The Path to Quality in Outpatient Practice: Meaningful Use, Patient-Centered Medical Homes, Financial Incentives, and Technical Assistance.

Adoption and meaningful use of electronic health records is considered an essential step to improve the quality of health care. The authors assessed whether a series of Connecticut primary care providers who achieved Stage I Meaningful Use of electronic health records used quality improvement strategies that are associated with improvements in care. Practice structural characteristics, quality improvement-related electronic health record processes, outcomes, and barriers were assessed in 14 primary care practices. Implementation of quality improvement-related electronic health record processes was variable and barriers were common. Only 4 practices used data consistently to assess their performance, and only 3 reported improvements in care. Practices that were patient-centered medical homes scored higher on all quality improvement domains and received financial rewards more commonly. These findings suggest that primary care quality may be improved by formal alignment of Meaningful Use and Patient-Centered Medical Home criteria and by ongoing technical assistance to practices.

A descriptive study of educational outreach to promote use of quality improvement tools in primary care private practice.

The objective of this study was to describe the experience of a Quality Improvement Organization (QIO) providing educational outreach to promote use of quality improvement (QI) tools in primary care private practice. Two QIO outreach workers conducted visits with physicians and targeted staff. Data were analyzed on physician demographics, visits, and use of QI tools using standard quantitative and qualitative methods. QIO staff frequently encountered difficulty in accessing physicians and administrative staff and reported many barriers to QI. Despite these challenges, outreach visits were associated with adoption of QI tools, and certain physician characteristics were associated with greater numbers of outreach visits and tools adopted. QIOs and other external parties who seek to improve quality of care in private practice primary care physician offices face challenges in gaining access to physicians and administrative personnel. Additional study is needed to better understand associations between physician characteristics, educational outreach visits, and adoption of QI tools.

Using public reports of patient satisfaction for hospital quality improvement.

OBJECTIVE: To explore the impact of statewide public reporting of hospital patient satisfaction on hospital quality improvement (QI), using Rhode Island (RI) as a case example. DATA SOURCE: Primary data collected through semi-structured interviews between September 2002 and January 2003. STUDY DESIGN: The design is a retrospective study of hospital executives at all 11 general and two specialty hospitals in RI. Respondents were asked about hospital QI activities at several points throughout the public reporting process, as well as about hospital structure and processes to accomplish QI. Qualitative analysis of the interview data proceeded through an iterative process to identify themes and categories in the data. PRINCIPAL FINDINGS: Data from the standardized statewide patient satisfaction survey process were used by hospitals to identify and target new QI initiatives, evaluate performance, and monitor progress. While all hospitals fully participated in the public reporting process, they varied in the stage of development of their QI activities and adoption of the statewide standardized survey for ongoing monitoring of their QI programs. Most hospitals placed responsibility for QI within each department, with results reported to top management, who were perceived as giving strong support for QI. The external environment facilitated QI efforts. CONCLUSION: Public reporting of comparative data on patient views can enhance and reinforce QI efforts in hospitals. The participation of key stakeholders facilitated successful implementation of statewide public reporting. This experience in RI offers lessons for other states or regions as they move to public reporting of hospital quality data.

Improving the quality of preventive cardiovascular care provided by primary care physicians: insights from a US Quality Improvement Organization.

BACKGROUND: During 2000-03, Qualidigm, a US Quality Improvement Organization, conducted a project to improve the care received by elderly Medicare patients with coronary artery disease or cardiovascular risk factors. METHODS: We recruited primary care physicians in private practice in the state of Connecticut. Then, we identified approximately 30-50 patients per physician from the periods 1 January 2000 to 31 December 2000 and 1 November 2001 to 31 October 2002. We abstracted medical records to assess processes and outcomes of care, and we provided the physicians with performance data and a variety of practice-enhancing materials. The physicians utilized those materials that they perceived to be most helpful. RESULTS: We identified and recruited 974 primary care physicians to participate. Of these, 103 (10.6%) committed to participate, and 85 of the 103 completed the project. Among the intervention tools, physicians and their office personnel utilized personal digital assistants (PDAs) (36.5%) and patient education materials (34.1%) most commonly. Overall, quality of care improved for most physicians (mean quality score 62.0 to 67.8%, P < 0.001). However, not all improved, and most improvements were modest [mean absolute improvement in quality score 5.8%, standard deviation (SD) 6.8%]. CONCLUSIONS: Quality Improvement Organizations and others interested in improving outpatient quality of care face significant challenges in recruiting self-employed primary care physicians to quality improvement projects and in bringing about transformational change. Future primary care quality improvement projects should include careful assessments of practice-specific barriers, interventions that are linked to these barriers, and support of the practices on implementation.

A collaborative initiative to improve the care of elderly Medicare patients with hypertension.

Qualidigm, the Connecticut Quality Improvement Organization (QIO), collaborated with 17 primary care physicians (PCPs) in private practice to improve the care of elderly patients with hypertension. Patients were identified from Medicare billing data and care was assessed from medical records. Improvement interventions included feedback of baseline performance data and provision of a variety of practice enhancing materials. Care was assessed for 590 patients in 1997 (16-47 patients/PCP) and 547 patients in 1999 (7-51 patients/PCP). Patient characteristics were similar in both periods. Use of recommended therapies and blood pressure control, ie, percent < 140/90 mm Hg, was low and did not improve significantly between the 2 periods (aggregate 39% in 1997 versus 42% in 1999; P = .24). Care of elderly patients with hypertension was not improved with a multifaceted QIO intervention. Additional study is required to determine incentives, barriers, and facilitating factors for quality improvement in the private practice primary care setting.

Preventing pressure ulcers in Connecticut hospitals by using the plan-do-study-act model of quality improvement.

BACKGROUND: Seventeen hospitals and the Peer Review Organization of Connecticut (Qualidigm) attempted to increase early identification of high-risk patients and utilization of pressure ulcer preventive measures. METHODS: A multihospital retrospective cohort study with medical record abstraction was used to obtain a total of 1,955 (baseline) and 891 (follow-up) patients aged 65 years and older discharged after treatment for pneumonia, cerebrovascular disease, or congestive heart failure with a length of stay > or = five days. During a nine-month period, the hospitals conducted four plan-do-study-act improvement cycles and shared their results in conference calls and group meetings. RESULTS: Statistically significant increases were noted from baseline (1/1/96-12/31/96) to follow-up (10/1/97-3/31/98) in identification of high-risk patients, repositioning of bed-bound or chair-bound patients, nutritional consults in malnourished patients, and staging of acquired Stage II pressure ulcers. Daily skin assessments occurred at a high rate in both periods. There were no statistically significant changes in other processes of care, pressure ulcer incidence, or mortality. DISCUSSION: Performance of four pressure ulcer prevention processes of care increased concurrently with a multifaceted improvement intervention.