact on improving desirable work outcomes, and a small to moderate effect on reducing undesirable work outcomes, suggesting that the effects of PPIs are not trivial, but also not large. Whereas this may be related to the difficulty of changing oneself or one's happiness levels, the relatively small effects of PPIs may also be due to the predominant use of one-off interventions instead of more structural interventions that reflect policy level commitment. Furthermore, since most PPIs tend to focus on the individual, one could question the long-term effectiveness of such interventions, especially when the work environment remains unchanged. In this manuscript, I introduce a typology of PPIs in organizations by distinguishing between the organizational level they target (the individual or group level), and between one-off and structural interventions. I argue that different types of interventions can strengthen each other, and that to make a sustainable contribution to the optimal functioning of workers, PPIs need to comprise a wide variety of one-off and structural interventions targeting both individuals and groups in organizations. Furthermore, I make suggestions for improving the long-term effectiveness of PPIs by drawing on the literature on transfer of training, nudging, and positive design.

Outcomes, mechanisms and contextual factors of positive psychology interventions for health workers: a systematic review of global evidence

BACKGROUND

Interventions using positive psychology (PP), which build on positive qualities of healthcare personnel and institutions, could potentially enhance organisational performance in healthcare. The aim of this systematic review was to identify if PP interventions have an impact on organisational performance of healthcare personnel, and if so, how this impact can be achieved. We developed a logic model to explain the impact of PP interventions on organisational performance.

METHODS

We searched Web of Science, Medline, Psychinfo, Embase, Scopus and CINAHL (from inception until March 2019) and references of included articles to identify studies that evaluated the impact of a PP intervention for health personnel. Study quality was assessed using the SQUIRE checklist for quality improvement studies. Data were extracted about study details, setting, participants, intervention, method of evaluation and results. Outcomes, mechanisms and contexts were coded in nVivo. Data synthesis was guided by Lewis' theory of the impact of PP interventions on organisational performance and Kneale et al.'s method for logic model development. Collected data were integrated into a logic model explaining initial inputs, processes, and intermediate outcomes of PP interventions that lead to improved organisational performance in healthcare settings.

RESULTS

We retrieved 4638 articles and identified five through references of included articles of which 29 studies (31 articles) met our inclusion criteria. Most articles were of low quality (n = 19) and outcome measures varied widely. We identified 54 different outcomes of PP interventions, including 'improved well-being' and 'improved interaction and support'. Forty-nine mechanisms were identified including 'recognising and reframing negative interpretations'. Twenty four contextual factors were identified of which seven acted as barriers. 'Managerial support' was a facilitator mentioned in eight studies. All identified outcomes, mechanisms and contextual factors were integrated into a logic model explaining how interventions using PP can impact organisational performance in healthcare.

CONCLUSION

Few identified outcomes were statistically significant, however, trends in both quantitative and qualitative outcomes show that PP interventions can increase well-being and interaction and support and thus improve organisational performance in healthcare. The developed logic model can be used in the implementation and evaluation of interventions using PP for health personnel.

Leading Innovative Practice: Leadership Attributes in LEAP Practices

Policy Points An onslaught of policies from the federal government, states, the insurance industry, and professional organizations continually requires primary care practices to make substantial changes; however, ineffective leadership at the practice level can impede the dissemination and scale-up of these policies. The inability of primary care practice leadership to respond to ongoing policy demands has resulted in moral distress and clinician burnout. Investments are needed to develop interventions and educational opportunities that target a broad array of leadership attributes.

CONTEXT

Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes.

METHODS

A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices.

FINDINGS

We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others.

CONCLUSIONS

Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.

Health management committee strengthening and community mobilisation through women's groups to improve trained health worker attendance at birth in rural Nepal: a cluster randomised controlled trial

Background

Engaging citizens and communities to make services accountable is vital to achieving health development goals. Community participation in health management committees can increase public accountability of health services. We conducted a cluster randomised controlled trial to test the impact of strengthened health management committees (HMCs) and community mobilisation through women’s groups on institutional deliveries and deliveries by trained health workers in rural Nepal.

