Changing roles for primary-care physicians: addressing challenges and opportunities.

Direct-to-consumer advertising is but one example of a process called disintermediation that is directly affecting primary-care physicians and their patients. This paper examines the trends and the actors involved in disintermediation, which threatens the traditional patient-physician relationship. The paper outlines the social forces behind these threats and illustrates the resulting challenges and opportunities. A rationale and strategies are presented to rebuild, maintain and strengthen the patient-physician relationship in an era of growing disintermediation and anticipated advancements in cost-effective office-based information systems. Primary care--as we know it--is under siege from a number of trends in healthcare delivery, resulting in loss of physician autonomy, disrupted continuity of care and potential erosion of professional values (Rastegar 2004; Future of Family Medicine Project Leadership Committee 2004). The halcyon days of medicine as a craft guild with a monopoly on (1) technical knowledge and (2) the means of implementation, reached its zenith in the mid-twentieth century and has been under pressure ever since (Starr 1982; Schlesinger 2002). While this is a trend within the US health system, it is likely to affect other delivery systems in the years ahead.

Building client centered systems of care: choosing a process direction for the next century.

Forecasting the future of health care is difficult. However, we argue that this future will include the movement of health care through process improvement (enhancement) toward the objective of mass customization. This article discusses how mass customization might apply to specific portions of client-centered health care.

Rebuilding community and regional collaboration: the Kingsport, Tennessee experience.

BACKGROUND: In 1988, business, health care, and community leaders in Kingsport, Tennessee, initiated the Kingsport Area Health Improvement Project (KAHIP) to improve the health status of local citizens. KAHIP's efforts continued to move, albeit slowly, until late 1993, when managed care organizations began to deselect hospitals and physicians and competition began to overcome hopes for collaboration. In 1994 KAHIP and other community leaders reaffirmed seven principles, including the need for continued dialogue and collaboration. By early 1998 ten community improvement teams were functioning, six chartered by KAHIP. MATURE PROJECTS: Four established projects have continued to expand either in scope or through institutionalization in the community or both, including Drive Smart, a collaborative learning project concerned with reducing preventable injuries and death among youth from motor vehicle crashes, and the Network of Employers for Traffic Safety, a public-private partnership dedicated to reducing the number of deaths and injuries in the workforce. NEW TEAMS: Four other teams are operating in Kingsport. One, the Kingsport Community Alliance Linking Enforcement, Responsibility and Treatment (ALERT), is dedicated to reducing the impact of substance abuse. Another, the Community Database Team, works on developing a database focused on community health status information. LESSONS LEARNED: In a community with widespread knowledge of continuous improvement philosophy and techniques, it makes sense to encourage other agencies to take the initiative and the credit and not worry about whether a specific process is adopted. The role of the public health system in health assessment, policy assessment, and quality improvement in an era of managed care and reduced government should be encouraged.

Evaluating the quality control system for managed care in the United States.

Though idiosyncratic, the system for controlling managed care in the United States is surprisingly robust. This article reviews the mechanisms available to providers, patients, insurers, and governments to assess ongoing quality of care. It suggests that those contracting for care use the Donabedian Matrix to assess where contracts are strong and where the provisions are weak.

Total quality management issues in managed care.

The implementation of total quality management (TQM) in health care has gone on in parallel with the growth of managed care. What is the interaction between the two? Key issues are the ascendance of cost control over quality in many areas, erosion of employee commitment and loyalty, and a short-run orientation. Associated with this is an emphasis on organizational learning rather than learning by autonomous professionals. Both TQM and managed care acknowledge the dynamic nature of clinical processes and the ability and responsibility of both institutions and clinicians to improve their processes. Both are consistent with efforts to identify and implement best practices. However, these similarities should not mask fundamental differences. Continuous improvement must shift its focus from avoiding unnecessary variation to facilitating rapid organizational learning and institutionalizing mass customization into the delivery of health services.

Maintaining the new practice networks.

Unless acquired physicians are managed carefully, many will flee the acquiring networks in anger and frustration. Because older networks relied on a self-selected population of physicians, the newer networks will have to develop alternative strategies to motivate those physicians who did not self-select for employment. This article makes recommendations about how to build a corporate practice culture under these new conditions.

