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Ninety percent of health care systems now offer patient portals to access electronic health records (EHRs) in the United States, but only 15% to 30% of patients use these platforms. Using PubMed, the authors identified 53 studies published from September 2013 to June 2019 that informed best practices and priorities for future research on patient engagement with EHR data through patient portals, These studies mostly involved outpatient settings and fell into 3 major categories: interventions to increase use of patient portals, usability testing of portal interfaces, and documentation of patient and clinician barriers to portal use. Interventions that used one-on-one patient training were associated with the highest portal use. Patients with limited health or digital literacy faced challenges to portal use. Clinicians reported a lack of workflows to support patient use of portals in routine practice. These studies suggest that achieving higher rates of patient engagement through EHR portals will require paying more attention to the needs of diverse patients and systematically measuring usability as well as scope of content. Future work should incorporate implementation science approaches and directly address the key role of clinicians and staff in promoting portal use. [ABSTRACT FROM AUTHOR]

Purpose: To provide guidance on using measurement to support the conduct of local quality improvement projects that will strengthen the evaluation of results and increase their potential for publication. Target Group: Individuals leading quality improvement efforts who wish to enhance their use of measurement. Procedures to Promote Good Measurement: Eleven procedures are offered to promote intelligent measurement in quality improvement research that may become publishable: 1. Start with an important topic 2. Develop a clear aim statement 3. Turn the aim statement into key questions 4. Develop a theory about causes and effects, process changes and predictable sources of variation 5. Construct a research design and accompanying dummy data displays to answer your primary research questions 6. Develop and use operational definitions for each variable needed to make your dummy data displays 7. Design a data collection plan to gather information on each variable that will enable you to generate reliable, valid, and sensitive measures related to each research question 8. Pilot test the data collection plan, construct preliminary data displays, and revise your methods based on what you learn 9. Stay close to the data collection process as the data plan goes from idea to execution 10. Perform data analysis and display results in a way that answers your key questions 11. Review and document the strengths and limitations of your measurement work and use this knowledge to guide intelligent interpretation of the observed results. [ABSTRACT FROM AUTHOR]

Background: Shared decision making (SDM) is the process by which patients and clinicians exchange information and preferences to come to joint healthcare decisions. Clinical dashboards can support SDM by collecting, distilling, and presenting critical information, such as patient-reported outcomes (PROs), to be shared at points of care and in between appointments. We describe the implementation strategies and outcomes of a multistakeholder collaborative process known as "co-design" to develop a PRO-informed clinical dashboard to support SDM for patients with advanced cancer or chronic kidney disease (CKD). Methods: Across 14 sessions, two multidisciplinary teams comprising patients, care partners, clinicians, and other stakeholders iteratively co-designed an SDM dashboard for either advanced cancer (N = 25) or CKD (N = 24). Eligible patients, care partners, and frontline clinicians were identified by six physician champions. The co-design process included four key steps: (1) define "the problem", (2) establish context of use, (3) build a consensus on design, and (4) define and test specifications. We also evaluated our success in implementing the co-design strategy using measures of fidelity, acceptability, adoption, feasibility, and effectiveness which were collected throughout the process. Results: Mean (M) scores across implementation measures of the co-design process were high, including observer-rated fidelity and adoption of co-design practices (M = 19.1 on a 7–21 scale, N = 36 ratings across 9 sessions), as well as acceptability based on the perceived degree of SDM that occurred during the co-design process (M = 10.4 on a 0 to 12 adapted collaboRATE scale). Capturing the feasibility and adoption of convening multistakeholder co-design teams, min–max normalized scores (ranging from 0 to 1) of stakeholder representation demonstrated that, on average, 95% of stakeholder types were represented for cancer sessions (M = 0.95) and 85% for CKD sessions (M = 0.85). The co-design process was rated as either "fully" or "partially" effective by 100% of respondents, in creating a dashboard that met its intended objective. Conclusions: A co-design process was successfully implemented to develop SDM clinical dashboards for advanced cancer and CKD care. We discuss key strategies and learnings from this process that may aid others in the development and uptake of patient-centered healthcare innovations. [ABSTRACT FROM AUTHOR]