Methods

The study was conducted in all Village Development Committee clusters in the hills district of Makwanpur (population of 420,500). In 21 intervention clusters, we conducted three-day workshops with HMCs to improve their capacity for planning and action and supported female community health volunteers to run women’s groups. These groups met once a month and mobilised communities to address barriers to institutional delivery through participatory learning and action cycles. We compared this intervention with 22 control clusters. Prospective surveillance from October 2010 to the end of September 2012 captured complete data on 13,721 deliveries in intervention and control areas. Analysis was by intention to treat.

Results

The women’s group intervention was implemented as intended, but we were unable to support HMCs as planned because many did not meet regularly. The activities of community based organisations were systematically targeted at control clusters, which meant that there were no true ‘control’ clusters. 39% (5403) of deliveries were in health institutions and trained health workers attended most of them. There were no differences between trial arms in institutional delivery uptake (1.45, 0.76–2.78) or attendance by trained health workers (OR 1.43, 95% CI 0.74–2.74).

Conclusions

The absence of a true counterfactual and inadequate coverage of the HMC strengthening intervention impedes our ability to draw conclusions. Further research is needed to test the effectiveness of strengthening public accountability mechanisms on increased utilisation of services at delivery.

Trial registration

Current Controlled Trials ISRCTN99834806.

Date of registration:28/09/10.

The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: a systematic review

Background

Efforts to improve the quality, safety, and efficiency of health care provision have often focused on changing approaches to the way services are organized and delivered. Continuous quality improvement (CQI), an approach used extensively in industrial and manufacturing sectors, has been used in the health sector. Despite the attention given to CQI, uncertainties remain as to its effectiveness given the complex and diverse nature of health systems. This review assesses the effectiveness of CQI across different health care settings, investigating the importance of different components of the approach.

Methods

We searched 11 electronic databases: MEDLINE, CINAHL, EMBASE, AMED, Academic Search Complete, HMIC, Web of Science, PsycINFO, Cochrane Central Register of Controlled Trials, LISTA, and NHS EED to February 2019. Also, we searched reference lists of included studies and systematic reviews, as well as checking published protocols for linked papers. We selected randomized controlled trials (RCTs) within health care settings involving teams of health professionals, evaluating the effectiveness of CQI. Comparators included current usual practice or different strategies to manage organizational change. Outcomes were health care professional performance or patient outcomes. Studies were published in English.

Results

Twenty-eight RCTs assessed the effectiveness of different approaches to CQI with a non-CQI comparator in various settings, with interventions differing in terms of the approaches used, their duration, meetings held, people involved, and training provided. All RCTs were considered at risk of bias, undermining their results. Findings suggested that the benefits of CQI compared to a non-CQI comparator on clinical process, patient, and other outcomes were limited, with less than half of RCTs showing any effect. Where benefits were evident, it was usually on clinical process measures, with the model used (i.e., Plan-Do-Study-Act, Model of Improvement), the meeting type (i.e., involving leaders discussing implementation) and their frequency (i.e., weekly) having an effect. None considered socio-economic health inequalities.

Conclusions

Current evidence suggests the benefits of CQI in improving health care are uncertain, reflecting both the poor quality of evaluations and the complexities of health services themselves. Further mixed-methods evaluations are needed to understand how the health service can use this proven approach.

Trial registration

Protocol registered on PROSPERO (CRD42018088309).

