Quality improvement (QI) is difficult, especially in disadvantaged populations in which financial strains and other challenges can interfere with health concerns. However, a collaborative effort involving dozens of community health centers has demonstrated that with the appropriate resources, leadership, and framework for action, improvement can be achieved.
Reporting in the March 6 New England Journal of Medicine (NEJM), investigators found that a series of interventions designed to improve care for asthma, diabetes, and hypertension did, in fact, improve performance on a range of key process measures relating to these diseases.1
Although these improvements did not translate into improved clinical outcomes—at least not during the one-year intervention period—clinicians from some of the participating sites believe that they have hit upon a winning formula for continued progress. And they are moving forward with efforts to broaden many of the QI processes that they have implemented with respect to specific chronic diseases in order to benefit their entire population of patients.
Health centers share successful strategies
The interventions were implemented as part of the Health Disparities Collaboratives, a network of community health centers across the country that work individually and collectively to nurture QI on a range of health measures. Sponsored by the Health Resources and Services Administration (HRSA), the collaboratives continue to pilot tools and strategies aimed at improving quality/efficiency, and they exchange information regularly so that the participating centers can learn from each other.
In the NEJM study “Improving the Management of Chronic Disease at Community Health Centers,” investigators analyzed interventions with 9,658 patients at 44 health centers that participated in the collaboratives and 20 centers that did not, in order to serve as control centers. They abstracted quality measures through chart reviews at each center, focusing on the one-year period prior to the interventions and the year immediately following the interventions. They then calculated overall quality scores.
Based on these data, investigators noted significant improvements at the intervention centers in process measures related to prevention and screening, including the following:
However, the intervention centers did not significantly outperform the control centers with respect to processes-of-care measures related to hypertension. The lead author of the study, Bruce Landon, MD, MBA, from the Department of Health Care Policy at Harvard Medical School in Boston, points out that the measures related to hypertension were the most limited of the three conditions that researchers looked at. “The collaboratives were actually designed for CVD, and we focused on hypertension as the condition we looked at within that, so there were certainly a lot of other [measures] that may have been improved,” he says. “There were also fewer measures to look at with regards to hypertension.”
Why the process improvements did not carry over to clinical improvements, as well, may be explained by the short study period. Further, some of the clinicians involved with the effort maintain that the collaborative approach is definitely making a difference at their health centers.
“The collaborative process is different than typical DM in that it is an ongoing process, so there isn’t simply a tool that you apply, but rather you apply a tool and test it, and if it doesn’t work well, then you adjust it and move on,” says Mark Loafman, MD, MPH, chief medical officer at PCC Wellness Center in Oak Park, IL. “[The model] is a lot more dynamic because it allows the practice to test and assess their own unique ways to make things better as opposed to just taking an externally derived package and trying to make it fit.”
In addition, Loafman stresses that the regularly scheduled conference calls with other collaborative participants have a way of keeping people focused on issues or interventions that have been prioritized.
“The regular check-in times with the peer group enable you to keep performance improvement and guideline issues on the front burner, because people are aware that you will be calling in next week; they need to get their data together, and [they ask themselves whether] they did the things that they said they were going to do,” he says. PCC Wellness Center staff members have gotten several good ideas from other centers through this channel of communications. For example, Loafman says that they now get medical assistants much more involved in care tasks that are recommended by guidelines.
“The medical assistants were historically waiting for the providers to tell them what needed to happen . . . but preapproved standing orders allow the medical assistants to go ahead and collect a specimen or set up for a procedure,” he says, noting that some of the other participating health centers had already figured out that they needed to get things automated in this way so that they did not depend so heavily on the provider. “That is probably the biggest cultural or organization change that we have done, and we are now applying it to many other situations,” he says.
Although working with registries and care teams has been helpful in boosting performance for several chronic conditions, HRSA is now looking to expand the model to apply the same care practices to the entire patient population. “The idea is to move from a DM model to a more comprehensive model [in which] every patient has a planned visit,” says Loafman. To do that, leaders within the collaboratives recognize that the health centers will need to adopt an electronic medical record (EMR). “If you are going to say that there is going to be a planned visit for every patient, and every patient will get what they will need, you can’t use a system like a registry [in which] you have to have staff to enter things and worry about data entry,” says Paul Kaye, MD, chief medical officer of collaboratives member Hudson River HealthCare in Peekskill, NY. “So identifying EMRs that also do the functions of DM that help us take care of patients better—not just record what we did with them, but help us do a better job—is our next big issue.” Second, in order to adequately prepare for every visit, Kaye emphasizes that every provider needs to have adequate support staff and must clearly define the responsibilities of each person. To pay for an expanded care team, health centers will also need to generate more patient visits.
“We have an acute care–based system that isn’t designed to produce chronic disease management or interventions for prevention,” says Kaye. “So one of the real challenges for all of the health centers is how to keep this work going financially when the system doesn’t really recognize it. The only thing you can do is get more patients, because that is the only way you can get more funds. It’s a major national issue that has to be addressed.”
Clearly, multiple challenges are involved in implementing the idea of a planned visit for every patient, but Kaye and Loafman believe that the same collaborative process that they have used to drive improvements in process measures will help the participating health centers accomplish this goal. “If we haven’t quite put our finger on everything that has to be changed—well, neither has the rest of the healthcare system,” says Kaye. “But I think the methodology suggests that you can change small and large systems using these methods.”
1. Landon B, Hicks L, O’Malley AJ, et al. “Improving the Management of Chronic Disease at Community Health Centers.” NEJM 2007. 356:921–34.
Implement change through the PDSA method
Staff members at Hudson River HealthCare in Peekskill, NY, follow a simple formula to implement improvements. It’s a strategy that they have borrowed from the Institute for Healthcare Improvement, based in Cambridge, MA, and it boils down to four steps referred to as PDSA: plan, do, study, and act, explains Paul Kaye, MD, Hudson Rivers’ chief medical officer.
“You do small test cycles that we call PDSA cycles,” he says, noting that it enables people to continually improve a tool or a task before implementing it on a large scale. “You develop a new diabetes form, but before you print out 10,000 of them, you take your first draft and show it to a patient. When the patient says it makes no sense, you redesign it . . . so these small test cycles of change, done rapidly, are the methodology for improving things.”
In fact, Kaye notes that PDSA has become a verb that everyone in his organization understands. When people are going to try out something new, they say they are going to PDSA it, he says. “It has really helped us to develop a culture of change and a culture of quality.”