A Quasi-experimental Evaluation of Performance Improvement Teams in the Safety-Net: A Labor-Management Partnership Model for Engaging Frontline Staff.

BACKGROUND: Unit-based teams (UBTs), initially developed by Kaiser Permanente and affiliated unions, are natural work groups of clinicians, managers, and frontline staff who work collaboratively to identify areas for improvement and implement solutions. OBJECTIVE: We evaluated the UBT model implemented by the Los Angeles County Department of Health Services in partnership with its union to engage frontline staff in improving patient care. DESIGN: We conducted a quasi-experimental study, comparing surveys at baseline and 6 months, among personnel in 10 clinics who received UBT training to personnel in 5 control clinics. We also interviewed staff from 5 clinics that received UBT training and 3 control clinics. PARTICIPANTS: We conducted 330 surveys and 38 individual, semi-structured interviews with staff at an outpatient facility in South Los Angeles. INTERVENTIONS: Each UBT leader received an 8-hour training in basic performance improvement methods, and each UBT was assigned a team "coach." MAIN MEASURES: Our outcome measure was 6-month change in the "adaptive reserve" score, the units' self-reported ability to make and sustain change. We analyzed transcripts of the interviews to find common themes regarding the UBT intervention. KEY RESULTS: The survey response rate was 63% (158/252) at baseline and 75% (172/231) at 6 months. There was a significant difference-in-change in adaptive reserve between UBTs and non-UBTs at 6 months (+0.11 vs -0.13; P = .02). Nine of the 10 UBTs reported increases in adaptive reserve and 8 UBTs reported decreased no-show rates or patient length of stay in clinic. Staff overwhelmingly felt the UBTs were a positive intervention because it allowed all levels of staff to have a voice in improvement. CONCLUSIONS: Our results indicate that partnership between management and unions to engage frontline staff in teams may be a useful tool to improve delivery of health care in a safety-net setting.

Effectiveness of a smartphone application for weight loss compared with usual care in overweight primary care patients: a randomized, controlled trial.

BACKGROUND: Many smartphone applications (apps) for weight loss are available, but little is known about their effectiveness. OBJECTIVE: To evaluate the effect of introducing primary care patients to a free smartphone app for weight loss. DESIGN: Randomized, controlled trial. (ClinicalTrials.gov: NCT01650337). SETTING: 2 academic primary care clinics. PATIENTS: 212 primary care patients with body mass index of 25 kg/m2 or greater. INTERVENTION: 6 months of usual care without (n = 107) or with (n = 105) assistance in downloading the MyFitnessPal app (MyFitnessPal). MEASUREMENTS: Weight loss at 6 months (primary outcome) and changes in systolic blood pressure and behaviors, frequency of app use, and satisfaction (secondary outcomes). RESULTS: After 6 months, weight change was minimal, with no difference between groups (mean between-group difference, -0.30 kg [95% CI, -1.50 to 0.95 kg]; P = 0.63). Change in systolic blood pressure also did not differ between groups (mean between-group difference, -1.7 mm Hg [CI, -7.1 to 3.8 mm Hg]; P = 0.55). Compared with patients in the control group, those in the intervention group increased use of a personal calorie goal (mean between-group difference, 2.0 d/wk [CI, 1.1 to 2.9 d/wk]; P < 0.001), although other self-reported behaviors did not differ between groups. Most users reported high satisfaction with MyFitnessPal, but logins decreased sharply after the first month. LIMITATIONS: Despite being blinded to the name of the app, 14 control group participants (13%) used MyFitnessPal. In addition, 32% of intervention group participants and 19% of control group participants were lost to follow-up at 6 months. The app was given to patients by research assistants, not by physicians. CONCLUSION: Smartphone apps for weight loss may be useful for persons who are ready to self-monitor calories, but introducing a smartphone app is unlikely to produce substantial weight change for most patients. PRIMARY FUNDING SOURCE: Robert Wood Johnson Foundation Clinical Scholars Program, National Institutes of Health/National Center for Advancing Translational Sciences for the UCLA Clinical and Translational Science Institute, and the Resource Centers for Minority Aging Research Center for Health Improvement of Minority Elderly under the National Institutes of Health/National Institute on Aging.

Primary care's eroding earnings: is congress concerned?

PURPOSE: Despite increasing data demonstrating the positive impact primary care has on quality of care and costs, our specialty faces uncertainty. Its popularity among medical students is declining, and the income gap is growing between primary care and other specialties. Congress has the power to intervene in this impending crisis. If we want to influence lawmakers' actions, we need to know how they are thinking about these issues. METHODS: Using a set of questions covering several physician payment topics, we interviewed 14 congressional staff aides (5 aides on Medicare-oversight committees, 9 general staff aides) and one representative from each of 3 governmental agencies: the Medicare Payment Advisory Commission, Congressional Budget Office, and Government Accountability Office. RESULTS: Interviewees revealed that issues in primary care are not high on the congressional agenda, and that Medicare's Sustainable Growth Rate (SGR) is the physician-payment issue on the minds of congressional staff members. CONCLUSION: Attempts to solve primary care's reimbursement difficulties should be tied to SGR reform.

Introducing the "teamlet": initiating a primary care innovation at san francisco general hospital.

CONTEXT: The 15-minute office visit to primary care clinicians cannot meet the health care needs of patients. Innovation is needed to address this limitation, but practice redesign is challenging in clinical settings. OBJECTIVE: Here we describe the implementation of a practice innovation, the teamlet model, in a San Francisco safety-net clinic. The teamlet consists of a clinician and "health coach" who expand the traditional medical visit into previsit, visit, postvisit, and between-visit care. DESIGN: Teamlet implementation is occurring in phases. Phase 1 is evaluated using plan-do-study-act improvement cycles and interviews with a few patients, clinicians, and coaches. Phase 2 is evaluated using a pre- and postevent questionnaire, focused interviews, and focus groups with patients, faculty, clinicians, and coaches. MAIN OUTCOME MEASURES: Phase 1: Plan-do-study-act cycles generate ideas to improve implementation. Phase 2 evaluation will query demographics, satisfaction, knowledge of self-management support, access, teamwork, and benefits/challenges of the teamlet model. Future research would measure objective clinical outcomes. RESULTS: Phase 1 of the teamlet project led to useful adaptations, with anecdotal evidence that patients and clinicians were satisfied overall with practice improvements. Logistic problems made implementation of the innovation challenging. Phase 2 is currently underway, with results expected in 2008. CONCLUSIONS: Primary care innovation requires multiple perspectives and constant revision. Traditional randomized controlled trials and quantitative evaluation designs are not appropriate for assessing practice-improvement pilot projects because projects must change and develop in their early stages. Despite numerous challenges, the teamlet practice redesign has the potential for improving on the traditional 15-minute physician's office visit.

The teamlet model of primary care.

The 15-minute visit does not allow the physician sufficient time to provide the variety of services expected of primary care. A teamlet (little team) model of care is proposed to extend the 15-minute physician visit. The teamlet consists of 1 clinician and 2 health coaches. A clinical encounter includes 4 parts: a previsit by the coach, a visit by the clinician together with the coach, a postvisit by the coach, and between-visit care by the coach. Medical assistants or other practice personnel would require retraining to assume the health coach role. Some organizations have instituted aspects of the teamlet model. Primary care practices interested in trying out the teamlet concept need to train 2 health coaches for each full-time equivalent clinician to ensure smooth patient flow.