Abstract: We conducted a trial to evaluate the impact of medical self-care education on 330 elders whose average age was 71. The test group participated in a 13-session educational intervention with training in clinical medicine, life-style, and use of health services. The comparison group received a two-hour lecture-demonstration. Both groups were assessed pre-intervention, post-intervention, and one year after entry. The rest. Its indicate medical self-care instruction: produces substantial improvements, that were sustained for one year, in health knowledge, skills performance, and skills confidence; stimulates many attempts to improve life-style, and generates improvements in life quality. The program had little influence on utilization of medical care or hearth status. [ABSTRACT FROM AUTHOR]

Presents information on a study of patients with chronic disease while comparing inpatient and outpatient utilization rates between prepaid (PPD) and fee-for-service (FFS) insurance coverage for these patients. Collection of data from the Medical Outcomes Study; Information on a longitudinal observational study of chronic disease patients; Whom was the study conducted by; Detailed information on the methods; Examination of the results.

Clinicians can use data to improve daily clinical practice. This paper offers eight principles for using data to support improvement in busy clinical settings: 1) seek usefulness, not perfection, in the measurement; 2) use a balanced set of process, outcome, and cost measures; 3) keep measurement simple (think big, but start small); 4) use qualitative and quantitative data; 5) write down the operational definitions of measures; 6) measure small, representative samples; 7) build measurement into daily work; and 8) develop a measurement team. The following approaches to using data for improvement are recommended. First, begin with curiosity about outcomes or a need to improve results. Second, try to avoid knee-jerk, obstructive criticism of proposed measurements. Instead, propose solutions that are practical, goal-oriented, and good enough to start with. Third, gather baseline data on a small sample and check the findings. Fourth, try to change and improve the delivery process while gathering data. Fifth, plot results over time and analyze them by using a control chart or other graphical method. Sixth, refine your understanding of variation in processes and outcomes by dividing patients into clinically homogeneous subgroups (stratification) and analyzing the results separately for each subgroup. Finally, make further changes while measuring key outcomes over time. Measurement and improvement are intertwined; it is impossible to make improvements without measurement. Measuring and learning from each patient and using the information gleaned to test improvements can become part of daily medical practice in local settings. [ABSTRACT FROM AUTHOR]

Introduction: The Cystic Fibrosis (CF) Foundation sponsored the design, pilot testing, and implementation of the CF Learning Network (CFLN) to explore how the Foundation's Care Center Network (CCN) could become a learning health system. Six years after the design, the Foundation commissioned a formative mixed methods evaluation of the CFLN to assess: CFLN participants' understanding of program goals, attributes, and perceptions of current and future impact. Methods: We performed semi‐structured interviews with CFLN participants to identify perceived goals, attributes, and impact of the network. Following thematic analyses, we developed and distributed a survey to CFLN members and a matched sample of CCN programs to understand whether the themes were unique to the CFLN. Results: Interviews with 24 CFLN participants were conducted. Interviewees identified the primary CFLN goal as improving outcomes for people living with CF, with secondary goals of providing training in quality improvement (QI), creating a learning community, engaging all stakeholders in improvement, and spreading best practices to the CCN. Project management, use of data, common QI methods, and the learning community were seen as critical to success. Survey responses were collected from 103 CFLN members and 25 CCN members. The data revealed that CFLN respondents were more likely than CCN respondents to connect with other CF programs, routinely use data for QI, and engage patient and family partners in QI. Conclusions: Our study suggests that the CFLN provides value beyond that achieved by the CCN. Key questions remain about whether spread of the CFLN could improve outcomes for more people living with CF. [ABSTRACT FROM AUTHOR]

Patients at the center of care is often the stated focus of clinicians and healthcare services. The quality and safety movement has shown that effective organization of care is needed, in addition to professional skills. This movement has provided professionals and others with methods to improve both organization and practice for patients. These methods include measurement to give those carrying out improvement feedback about the effects of their changes. New types of measures that enable patients to report treatment outcomes can now be use in quality improvement and quality reporting to bring a renewed focus on making care more patient-centered. Although used for some time in research, these measures are relatively new tools for quality improvement and not all research measures are suitable for everyday feedback or improvement projects. The purpose of the paper is to provide an introduction to the use and value of patient-reported outcome measures in quality improvement and to give practical guidance and resources for using PROMs for quality improvement. It draws on the authors' experiences using patient reported outcomes measures for quality research and improvement and their workshop at the 2016 Tokyo ISQUA conference, as well as on reviews and guidance documents about the use of PROMs. It does not provide a comprehensive and systematic review of research, but an overview and introduction to PROMs for quality improvement. [ABSTRACT FROM AUTHOR]