Making the Random the Usual: Appreciative Inquiry/Boot Camp Translation-Developing Community-Oriented Evidence That Matters

Background: The evidence underlying clinical guidelines arising from typical scientific inquiry may not always match the needs and concerns of local communities. Our High Plains Research Network Community Advisory Council (HPRN CAC) identified a need for evidence regarding how to assist members of their community suffering from mental health issues to recognize their need for help and then obtain access to mental health care. The lack of evidence led our academic team to pursue linking Appreciative Inquiry with Boot Camp Translation (AI/BCT). This article describes the development and testing of this linked method. Method: We worked with the HPRN CAC and other communities affiliated with the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP) practice-based research networks to identify 5 topics for testing of AI/BCT. For each topic, we developed AI interview recruitment strategies and guides with our community partners, conducted interviews, and analyzed the interview data. Resulting themes for each topic were then utilized by 5 groups with the BCT method to develop community relevant messages and materials to communicate the evidence generated in each AI set of interviews. At each stage for each topic, notes on adaptations, barriers, and successes were recorded by the project team. Results: Each topic successfully led to generation of community specific evidence, messages, and materials for dissemination using the AI/BCT method. Beyond this, 5 important lessons emerged regarding the AI/BCT method: Researchers must (1) first ensure whether the topic is a good fit for AI, (2) maintain a focus on "what works" throughout all stages, (3) recruit one or more experienced qualitative analysts, (4) ensure adequate time and resources for the extensive AI/BCT process, and (5) present AI findings to BCT participants in the context of existing evidence and the local community and allow time for community partners to ask questions and request additional data analyses to be done. Conclusions: AI/BCT represents an effective way of responding to a community's need for evidence around a specific topic where standard evidence and/or guidelines do not exist. AI/BCT is a method for turning the "random" successes of individuals into "usual" practice at a community level.

Learning medical professionalism - the application of appreciative inquiry and social media

BACKGROUND

Medical professionalism is often considered difficult to be clearly observed and learned. However, although most medical students or residents affirm the necessity of medical professionalism courses, few agree that those currently offered are adequate for a medical career.

OBJECTIVE

To develop a curriculum for teaching professionalism by enabling students to share positive examples of professionalism in social media that reflects the authentic experience in clinical environment.

DESIGN

Between October 2015 and June 2017, the authors developed a clerkship program to teach professionalism with the support of social media and appreciative inquiry. Medical students were required to write posts on the positive behaviors they observed during clinical practice in the Facebook group. Other students and course instructors commented or responded to the posted content. The content on Facebook analyzed by course instructors and was based on the definition of medical professionalism according to the 18 attributes proposed by Cruess et al. Results: In total, 103 medical students in their first clinical year participated and posted 435 records of role model learning in the Facebook group. The majority of students learned the most when the clinical instructors were passionate about their teaching and guidance in medical expertise; this accounted for 23.0% of all role model behaviors. Other attributes of professionalism that students appreciated most were being caring and compassionate (17.2%), competence (9.6%), openness (8.8%), and presence (7.7%). More than 90% of the students reported enjoying this type of course and would like to integrate their learning experiences into future behavior.

CONCLUSIONS

This innovative training program was well accepted in the formal curriculum and the predesigned social media environment. Appreciative inquiry for medical professionalism should be integrated into the organizational culture and the culture of social media interaction.

Using Appreciative Inquiry to Inform Program Evaluation in Graduate Medical Education

BACKGROUND

Graduate medical education programs are expected to conduct an annual program evaluation. While general guidelines exist, innovative and feasible approaches to program evaluations may help efforts at program improvement. Appreciative Inquiry is an approach that focuses on successful moments, effective processes, and programs' strengths.

OBJECTIVE

We implemented a novel application of Appreciative Inquiry and its 4 phases (Inquire, Imagine, Innovate, and Implement) and demonstrate how it led to meaningful improvements in a pediatric pulmonology fellowship program.

METHODS

As part of the Inquire and Imagine phases, the authors developed an interview guide that aligned with Appreciative Inquiry concepts. Two faculty members conducted semistructured interviews with a convenience sample of 11 of 14 fellowship alumni. Interviews were audiotaped, transcribed, and reviewed. A summary of the findings was presented to the Program Evaluation Committee, which then directed the Innovate and Implement phases.

