Improving medical grand rounds: recommendations.

BACKGROUND: The literature provides increasing evidence on how continuing medical education (CME) programs can change provider behavior and improve patient outcomes. Few authors discuss the application of those findings on a relatively common CME activity--grand rounds. Two recent publications about a case study of Medical Grand Rounds provide such an opportunity. DISCUSSION: Multiple opportunities exist to improve Medical Grand Rounds across each of five evidence-based practices of effective CME: needs assessment, multifaceted intervention strategy, sequencing, interaction, and commitment to change. Planners, presenters, and participants each have a distinct and important role in improving Medical Grand Rounds. CONCLUSION: This article identifies important opportunities for planners, presenters, and participants to improve Medical Grand Rounds as a vehicle for changing provider behavior and improving patient outcomes.

Improving medical grand rounds: barriers to change.

BACKGROUND: Grand rounds programs may not be consistently structured to bring benefit from evidence-based practices of effective continuing medical education. In order to make improvements in this common educational forum, educational leaders need to consider and possibly overcome some barriers as perceived by planners, presenters, and participants. Research on perceived barriers to improving grand rounds is lacking. METHODS: Using an instrumental case-study approach, the investigators sought to describe perceived barriers to improving a Medical Grand Rounds program held at an academic medical center in the Northeast. Perceived barriers were identified by program planners, presenters, and participants. The study used qualitative data collected from each group via key informant interviews and a focus group to assess barriers in relation to five evidence-based practices: needs assessment, multifaceted intervention strategy, sequencing, interaction, and commitment to change. The study used an intensive, inductive approach to analyze data to determine barrier themes from each group. RESULTS: Studied during 2007, program constituents of Medical Grand Rounds suggested a variety of important barriers. Understanding such barriers informs some recommendations to improve the program and possibly other programs similar to it. CONCLUSION: This study has identified important barriers to improving a specific grand rounds program and discusses the implications of such barriers on recommendations for improvement.

A case study of medical grand rounds: are we using effective methods?

BACKGROUND: Grand rounds are a time-honored continuing medical education activity that is intended to keep doctors current and competent. In addition, health care leaders and medical educators often rely on grand rounds to change physician behavior and improve patient outcomes. However, the extent to which grand rounds programs are consistent with evidence-based educational practices is unknown. METHOD: The authors used an instrumental case study approach in 2007 to determine whether one grand rounds program, such as medical grand rounds held at a U.S. academic medical center, adhered to well-accepted educational practices. Qualitative data collected from program planners, presenters, and participants via structured observations, key informant interviews, and a focus-group session allowed an assessment of consistency with five evidence-based practices. The authors used an intensive, inductive approach to analyze data to determine the extent to which the medical grand rounds program incorporated the five practices. RESULTS: Studied during 2007, this traditional medical grand rounds program only minimally reflected the five evidence-based educational practices of needs assessment, multifaceted intervention strategy, sequencing, interaction, and commitment to change. Authors found grand rounds sessions to be slide-driven, passive presentations reflecting a broad range of subspecialty topics. Opportunities for questions were limited, and audience attendance was inconsistent and varied, particularly for nonfaculty participants. CONCLUSIONS: This study has identified important opportunities for improving a specific grand rounds program and for researching similar examples of this common, traditional educational forum for physicians.

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.

Understanding barriers to participation in mammography by women with disabilities.

PURPOSE: The study purpose was to identify barriers to mammography screening among women with different disabilities and to suggest interventions to address barriers. METHODS: Forty-two women with self-reported disabilities, ages 40 to 69 years participated. They resided in 24 Connecticut towns, and most had a prior mammogram. Data were collected through six disability-specific focus groups from women with sensory, physical, psychiatric, and cognitive/intellectual impairments. Facilitator-conducted groups used a semistructured guide. Qualitative analysis applied an iterative coding process to generate themes and categories. RESULTS: We identified four themes (i.e., access, beliefs, social support, and comfort/ accommodations) and nine subthemes that characterized barriers. In all focus groups, women mentioned physical access and physical comfort/accommodations as types of barriers. Other major subthemes were communication and professional support. Women also described mammography facilitators. CONCLUSION: Despite frequent use of health care and personal strategies to facilitate mammography screening, women with disabilities reported barriers to getting mammograms. Findings suggest a multifaceted approach to address these barriers.

Physicians' views on public reporting of hospital quality data.

This article describes physicians' responses to patient questions and physicians' views about public reports on hospital quality. Interviews with 56 office-based physicians in seven states/regions used hypothetical scenarios of patients questioning referrals based on public reports of hospital quality. Responses were analyzed using an iterative coding process to develop categories and themes from data. Four themes describe physicians' responses to patients: (a) rely on existing physician-patient relationships, (b) acknowledge and consider patient perspectives, (c) take actions to follow up on patient concerns, and (d) provide patients' perspectives on quality reports. Three themes summarize responses to hospital quality reports: perceived lack of methodological rigor, content considerations in reports, and attitudes/experience regarding reports. Findings suggest that physicians take seriously patients' questions about hospital-quality reports and consider changing referral recommendations based on their concerns and/or preferences. Results underscore the importance of efforts by report developers and physician outreach/education to address physicians' methodological concerns.

The state of physician office-based health information technology in Connecticut: current use, barriers and future plans.

Qualidigm and the Connecticut State Medical Society-Independent Practice Association (CSMS-IPA), Inc. have conducted a survey of the physicians participating in the CSMS-IPA to assess current use of health information technology in their offices and their plans for future use. The survey was conducted to assist eHealth Connecticut, a Connecticut-based nonprofit organization, in its charge to promote electronic health information exchange in Connecticut. The survey was distributed to 2,366 medical offices representing 6,956 physicians in Connecticut. Survey results revealed that the most commonly utilized types of technology were practice management systems (70%) and e-mail (64%). The most common barriers to the adoption of new technologies were cost (71%) and time requirements (39%). Primary-care providers and small practices were more likely to cite cost as a barrier to technology implementation. Despite these challenges, many physicians reported plans to implement electronic medical records (25%) or electronic prescribing (20%) in the next year.

Profiling variations in outpatient care for Medicare beneficiaries in Connecticut.

Qualidigm, the Medicare Quality Improvement Organization for Connecticut, is reporting the rates of four outpatient services for Medicare beneficiaries on its website (www.qualidigm.org). These measures include screening for breast cancer (mammography) and chronic disease management for diabetes (HbAlc, eye exam and lipid profile). Maps of Connecticut illustrate the rates for Whites and Non-whites by Health Service Area. The maps highlight variation across small local areas and between Whites and Non-whites. By reporting these rates publicly, Qualidigm hopes to facilitate ongoing efforts by community organizations and health care providers to make improvements in care, especially for the underserved populations throughout the state.

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.

Lessons learned from performance feedback by a quality improvement organization.

Performance feedback is a common quality improvement (QI) intervention strategy in the outpatient setting. This article describes the use by one quality improvement organization (QIO) of performance feedback to primary-care physicians with claims-based measures relating to diabetes, adult vaccinations, and mammography screening. Feedback from the physicians identified themes relating to data accuracy, methodology of the feedback reports, reasons for low performance rates, and suggestions on how the QIO could improve its intervention strategy. The article highlights the value of collecting and analyzing formative data on the process and offers specific recommendations to other QI professionals contemplating the use of claims data for performance feedback.