Improving service quality in primary care.

A framework for improving health care service quality was implemented at a 12-provider family medicine practice in 2010. A national patient satisfaction research vendor conducted weekly telephone surveys of 840 patients served by that practice: 280 patients served in 2009, and 560 served during 2010 and 2011. After the framework was implemented, the proportion of "excellent" ratings of provider service (the highest rating on a 5-point scale) increased by 5% to 9%, most notably thoroughness (P = .04), listening (P = .04), and explaining (P = .04). Other improvements included prompt test result notification and telephone staff courtesy (each by 10%, P = .02), as well as teamwork (by 8%, P = .04). Overall quality increased by 10% (P = .01), moving the practice from the 68th to the 91st percentile of medical practices in the research vendor's database. Improvements in patient satisfaction suggest that this framework may be useful in value-based payment models.

Addressing antibiotic use for acute respiratory tract infections in an academic family medicine practice.

The objective of this study was to educate health care providers and patients to reduce overall antibiotic prescription rates for patients with acute respiratory tract infection (ARTI). An interdisciplinary quality improvement team used the Define, Measure, Analyze, Improve, and Control quality improvement process to change patient expectations and provider antibiotic prescribing patterns. Providers received personal and group academic detailing about baseline behaviors, copies of treatment guidelines, and educational materials to use with patients. Get Smart About Antibiotics Week materials educated patients about appropriate antibiotic use. Providers collected demographic and clinical information about a case series of patients with ARTIs and their subsequent provision of antibiotics. In total, 241 patients with ARTIs were accrued. The antibiotic prescribing rate for patients aged 18 years and older was significantly reduced from 69% at baseline to 56% after interventions (95% confidence interval = 49.1%-63.4%; P<.001). Providers' prescribing behaviors significantly improved after multiple quality improvement interventions.

Validation of the Revised Physical Therapist Clinical Performance Instrument (PT CPI): Version 2006.

BACKGROUND: Based on changes in core physical therapy documents and problems with the earlier version, the Physical Therapist Clinical Performance Instrument (PT CPI): Version 1997 was revised to create the PT CPI: Version 2006. OBJECTIVE: The purpose of this study was to validate the PT CPI: Version 2006 for use with physical therapist students as a measure of clinical performance. DESIGN: This was a combined cross-sectional and prospective study. METHODS: A convenience sample of physical therapist students from the United States and Canada participated in this study. The PT CPI: Version 2006 was used to collect CPI item-level data from the clinical instructor about student performance at midterm and final evaluation periods in the clinical internship. Midterm evaluation data were collected from 196 students, and final evaluation data were collected from 171 students. The students who participated in the study had a mean age of 24.8 years (SD=2.3, range=21-41). Sixty-seven percent of the participants were from programs in the United States, and 33% were from Canada. RESULTS: The PT CPI: Version 2006 demonstrated good internal consistency, and factor analysis with varimax rotation produced a 3-factor solution explaining 94% of the variance. Construct validity was supported by differences in CPI item scores between students on early compared with final clinical experiences. Validity also was supported by significant score changes from midterm to final evaluations for students on both early and final internships and by fair to moderate correlations between prior clinical experience and remaining course work. LIMITATIONS: This study did not examine rater reliability. CONCLUSION: The results support the PT CPI: Version 2006 as a valid measure of physical therapist student clinical performance.

Development of a unique triage system for acute care physical therapy and occupational therapy services: an administrative case report.

BACKGROUND AND PURPOSE: This administrative case report documents the development of a mechanism by which systematic triage was used to assign patients to therapists in acute care settings. The primary objective was to develop a triage tool to improve patient access to medically necessary therapy services. CASE DESCRIPTION: A unique triage tool and a decision tree were developed to determine which patients referred to therapists for acute care therapy required skilled services. The triage tool was used to examine therapy referrals for patients from 2 large academic hospitals; 6 criteria were used to determine which evaluations should be cancelled. During the trial period, the predictive ability of individual triage criterion items was analyzed, the tool was modified and validated, and a decision tree was established. Descriptive and chi-square analyses were performed on all variables of interest. OUTCOMES: The systematic triage system reduced the number of therapy evaluations that were not appropriate by 29%, resulting in an improvement in the availability of therapy services for patients who required skilled care. The average number of patients per therapist per workday decreased from 18.9 to 12.1 and from 15.1 to 12.8 in the 2 hospitals. An improvement in a newly developed "workload index" related to missed patient visits also indicated the success of this project. DISCUSSION: A novel systematic triage system reduced the number of therapy evaluations that were not appropriate, resulting in an improvement in the availability of therapy services for patients who require skilled intervention.

Minimum detectable change in gait velocity during acute rehabilitation following hip fracture.

PURPOSE: Early ambulation and rehabilitation are recommended for patients undergoing surgical fixation of hip fracture. Gait velocity may be used as an outcome measure for these patients during acute rehabilitation. As an outcome measure, an estimate of meaningful change (responsiveness) in gait velocity for these patients, however, has not been described. The minimum detectable change (MDC) is a value that represents true change in a measure beyond that accounted for by measurement error. The purpose of this study was to quantify MDC in gait velocity as an index of responsiveness for persons in the acute stage of rehabilitation following hip fracture. METHODS: The study design was a descriptive cohort study with one repeated measure. A volunteer sample of 16 subjects over the age of 65, at a mean of 4.7 days postsurgical fixation of unilateral hip fracture, participated in the study. The study was conducted in an acute care rehabilitation practice in a large, tertiary care hospital. We measured gait velocity with the 10-meter walk test, estimated test-retest reliability with an intraclass correlation coefficient and quantified responsiveness of gait velocity as the MDC at a 95% level of confidence. RESULTS: Mean gait velocity was 15 cm/s and the test-retest reliability coefficient was equal to 0.823. The MDC in gait velocity during acute rehabilitation following surgical repair for hip fracture was 8.2 cm/s. CONCLUSIONS: Self-selected gait velocity in patients during acute rehabilitation following surgical fixation for hip fracture must improve by 8.2 cm/s or more to designate the change as being real change beyond the bounds of measurement error.