Health Quality Innovation

Comprehensive Program Featuring Registry, Self-Management Education, Action Plans, and Home Visits Reduces Asthma-Related Admissions and Emergency Department Visits

The University of Michigan Health System implemented a comprehensive asthma management program that includes the following elements:

• a registry of all patients with asthma,
• standardized patient education and self-management asthma action plans,
• periodic home visits from nurses, and
• specialized programs for children with asthma who are at high risk for emergency department visits or hospitalizations.

Overseen by a multidisciplinary committee, this program allows the health system to develop innovative interventions tailored to the unique needs of individual patients with asthma. The initiative has led to more patients having self-management plans, fewer asthma-related hospitalizations (both overall and among children), and fewer emergency department visits among children with asthma.

Read the full innovation profile at the AHRQ Health Care Innovations Exchange...

Case Study: The Mount Auburn Cambridge Independent Practice Association (MACIPA)

The Commonwealth Fund (Quality Matters, JUNE/JULY) offers this case study that follows the development of an independent practice association (IPA) in an urban setting. It provides a description of the design/development process and lessons learned from this organization's experience. Although the case study describes an urban center, the lessons learned can translate to other geographic health care settings. 

These include:

1. Mutual respect of partners is key element for overall success.
2. Physician leadership is critical.
3. The value of primary care and a shared incentive to retain the loyalty of patients is a core value.

IMPLICATIONS (from article):  MACIPA's experience demonstrates that it is possible to create a physician-led accountable care organization that finds common ground with a hospital when they have a joint interest in preserving and expanding their patient base by providing better care. This in turn requires that physicians prepare to take a leadership role and that hospital administrators partner with them to do so. It also requires a willingness to invest resources in building a shared local infrastructure for data analysis, care management, and quality improvement...

Read or download case study from The Commonwealth Fund...

 

Building Accountable Care Organizations That Improve Quality and Lower Costs

 Building Accountable Care Organizations That Improve Quality and Lower Costs - A View from the Field, published on-line by The Commonwealth Fund, Quality Matters, June/July 2009, provides a description of 'Accountable Care Organizations' and the potential role they may play within implementation of National Health Care Reform. 

In addition, this article includes 'lessons learned' and advice from participants of the recently concluded five-year Physician Group Practices Demonstration Project conducted by the Centers for Medicare and Medicaid Services' (CMS) which looked at quality and cost reduction models within group practices. Feedback from groups outlines practice innovations implemented by participating organizations and 'next steps' for these practices.

SUMMARY (from article):  In less than 18 months, Medicare will launch a shared savings program to reward primary care physicians, specialists, and hospitals that form accountable care organizations and collaborate in the redesign of care processes, improve care coordination, and promote high-quality, cost-efficient care. To receive payment, providers must demonstrate the impact their efforts have on specific quality-of-care and cost-reduction goals. Doing so is no small task. Quality Matters asked organizations that have been working toward these goals what advice they have for others.

Read or download this article from The Commonwealth Fund...

 

 

AHRQ Report Looks at Medical Teamwork and Patient Safety

This 2005 report, commissioned by the Agency for Healthcare Research and Quality (AHRQ), assesses the status of relevant team training research from aviation and other domains and applies this research to the field of medicine. It additionally provides a comprehensive review and evaluation of current medical team training initiatives and their effectiveness.

Key Conclusions

1. The science of team performance and training can help the medical community improve patient safety. A general science of team performance and training has evolved and matured over the last 20 years. This science has produced a number of principles, lessons learned, tools, and guidelines that will serve the patient safety movement.

2. Research has already identified many of the competencies that are necessary for effective teamwork in medical environments. The science of team performance and training has identified the competencies that are required for effective team functioning in a number of complex settings. Many, if not most, of these competencies apply to the medical community.

3. A number of proven instructional strategies are available for promoting effective teamwork. The science of team performance and training has also developed and validated numerous training strategies that can provide requisite competencies to teams who perform in complex environments. These strategies extend beyond CRM training and could easily be adapted to health care.

4. The medical community has made considerable progress in designing and implementing team training across a number of settings. Our review of existing medical team training programs clearly shows that the health care community is striving to implement CRM training across a number of medical domains. We recommend that this trend be continued. However, the extent to which these programs are being implemented with the help of what we know from the science of learning, of team performance and of training is less clear. Thus, we recommend strengthening the link between scientific knowledge and medical-team training.

5. The institutionalization of medical-team training across different medical settings has not been addressed. To make teamwork a common, effective practice throughout the delivery of health care, there is an imperative need to embed team training in professional development. By "embedding" we mean implementing and regulating team training throughout a health care provider's career.

