The Joint Commission journal on quality improvement
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Jt Comm J Qual Improv · Sep 1999
ReviewPooling research results: benefits and limitations of meta-analysis.
Meta-analysis, the systematic and quantitative synthesis of evidence, has developed considerably in the 1990s and is emerging as an important methodology in medical decision making. As a research methodology, meta-analysis has benefits and limitations that must be acknowledged in its application. ⋯ Meta-analysis has promoted the sense that obtaining evidence is a global enterprise and that complete information needs to be evaluated and synthesized to obtain the most unbiased results. Analyzing sources of bias and diversity is essential to performing, understanding, and using meta-analyses in medical care.
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Jt Comm J Qual Improv · Sep 1999
ReviewOne size does not fit all: questions to answer before intervening to change physician behavior.
Many interventions have been conducted to change physician behavior, but there is not much evidence regarding their effectiveness. A list of questions is proposed for those who would attempt such interventions: 1. Does the behavior (or decision making) need to be changed? This implies the next two questions. 1a. Is there a logical, evidence-based argument that one decision alternative is preferable for a particular situation? If the would-be behavior changer cannot make an evidence-based argument for changing behavior, there is little moral authority to intervene. 1b. Is there evidence that physicians are not choosing this decision alternative when they should? Interventions are often prompted by evidence that utilization of an alternative was too high or low, but physicians' decisions are not the only determinants of utilization. 2. What is the problem with the decision making? Common sense suggests that different problems require different solutions. Yet interventions are often pursued in the absence of clear information about the reasons physicians did not exhibit the preferred behavior. 3. How could the decision making best be changed? Finding the cognitive problems that caused "wrong" behavior should directly lead to the design of simple, targeted, effective interventions to change this behavior. The judgment and decision making psychology literature suggests that general instruction in reasoning and probability may improve judgments and decision processes. ⋯ Physicians' behavior appears to be resistant to change. Understanding why the behavior should be changed and what caused it may make the process of designing interventions more complicated. The resulting interventions, however, are more likely to be simple and successful.
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Jt Comm J Qual Improv · Aug 1999
Clinical performance improvement series. Classic CQI integrated with comprehensive disease management as a model for performance improvement.
In recent years, health and disease management has emerged as an effective means of delivering, integrating, and improving care through a population-based approach. Since 1997 the University of Pennsylvania Health System (UPHS) has utilized the key principles and components of continuous quality improvement (CQI) and disease management to form a model for health care improvement that focuses on designing best practices, using best practices to influence clinical decision making, changing processes and systems to deploy and deliver best practices, and measuring outcomes to improve the process. Experience with 28 programs and more than 14,000 patients indicates significant improvement in outcomes, including high physician satisfaction, increased patient satisfaction, reduced costs, and improved clinical process and outcome measures across multiple diseases. DIABETES DISEASE MANAGEMENT: In three months a UPHS multidisciplinary diabetes disease management team developed a best practice approach for the treatment of all patients with diabetes in the UPHS. After the program was pilot tested in three primary care physician sites, it was then introduced progressively to additional practice sites throughout the health system. The establishment of the role of the diabetes nurse care managers (certified diabetes educators) was central to successful program deployment. Office-based coordinators ensure incorporation of the best practice protocols into routine flow processes. A disease management intranet disseminates programs electronically. Outcomes of the UPHS health and disease management programs so far demonstrate success across multiple dimensions of performance-service, clinical quality, access, and value. ⋯ Health care has traditionally invested extraordinary resources in developing best practice approaches, including guidelines, education programs, or other tangible products and services. Comparatively little time, effort, and resources have been targeted to implementation and use, the stage at which most efforts fail. CQI's emphasis on data, rapid diffusion of innovative programs, and rapid cycle improvements enhance the implementation and effectiveness of disease management.
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Jt Comm J Qual Improv · Jun 1999
Lessons from Europe on quality improvement: report on the Velen Castle WHO meeting.
In conjunction with the German Ministry of Health, the European Regional Office of the World Health Organization (WHO/EURO) held a workshop, "Experiences with Quality Management in an International Context," at Velen Castle, Velen (Nordrhein-Westfalen), Germany, January 15-17, 1998. The approximately 50 participants were selected in part on the basis of recommendations of their respective countries' health ministries. ⋯ Successful implementation of quality improvement benefits from local, professional, and national policies and objectives. A balance of incentives can reward efficiency or specific activities. Laws, rules, and regulations can be useful, especially if used sparingly. More education is needed at all levels of the health care system about how to understand and use information and information systems. Research is needed on what processes result in favorable outcomes. Despite optimism about the cost-saving potential of quality improvement efforts, many interventions are likely to be cost-effective without actually saving costs. Public release of performance data requires careful consideration, with participation of the professions.
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Jt Comm J Qual Improv · Jun 1999
Understanding patient willingness to recommend and return: a strategy for prioritizing improvement opportunities.
Beginning in April 1995, an ongoing, comprehensive measurement system has been developed and refined at BJC Health System, a regional integrated delivery and financing system serving the St Louis metropolitan area, mid-Missouri, and Southern Illinois, to assess patient satisfaction with inpatient treatment, outpatient treatment, outpatient surgery, and emergency care. This system has provided the mechanism for identifying opportunities, setting priorities, and monitoring the impact of improvement initiatives. ⋯ Results suggest that some core issues are of extreme importance to patients regardless of whether they are receiving care in an inpatient, outpatient, or emergency setting. The compassion with which care is provided appears to be the most important factor in influencing patient intentions to recommend/return, regardless of the setting in which care is provided.