The implementation of best practices to improve the quality and efficiency of health care involves making changes to both decision-making and care-delivery processes. The care management methods for improving these processes are largely borrowed from the work of Deming, Crosby, Juran, Ishikawa, and other practitioners of industrial process improvement. These methods are alternatively described as Continuous Process Improvement (CQI) and Total Quality Management (TQM). Berwick, James, and others described the adaptation of these methods for health care.
On a practical level, clinicians apply these methods by working with other members of their clinical team to make local improvements, or, in larger health care organizations, by participating in multi-disciplinary teams organized at an organizational level. These teams often require expert consultation in analytical and statistical methods. Statistical process control involves the application of quality engineering concepts to administrative, support and care delivery processes in order to (1) detect changes in process performance over time, (2) identify assignable causes of variation, and (3) adjust relevant process input variables so as to maintain a process performance criterion within a desirable range.
Another implementation approach is staff training or continuing medical education. This involves the development and delivery of classes and organized curricula, with the objective to improve knowledge and skills to increase the effectiveness of clinicians, administrative staff, and support staff. Some training is intended to increase knowledge and skills in process improvement methods, to improve the effectiveness of CQI or TQM teams. Other training is intended to have a more direct effect to improve decision-making and care delivery processes by teaching clinicians about specific diagnosis and treatment strategies. Traditionally, this latter approach has been accomplished through grand rounds and seminars. Another approach, based on methods developed for the marketing of pharmaceuticals and devices, is academic detailing. Academic detailing is a form of educational outreach involving the the personal delivery to clinicians of brief educational messages designed to change clinical practice behaviors.
Another approach to implementation involves patient education. Therefore, the methods of patient education materials development represent an important domain of care management. These methods involve the development and pilot testing of brochures, pamphlets, audio and video tapes, class materials, web-based materials, and other products designed to provide useful and timely information to patients regarding their health. An understanding and appreciation of the principles of adult learning are essential to this process.
Finally, clinical policy implementation requires the effective application of information technology. Medical informatics is the term used to describe the broader field of information technology applications to health and medical care. Managing intranet resources is an emerging methodological domain of care management, involving the development of internal web-based materials, such as a best practices library or a care management support system. Another important medical informatics method involves the development of computer-based decision aids such as reminders, alerts, and prompts. These are incorporated into the electronic health record as well as associated structured data capture into the clinician workstation and other information systems used by care providers as part of routine practice.
A review of rigorous evaluations of clinical policy implementation methods conducted by Grimshaw, et al. revealed the importance of the methods of guideline development, dissemination, and implementation in predicting clinician behavior change (see table below).
Effectiveness of Guideline Development, Dissemination, and Implementation Methods in Terms of Clinician Behavior Change (adapted from Grimshaw, et al)
|Most Effective||Moderately Effective||Least Effective|
|Guideline Development||Internal development||External, local development||National development|
|Guideline Dissemination||Specific educational interventions||Continuing education
|Publication in Journals|
|Guideline Implementation||Patient-specific reminders at the time of the clinical encounter||Feedback measures||General reminders|
In general, multi-faceted implementation approaches have been found to be most effective for improvement processes that involve physician behavior change.
These clinical policy implementation methods are used to effect change in clinical processes. However, many care management initiatives, including those described in this web site, involve the establishment and ongoing management of a new set of resources to support improved clinical processes, including the following:
- Call centers, which receive customer calls and either provides customer service or directs the customer to appropriate staff or resources. Such services may include on-call nurse advice, appointment scheduling, lab result reporting, directions to facilities, billing inquiries, etc.
- Telephone survey and counseling staff make outgoing calls to patients for the purpose of acquiring information from the patient, such as for a health risk appraisal, survey or follow-up call. They also offer information or services to the patient, such as counseling, needs assessment, and patient education.
- Distribution of care management materials, including the management of a mail room and stock room to efficiently route care management materials to patients, including patient educational materials and self care supplies.
- Case managers, typically nurses or other allied health professionals, are required to track patients with defined conditions, assess patient needs, solve problems and deliver other patient services such as counseling, patient education, and social services.
In large health care organizations and health plans, these resources may be developed internally. In small and medium size organizations, these services can be outsourced to a growing number of external service suppliers.