RESULTS

Appreciative Inquiry was acceptable to the alumni and feasible with the authors' self-directed learning approach and minimal administrative and financial support. In the Inquire phase, alumni identified program strengths and successes. In the Imagine phase, alumni identified program changes that could aid transition to independent practice for future fellows (an identified program goal). Based on the results of the Appreciative Inquiry, program leadership and the Program Evaluation Committee selected improvements for implementation.

CONCLUSIONS

For small programs, Appreciative Inquiry is an innovative and feasible approach to program evaluation that facilitates actionable program improvement recommendations.

Use of Appreciative Inquiry To Engage Parents as Codesigners of a Weight Management Intervention for Adolescents

BACKGROUND

Focus groups are often used to involve families as codesigners of weight management interventions. Focus groups, however, are seldom designed to elicit families' strengths and positive experiences. The purpose of this study was to describe the use of the Appreciative Inquiry process in the conduct of focus groups to engage families in the design of a weight management intervention for adolescents.

METHODS

A convenience sample of 44 parents (84% female; 82% minority) of adolescent children with a BMI ≥ 85th percentile, who were in the 6th-8th grade in a large urban school, participated in focus groups designed to elicit family-positive experiences and strengths regarding healthy living. A structured set of questions based on the Appreciative Inquiry process was used in the focus groups. Analyses consisted of the constant comparative method to generate themes.

RESULTS

Parent-positive perceptions regarding their family's healthy living habits were reflected in five themes: (1) Having healthy children is a joy; (2) Becoming healthy is a process; (3) Engaging in healthy habits is a family affair; (4) Good health habits can be achieved despite obstacles; and (5) School, community, and social factors contribute to their family's health habits. Parents generated ideas to improve their families' health.

CONCLUSIONS

Focus groups based on the Appreciative Inquiry process were found to be a useful approach to discover features that are important to low-income, urban-living parents to include in an adolescent weight management program. Recommendations for designing and conducting focus groups based on the Appreciative Inquiry process are provided.

Systematic review of interventions to improve the psychological well-being of general practitioners

BACKGROUND

The health of doctors who work in primary care is threatened by workforce and workload issues. There is a need to find and appraise ways in which to protect their mental health, including how to achieve the broader, positive outcome of well-being. Our primary outcome was to evaluate systematically the research evidence regarding the effectiveness of interventions designed to improve General Practitioner (GP) well-being across two continua; psychopathology (mental ill-health focus) and 'languishing to flourishing' (positive mental health focus). In addition we explored the extent to which developments in well-being research may be integrated within existing approaches to design an intervention that will promote mental health and prevent mental illness among these doctors.

METHODS

Medline, Embase, Cinahl, PsychINFO, Cochrane Register of Trials and Web of Science were searched from inception to January 2015 for studies where General Practitioners and synonyms were the primary participants. Eligible interventions included mental ill-health prevention strategies (e.g. promotion of early help-seeking) and mental health promotion programmes (e.g. targeting the development of protective factors at individual and organizational levels). A control group was the minimum design requirement for study inclusion and primary outcomes had to be assessed by validated measures of well-being or mental ill-health. Titles and abstracts were assessed independently by two reviewers with 99% agreement and full papers were appraised critically using validated tools.

RESULTS

Only four studies (with a total of 997 GPs) from 5392 titles met inclusion criteria. The studies reported statistically significant improvement in self-reported mental ill-health. Two interventions used cognitive-behavioural techniques, one was mindfulness-based and one fed-back GHQ scores and self-help information.

CONCLUSION

There is an urgent need for high quality, controlled studies in GP well-being. Research on improving GP well-being is limited by focusing mainly on stressors and not giving systematic attention to the development of positive mental health.

Using appreciative inquiry during care transitions: an exploratory study

The purpose of the study was to evaluate the effectiveness of a transitional care coaching intervention offered to chronically ill medical patients during the transition from hospital to home. This 2-arm randomized pilot study uses a coaching framework based on appreciative inquiry theory. This article reviews the appreciative inquiry literature and identifies the characteristics of patients who participated in appreciative inquiry coaching. Lessons learned are summarized, and suggestions for future research are offered.

