Research Article |
Improving Quality in Primary Care: A Model for Change
Author(s) : Dr. Jose A. PonceVega and Dr. Irene A. Williams
Publisher : FOREX Publication
Published : 10 September 2021
e-ISSN : 2347-4696
Page(s) : 320-329
Abstract
Health care spending accounts for 17.7% of the gross domestic product in the United States, and it is expected to continue rising at an annual rate of 5.3%. Despite high costs, health care quality lags behind other high-income countries; yet, over 70% of change initiatives fail. The purpose of this multiple case study was to explore strategies primary care leaders use for implementing quality improvement initiatives to improve patient outcomes and reduce waste in primary care facilities. The target population consisted of 3 health care leaders of 3 primary care facilities in southern California who successfully implemented quality improvement initiatives. The conceptual framework for this study was Kotter’s 8-step of change management. Data were collected through face-to-face semi-structured interviews with senior health care leaders, document review, and quality reports. Patterns were identified through a rigorous process of data familiarization, data coding, and theme development and revision. Interpretations from the data were subjected to member-checking to ensure trustworthiness of the findings. Four themes emerged from this study: communication, leadership support, inclusive decision-making, and employee recognition.
Keywords: Health care
, Primary care
, Quality
, Quality improvement
, Change management
Dr. Jose A. PonceVega ,College of Management and Technology, Walden University, Minneapolis, Minnesota, USA ; Email: joseponcevega@gmail.com
Dr. Irene A. Williams ,College of Management and Technology, Walden University, Minneapolis, Minnesota, USA
[1] Lee, V. S., Kawamoto, K., Hess, R., Park, C., Young, J., et al. (2016). Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality. Journal of American Medical Association, 316, 1061-1072. [Cross Ref]
[2] Martin, A. B., Hartman, M., Benson, J., & Catlin, A. (2016). National health spending in 2014: Faster growth driven by coverage expansion and prescription drug spending. Health Affairs, 35, 150-160. [Cross Ref]
[3] Riggs, K. R. (2015). The health care “iron triangle.” Cleveland Clinic Journal of Medicine, 82, 332.
[4] Donnelly, L. F. (2017). Avoiding failure: Tools for successful and sustainable quality-improvement projects. Pediatric Radiology, 47, 793-797. [Cross Ref]
[5] Longenecker, C. O., & Longenecker, P. D. (2014). Why hospital improvement efforts fail: A view from the front line. Journal of Healthcare Management / American College of Healthcare Executives, 59, 147-157. [Cross Ref]
[6] Silver, S. A., McQuillan, R., Harel, Z., Weizman, A. V, Thomas, A., et al. (2016). How to sustain change and support continuous quality improvement. Clinical Journal of the American Society of Nephrology, 11, 916-924.[Cross Ref]
[7] Center for Disease Control and Prevention. (2016). National Ambulatory Medical Care Survey: 2014 State and National Summary Tables.
[8] Williamsson, A., Eriksson, A., & Dellve, L. (2016). Organization of change agents during care process redesign in Swedish health care. Journal of Hospital Administration, 5(3), 20-32. [Cross Ref]
[9] Kotter, J. P. (1995). Leading change: Why transformation efforts fail. Harvard Business Review, 2, 59-67.
[10] Burden, M. (2016). Using a change model to reduce the risk of surgical site infection. British Journal of Nursing, 25, 949-954. [Cross Ref]
[11] Pollack, J., & Pollack, R. (2015). Using Kotter’s eight stage process to manage an organisational change program: Presentation and practice. Systemic Practice and Action Research, 28, 51-66. [Cross Ref]
[12] Hughes, M. (2016). Leading changes: Why transformation explanations fail. Leadership, 12, 449-469. [Cross Ref]
[13] Tolk, J. N., Cantu, J., & Beruvides, M. (2015). High reliability organization research: A literature review for health care. Engineering Management Journal, 27, 218-237. [Cross Ref]
[14] Chassin, M. R., & Loeb, J. M. (2013). High-reliability health care: Getting there from here. Milbank Quarterly, 91, 459-490. [Cross Ref]
[15] Vogus, T. J., & Iacobucci, D. (2016). Creating highly reliable health care: How reliability-enhancing work practices affect patient safety in hospitals. Industrial and Labor Relations Review, 69, 911-938. [Cross Ref]
[16] Griffith, J. R. (2015). Understanding high-reliability organizations: Are Baldrige recipients models? Journal of Healthcare Management, 60, 44-61. [Cross Ref]
[17] Fleiszer, A. R., Semenic, S. E., Ritchie, J. A., Richer, M. C., & Denis, J. L. (2015). The sustainability of healthcare innovations: A concept analysis. Journal of Advanced Nursing, 71, 1484-1498. [Cross Ref]