 

To learn more click on any of the links below to go to AHRQ.gov:

Medical Teamwork and Patient Safety: The Evidence based Relation (full report) 

Abstract and Summary

Primary teamwork competencies (Table)

Individual and Team-level Training Strategies (Table)

Electronic Prescriptions Shown to Reduce Errors by Seven-Fold

The use of electronic prescribing has become a central strategy in assuring patient safety and improving quality in the context of the patient-centered medical home.  The evidence base for electronic prescribing continues to grow, as shown in a recent study led by physician-scientists from Weill Cornell Medical College.  This study is one of the first to compare e-prescribing to handwritten methods, and the results are compelling.  Studies like this are important for demonstrating the value of technology-driven innovation and starting dialog about change with health care practice teams and administrators.

Read a concise summary of the study here..

Sustaining Quality Improvement in Community Health Centers: Perceptions of Leaders and Staff

 

Marshal H. Chin, MD, MPH, et. al. J Ambul Care Manage. Author manuscript; available in PMC 2009 October 1.Published in final edited form as: J Ambul Care Manage. 2008; 31(4): 319–329.

The Health Disparities Collaboratives (HDC) are the largest national quality improvement (QI) initiative in community health centers. This paper identifies the incentives and assistance personnel believe are necessary to sustain QI.

In a 2004 of more than 1000 leaders and staff at 165 community health centers, the authors found several factors that must be addressed if quality improvement is to be sustained or enlarged. The critical factors cluster in three areas:

1) Time and resources to perform quality improvement work;

2) Additional tools and techniques for improving quality; and

3) Financial reimbursement implications of providing higher quality care.

The authors note that the first two factors likely apply to both community health centers and private practices. Financial reimbursement issues will vary somewhat between those two settings because of different payer mixes. 

The surveyed health center leaders and staff noted that if quality improvement efforts are to continue over time, several factors should be addressed, including:

1) Creating relatively low-cost recognition and career advancement opportunities for staff,

2) Developing targeted interventions for difficult challenges such as changing patient behavior, and

3) Reforming the health care financing systems to reward quality improvement, especially for poorly reimbursing patients.

Click here to read the complete article online at the National Institutes of Health website.

 

 

Group Health: Research Shows Positive Clinician Reaction to PCMH

Clin Med Res.2010 Mar;8(1):44.. C-b2-03: patient and clinician experience in a patient-centered medical home demonstration. Ross TR, Reid RJ, Fishman P, Yu O, Tufano JT, Larson EB.

As the patient-centered medical home model is tried in more settings, one driver of resistance to change has been concern about physician burnout as a result of the transition.  Group Health of Seattle studied both patient experience and physician burnout following adoption of patient-centered medical home model of care.  Twelve months following adoption, patients at the PCMH clinic reported superior patient experience compared to control clinics. Clinicians at the PCMH clinic also reported significantly less burnout compared to their control counterparts.  These results suggest that the transition to a PCMH model of care can be managed to enhance both the patient experience and the clinician experience.

Read the study abstract at PubMed

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Leading Practice Change: Aubrey Daniels on the 'Measure of a Leader'

Aubrey C. Daniels is an internationally recognized expert on management, leadership, and workplace issues.  In his book Measure of a Leader: Bring Out the Best in People,  he presents an innovative, data-driven model of leadership measurement based not only on the behaviors of the leader, but also (and primarily) on followers' behavior.  Applying this model to health quality improvement raises some compelling questions for leaders of health quality iniatives.

A New Model of Leadership

Daniels' model posits four criteria of the followers' behavior that define leadership (from page 5 of the book):

1. Followers deliver discretionary behavior directed toward the leader's goals
2. Followers make sacrifices for the leader's cause
3. Followers tend to reinforce or correct others so that they also conform to the leader's teachings and example
4. Followers set guidelines for their own personal behavior based on their perceived estimate of that which the leader would approve or disapprove.

At first glance these criteria might suggest that Daniels believes leadership is 'all about the leader.'  This is not the case.  These criteria are measures of leadership impact, not guidelines for leadership behavior.  Daniels discusses in substantial depth the leadership principles and strategies require to achieve this kind of performance in followers.  First on the list loyalty - not to the leader as an individual, but to the vision and values or the organization as shared by the leader and the team. 