Manifestations and implications of uncertainty for improving healthcare systems: an analysis of observational and interventional studies grounded in complexity science

Background

The application of complexity science to understanding healthcare system improvement highlights the need to consider interdependencies within the system. One important aspect of the interdependencies in healthcare delivery systems is how individuals relate to each other. However, results from our observational and interventional studies focusing on relationships to understand and improve outcomes in a variety of healthcare settings have been inconsistent. We sought to better understand and explain these inconsistencies by analyzing our findings across studies and building new theory.

Methods

We analyzed eight observational and interventional studies in which our author team was involved as the basis of our analysis, using a set theoretical qualitative comparative analytic approach. Over 16 investigative meetings spanning 11 months, we iteratively analyzed our studies, identifying patterns of characteristics that could explain our set of results.

Our initial focus on differences in setting did not explain our mixed results. We then turned to differences in patient care activities and tasks being studied and the attributes of the disease being treated. Finally, we examined the interdependence between task and disease.

Results

We identified system-level uncertainty as a defining characteristic of complex systems through which we interpreted our results. We identified several characteristics of healthcare tasks and diseases that impact the ways uncertainty is manifest across diverse care delivery activities. These include disease-related uncertainty (pace of evolution of disease and patient control over outcomes) and task-related uncertainty (standardized versus customized, routine versus non-routine, and interdependencies required for task completion).

Conclusions

Uncertainty is an important aspect of clinical systems that must be considered in designing approaches to improve healthcare system function. The uncertainty inherent in tasks and diseases, and how they come together in specific clinical settings, will influence the type of improvement strategies that are most likely to be successful. Process-based efforts appear best-suited for low-uncertainty contexts, while relationship-based approaches may be most effective for high-uncertainty situations.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-014-0165-1) contains supplementary material, which is available to authorized users.

The effect of surveillance and appreciative inquiry on puerperal infections: a longitudinal cohort study in India

Objective

To evaluate the effects of an intervention comprising surveillance and an organisational change called Appreciative Inquiry on puerperal infections in hospitals in Gujarat state, India.

Methods

This longitudinal cohort study with a control group was conducted over 16 months between 2010 and 2012. Women who delivered in six hospitals were followed-up. After a five month pre-intervention period, the intervention was introduced in three hospitals. Monthly incidence of puerperal infection was recorded throughout the study in all six hospitals. A chi-square test and logistic regression were used to examine for associations, trends and interactions between the intervention and control groups.

Findings

Of the 8,124 women followed up, puerperal infections were reported in 319 women (3.9%) over the course of the study. Puerperal sepsis/genital tract infections and urinary tract infections were the two most common puerperal infections. At the end of the study, infection incidence in the control group halved from 7.4% to 3.5%. Levels in the intervention group reduced proportionately even more, from 4.3% to 1.7%. A chi-square test for trend confirmed the reduction of infection in the intervention and control groups (p<0.0001) but the trends were not statistically different from one another. There was an overall reduction of infection by month (OR = 0.94 95% CI 0.91–0.97). Risk factors like delivery type, complications or delivery attendant showed no association with infection.

Conclusion

Interruption of resource flows in the health system occurred during the intervention phase, which may have affected the findings. The incidence of infection fell in both control and intervention groups during the course of the study. It is not clear if appreciative inquiry contributed to the reductions observed. A number of practical and methodological limitations were faced.