Background: Modifiable risks account for a large fraction of disease and death, but clinicians and patients lack tools to identify high risk populations or compare the possible benefit of different interventions. Methods: We used data on the distribution of exposure to 12 major behavioral and biometric risk factors in the US population, mortality rates by cause, and estimates of the proportional hazards of risk factor exposure from published systematic reviews to develop a risk prediction model that estimates an adult's 10 year mortality risk compared to a population with optimum risk factors. We compared predicted risk to observed mortality in 8,241 respondents in NHANES 1988-1994 and NHANES 1999-2004 with linked mortality data up to the end of 2006. Results: Predicted risk showed good discrimination with an area under the receiver operating characteristic (ROC) curve of 0.84 (standard error 0.01) for women and 0.84 (SE 0.01) for men. Across deciles of predicted risk, mortality was accurately predicted in men (X² statistic = 12.3 for men, p=0.196) but slightly overpredicted in the highest decile among women (X² statistic = 22.8, p=0.002). Mortality risk was highly concentrated; for example, among those age 30-44 years, 5.1 % (95 % CI 4.1 % - 6.0 %) of the male and 5.9 % (95 % CI 4.8 % - 6.9 %) of the female population accounted for 25 % of the risk of death. Conclusion: The risk model accurately predicted mortality in a representative sample of the US population and could be used to help inform patient and provider decision-making, identify high risk groups, and monitor the impact of efforts to improve population health. [ABSTRACT FROM AUTHOR]

Background: Modifiable risks account for a large fraction of disease and death, but clinicians and patients lack tools to identify high risk populations or compare the possible benefit of different interventions. Methods: We used data on the distribution of exposure to 12 major behavioral and biometric risk factors inthe US population, mortality rates by cause, and estimates of the proportional hazards of risk factor exposure from published systematic reviews to develop a risk prediction model that estimates an adult's 10 year mortality risk compared to a population with optimum risk factors. We compared predicted risk to observed mortality in 8,241 respondents in NHANES 1988-1994 and NHANES 1999-2004 with linked mortality data up to the end of 2006. Results: Predicted risk showed good discrimination with an area under the receiver operating characteristic (ROC) curve of 0.84 (standard error 0.01) for women and 0.84 (SE 0.01) for men. Across deciles of predicted risk, mortality was accurately predicted in men ((Χ2 statistic = 12.3 for men, p=0.196) but slightly overpredicted in the highest decile among women (Χ2 statistic = 22.8, p=0.002). Mortality risk was highly concentrated; for example, among those age 30-44 years, 5.1 % (95 % CI 4.1 % - 6.0 %) of the male and 5.9 % (95 % CI 4.8 % - 6.9 %) of the female population accounted for 25 % of the risk of death. Conclusion: The risk model accurately predicted mortality in a representative sample of the US population and could be used to help inform patient and provider decision-making, identify high risk groups, and monitor the impact of efforts to improve population health. [ABSTRACT FROM AUTHOR]

The findings of this body of work are presented in the eight articles included in this supplement. The impact and perspectives of adult and pediatric care teams and patient/families are covered with special attention to mental health care, the financial and personnel impacts within care programs, the experiences of vulnerable and underrepresented patient populations, and implementation of remoting monitoring. Commentaries from colleagues provide a broader perspective, offering reflections on the findings and their implications regarding the future CF care model. [ABSTRACT FROM AUTHOR]

Aim To investigate health care improvement team coaching activities from the perspectives of coachees, coaches and unit leaders in two national improvement collaboratives. Background Despite numerous methods to improve health care, inconsistencies in success have been attributed to factors that include unengaged staff, absence of supportive improvement resources and organisational inertia. Methods Mixed methods sequential exploratory study design, including quantitative and qualitative data from interprofessional improvement teams who received team coaching. The coachees ( n = 382), coaches ( n = 9) and leaders ( n = 30) completed three different data collection tools identifying coaching actions perceived to support improvement activities. Results Coachees, coaches and unit leaders in both collaboratives reported generally positive perceptions about team coaching. Four categories of coaching actions were perceived to support improvement work: context, relationships, helping and technical support. Conclusions All participants agreed that regardless of who the coach is, emphasis should include the four categories of team coaching actions. Implications for nursing management Leaders should reflect on their efforts to support improvement teams and consider the four categories of team coaching actions. A structured team coaching model that offers needed encouragement to keep the team energized, seems to support health care improvement. [ABSTRACT FROM AUTHOR]

