Good intentions aren’t enough! Systems must change for better care
February 1, 1998 4 minutes read
Good intentions aren’t enough! Systems must change for better care
Quality teams can bridge gaps in preventive care
If good intentions were all that mattered in health care, close to 100% of patients would receive the mammograms, cholesterol screening, and other preventive services they need.
But in reality, only action counts. Doctors at one medical group thought they were doing a good job, until they measured their performance and discovered only 19% of female patients between the ages of 50 and 75 had received a mammogram in the last two years.
That gap between intention and practice is commonplace. In one study, 99% of clinicians agreed that it was important or very important to provide Pap smears, mammograms, and breast exams, but only 15% to 29% of patients needing those services were offered them during a recent office visit.1
"It’s primarily because our medical care system is based on encounters, and our tradition is to build the visit around the patient’s complaint or concerns or presenting problem," says Leif I. Solberg, MD, clinical director of research for the Group Health Foundation in Minneapolis. "Clinicians barely have time to deal with the presenting complaints much less go into the background issues.
"The only way to change this is to build in supportive systems that make these [preventive services] happen naturally," he says.
Through quality improvement teams, that is just what some medical groups are doing.
In the IMPROVE project (Improving Preventive Services through Organization, Vision, and Empowerment), 22 clinics received training and support for continuous quality improvement while another 22 served as a control. The project was funded by the Agency for Health Care Policy and Research in Rockville, MD. Solberg is principal investigator.
While data are not yet available on the overall IMPROVE results, individual clinics report making significant strides in providing preventive care.
At the multispecialty Stillwater (MN) Medical Group, a QI team led by internist Martha Sanford, MD, measured the delivery of nine preventive services in December 1994. (The group later added a 10th service, colorectal cancer screening by flexible sigmoidoscopy.)
The results were disappointing:
• 52% of charts documented the patients’ tobacco use status.
• 12% of patients over 65 received the recommended pneumococcal vaccination.
• 48% of women received an annual breast exam.
• 19% of women between the ages of 50 and 75 had received the recommended biannual mammogram.
"It’s eye-opening to a lot of docs," says Sanford. "Your impression is, I’m doing a lot of this. Everyone must be getting it.’ Having that data motivates people."
Quality team kept patient first
With consultation and training from IMPROVE, a quality team met monthly or more often, as needed. The team even held an all-day, off-site retreat to work out changes the practice needed to make. The team included Sanford; a head nurse who served as facilitator; another nurse and physician; representatives from the laboratory, coding, and medical records; and an appointment scheduler.
The key was targeting systems not people who were at fault. "You’ve got to keep the patient in dead-center," advises Sanford. "It doesn’t matter what system you built. If the patient isn’t getting better care, it isn’t working."
For physicians, systems changes often means delegating some responsibility to nurses or others in the office. "When a patient comes in for a visit, the nurse who does the room preparation identifies at least the main services they might need and goes ahead and sets up the order for them," says Solberg. "If they need a tetanus immunization, go ahead and give it. If they need a cholesterol screen, set up the order for it.
"Allow the physicians to change that if they feel this particular patient doesn’t need it," he says. "But the onus should be on this happening automatically, instead of everybody waiting for the physician to do it."
A first step: Chart reviews
The quality team first identified root causes and barriers to providing preventive services. For example, the team discovered it took 15 minutes to review a single chart to determine if a patient needed screening or immunizations. That was a prohibitive amount of time for a busy practice with four internists, eight family practitioners, and a surgeon. (The practice has since merged with another and now has six internists, about 28 family practitioners, four pediatricians, five obstetrician/gynecologists, a general surgeon, and an otolaryngologist.)
Again, that problem is common. "Our data suggest that even at those [routine physical exam] visits, a lot of these services are not provided because of a lack of a way to consistently identify needs and provide the services," says Solberg.
Stillwater Medical Group created a green summary sheet that listed preventive services. (For more information on preventive care flow sheets, see Patient Satisfaction & Outcomes Management, July 1997, p. 78.)
A nurse would review the patient’s chart before the office visit and circle those services needed. The nurse could then go over those items with patients and explain why they were receiving breast exams or mammogram referrals even if they came in because of cold symptoms.
More recently, the practice has been able to print out information about preventive services using codes on a billing database, which eliminates the time-consuming review of charts. The group also is adding services required for chronically ill patients, such as eye exams for diabetics.
When the quality team measured preventive care in February 1997, the group’s performance had improved dramatically. Now, tobacco use is documented in 72% of charts. Some 62% of women have appropriate mammograms, and 78% have annual breast exams. More than half of patients over 65 received pneumococcal vaccines.
Those stats and the quality improvement process behind them will prove valuable as the group begins to negotiate directly with employers to provide care, Sanford says. "The business world is demanding it," she says of preventive care and quality improvement. "Plus, it’s just good medical practice."
Reference
1. Solberg LI, Brekke ML, Kottke TE. How important are clinician and nurse attitudes to the delivery of clinical preventive services? J Fam Pract 1997; 44:451-461.
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