Including patients in care

Improvements in patient education were reported in areas such as immunisation,23 diabetes,27 chronic kidney disease,28 medication management,21 depression29 and colorectal cancer screening.22 Activities included education sessions and the production of information resources. Increased patient self-management was reported.

Participants explained how increasing patient involvement and supporting self-management seemed to improve patient knowledge, adherence to treatment, and skills in self-management. (Harris et al27)

Reported patient experience outcomes were often related to improved access to care. Some described improved relationships with care teams.

Family satisfaction appeared to stem from better access, care, and safety, and having a strong relationship with their health care team. (McAllister et al30)

Improved care coordination was reported to result in saved time, reduction in unnecessary appointments and improved satisfaction.

We saved that family unnecessary visits and tests—that was a result of having a coordinator to help right the ship a little bit. (physician champion, practice 4) (McAllister et al30)

Some reported that teams had become more patient-centred through changes such as joint goal setting with patients and providing patients with more choices.

We have now become more patient-centric… depending on what the patients are wishing to do and how we can help them. (Harris et al27)

Administrative systems

Participants cited improvement in systems within their practice as a major benefit to participation. (Brown et al20)

Reported changes to financial systems included improved billing practices and growth in billing relative to costs. Some reported participation provided data which was used to approach insurance companies and external funders for increased funding.31

Better data management by practices leads to financial gains, because patients are better managed, and additional Medicare item numbers can be claimed. Improvements in staff and resource management have allowed for better patient access and improved finance. (Brown et al20)

Patient care

The use of disease registries was cited as a foundational improvement. This enabled the identification of populations of interest and clinical variation including patients not attending for care.

Central to the design was a patient registry and guideline-based work flow sheet that enabled physicians to track whether they are actually ‘doing’ what they ‘know’ as best care for their chronic disease patients. (Green et al32)

Some studies recorded a paradigm shift from reactive, episodic care to more active population management. Through systematic approaches, practices could become aware of patients with poor clinical measures or patients who were failing to attend for care.

Teams developed various strategies to systematically follow-up and track patients by developing diabetes registries, flow sheets and reminder systems in EMRs [electronic medical records], fostering a sense of improved care by ensuring appropriate and timely follow-up. (Harris et al22)

Other clinical process improvements reported included use of care coordination, care bundles, guidelines, care plans, patient tracking and care templates.

…programme participation had enabled them to identify suboptimal care in these areas and take action such as: clean up-related patient registers and improve identification of patients with LVSD [left ventricular systolic dysfunction]; optimise heart failure management through specialist clinics leading to reported improvements in, for example, New York Heart Association [NYHA], recording and increased pneumococcal vaccinations; implement more robust monitoring of medications and improved patient contacts and care education. (Bowie et al21)

Electronic medical records, while challenging to implement,22 were a key innovation credited with facilitating population management and seen as pivotal to achieving outcomes.

With this EMR, it’s so much easier to track patients that have been missed out of the system… (Taliani et al33)

Models of care such as the Chronic Care Model and the Patient Centred Medical Home were used in some studies to inform changes to care processes.

The unique combination of two evidence-based models, the expanded chronic care model, and the IHI [Institute for Healthcare Improvement] break-through series resulted in the critical integration of quality improvement and education to realize change in chronic disease care. (Green et al32)

Some noted little change as a result of the QIC.22 34

Improving teamwork

The inclusion of patients in the practice team was reported by some as an important outcome which could motivate the whole team. Though motivating, it required considerable effort to include consumers in care team processes.

…these new points of contact gave staff opportunities to glean insights or make contributions to patient care that might not otherwise happen. Practice staff observed that, for personal, social, or cultural reasons, patients sometimes preferred to disclose critical information to nonphysician members of the team. (Kyle et al35)

Physician champions found this parental involvement motivating but acknowledged that the recruitment, orientation, and engagement of parent partners were difficult. (McAllister et al30)

Improvements in practice team communication were also reported with particular reference to increased regular practice meetings and off-site meetings.

Some practices cited more effective communication channels within their practices, incorporating regular team meetings, as a positive outcome of the [Australian Primary Care Collaboratives] program.

GP007. “Previously, we had one, between one and four (meetings) a year, after Collaboratives we had more. Since last year we have them fortnightly”. (Brown et al20)

A common narrative was that QIC participation helped team members to get to know each other. Better understanding of each other’s roles led to increased trust. This empowered different members, including non-clinical staff, to work to their scope, develop as leaders and take on redistributed tasks.

Understanding each other’s role emerged as an important component of team building, and participants described experiencing more trust and respect among team members and fewer professional silos within their teams. (Harris et al22)

This task-shifting relieved some of the burden on physicians and felt rewarding to nonphysicians, contributing to a culture of mutual regard and respect, which in turn reinforced confidence in, and reduced discomfort with, the redistribution of tasks and responsibilities. (Kyle et al35)

Improved team functioning was reported to underpin improved patient care.