The article presents information on the development cystic fibrosis (CF) patients and family member experience of care survey. Individuals with CF is confronted with various health concerns such as poor growth, chronic infection and inflammation of the airways. Important issues that was covered in the survey sponsored by CF Foundation include infection control, treatment burden, depression and anxiety. The survey was headed by Dartmouth Institute for Health Policy and Clinical Practice.

The article presents a study on the essential properties affecting the feed forward systems (FFS) in the U.S. and Sweden. It notes on the use of quantitative and qualitative data in identifying and confirming the perspective of consumer and health care provider on the acceptance, use, and utility of FFS. It asserts on the spread of FFS to achieve patient-centered care and to improve clinical information as well as quality management.

Plan-do-study-act (PDSA) quality improvement is the application of the scientific method to implement and test the effects of change ideas on the performance of the health care system. Users of quality improvement could benefit with markers to gauge the "best" science. Four core questions can determine the value of a quality improvement study: Is the quality improvement study pertinent and relevant? Are the results valid? Are appropriate criteria used to interpret the results? Will the study help you with your practice or organization of care? A set of guidelines is provided to help answer these questions. Similar guidelines exist for randomized clinical trials and clinical-epidemiologic observational studies. Analogous to these existing research guidelines, the PDSA quality improvement guidelines will provide researchers an d reviewers with succinct standards of methodological rigor to assist in critical appraisal of quality improvement protocols an d publications. [ABSTRACT FROM AUTHOR]

• A visual dashboard was co-designed by people living with CF and clinicians to support patient-clinician partnerships. • Two-thirds of people living with CF used the dashboard during a clinic visit, and three-fifths used it outside a clinic visit. • Most people living with CF (92%) used the dashboard to view clinical trends, including their registry data. • Most clinicians (76%) used the dashboard to support visit planning, and view patient concerns and requests. • Embedding data streams within existing information technology tools is critical, and was identified as a theme by each care team. Healthcare coproduction engages patients and clinicians to design and execute services, yet little is known about tools that facilitate coproduction. Our objective was to understand uptake, experiences, benefits, and limitations of a dashboard to support patient-clinician partnerships within the cystic fibrosis (CF) community. People living with CF (PwCF) and clinicians co-designed a dashboard that displayed patient-reported and clinical data. Eight CF programmes, including 21 clinicians, and 131 PwCF participated in a pilot study of the dashboard. We conducted descriptive statistics and thematic analyses of surveys (82 PwCF; 21 clinicians); semi-structured interviews (13 PwCF; 8 care teams); and passively-collected usage data. Two-thirds of the 82 PwCF used the dashboard during a visit, and 59% used it outside a visit. Among 48 PwCF using the dashboard outside the clinic, 92% viewed their health information and 46% documented concerns or requests. Most of the 21 clinicians used the dashboard to support visit planning (76%); fewer used it during a visit (48%). The dashboard supported discussions of what matters most (69% PwCF; 68% clinicians). Several themes emerged: access to patient outcomes data allows users to learn more deeply; participation in pre-visit planning matters; coproduction is made possible by inviting new ways to partner; and lack of integration with existing information technology (IT) systems is limiting. A dashboard was feasible to implement and use. Future iterations should provide patients access to their data, be simple to use, and integrate with IT systems in use by clinicians and PwCF. [ABSTRACT FROM AUTHOR]