Balancing collaboration and competition: the Kingsport, Tennessee experience.

BACKGROUND: In 1988, business, health care, and community leaders in Kingsport, Tennessee, initiated the Kingsport Area Health Improvement Project (KAHIP) to improve the health status of local citizens. The community has good conditions for collaboration: (1) a large employer that was a 1993 winner of the Malcolm Baldrige National Quality Award, (2) community structures for the implementation of collaborative efforts, (3) relative stability in community employment and income, (4) adequate medical resources, (5) outside support from foundations and national organization, and (6) the confidence and commitment of its leaders to make quality efforts work. BARRIERS TO IMPROVEMENT: Barriers to improvement have included 1) two large acute care hospitals competing for many of the same physicians and patients, 2) the uncertainties introduced by the restructuring of the community's largest employer, and 3) ongoing moves in the managed care arena by some key players, which have left a degree of anger and mistrust. Realizing that the approach taken in the late 1980s and early 1990s was no longer working in the new competitive environment, KAHIP reconstituted itself in 1994. Providers now have a greater leadership role in community improvement efforts. As a result, improvement efforts in Kingsport include the institution of interventions to reduce injuries to children/adolescents resulting from motor vehicular accidents, the establishment of a primary care health center for the uninsured/underserved, and development of a smoking-cessation program. LESSONS LEARNED: The keys to continued leadership are 1) explicit faith in the continuous quality improvement approach, 2) commitment to communitywide change, 3) willingness to continue to engage in dialogue, 4) willingness to try new organizational alliances and structures to revitalize the effort, and 5) willingness to address those issues that individuals and institutions can agree to work on and set aside those they cannot agree on.

Quality improvement: beyond the institution.

This article considers the potential of community-based quality improvement initiatives. Challenges facing managers as they function beyond the institution are presented along with action steps to assure the potential success of quality improvement within the larger community.

Integrating guidelines with continuous quality improvement: doing the right thing the right way to achieve the right goals.

Will guidelines reduce inappropriate care in clinical practice? Although expectations are high, it is likely that guidelines are insufficient. Clinical guidelines help physicians to "do the right thing," but fail to address the corresponding issue of how to help organizations, departments, and health care workers do the right thing "in the right way." Attention needs to be given to the context in which guidelines function and the process by which guidelines are adopted in health care organizations. Linking guidelines with the improvement of ongoing clinical and organizational processes is critical to ensure their intended effect.

TQM as a managerial innovation: research issues and implications.

TQM is a managerial innovation that is likely to have profound consequences on the delivery of health services. As an innovation, it is important that attention be given to the fundamental research issues associated with implementation and impact. Using a variance and process perspective, selected research issues are identified within organizations and among work units within these organizations. The variance perspective at both the organizational and work unit level considers the explanation of impact and adoption at a particular point in time. The process perspective considers the particular steps or events in the overall adoption process. The managerial implications for each perspective are discussed.

Continuous quality improvement for continuity of care.

BACKGROUND: Continuous quality improvement (CQI) techniques have been used most frequently in hospital operations such as pharmaceutical ordering, patient admitting, and billing of insurers, and less often to analyze and improve processes that are close to the clinical interaction of physicians and their patients. This paper describes a project in which CQI was implemented in a family practice setting to improve continuity of care. METHODS: A CQI study team was assembled in response to patients' complaints about not being able to see their regular physician providers when they wanted. Following CQI methods, the performance of the practice in terms of provider continuity was measured. Two "customer" groups were surveyed: physician faculty members were surveyed to assess their attitudes about continuity, and patients were surveyed about their preferences for provider continuity and convenience factors. RESULTS: Process improvements were selected in the critical pathways that influence provider continuity. One year after implementation of selected process improvements, repeat chart audit showed that provider continuity levels had improved from .45 to .74, a 64% increase from 1 year earlier. CONCLUSIONS: The project's main accomplishment was to establish the practicality of using CQI methods in a primary care setting to identify a quality issue of value to both providers and patients, in this case, continuity of provider care, and to identify processes that linked the performance of health care delivery procedures with patient expectations.

Evaluating productivity in clinical research programs: the National Cancer Institute's (NCI) Community Clinical Oncology Program (CCOP).

