After the collaborative is over: what sustains quality improvement initiatives in primary care practices?

BACKGROUND: Multisite quality improvement (QI) initiatives, often known as collaboratives, involving primary care practices such as community health centers, academic practices, and managed care groups have been reported. Yet relatively little is known about the sustainability of these QI initiatives after the initial project, and frequently its funding, has ended. A series of practice characteristics that constitute critical elements for QI sustainability activities, as described in a Sustainability Pyramid Model, were proposed. METHODS: Approximately five months after the cessation of formalized activities of the final collaborative, 25 in-person interviews were conducted in 13 primary care practices that had participated in the three North Carolina Chronic Disease Management collaboratives, which initially involved 33 practices. Clinical outcomes were not considered. FINDINGS: Twelve of the 13 practices stated that the collaborative work resulted in improvement in one or more process and/or outcome clinical measures and those improvements have been continued. Five of the 13 practices reported that sustaining improvements had been a challenge since the collaboratives ended. Content analysis of the interviews indicated that the practices variously cited the practice characteristics, as included in the Sustainability Pyramid Model: regular meetings to study practice population data, leadership commitment, availability of infrastructure/staff support, pursuit of additional funding, publicity, and strategic partnerships. DISCUSSION: Although the improvement activities initiated during the collaborative were sustained, the process of developing and implementing new QI activities appeared to be more challenging for almost half of the practices. The practices that could accomplish this ongoing new QI process had "institutionalized" their QI strategies--a finding with important implications for sustainability.

Assessing local health department performance in diabetes prevention and control--North Carolina, 2005.

INTRODUCTION: To improve the public health system's ability to prevent and control chronic diseases, we must first understand current practice and develop appropriate strategies for measuring performance. The objectives of this study were to measure capacity and performance of local health departments in diabetes prevention and control and to investigate characteristics associated with performance. METHODS: In 2005, we conducted a cross-sectional mailed survey of all 85 North Carolina local health departments to assess capacity and performance in diabetes prevention and control based on the 10 Essential Public Health Services and adapted from the Local Public Health System Performance Assessment Instrument. We linked survey responses to county-level data, including data from a national survey of local health departments. RESULTS: Local health departments reported a median of 0.05 full-time equivalent employees in diabetes prevention and 0.1 in control. Performance varied across the 10 Essential Services; activities most commonly reported included providing information to the public and to policy makers (76%), providing diabetes education (58%), and screening (74%). The mean score on a 10-point performance index was 3.5. Characteristics associated with performance were population size, health department size and accreditation status, and diabetes-specific external funding. Performance was not better in localities where the prevalence of diabetes was high or availability of primary care was low. CONCLUSION: Most North Carolina local health departments had limited capacity to conduct diabetes prevention or control programs in their communities. Diabetes is a major cause of illness and death, yet it is neglected in public health practice. These findings suggest opportunities to enhance local public health practice, particularly through targeted funding and technical assistance.

Quality care improvement program in a community-based participatory research project: example of Project DIRECT.

A continuous quality care improvement program (CQIP) was built into Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together) to improve providers' patterns of diabetes care and patients' glycemic control. Project DIRECT consisted of a comprehensive program aimed at reducing the burden of diabetes in the vulnerable high-risk African-American population of southeast Raleigh, NC. Forty-seven providers caring for this target population of adult diabetes patients were included in this quasi-experimental study. At the initial session, providers learned about the CQIP components, completed a planning worksheet, and chose a CQIP coordinator. Educational events included continuing education in practices and through conferences by experts, and guideline distribution. Follow-up was accomplished through phone calls and visits. Effectiveness was measured by a change in prevalence of selected patterns of care abstracted from 1,006 medical charts. Appropriate statistical methods were used to account for the cluster design and repeated measures. At the fourth follow-up year, approximately 40% of providers still participated in the program. Among the providers who stayed in the program for the whole study period, most selected quality care patterns showed significant upward trends. Glycemic control indicators did not change, however, despite an increased number of hemoglobin A1c tests per year. A diabetes CQI program can be effectively implemented in a community setting. Improved performance measures were not associated with improved outcomes. These results suggest that a patient-centered component should reinforce the provider-centered component.

The North Carolina experience with the diabetes health disparities collaboratives.

BACKGROUND: The Bureau of Primary Health Care (BPHC) adopted a collaborative approach that used the Chronic Care Model and quality improvement methods. The North Carolina Diabetes Prevention and Control Branch has partnered with the 12 participating community health centers since early 2000. METHODS: Team leaders of the first four centers that participated in the collaboratives were interviewed. Information obtained included previous diabetes efforts, benefits of the collaborative, success factors, and barriers to sustainability. CASE STUDY: In one of two case studies, a nonprofit community health center made Chronic Care Model-based changes to the organization of health care, clinical information systems, and delivery system design. RESULTS: Centers tracked used the electronic registry to establish a baseline, trend key process and outcome measures, and raise the standard of care. Success factors included senior leadership support, physician champions, multidisciplinary teams, and priority of collaborative activities. Barriers included staff turnover and low priority in strategic planning. Glycohemoglobin (A1C) values from aggregated reports demonstrated improvement. DISCUSSION: Useful strategies for future collaboratives may include providing provider-specific data, imparting vision to new team members, ensuring that leadership provides collaborative structure and resources, and pairing veteran and new participating sites.