Application to Health Quality Improvement

Daniels' model of measuring the impact of a leader provides a compelling framework for thinking about health quality improvement.  Any physician, nurse, or administrator involved in leading a health quality improvement effort might gain helpful insight by asking:

1. Are team members delivering the right kind of discretionary behavior to advance health quality improvement?
2. Are team members willing to make sacrifices for the cause of health quality improvement?
3. Do team members reinforce or correct each other so that they also advance the cause of health quality improvement?
4. Do team members set guidelines for their own personal behavior based on their perceived importance of success in health quality improvement?

If the answer to any of these four questions is less than a solid 'most of the time,' then there is work to be done to strengthen the team commitment to health quality improvement.  Based on the Health Quality Innovation Model, leadership strategies to consider include:

• Think Long Term. Ensure that the team has a clear vision of long-term success
• Build ROI. Ensure that the key players perceive an authentic return on investment in the quality initiative 
• Focus Intentions. Ensure that everyone on the team is focused on the right intentions for the quality initiative (mission, vision, goals, strategies)
• Develop Capacity. Ensure that the team has the right capacity - people, partners, systems, facilities, financing - to execute the quality initiative
• Strengthen Culture. Ensure that the team has the right culture for success, including a patient-first mentality, mutual trust, freedom to innovate, incentive to collaborate, and a sense of being appreciated for their commitment.
• Assure Execution.  Ensure that the team is executing by providing direction; enabling people for action; adapting to contingencies, confronting problems, and measuring results.

By working these essential leadership strategies on a consistent basis, you will be in better position to cultivate the kind of team which will routinely meet Aubrey Daniels' criteria for measuring leadership impact.

Leading Practice Change: Lessons from John Kotter

John P. Kotter is internationally known and widely regarded as the foremost speaker on the topics of Leadership and Change.  Over decades of work he has identified eight reasons why organizational transformations fail, and eight steps to transforming an organization.  These findings and action steps can help practice team leaders anticipate resistance to practice change and take proactive steps to lead the team or organization to success.

Why Transformation Efforts Fail

Dr, Kotter identifies eight common reasons why transformation fails:

• Error 1. Not Establishing a Great Enough Sense of Urgency
• Error 2. Not Creating a Powerful Enough Guiding Coalition
• Error 3. Lacking a Vision
• Error 4. Under-communicating the Vision by a Factor of Ten
• Error 5. Not Removing Obstacles to the New Vision
• Error 6. Not Systematically Planning for, and Sustaining, Short-Term Wins
• Error 7. Declaring Victory too Soon
• Error 8. Not Anchoring Changes in the Culture

Eight Steps to Transforming Your Organization

Given the reasons why transformation efforts fail, and based on extensive study of successful transformation efforts, Dr. Kotter has constructed an eight-step process for transforming an organization.

• Step 1. Establish a Sense of Urgency
• Step 2. Form a Powerful Guiding Coalition
• Step 3. Create a Vision
• Step 4. Communicate the Vision
• Step 5. Empower Others to Act on the Vision
• Step 6. Plan for and Create Short-term Wins
• Step 7. Consolidate Improvements and Produce Still More change
• Step 8. Institutionalize New Approaches

Implications for Practice Change

Given Dr. Kotter's framework, we can more systematically approach practice change for quality improvement.  Eight leadership questions can help us focus our leadership and team building energy where it is most needed.

• Question 1. Do we have a sense of urgency to implement quality improvement changes?
• Question 2. Do we have a powerful guiding coalition to help lead change?
• Question 3. Do we have a clear vision of excellence resulting from change?
• Question 4. Are we communicating the vision to everyone every day?
• Question 5. Are people truly empowered to act on the vision?
• Question 6. What are the short-term wins we hope to achieve?
• Question 7. Are we capturing short-term wins and using them to build momentum for more change?
• Question 8. Are we institutionalizing what works in quality improvement?

Learn More

Learn more about Dr. Kotter's eight steps for transforming organizations from this Harvard Business Review article made available by the Dalhouse University Division of Medical Education (pdf format)...

Sustaining Quality Improvement in Community Health Centers

The Health Disparities Collaboratives (HDC) are the largest national quality improvement (QI) initiative in community health centers. This paper identifies the incentives and assistance personnel believe are necessary to sustain QI. 

• More than 1006 survey respondents at 165 centers participated in a 2004 survey about their experience in quality improvement. 
• Respondents cited lack of resources, time, and staff burnout as common barriers to quality improvement. Release time was the most desired personal incentive for engaging in quality improvement.
• The highest funding priorities were direct patient care services (44% ranked #1), data entry (34%), and staff time for QI (26%).
• Participants also needed help with patient self-management (73%), information systems (77%), and getting providers to follow guidelines (64%).

Read the full article online at the NIH website...

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