Background: New opportunities to record, collate, and analyze routine patient data have prompted optimism about the potential of learning health systems. However, real-life examples of such systems remain rare and few have been exposed to study. We aimed to examine the views of design stakeholders on designing and implementing a US-based registry-enabled care and learning system for cystic fibrosis (RCLS-CF).Methods: We conducted a two-phase qualitative study with stakeholders involved in designing, implementing, and using the RCLS-CF. First, we conducted semi-structured interviews with 19 program personnels involved in design and delivery of the program. We then undertook 11 follow-up interviews. Analysis of interviews was based on the constant comparative method, supported by NVivo software.Results: The organizing principle for the RCLS-CF was a shift to more partnership-based relationships between patients and clinicians, founded in values of co-production, and facilitated by technology-enabled data sharing. Participants proposed that, for the system to be successful, the data it collects must be both clinically useful and meaningful to patients and clinicians. They suggested that the prerequisites included a technological infrastructure capable of supporting data entry and joint decision-making in an accessible way, and a set of social conditions, including willingness from patients and clinicians alike to work together in new ways that build on the expertise of both parties. Follow-up interviews highlighted some of the obstacles, including technical challenges and practical constraints on refiguring relationships between clinicians and patients.Conclusions: The values and vision underlying the RCLS-CF were shared and clearly and consistently articulated by design stakeholders. The challenges to realization were often not at the level of principle, but were both practical and social in character. Lessons from this study may be useful to other systems looking to harness the power of "big data" registries, including patient-reported data, for care, research, and quality improvement. [ABSTRACT FROM AUTHOR]

Background: Palliative care offers an approach to the care of people with serious illness that focuses on quality of life and aligning care with individual and family goals, and values in the context of what is medically achievable. Objective: Measurement of the impact of palliative care is critical for determining what works for which patients in what settings, to learn, improve care, and ensure access to high value care for people with serious illness. Methods: A learning health system that includes patients and families partnering with clinicians and care teams, is directly linked to a registry to support networks for improvement and research, and offers an ideal framework for measuring what matters to a range of stakeholders interested in improving care for this population. Measurements: Measurement focuses on the individual patient and family experience as the fundamental outcome of interest around which all care delivery is organized. Results: We describe an approach to codesigning and implementing a palliative care registry that functions as a learning health system, by combining patient and family inputs and clinical data to support person-centered care, quality improvement, accountability, transparency, and scientific research. Discussion: The potential for a palliative care learning health system that, by design, brings together enriched information environments to support coproduction of healthcare and facilitated peer networks to support patients and families, collaborative clinician networks to support palliative care program improvement, and collaboratories to support research and the application of research to benefit individual patients is immense. [ABSTRACT FROM AUTHOR]

Background: There is a distinct difference between what we know and what we do in healthcare: a gap that is impairing the quality of the care and increasing the costs. Quality improvement efforts have been made worldwide by learning collaboratives, based on recognized continual improvement theory with limited scientific evidence. The present study of 132 quality improvement projects in Norway explores the conditions for improvement from the perspectives of the frontline healthcare professionals, and evaluates the effectiveness of the continual improvement method.Methods: An instrument with 25 questions was developed on prior focus group interviews with improvement project members who identified features that may promote or inhibit improvement. The questionnaire was sent to 189 improvement projects initiated by the Norwegian Medical Association, and responded by 70% (132) of the improvement teams. A sub study of their final reports by a validated instrument, made us able to identify the successful projects and compare their assessments with the assessments of the other projects. A factor analysis with Varimax rotation of the 25 questions identified five domains. A multivariate regression analysis was used to evaluate the association with successful quality improvements.Results: Two of the five domains were associated with success: Measurement and Guidance (p = 0.011), and Professional environment (p = 0.015). The organizational leadership domain was not associated with successful quality improvements (p = 0.26).Conclusion: Our findings suggest that quality improvement projects with good guidance and focus on measurement for improvement have increased likelihood of success. The variables in these two domains are aligned with improvement theory and confirm the effectiveness of the continual improvement method provided by the learning collaborative. High performing professional environments successfully engaged in patient-centered quality improvement if they had access to: (a) knowledge of best practice provided by professional subject matter experts, (b) knowledge of current practice provided by simple measurement methods, assisted by (c) improvement knowledge experts who provided useful guidance on measurement, and made the team able to organize the improvement efforts well in spite of the difficult resource situation (time and personnel). Our findings may be used by healthcare organizations to develop effective infrastructure to support improvement and to create the conditions for making quality and safety improvement a part of everyone's job. [ABSTRACT FROM AUTHOR]