[18] Edwards, S. T., Bitton, A., Hong, J., & Landon, B. E. (2014). Patient-centered medical home initiatives expanded in 2009-2013: Providers, patients, and payment incentives increased. Health Affairs, 33, 1823-1831. [Cross Ref]
[19] Van Loenen, T., Faber, M. J., Westert, G. P., & Van Den Berg, M. J. (2016). The impact of primary care organization on avoidable hospital admissions for diabetes in 23 countries. Scandinavian Journal of Primary Health Care, 34, 5-12. [Cross Ref]
[20] Bodenheimer, T., Ghorob, A., Willard-Grace, R., Grumbach, K., & Care, U. C. (2014). The 10 building blocks of primary care forming stable teamlets. Annals of Family Medicine, 12, 166-171. [Cross Ref]
[21] Abrams, M., Nuzum, R., Zezza, M., Ryan, J., Kiszla, J., et al. (2015). The Affordable Care Act’s payment and delivery system reforms: A progress report at five years. Issue Brief (Commonwealth Fund), 12, 1-16. [Cross Ref]
[22] Simou, E., Pliatsika, P., Koutsogeorgou, E., & Roumeliotou, A. (2015). Quality indicators for primary health care: A systematic literature review. Journal of Public Health Management and Practice, 21(5), E8–E16. [Cross Ref]
[23] van den Driessen Mareeuw, F. A., Hollegien, M. I., Coppus, A. M. W., Delnoij, D. M. J., & De Vries, E. (2017). In search of quality indicators for Down syndrome healthcare: A scoping review. BMC Health Services Research, 17, 284-297. [Cross Ref]
[24] Harris, S. B., Green, M. E., Brown, J. B., Roberts, S., Russell, G., et al. (2015). Impact of a quality improvement program on primary healthcare in Canada: A mixed-method evaluation. Health Policy, 119, 405-416. [Cross Ref]
[25] Sibthorpe, B., Agostino, J., Coates, H., Weeks, S., Lehmann, D., et al. (2017). Indicators for continuous quality improvement for otitis media in primary health care for Aboriginal and Torres Strait Islander children. Australian Journal of Primary Health, 23, 1-9. [Cross Ref]
[26] Young, R. A., Roberts, R. G., & Holden, R. J. (2017). The challenges of measuring, improving, and reporting quality in primary care. Annals of Family Medicine, 15(2), 175-182. [Cross Ref]
[27] Saust, L. T., Monrad, R. N., Hansen, M. P., Arpi, M., & Bjerrum, L. (2016). Quality assessment of diagnosis and antibiotic treatment of infectious diseases in primary care: A systematic review of quality indicators. Scandanavian Journal of Primary Health Care, 34, 258-266. [Cross Ref]
[28] Pavlič, D. R., Sever, M., Klemenc-Ketiš, Z., & Švab, I. (2015). Process quality indicators in family medicine: results of an international comparison. BMC Family Practice, 16(172), 1-11. [Cross Ref]
[29] Manzoli, L., Flacco, M. E., De Vito, C., Arcà, S., Carle, F., et al. (2014). AHRQ prevention quality indicators to assess the quality of primary care of local providers: A pilot study from Italy. European Journal of Public Health, 24, 745-750. [Cross Ref]
[30] Grace, S. L., Poirier, P., Norris, C. M., Oakes, G. H., Somanader, D. S., et al. (2014). Pan-Canadian development of cardiac rehabilitation and secondary prevention quality indicators. Canadian Journal of Cardiology, 30, 945-948. [Cross Ref]
[31] Rinke, M. L., Abdullah, F., Colantuoni, E., Zhang Y., Miller R., M., et al. (2015). State-mandated hospital infection reporting is not associated with decreased pediatric health care-associated infections. Journal of Patient Safety, 11, 123-134. [Cross Ref]
[32] Trivedi, A. N., Wilson, I. B., Charlton, M. E., & Kizer, K. W. (2016). Agreement between HEDIS performance assessments in the VA and Medicare Advantage: Is quality in the eye of the beholder? A Journal of Medical Care Organization, Provision and Financing, 53, 1-3. [Cross Ref]
[33] Hu, J., Schreiber, M., Jordan, J., George, D. L., & Nerenz, D. (2018). Associations between community sociodemographics and performance in HEDIS quality measures: A study of 22 medical centers in a primary care network. American Journal of Medical Quality, 33, 5-13. [Cross Ref]
[34] Harris, A., Ellerbe, L., Phelps, T. E., Finney, J. W., Bowe, T., et al. (2015). Examining the specification validity of the HEDIS quality measures for substance use disorders. Journal of Substance Abuse Treatment, 53, 16-21. [Cross Ref]
[35] Robst, J., Rost, K., & Marshall, D. (2013). Do employers know the quality of health care benefits they provide? Use of HEDIS depression scores for health plans. Psychiatric Services, 64, 1134-1139. [Cross Ref]
[36] DeVoe, J. E., Huguet, N., Likumahuwa-Ackman, S., Angier, H., Nelson, C., et al. (2015). Testing health information technology tools to facilitate health insurance support: A protocol for an effectiveness-implementation hybrid randomized trial. Implementation Science, 10, 1-9. [Cross Ref]
[37] Pawlson, L. G., Scholle, S. H., & Powers, A. (2007). Comparison of administrative-only versus administrative plus chart review data for reporting HEDIS hybrid measures. American Journal of Managed Care, 13, 553-558.
