Taking responsibility for closing the holes.

Healthcare leaders must assume responsibility for closing the "holes" in their organizations. At the organizational level, this means taking personal responsibility for error, making safety an explicit organizational goal and building an organization with the people, resources and courage to achieve the goal. At the process level, it requires removing unnecessary complexity from processes. At the practitioner level, it means changing the design and administration of individual roles, and the way individuals work in teams

Collaborating outside the box: three years later.

BACKGROUND: In 1992, 15 employers in Minneapolis-St Paul, operating as the Business Health Care Action Group (BHCAG), combined their self-insured plans. To successfully bid for the BHCAG contract, three competing group practices and a health plan cooperated, operating like a fully integrated care system to measure outcomes, develop practice guidelines, and meet other BHCAG requirements. To accomplish this, a new organization, the Institute for Clinical Systems Integration (ICSI), was conceived. ICSI IN THE EVOLVING MINNEAPOLIS MARKETPLACE: From a business standpoint, ICSI members stood to gain market share by being members of ICSI and the "chosen" consortium. From a professional standpoint, they could realize the fulfillment and satisfaction of knowing that they were innovating, improving care, reducing waste, and sharing their knowledge with others. A NEW MARKET MODEL: To drive the same kind of change for the entire care delivery system in the region, not just for the subset that happened to win the original bid, BHCAG changed the purchase model in February 1995--enrollees could now choose among 16 to 20 discrete care delivery systems instead of preferentially channeling them to the ICSI-HealthPartners network of group practices. All the care systems had become competitors on every level, including quality of care. The "special" customer-supplier relationship between BHCAG and the ICSI medical groups was no longer present. LESSONS LEARNED: Despite major changes in the market dynamics, with the marked decline in the business reason for collaboration which had prompted ICSI to form in the first place, physicians, nurses, and administrative staff from participating medical groups continue to devote massive effort to the development and implementation of best practices.

Physicians as leaders in the improvement of health care systems.

Physicians are often asked to assume leadership roles in their practices, hospitals, and academic departments. These positions can be excellent leverage points for improvement of health care quality. To make optimal use of these opportunities, physicians must learn how to lead. This paper is intended to be a primer for physicians who are asked to lead and want to learn how to lead well. A body of knowledge that physician-leaders should acquire is described, and case examples are used to address such topics as the nature of leadership, the relation between leadership and management, and ways in which physicians might approach a new leadership assignment. Guidelines for physicians who must play the role of followers are offered, and challenges that physicians who lead other physicians may face are described.

Collaborating outside the box: when employers and providers take on environmental barriers to guideline implementation.

BACKGROUND: In 1992 15 employers in Minneapolis/St Paul, operating as the Business Health Care Action Group (BHCAG), combined their self-insured plans. To successfully bid for the BHCAG contract, three competing group practices and a health plan cooperated, operating functionally like a fully integrated care system to measure outcomes, develop practice guidelines, and meet other BHCAG requirements. To accomplish this, a new organization, the Institute for Clinical Systems Integration (ICSI), was conceived. PROVIDERS AND EMPLOYERS COLLABORATE: To reduce costs ICSI has implemented 16 of 80 planned guidelines. Teams including members from clinics and BHCAG develop best-practice algorithms. Each guideline is then reviewed and piloted before being implemented in all ICSI clinics. MANAGING EXTERNAL ENVIRONMENT: The guideline on cystitis in healthy women eliminated two costly practices-obtaining a urine culture and visiting the doctor. Yet many physicians and the clinics were afraid of losing significant revenue because they were reimbursed by BHCAG on a fee-for-service basis. In turn, BHCAG's hands were tied. If they changed to a capitated payment system, they would face onerous state insurance requirements. The solution lay in collaborating at a higher level. ICSI and BHCAG leaders persuaded the state legislature to pass a new law that allowed BHCAG to capitate providers without state regulation. As a result, the cystitis guideline is now widely implemented in ICSI clinics. LESSONS LEARNED: The cystitis guideline experience highlights the need to manage the external environment so that it reinforces, rather than inhibits, quality improvement in medical practices. Guidelines will not be implemented unless the macro-environment into which they are introduced is supportive.

Team managed outpatient care for early onset chronic inflammatory arthritis.

OBJECTIVE: To determine whether an outpatient team management program for persons with early chronic inflammatory arthritis would produce improved clinical outcomes and lower costs than traditional, nonteam outpatient rheumatologic care in a clinic setting. METHODS: One hundred eighteen patients with chronic inflammatory arthritis were randomly assigned to a team managed outpatient care program (TEAMCARE) or to traditional, one on one, nonteam managed rheumatologic care (TRADCARE). The TEAMCARE program consisted of a half day educational program, a needs assessment intake interview, and quarterly telephone calls, monthly team meetings, and routine rheumatologic care. TRADCARE patient received unconstrained, routine primary and specialty outpatient care as practised typically by rheumatologists at this large multi-specialty clinic. All patients had numerous physical and laboratory outcome assessments by rheumatologists at office visit. Every 6 months, patients completed several self-report measures of functional status, pain, psychosocial status, and costs. RESULTS: One hundred seven patients completed one year of study participation. No significant differences were found between groups in measures of physical status, physical functioning, psychosocial status, or pain. There were no differences between groups in economic or utilization measures. CONCLUSION: This team managed outpatient program for persons with recent onset chronic inflammatory arthritis afforded no advantage to routine outpatient care, characterized mainly by one on one relationships between patients and primary care doctors and rheumatologists, in our active outpatient clinical environment.

Driving the quality transformation: what's missing?

Around the country, healthcare providers are using the tools of continuous improvement to redesign patient care, match customer needs with available resources, and make management decisions based on data-driven analyses of key processes. Initiatives such as these are producing positive changes within healthcare organizations, but two serious barriers all but preclude improvement at the system level: a compensation process that punishes innovation and the emergence of integrated care systems that lack a common vision. Unless these barriers can be removed, insists the author, healthcare providers ultimately will be unsuccessful in their effort to improve value for their customers.

Histocompatibility antigen combinations in rheumatoid arthritis.

The frequencies of HLA-A, -B, -C, DR and MT lymphocyte alloantigens in clinical and serologic subsets of rheumatoid arthritis (RA) were determined in 65 Caucasian patients with definite or classical disease and compared to frequencies observed in normal individuals. The elevation in frequency of several antigens controlled by different genes in the major histocompatibility complex (MHC) suggested that combinations of antigens may be associated with RA. Significant associations were found for HLA-A1-DR4 and A1-MT2 (p less than 0.001), Bw40-DR4 (p less than 0.002) and Cw3-DR4 (p less than 0.001). The results indicate that combinations of genes in the MHC are influential in predisposing to RA.

An epidemiologic study of households exposed to canine systemic lupus erythematosus.

To determine whether exposure to canine lupus is a risk for human lupus, we studied 83 members of 23 households exposed to 19 dogs with high titer antinuclear antibodies and compared these contact households to 50 members of 18 control households matched for dog age, sex, and primary veterinarian. No differences were found between contacts and controls in titer of antinuclear, antiDNA, antiRNA, and antilymphocyte antibodies, frequency of positive rheumatoid factor, or elevated serum immunoglobulins. Further analysis of subgroups by age, sex, and intensity of dog exposure did not reveal any serologic differences between contacts and controls. No cases of lupus were identified in either group. Three contact households and no controls reported a family history (remote from the household) of lupus. This study did not detect any clinical or serologic effect of human household exposure to dogs with high titer antinuclear antibodies.