This paper outlines an approach to studying productivity in clinical research programs that incorporates environmental, organizational, provider, and patient specific factors in the model of production process. We describe how this approach has been applied to the National Cancer Institute's (NCI) Community Clinical Oncology Programs (CCOPs). Next, a practical evaluative model of the productive process in CCOPs is outlined and its use in evaluation and monitoring performance in CCOPs is discussed. Each level of the model is described and a number of factors potentially affecting each level are explored. Finally, we discuss the strengths and weaknesses of this approach and show how management can use it to study and improve the productivity of clinical research programs.

Managing transitions: assuring the adoption and impact of TQM.

Assuring the full adoption and impact of total quality management (TQM) requires the understanding that TQM involves transitional challenges to managers, individuals, work groups, and the organization as a whole. This article presents some of these challenges and describes how they might be met over time to determine the ultimate success of TQM adoption in an organization.

Applying total quality management concepts to public health organizations.

Total quality management (TQM) is a participative, systematic approach to planning and implementing a continuous organizational improvement process. Its approach is focused on satisfying customers' expectations, identifying problems, building commitment, and promoting open decision-making among workers. TQM applies analytical tools, such as flow and statistical charts and check sheets, to gather data about activities within an organization. TQM uses process techniques, such as nominal groups, brainstorming, and consensus forming to facilitate communication and decision making. TQM applications in the public sector and particularly in public health agencies have been limited. The process of integrating TQM into public health agencies complements and enhances the Model Standards Program and assessment methodologies, such as the Assessment Protocol for Excellence in Public Health (APEX-PH), which are mechanisms for establishing strategic directions for public health. The authors examine the potential for using TQM as a method to achieve and exceed standards quickly and efficiently. They discuss the relationship of performance standards and assessment methodologies with TQM and provide guidelines for achieving the full potential of TQM in public health organizations. The guidelines include redefining the role of management, defining a common corporate culture, refining the role of citizen oversight functions, and setting realistic estimates of the time needed to complete a task or project.

Continuous quality improvement in the clinical setting: enhancing adoption.

Our ability to involve physicians in Continuous Improvement depends on our understanding of (1) professional norms and behaviors, (2) how organizational structures and systems affect physicians, and (3) basic adoption processes within health care organizations and by their professionals.

Total quality and the management of laboratories.

Total Quality Management (TQM) is a continuous quality improvement process that evaluates processes from a customer satisfaction point-of-view. The aim is continuous process improvement. TQM is a paradigm shift for most health-care organizations and will require changes in hospital conditions. TQM uses old tools--such as check sheets, run charts, and flow charts--in new ways. Laboratories are particularly suited to TQM because laboratorians are already familiar with these tools. However, laboratorians must learn to apply these tools to new areas. This may be perceived as threatening by some. This article will describe how TQM uses old tools in new ways, barriers to implementing TQM, and how to overcome these barriers.

Ambulatory surgery and the hospital.

Ambulatory surgery can be a win-win proposition for patients, physicians, payers, and even for hospitals. The main elements at risk are high costs and the traditional models of hospital-based surgical care. If hospitals delay their responses to the challenges of the free-standing surgicenter, the latter will become as common as the multispecialty group practice. Health care institutions need to address some questions in responding to this trend: how hospitals should act to transform their bureaucratic, inefficient systems; who should assume the leadership role; and how much autonomy and pluralism will be appropriate.

Total quality management in health: making it work.

Many health organizations are trying total quality management (TQM). This approach represents a total paradigm shift in health care management and presents a series of potential conflict areas in the way health organizations are managed. These areas include TQM's participatory approach versus professional and managerial authority, collective versus individual responsibility, quality assurance and standards versus continuous improvement, and flexible versus rigid objectives and plans. This article reviews the areas of conflict and suggests a number of action guidelines for the successful implementation of TQM.

Product lines in a complex marketplace: matching organizational strategy to buyer behavior.

Product-line strategy should be developed in relation to markets. This article focuses on designing product-line strategy in relation to four purchaser types: (1) traditional purchasers, (2) motivated purchasers, (3) HMO-type purchasers, and (4) PPO-type purchasers. In many cases, product-line strategy may have to adopt various combinations of the above.