[38] National Committee for Quality Assurance. (2018). HEDIS 2018 Measures.
[39] Rosenthal, M., Sinaiko, A., Eastman, D., Chapman, B., & Partridge, G. (2015). Impact of the Rochester medical home inititiative on primary care practices, quality, utilization, and costs. Medical Care, 53, 967-973. [Cross Ref]
[40] Harvey, G., & Lynch, E. (2017). Enabling continuous quality improvement in practice: The role and contribution of facilitation. Frontiers in Public Health, 5, 1-5. [Cross Ref]
[41] Quraishi, J., & Jordan, L. (2015). Quality and performance measurement: National efforts to improve quality of care through measurement development. American Association of Nurse Anesthetists, 82, 184-188.
[42] Abdallah, A. (2014). Implementing quality initiatives in healthcare organizations: Drivers and challenges. International Journal of Health Care Quality Assurance, 27, 166-181. [Cross Ref]
[43] Van der Biezen, M., Derckx, E., Wensing, M., & Laurant, M. (2017). Factors influencing decision of general practitioners and managers to train and employ a nurse practitioner or physician assistant in primary care: A qualitative study. BMC Family Practice, 18, 1-10. [Cross Ref]
[44] Renedo, A., & Marston, C. (2015). Spaces for citizen involvement in healthcare: An ethnographic study. Sociology, 49, 488-504. [Cross Ref]
[45] Solberg, L. I., Crain, a L., Tillema, J. O., Fontaine, P. L., Whitebird, R. R., et al. (2014). Challenges of medical home transformation reported by 118 patient-centered medical home (PCMH) leaders. Journal of the American Board of Family Medicine, 27, 449-457. [Cross Ref]
[46] Basta, Y. L., Zwetsloot, I. M., Klinkenbijl, J. H. G., Rohof, T., Monster, M. M. C., et al. (2016). Decreasing the dispatch time of medical reports sent from hospital to primary care with Lean Six Sigma. Journal of Evaluation in Clinical Practice, 22, 690-698. [Cross Ref]
[47] Ha, C., McCoy, D. A., Taylor, C. B., Kirk, K. D., Fry, R. S., et al. (2016). Using Lean Six Sigma methodology to improve a mass immunizations process at the United States Naval Academy. Military Medicine, 181, 582-588. [Cross Ref]
[48] Scott, C. P. R., Jiang, H., Wildman, J. L., & Griffith, R. (2018). The impact of implicit collective leadership theories on the emergence and effectiveness of leadership networks in teams. Human Resource Management Review 28, 464-481. [Cross Ref]
[49] Hudson, S. M., Hiott, D. B., Cole, J., Davis, R., Egan, B. M., et al. (2014). Increasing capacity for quality improvement in underresourced primary care settings. Quality Management in Health Care, 23, 155-162. [Cross Ref]
[50] Crouzet, B., Parker, D., & Pathak, R. (2014). Preparing for productivity intervention initiatives. International Journal of Productivity and Performance Management, 63, 946-959. [Cross Ref]
[51] Lessard, S., Bareil, C., Lalonde, L., Duhamel, F., Hudon, E., et al. (2016). External facilitators and interprofessional facilitation teams: A qualitative study of their roles in supporting practice change. Implementation Science, 11(97), 1–13. [Cross Ref]
[52] Thomas, P. (2017). Collaborating sites for community-oriented integrated care and health promotion. London Journal of Primary Care, 9, 2-6. [Cross Ref]
[53] Makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the US. British Medical Journal, 353, i2139. [Cross Ref]
[54] Tumele, S. (2015). Case study research. International Journal of Sales, Retailing and Marketing, 4(9), 68-78.
