Ed Wagner

A Multi-Institutional Quality Improvement Initiative to Transform Education for Chronic Illness Care in Resident Continuity Practices

BACKGROUNDThere is a gap between the need for patient-centered, evidence-based primary care for the large burden of chronic illness in the US, and the training of resident physicians to provide that care.OBJECTIVETo improve training for residents who provide chronic illness care in teaching practice settings.DESIGNUS teaching hospitals were invited to participate in one of two 18-month Breakthrough Series Collaboratives—either a national Collaborative, or a subsequent California Collaborative—to implement the Chronic Care Model (CCM) and related curriculum changes in resident practices. Most practices focused on patients with diabetes mellitus. Educational redesign strategies with related performance measures were developed for curricular innovations anchored in the CCM. In addition, three clinical measures—HbA1c <7%, LDL <100xa0mg/dL, and blood pressure ≤130/80—and three process measures—retinal and foot examinations, and patient self-management goals—were tracked.PARTICIPANTSFifty-seven teams from 37 self-selected teaching hospitals committed to implement the CCM in resident continuity practices; 41 teams focusing on diabetes improvement participated over the entire duration of one of the Collaboratives.INTERVENTIONSTeaching-practice teams—faculty, residents and staff—participated in Collaboratives by attending monthly calls and regular 2-day face-to-face meetings with the other teams. The national Collaborative faculty led calls and meetings. Each team used rapid cycle quality improvement (PDSA cycles) to implement the CCM and curricular changes. Teams reported education and clinical performance measures monthly.RESULTSPractices underwent extensive redesign to establish CCM elements. Education measures tracked substantial development of CCM-related learning. The clinical and process measures improved, however inconsistently, during the Collaboratives.CONCLUSIONSThese initiatives suggest that systematic practice redesign for implementing the CCM along with linked educational approaches are achievable in resident continuity practices. Improvement of clinical outcomes in such practices is daunting but achievable.

Putting Population-Based Care Into Practice: Real Option or Rhetoric?

Background: Efforts to improve care have focused on population-based approaches, though little practical information exists about implementation. Methods: This report reviews relevant literature on teamwork in the context of a time-series evaluation of a demonstration project to reorganize care of a single panel of patients in a managed care setting. The proportion of the study panel achieving recommended levels for breast and colon cancer screening, warfarin control, and diabetic eye care was compared with the surrounding practice panels and the managed care population as a whole. Using unconditional logistic regression, we compared changes within populations between March 1993 and March 1995, and the rate of change between populations during the same period. Results: A model of team care was successfully implemented. Colon (occult blood in the stool) and breast (mammography) screening increased more rapidly in the study population than in the surrounding practices or plan as a whole (P < 0.05 for all comparisons). There was no significant improvement in warfarin control or diabetic eye examinations, though absolute increases occurred. Conclusion: This work shows that a team approach to population-based care is a real option. Such an approach, however, will not generalize to other settings or all conditions, and its implementation involves some major challenges.

Joy and Challenges in Improving Chronic Illness Care: Capturing Daily Experiences of Academic Primary Care Teams

BACKGROUNDTwo chronic care collaboratives (The National Collaborative and the California Collaborative) were convened to facilitate implementing the chronic care model (CCM) in academic medical centers and into post-graduate medical education.OBJECTIVEWe developed and implemented an electronic team survey (ETS) to elicit, in real-time, team member’s experiences in caring for people with chronic illness and the effect of the Collaborative on teams and teamwork.DESIGNThe ETS is a qualitative survey based on Electronic Event Sampling Methodology. It is designed to collect meaningful information about daily experience and any event that might influence team members’ daily work and subsequent outcomes.PARTICIPANTSForty-one residency programs from 37 teaching hospitals participated in the collaboratives and comprised faculty and resident physicians, nurses, and administrative staff.APPROACHEach team member participating in the collaboratives received an e-mail with directions to complete the ETS for four weeks during 2006 (the National Collaborative) and 2007 (the California Collaborative).KEY RESULTSAt the team level, the response rate to the ETS was 87% with team members submitting 1,145 narrative entries. Six key themes emerged from the analysis, which were consistent across all sites. Among teams that achieved better clinical outcomes on Collaborative clinical indicators, an additional key theme emerged: professional work satisfaction, or “Joy in Work”. In contrast, among teams that performed lower in collaborative measures, two key themes emerged that reflected the effect of providing care in difficult institutional environments—“lack of professional satisfaction” and awareness of “system failures”.CONCLUSIONSThe ETS provided a unique perspective into team performance and the day-to-day challenges and opportunities in chronic illness care. Further research is needed to explore systematic approaches to integrating the results from this study into the design of improvement efforts for clinical teams.

Clinical effectiveness research in managed-care systems: lessons from the Pediatric Asthma Care PORT. Patient Outcomes Research Team.

OBJECTIVEnTo highlight the unique challenges of evaluative research on practice behavior change in the real world settings of contemporary managed-care organizations, using the experience of the Pediatric Asthma Care PORT (Patient Outcomes Research Team).nnnSTUDY SETTINGnThe Pediatric Asthma Care PORT is a five-year initiative funded by the Agency for Healthcare Research and Quality to study strategies for asthma care improvement in three managed-care plans in Chicago, Seattle, and Boston. At its core is a randomized trial of two care improvement strategies compared with usual care: (1) a targeted physician education program using practice based Peer Leaders (PL) as change agents, (2) adding to the PL intervention a Planned Asthma Care Intervention incorporating joint asthma check-tips by nurse-physician teams. During the trial, each of the participating organizations viewed asthma care improvement as an immediate priority and had their own corporate improvement programs underway.nnnDATA COLLECTIONnInvestigators at each health plan described the organizational and implementation challenges in conducting the PAC PORT randomized trial. These experiences were reviewed for common themes and lessons that might be useful to investigators planning interventional research in similar care-delivery settings.nnnCONCLUSIONSnRandomized trials in real world settings represent the most robust design available to test care improvement strategies. In complex, rapidly changing managed-care organizations, blinding is not feasible, corporate initiatives may complicate implementation, and the assumption that a usual care arm will be static is highly likely to be mistaken. Investigators must be prepared to use innovative strategies to maintain the integrity of the study design, including: continuous improvement within the intervention arms, comanagement by researchers and health plan managers of condition-related quality improvement initiatives, procedures for avoiding respondent burden in health plan enrollees, and anticipation and minimization of risks from experimental arm contamination and major organizational change. With attention to these delivery system issues, as well as the usual design features of randomized trials, we believe managed-care organizations can serve as important laboratories to test care improvement strategies.

The Evidence Is at Hand for Improving Care in Settings Where Residents Train

Seven years ago the Institute of Medicine’s report, Crossing the Quality Chasm1, issued a challenge to transform America’s healthcare system. If this challenge is to be met any time soon, it will require profound leadership by general internists. This, in turn, requires that the next generation of internists be trained in residency programs with a commitment to transforming healthcare in the settings where those future physicians train and practice. In 1999, the Accreditation Council for Graduate Medical Education (ACGME) radically redefined physician competence by framing two of the six core physician competencies as system redesign and improvement—Systems-Based Practice (SBP) and Practice-Based Learning and Improvement (PBLI).2 The American Board of Medical Specialties adopted the same competencies for specialty certification, thus acknowledging the importance of the continuum of a physician’s learning. These two competencies redefined healthcare and health professions’ education by acknowledging physicians’ professional responsibility to improve healthcare and systems.