Trial Registration

Controlled-Trials.com ISRCTN03513186

Metrics for assessing improvements in primary health care

Metrics focus attention on what is important. Balanced metrics of primary health care inform purpose and aspiration as well as performance. Purpose in primary health care is about improving the health of people and populations in their community contexts. It is informed by metrics that include long-term, meaning- and relationship-focused perspectives. Aspirational uses of metrics inspire evolving insights and iterative improvement, using a collaborative, developmental perspective. Performance metrics assess the complex interactions among primary care tenets of accessibility, a whole-person focus, integration and coordination of care, and ongoing relationships with individuals, families, and communities; primary health care principles of inclusion and equity, a focus on people's needs, multilevel integration of health, collaborative policy dialogue, and stakeholder participation; basic and goal-directed health care, prioritization, development, and multilevel health outcomes. Environments that support reflection, development, and collaborative action are necessary for metrics to advance health and minimize unintended consequences.

Engagement of groups in family medicine board maintenance of certification

PURPOSE

The American Board of Medical Specialties' Performance in Practice ("Part IV") portion of Maintenance of Certification (MOC) requirement provides an opportunity for practicing physicians to demonstrate quality improvement (QI) competence. However, specialty boards' certification of one physician at a time does not tap into the potential of collective effort. This article shares learning from a project to help family physicians work in groups to meet their Part IV MOC requirement.

METHODS

A year-long implementation and evaluation project was conducted. Initially, 348 members of a regional family physician organization were invited to participate. A second path was established through 3 health care systems and a county-wide learning collaborative. Participants were offered (1) a basic introduction to QI methods, (2) the option of an alternative Part IV MOC module using a patient experience survey to guide QI efforts, (3) practice-level improvement coaching, (4) support for collaboration and co-learning, and (5) provision of QI resources.

RESULTS

More physicians participated through group (66) than individual (12) recruitment, for a total of 78 physicians in 20 practices. Participation occurred at 3 levels: individual, intrapractice, and interpractice. Within the 1-year time frame, intrapractice collaboration occurred most frequently. Interpractice and system-level collaboration has begun and continues to evolve. Physicians felt that they benefited from access to a practice coach and group process.

CONCLUSIONS

Practice-level collaboration, access to a practice coach, flexibility in choosing and focusing improvement projects, tailored support, and involvement with professional affiliations can enhance the Part IV MOC process. Specialty boards are likely to discover productive opportunities from working with practices, professional organizations, and health care systems to support intra- and interpractice collaborative QI work that uses Part IV MOC requirements to motivate practice improvement.

Community mobilization in Mumbai slums to improve perinatal care and outcomes: a cluster randomized controlled trial

INTRODUCTION

Improving maternal and newborn health in low-income settings requires both health service and community action. Previous community initiatives have been predominantly rural, but India is urbanizing. While working to improve health service quality, we tested an intervention in which urban slum-dweller women's groups worked to improve local perinatal health.

METHODS AND FINDINGS

A cluster randomized controlled trial in 24 intervention and 24 control settlements covered a population of 283,000. In each intervention cluster, a facilitator supported women's groups through an action learning cycle in which they discussed perinatal experiences, improved their knowledge, and took local action. We monitored births, stillbirths, and neonatal deaths, and interviewed mothers at 6 weeks postpartum. The primary outcomes described perinatal care, maternal morbidity, and extended perinatal mortality. The analysis included 18,197 births over 3 years from 2006 to 2009. We found no differences between trial arms in uptake of antenatal care, reported work, rest, and diet in later pregnancy, institutional delivery, early and exclusive breastfeeding, or care-seeking. The stillbirth rate was non-significantly lower in the intervention arm (odds ratio 0.86, 95% CI 0.60-1.22), and the neonatal mortality rate higher (1.48, 1.06-2.08). The extended perinatal mortality rate did not differ between arms (1.19, 0.90-1.57). We have no evidence that these differences could be explained by the intervention.

CONCLUSIONS

Facilitating urban community groups was feasible, and there was evidence of behaviour change, but we did not see population-level effects on health care or mortality. In cities with multiple sources of health care, but inequitable access to services, community mobilization should be integrated with attempts to deliver services for the poorest and most vulnerable, and with initiatives to improve quality of care in both public and private sectors.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN96256793