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Quality of Care/Patient Safety

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Organizational culture and leadership, as well as medical informatics, play important roles in quality improvement

In a recent article introducing a journal issue on quality improvement, Carolyn M. Clancy, M.D., Director of the Agency for Healthcare Research and Quality, underscores the importance of organizational culture and leadership in improving quality of care. In a second paper, Dr. Clancy and Eduardo Ortiz, M.D., M.P.H., of AHRQ's Center for Primary Care Research, describe AHRQ's information technology initiatives to improve patient safety and promote quality improvement. A third AHRQ-supported study (HS06284) demonstrates that embedding clinical guidelines in an electronic medical record can improve documentation of care, quality of care, and patient satisfaction. These papers are briefly discussed here.

Clancy, C. (2003, April). "Quality improvement: Getting to how." Health Services Research 38(2), pp. 509-513.

In this introductory article, Dr. Clancy notes that public reports of clinical performance and patients' experiences of care have been developed and implemented widely. Several initiatives have begun or are on the horizon: mandatory reporting of nursing home performance, voluntary reporting for hospital performance, and products of the National Quality Forum's consensus development process. AHRQ and the Department of Health and Human Services will publish annual reports on the quality of health care and disparities in care starting in 2003.

However, transparency in the form of public performance reports is merely a first step in addressing the quality chasm. Research that clarifies how these reports can be used to generate widespread improvements is urgently needed, asserts Dr. Clancy. She addresses some key findings of four articles on this topic that appear in the same journal issue. These findings suggest that the path from hospital or nursing home report cards to improved care and outcomes involves multiple actors in addition to clinicians, and close attention to dimensions of organizational context, which have been challenging to elucidate. The findings also highlight the need to understand the balance between public reports, internal improvement, and the use of research skills and methods to motivate and understand change, not just describe it.

Reprints (AHRQ Publication No. 03-R041) are available from the AHRQ Publications Clearinghouse.

Ortiz, E., and Clancy, C.M. (2003, April). "Use of information technology to improve the quality of health care in the United States." Health Services Research 38(2), pp. xi-xxii.

As early as 1969, AHRQ funded its first project in medical informatics. Since then, the Agency has continued to support information technology (IT) research and development projects to improve health care, awarding $250 million to fund more than 150 projects in medical informatics. Currently funded Clinical Informatics to Promote Patient Safety (CLIPS) projects range from use of a real-time, point-of-care, handheld computerized decision support module used in the treatment of attention-deficit/hyperactivity disorder in children to a project that explores the relationship between human, machine, and environmental factors associated with the operation of infusion devices (e.g., intravenous pumps) in clinical settings.

AHRQ's Integrated Delivery System Research Network comprises nine partners that provide health care services to more than 55 million people and is an ideal way to study how IT can improve health care in diverse settings. For example, two network partners are studying how automated electronic reminders affect compliance with recommended guidelines for managing patients with diabetes.

Many of AHRQ's 36 Primary Care Practice-Based Research Networks (PBRNs) received recent awards to support their IT infrastructure and to evaluate ways of using IT to improve patient safety, quality of care, and bioterrorism preparedness. For instance, one PBRN is testing an Internet-based communication, surveillance, and data management system to enhance linkages between community practices, State health departments, and the State Epidemiological and Bioterrorism Surveillance System.

In its 13 new projects, AHRQ's Translating Research into Practice (TRIP) program emphasizes the use of IT as a key strategy for translating research findings into practice and improving quality of care. For instance, one group of investigators is using an interactive, multimedia computer program to improve diabetes-related knowledge, attitudes, self-efficacy, and compliance with self-care recommendations in clinics serving predominantly black and Hispanic patients. The Agency is also developing a variety of strategic partnerships to develop IT solutions that improve medical care.

Reprints (AHRQ Publication No. 03-R044) are available from the AHRQ Publications Clearinghouse.

Buller-Close, K., Schriger, D.L., Baraff, L.J., and others (2003, May). "Heterogeneous effect of an emergency department expert charting system." Annals of Emergency Medicine 41(5), pp. 644-652.

This study found that an electronic medical record, which provides real-time advice based on clinical guidelines embedded in the software, can improve emergency department (ED) care documentation, patient care, and patient satisfaction. The researchers compared the impact on documentation, patient care, and patient satisfaction of three different modules of the Emergency Department Expert Charting system: occupational exposure to blood and body fluids, low back pain, and fever in children younger than age 3 in a university hospital ED.

Documentation of care improved significantly for all three complaint areas with use of the expert charting system. The expert system consistently improved the appropriateness of diagnostic testing and treatment decisions for patients with occupational exposure to blood and body fluids, while decreasing median charges by $103. The low back pain and fever in children modules had less consistent improvements in appropriateness of testing and treatment and did not result in a decrease in charges.

Although 60 percent of physicians believed that the occupational exposure module surpassed standard care in ensuring that the correct tests and treatments were provided, only 31 percent felt that way for low back pain and 22 percent for fever in children. Physicians most used and were most satisfied with the occupational exposure module and least satisfied with the fever in children module. For all complaints, mean patient satisfaction was highest during use of the expert charting system.

In conclusion, the researchers note that the effect of the guideline/computer system varies with the complaint. They caution that "one size does not fit all" when it comes to modifying physician behavior. In other words, there is no one way to improve and/or standardize care. Instead, each clinical situation requires specific engineering that considers the clinical setting, the types of providers, and the clinical problem being addressed.

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