Team formation and continuous improvement efforts built on each other to help practices achieve effective team-based care. (Kyle et al35)

Building skills and knowledge

Participants described how the program gave them the knowledge, skills, and confidence to change how they deliver care. (Harris et al27)

Knowledge was reportedly gained in tools for care (eg, care plans, guidelines), clinical conditions (eg, chronic kidney disease, diabetes, screening), and local resources and services.

It has certainly increased my knowledge so hopefully we may have an increased knowledge I am delivering better patient care…[and]…made the doctors think a bit more on how they see their patients, how they read their patient’s records and what action they take. (practice nurse 2) (Bowie et al21)

Skills reported were in areas such as searching the electronic record21 and chronic disease care.36 For some, accrual of professional development ‘points’ was an important outcome promoting participation.

Interviewees….widely praised offering maintenance of certification (MOC) or continuing medical education (CME) credits—which provided ‘a big hook to bring in physicians,’ as one Idaho organizer put it. (Burton et al37)

Engagement or motivation

Increased motivation for change was attributed to numerous factors including the use of patient stories, the evidence-based nature of the collaborative interventions and evidence of better outcomes for patients. The most common and highly valued impact on motivation reported was from interaction with peers.

Far and away, the aspect of collaboratives that practices most frequently praised (in all 12 states) was learning from other practices, which typically occurred during in-person meetings, but sometimes also through practice-to-practice phone calls to troubleshoot issues or site visits to observe how another practice did. (Burton et al37)

It was the networking, the ability to get together with others who are passionate about improving health care and excited to work as a team towards making situations better for our patients. (PHC team) (Harris et al22)

Peer interaction provided moral support as well as access to new ideas. Sharing of successes, struggles and mistakes was highly valued. Some studies reported that participation had increased professional satisfaction28 30 38 39 and could empower individuals.

The coming together of multiple teams for off-site learning sessions (streams A and B) was described as the most effective activity because it facilitated interaction and created a sense of ‘togetherness’ that was enabling, energising, and motivating to tackle common challenges in QI. (Paquette-Warren et al40)

Hearing what other practices were doing motivated and invigorated practices and made change seem less daunting. (Burton et al37)

A common theme was the challenge of inspiring the rest of the practice to change.

…coming back to a busy practice back into all the time constraints and all the demands on your time to then try and pass on that energy is extremely difficult, that’s where a lot of it falters, it is actually very, very difficult to pass that on to the wider group. (Bowie et al21)

Participation in QICs was also reported to reduce motivation for change at times. Some factors cited included inadequate support, lack of remuneration, the lack of people to do improvement work, impact on personal time and competing priorities. Working in a team that did not know each other, or was resistant to change, discouraged some. Some studies reported concern about increased external oversight engendered by the sharing of practice data,20 competing priorities41 and loss of dedicated time.28

In teams where members did not know each other prior to the QIC, it was a very time-consuming process to reach a shared understanding of depression care and get clinicians engaged with the change process. (Franx et al42)

…practice members reported being overwhelmed with co-occurring events in the practice, such as electronic health record implementation or practice ownership changes. (Shaw et al41)

Regional practice support

Local support is a key part of the QIC intervention. Respondents noted that for some practices, this commenced a relationship with a regional organisation for the first time.

For many practices this was their first WREN project, which meant that PBRN [Practice-based Research Networks] staff were facilitating the intervention at the same time they were building new relationships with staff. (Lipman and Aspy28)

Reported support included provision of customised data and feedback to practices, training in information technology skills, training in QI skills and development of change champions.

Interviewees considered [primary health care organisation] staff needed to play the role of coach and educator when facilitating QI work. When these roles were performed well, interviewees perceived this to result in better teamwork, more reliable data collection, and increased use of PDSA [plan, do, study, act]cycles, improved guideline use, development of change champions and sharing of success stories. (Hespe et al43)

This support role enabled regional organisations to understand general practice better including the management of chronic disease and reasons for variation in success in improvement.

The use of the breakthrough series approach provided significant insight into GPs’ [general practitioners] management of patients with a chronic disease. (Jones et al36)

Poor quality or inadequate support was reported to contribute to frustration, decreased engagement and disempowerment for some.

Finally, survey comments from a handful of sites conveyed frustration with a perceived lack of support and engagement from local leadership; respondents from these sites felt that frontline staff had no input into planning and decisions around PACT [the Patient Aligned Care Teams project] and described an excess of ‘administrative red tape’ that inhibited innovation at the team level. (Butler et al44)

Implementing regional innovation

Some articles reported QICs had been effective in implementing innovation at a regional level. Examples included depression care models, chronic disease strategies, safety improvement methods, use of disease registers and models such the Chronic Care Model and the Patient Centred Medical Home. Resources such as guideline flow sheets either developed by QIC participant or by regional organisations were disseminated.

QICs offer a potentially powerful way of disseminating health care innovations through enhanced strategies for learning and change. Creating collaborative environments in which diverse participants learn, listen, reflect, and share together can enable them to take back to their own organizations key messages and change strategies that benefit them the most. (Shaw et al45)

QICs were reported as a strategy for targeting disadvantaged communities in a region.