Background: Little is known about the organization of clinical services for Huntington's disease (HD). Objective: To describe how health care services are organized and delivered in HD-clinics taking part in or eligible for the Enroll-HD study. Methods: In 2014, a 69-item survey was administered to sites taking part in or eligible for the Enroll-HD study. Results: Of 231 sites surveyed, 121 (52.2%) sites in Europe, North America, Latin America, and Oceania responded. Most sites in the sample serve large populations, with 61.1% serving more than 1.5 million people, and a further 33% serving >500,000. Almost all (86.0%) centers see patients from outside their region. The majority of centers (59.7%) follow 50-199 patients, 21.9% care for more than 200. Most centers provide care in all stages of HD, and nearly all review pre-symptomatic cases. Multidisciplinary case reviews are offered in 54.5% of sites, with outreach clinics offered by 48.1%.Videoconferencing and telemedicine are used by 23.6%. Separate consultations for caregivers are offered in more than half of the centers. Most centers (70.4%) report following published guidelines or local care pathways for HD. Conclusions: Most centers serve a large population and use a multidisciplinary approach. The survey gives insight into factors underpinning HD service delivery globally. There is a need for more in-depth studies of clinical practice to understand how services are organized and how such features may be associated with quality of care. [ABSTRACT FROM AUTHOR]

Objective: To develop and validate an instrument for guidance and evaluation of quality and safety improvement efforts in health care. Context: The instrument is based on the Plan-Do-Study-Act cycle and the 3 fundamental improvement questions regarding aims, measurement, and change-making. Methods: An interdisciplinary team of improvement experts developed the Change Process and Outcome (CPO) scale. After studying the improvement literature, the scale was tested and refined on a sample of 5 projects. The CPO evaluation process and classification system was developed when evaluating 189 of the quality improvement projects of the Norwegian Medical Association by their final reports. The scale was validated by applying statistical testing to the evaluation results. Results: The final CPO scale consists of 13 process items and 7 outcome items. Interrater reliability ranged from 0.53 to 0.79, and test-retest reliability was 0.82. Factor analyses with Varimax rotation identified 2 significant process domains: Aims/change-making and Measurement/reporting, with Cronbach a values 0.88 and 0.95, respectively. The classification system produced 3 performance levels: successful, promising, and uncertain. Conclusion: The CPO scale shows good internal consistency, reliability, and validity for evaluating the success of quality improvement initiatives. [ABSTRACT FROM AUTHOR]

This cross-site comparison of the early experience of four provider organizations participating in the Brookings-Dartmouth Accountable Care Organization Collaborative identifies factors that sites perceived as enablers of successful ACO formation and performance. The four pilots varied in size, with between 7,000 and 50,000 attributed patients and 90 to 2,700 participating physicians. The sites had varying degrees of experience with performance-based payments; however, all formed collaborative new relationships with payers and created shared savings agreements linked to performance on quality measures. Each organization devoted major efforts to physician engagement. Policy makers now need to consider how to support and provide incentives for the successful formation of multipayer ACOs, and how to align private- sector and CMS performance measures. Linking providers to learning networks where payers and providers can address common technical issues could help. These sites' transitions to the new payment model constitutes an ongoing journey that will require continual adaptation in the structure of contracts and organizational attributes. [ABSTRACT FROM AUTHOR]

Context: It is widely hoped that accountable care organizations (ACOs) will improve health care quality and reduce costs by fostering integration among diverse provider groups. But how do implementers actually envision integration, and what will integration mean in terms of managing the many social identities that ACOs bring together? Methods: Using the lens of the social identity approach, this qualitative study examined how four nascent ACOs engaged with the concept of integration. During multiday site visits, we conducted interviews (114 managers and physicians), observations, and document reviews. Findings: In no case was the ACO interpreted as a new, overarching entity uniting disparate groups; rather, each site offered a unique interpretation that flowed from its existing strategies for social-identity management: An independent practice association preserved members' cherished value of autonomy by emphasizing coordination, not 'integration'; a medical group promoted integration within its employed core, but not with affiliates; a hospital, engaging community physicians who mistrusted integrated systems, reimagined integration as an equal partnership; an integrated delivery system advanced its careful journey towards intergroup consensus by presenting the ACO as a cultural, not structural, change. Conclusions: The ACO appears to be a model flexible enough to work in synchrony with whatever social strategies are most context appropriate, with the potential to promote alignment and functional integration without demanding common identification with a superordinate group. 'Soft integration' may be a promising alternative to the vertically integrated model that, though widely assumed to be ideal, has remained unattainable for most organizations. [ABSTRACT FROM AUTHOR]

The article comments on the need for the health care industry to transform from cottage industry to postindustrial care to revolutionize health care delivery in the U.S. According to the authors, the transformation will be made by integrating the elements of standardizing care, measuring performance, and transparent reporting. They stress the importance of delivering evidence-based care to achieve this goal. This initiative will both benefit the patients and the physician's practice.

