Improving Medical Practice: A Conceptual Framework

Abstract

PURPOSEThe purpose of this article is to produce a relatively simple conceptual framework for guiding and studying practice improvement.METHODS I summarize the lessons from my experience with a variety of quality improvement research studies during the last 30 years, supplemented with relevant literature from both medicine and other industries about the issues associated with successful quality improvement.RESULTS My experience suggests that organizational leadership with an urgent vision for change, ability to manage the change process, and selection of systematic changes capable of fulfi lling the vision are each critical for successful quality improvement. Published literature from other industries emphasizes the importance of a goal-directed change process managed by leaders who recognize the need to engage their employees and other leaders in a disciplined but fl exible way that accommodates external and internal factors and uses teams and group learning. It also suggests the importance of organizational context and the level of external and internal barriers and facilitators for change. The resulting model proposes that priority, change process, and care process content are necessary for measurable improvements in quality of care and patient outcomes, although internal and external barriers must also be attended to and addressed. CONCLUSION This framework may provide a guide to those in the front lines of care who would like to make the care transformations that are needed to greatly improve care. It may also be helpful to those who are developing or testing interventions and recruiting medical practices for such change efforts. INTRODUCTIONC rossing the Quality Chasm, the landmark 2001 report from the Institute of Medicine (IOM), crystallized and dramatized the challenge facing American medicine by pointing out that incremental improvement was inadequate: " [B]etween the health care we have and the care we could have lies not just a gap, but a chasm." 1 This report, along with the earlier IOM report on medical errors, also highlighted the need to change the environment in which health care professionals provide care.2 Both reports clearly recognized the quality chasm as a problem of systems, not people.As with most paradigm shifts, these recommendations didn't come from nowhere. They were built on a growing body of research evidence about the inexplicable geographic variations in care, the inadequate implementation of evidence-based guidelines, and the need to shift from single interventions to change the behavior of individual physicians to focus instead on the practice systems and organizations in which physicians work. [3][4][5][6][7][8] Although there has been slow improvement in care quality, especially for some chronic conditions, the reports have not yet led to the dramatic improvements they called for. I suspect that this lack of improvement is due partly to the time needed for realignment of fi nancial incentives and widespread acceptance of the need for change, and partly to continuing...

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