[55] Nelson, J. (2016). Using conceptual depth criteria: Addressing the challenge of reaching saturation in qualitative research. Qualitative Research (Online). [Cross Ref]
[56] Palinkas, L. A., Horwitz, S. M., Green, C. A., Wisdom, J. P., Duan, N., et al. (2015). Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Administration and Policy in Mental Health and Mental Health Services Research, 42, 533-544. [Cross Ref]
[57] Elo, S., Kaariainen, M., Kanste, O., Polkki, T., Utriainen, K., et al. (2014). Qualitative content analysis: A focus on trustworthiness. SAGE Open, 4, 1-10. [Cross Ref]
[58] Malterud, K., Siersma, V. D., & Guassora, A. D. (2015). Sample size in qualitative interview studies: Guided by information power. Qualitative Health Research, 26(3), 1-8. [Cross Ref]
[59] Fugard, A., & Potts, H. (2015). Supporting thinking on sample sizes for thematic analyses: A quantitative tool. International Journal of Social Research Methodology, 18, 669-684. [Cross Ref]
[60] Morse, W. C., Lowery, D. R., & Steury, T. (2014). Exploring saturation of themes and spatial locations in qualitative public participation geographic information systems research. Society & Natural Resources, 27, 557-571. [Cross Ref]
[61] Dennison, L., Morrison, L., Conway, G., & Yardley, L. (2013). Opportunities and challenges for smartphone applications in supporting health behavior change: Qualitative study. Journal of Medical Internet Research, 15, 86.[Cross Ref]
[62] Helmich, E., Boerebach, B. C. M., Arah, O. A., & Lingard, L. (2015). Beyond limitations: Improving how we handle uncertainty in health professions education research. Medical Teacher, 37, 1043-1050. [Cross Ref]
[63] Fleming, N. S., da Graca, B., Ogola, G. O., Culler, S. D., Austin, J., et al. (2017). Costs of transforming established primary care practices to patient-centered medical homes (PCMHs). The Journal of the American Board of Family Medicine, 30, 460-471. [Cross Ref]
[64] Baxter, P., Cleghorn, L., Alvarado, K., Cummings, G., Kennedy, D., et al. (2016). Quality-based procedures in Ontario: Exploring health-care leaders’ responses. Journal of Nursing Management, 24, 50-58. [Cross Ref]
[65] Saruhan, N. (2014). The role of corporate communication and perception of justice during organizational change process. Business and Economics Research Journal, 5, 143-166.
[66] D’Innocenzo, L., Mathieu, J. E., & Kukenberger, M. R. (2016). A meta-analysis of different forms of shared leadership–team performance relations. Journal of Management, 42, 1964-1991. [Cross Ref]
[67] Mathieu, J. E., Tannenbaum, S. I., Donsbach, J. S., & Alliger, G. M. (2014). A review and integration of team composition models: Moving toward a dynamic and temporal framework. Journal of Management, 40, 130-160. [Cross Ref]
[68] Rogiest, S., Segers, J., & van Witteloostuijn, A. (2018). Matchmaking in organizational change: Does every employee value participatory leadership? An empirical study. Scandinavian Journal of Management, 34, 1-8. [Cross Ref]
[69] Downey, S. N., van der Werff, L., Thomas, K. M., & Plaut, V. C. (2015). The role of diversity practices and inclusion in promoting trust and employee engagement. Journal of Applied Social Psychology, 45, 35-44. [Cross Ref]
[70] Ramdhani, A., Ramdhani, M. A., & Ainisyifa, H. (2017). Model conceptual framework of corporate culture influenced on employees commitment to organization. International Business Management, 11, 826-830. [Cross Ref]
[71] Bakotić, D., & Rogošić, A. (2017). Employee involvement as a key determinant of core quality management practices. Total Quality Management and Business Excellence, 28, 1209-1226. [Cross Ref]
[72] Kosfeld, M., Neckermann, S., & Yang, X. (2017). The effects of financial and recognition incentives across work contexts: The role of meaning. Economic Inquiry, 55, 237-247. [Cross Ref]
[73] California Health and Human Services. (2018). 2017 Preliminary Primary Care Clinic Annual Utilization Data.
[74] Park, J., & Park, M. (2016). Qualitative versus quantitative research methods: Discovery or justification? Journal of Marketing Thought, 3(10), 1-7.
[75] McFadden, K. L., Stock, G. N., & Gowen, C. R. (2015). Leadership, safety climate, and continuous quality improvement: Impact on process quality and patient safety. Health Care Management Review, 40, 24–34. [Cross Ref]
Dr. Jose A. PonceVega and Dr. Irene A. Williams (2021), Improving Quality in Primary Care: A Model for Change. IJBMR 9(3), 320-329. DOI: 10.37391/IJBMR.090310.