…the CHIPRA [Children’s Health Insurance Program Reinsurance Act] quality demonstration targets a diverse set of practices that typically serve relatively large proportions of children insured through Medicaid and CHIP, which generally have fewer resources than practices that serve commercially insured children. (Devers et al46)

Patients in QI

Some teams included patients in QI efforts through sharing of outcome data and targets. One study recorded strategies for increased patient involvement as an important outcome theme of their project.

Eleven of 12 practices developed formalized QI team processes including active parent partner participation. (McAllister et al30)

Oregon collaborative organisers had parents give presentations at collaborative meetings, which they told us received practices’ highest ratings in meeting evaluations. (Burton et al37)

Theme 2. More active and involved patients

Information letter/sheet to patients with, for example, explanations of target values.

Questionnaire sent to patients before the visit.

Working more actively with patients’ individual targets.

Introduction of Diasend, which transfers, stores and displays patient data from different types of glucose metres, insulin pumps and continuous glucose monitors.

Active smoking cessation.

Procedures for blood pressure measurement at home. (Peterson et al47)

QI knowledge and skills

Respondents described satisfaction from gaining QI knowledge and skills which enabled them to change the way they provide care.

Practice staff generally valued…Satisfaction from learning more about quality measures, QI concepts and techniques, critical medical home components, and how to identify [Patient Centred Medical Home] capacity and performance gaps. (Devers et al46)

They reported increased awareness of QI opportunities, skills in data use and skills in making systematic change.

Participants said that the program: increased their awareness of opportunities for QI; helped build their knowledge, skills, and confidence related to chronic care; provided motivation and support to reach their goals; taught them how to use data to focus their QI efforts; and enhanced their appreciation of the time, continued effort, and support required for system-level change. (Paquette-Warren et al40)

Establishing a QI culture

Some recorded culture change towards a belief in the efficacy of QI methods to make sustained change.

A benefit of the collaborative nature of the QI process, as experienced through the [Australian Primary Care Collaboratives], was the ability for primary care teams to share ideas and solutions for common problems, which helped to build a culture of ‘Improvement’ within practice teams. (Hespe et al43)

Contact with peers was cited as a strong motivator for improvement.

Physicians benefited from peer-based learning, identifying the learning collaborative as ‘what got them started’ using an ongoing QI process. (McAllister et al30)

Some reported institutionalising change through articulation in job descriptions, remuneration plans, policies and in leadership.

Transformed practices also began to include QI activities in job descriptions and compensation plans for staff, thus institutionalizing the practice transformation. (Donahue et al25)

A strong narrative emerged of ambivalence about formalised improvement cycles. Some practices saw them as key to improvement while others saw them as formal, contrived and unnecessary.

Using incremental, small-scale PDSA cycles was reported to be a key to successfully integrating changes into existing routines (Q8.12). (Gingold et al23)

In most cases participants did not continue to use formal PDSA cycles to make changes within their practices after their participation in the 18-month APCC [Australian Primary Care Collaboratives] program. Instead, many practices cited an ongoing ‘informal’ use that consisted of PDSA style thinking without writing a formal PDSA plan. (Brown et al20)

For some, participation in the QICs resulted in fatigue regarding QI. Improvement activities were described as extra work, often unremunerated, carried out at night and on weekends and therefore hard to sustain.

Participants indicated that time constraints and competing work priorities meant that they quickly lost momentum and motivation after initially implementing the PDSA cycle process to test changes in care practices. (Bowie et al21)

QICs were described as having a useful role in building QI capacity at the system level.

States and practices also seemed to agree that QI collaboratives and related activities may be necessary but are perhaps not sufficient to facilitate QI and [Patient Centred Medical Home] capacity improvement, suggesting the need for additional QI strategies. (Devers et al46)

Protected time

A strong theme from many articles was the positive impact of ‘protected time’, within the practice and in external QIC meetings, in which data could be reviewed and QI activities be carried out.

Protected time for clinical team meetings, and undertaking PDSAs and other quality improvement work was frequently cited as a key enabler for the Collaborative’s quality improvement processes. (Palmer et al48)

Provision of practice data

Many studies reported that QIC implementation led to the provision of practice-level data within regions. Regional-level data were reported as leveraging the competitive nature of clinicians through critical comparison. The provision of outcome data was reported to drive culture change through demonstrating gaps and improvements.

Interviewees in several states…thought that showing practices how they compared to their collaborative peers on selected quality measures helped promote healthy competition. (Burton et al37)

Data became a tool that enabled individuals and teams to make sense of their work and practice environment, visualising successes, and locating barriers. (Kyle et al35)

The impact of sharing feedback data on motivation for improvement was a key finding. (Lipman and Aspy28)

Improvement champions

An important reported capacity-building impact of QICs was the creation of peer champions and QI leaders who could promote change at the regional level.

Participating practices included clinical leaders from all PHOs [primary healthcare organisations] and some of these leaders are now working with their PHOs to extend the use of the Collaborative approach. (Palmer et al48)

Both Divisions reported that the project generated interest in the process as an educational tool at practice level, and both Divisions reported using ‘champions’ to promote, among other things, the use of care for chronic disease management. (Jones and Piterman34)