Purpose Our purpose is to describe how coaches who are clinical faculty help in the developmental process of residents to become better physicians and to lead the improvement of quality and safety in the Dartmouth-Hitchcock Leadership Preventive Medicine Residency Program (DHLPMR). Methods Using a semi-structured interview guide, eight coaches were interviewed and two focus groups were held with a total of nine residents. The qualitative data were content analysed to understand how both the coaches and residents perceive coaches' work and their role. Results The interviews with the coaches suggest that they take great pride in their work: they find it to be challenging and meaningful. The coaches use various skills and techniques - asking questions, listening deeply, observing the resident in action, offering encouragement and challenging the resident to think or act differently. The residents also perceive the work of the coach to help them progress on their learning journey. The role of the coach tends to go beyond coaching residents relative to improving an aspect of health care performance to creating the conditions for transformation and growth for the residents and the coaches. Conclusion The DHLPMR program is a unique residency program that has the intention to foster the development of future physician leaders who have the ability to both practise medicine and improve the clinical practices in which they work. The coaches are a vital ingredient in this program as they convey the residents/fellows on their leadership learning journey. [ABSTRACT FROM AUTHOR]

Purpose: To identify and synthesize characteristics of successful data-driven Quality improvement learning collaboratives (QILCs) in the United States and Europe, and to extend previously discussed and newly identified guidelines for developing successful data-driven QILCs across health care settings and systems. Methods: An interview guide of open-ended questions was developed and posed to 18 key informants of various disciplines involved in the development and implementation of successful QILCs across 10 organizations in 3 countries. Aspects of successful QILCs were analyzed to identify patterns emerging from structure-process interactions between complex health care systems. Results: Shared patterns of successful collaboratives included cultivating trust, attendance to the human dimension, nonlinear development, attendance to organizational culture, integrated philosophy of quality improvement, and a focus on process and outcome measurement to drive change. This study extends the knowledge base through synthesis of findings from previous quality improvement research with the findings from this study to develop guidelines for establishing and developing successful QILCs. Conclusions: The core characteristics identified in this study were critical to successful collaboration when these approaches were used in the contexts identified. The intrinsic complexity of QILCs requires that effectiveness studies employ qualitative as well as quantitative methodologies. [ABSTRACT FROM AUTHOR]

BACKGROUND Abusive relationships are associated with several demographic factors and many clinical problems in women. However, practices often do not screen for abuse. METHODS This is a descriptive study of 1526 women aged 19 to 69 years who completed a health survey in 31 office practices. The 53-item survey included a question designed to screen for an abusive relationship. Our analysis compared self-reported measures of symptoms (N=13) and functional limitations (n=6) of women who had abusive relationships with those who did not. We also examined the utility of using a constellation of clinical problems to identify risk for abuse. RESULTS Women in abusive relationships were more likely to be poor (37% vs 14%; P < .001) and young (87% were younger than 51 years versus 69% of those who were not in such relationships; P < .001). They had twice as many bothersome symptoms (3.1 vs 1.7; P < .001) and functional problems (1.6 vs 0.8; P < .001). Approximately 40% (36/89) of low-income women with emotional problems were at risk for abuse versus only 6% (64/1025) of women with adequate financial resources and no emotional problems. However, because so many women were at low risk, almost twice as many in this group (n=64) reported abusive relationships than in the high-risk group (n=36). CONCLUSIONS Women in abusive relationships have many symptoms and functional limitations. However, symptoms and clinical problems provide insufficient clues for abuse. It is better just to ask. A single-item screening question appears adequate for this purpose. [ABSTRACT FROM AUTHOR]

Describes the development of The Spine Center, an ambulatory clinical practice for diagnosis and treatment of spine-related problems, and summarizes the first year of operations. History of the Spine Center initiative; Mission of the center; Creation of a high performing microsystem at the center; Integration of data collection into clinical care processes.

Cites the application of methods for monitoring the results of medical care. Determination of variations in patient outcomes; Differences in system of care, clinician specialty and clinician's interpersonal styles; Development of practical tools for the routine monitoring of patient outcomes; Physical, social and role functioning of patients.