An observational study of the effectiveness of practice guideline implementation strategies examined according to physicians' cognitive styles

Abstract Background Reviews of guideline implementation recommend matching strategies to the specific setting, but provide little specific guidance about how to do so. We hypothesized that the highest level of guideline-concordant care would be achieved where implementation strategies fit well with physicians' cognitive styles. Methods We conducted an observational study of the implementation of guidelines for hypertension management among patients with diabetes at 43 Veterans' Health Administration medical center primary care clinics. Clinic leaders provided information about all implementation strategies employed at their sites. Guidelines implementation strategies were classified as education, motivation/incentive, or barrier reduction using a pre-specified system. Physician's cognitive styles were measured on three scales: evidence vs. experience as the basis of knowledge, sensitivity to pragmatic concerns, and conformity to local practices. Doctors' decisions were designated guideline-concordant if the patient's blood pressure was within goal range, or if the blood pressure was out of range and a dose change or medication change was initiated, or if the patient was already using medications from three classes. Results The final sample included 163 physicians and 1,174 patients. All of the participating sites used one or more educational approaches to implement the guidelines. Over 90% of the sites also provided group or individual feedback on physician performance on the guidelines, and over 75% implemented some type of reminder system. A minority of sites used monetary incentives, penalties, or barrier reduction. The only type of intervention that was associated with increased guideline-concordant care in a logistic model was barrier reduction (p < 0.02). The interaction between physicians' conformity scale scores and the effect of barrier reduction was significant (p < 0.05); physicians ranking lower on the conformity scale responded more to barrier reduction. Conclusion Guidelines implementation strategies that were designed to reduce physician time pressure and task complexity were the only ones that improved performance. Education may have been necessary but was clearly not sufficient, and more was not better. Incentives had no discernible effect. Measurable physician characteristics strongly affected response to implementation strategies.http://deepblue.lib.umich.edu/bitstream/2027.42/112690/1/13012_2006_Article_70.pd

Changing Clinicians' Behaviors in an Academic Medical Center: Does Institutional Commitment to Total Quality Management Matter?

The purpose of this project was to determine whether changing clinicians' behaviors to reduce costs in a large academic medical center is facilitated by the prior existence of a total quality management program. Ten teams, made up primarily of clinicians, were charged with devising strategies for altering specific clinical behaviors to reduce costs without detriment to quality of care. Half the teams followed the center's total quality management approach. Team success was assessed by how well three key tasks were completed: problem definition, design of plan of action, and plan implementation. Two teams achieved outright success es, three had outright failures, and five were in between. Adherence to a total quality management approach was not found to be associated with team suc cess. A much better predictor of success was the level of involvement and support by clinicians and managers; because that factor is largely controlled by institution al incentives, those incentives may need to be realigned before the effectiveness of a total quality management approach can be properly evaluated.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/67013/2/10.1177_0885713x9701200102.pd

Determinants and Effects of Organizational Strategies of Control Directed At Quality of Care in Organized Ambulatory Care Settings.

A commonly used method for evaluating the quality of medical care services is to determine whether certain representative or critical clinical tasks and procedures were performed (for example, whether the patient's blood pressure was measured and recorded at a hypertension follow-up visit). When deficiencies using this assessment method are found in a clinic, the clinic chief and others responsible for overseeing the delivery of health services can be expected to consider taking administrative actions to correct the deficiency, as well as to prevent other, similar deficiencies from occurring. However, little is currently known about the effectiveness of such administrative actions and policies. This study was conducted to determine how and to what extent the performance of selected clinical tasks in outpatient clinics is affected by organizational "strategies of control," that is, administrative policies and practices designed to ensure that a given task, or a category of tasks, is performed. The design of the study incorporates concepts and hypotheses drawn from the organization theory literature about the relation between technology, structure, and performance. The specific objective of the study was to determine: (1) what factors influence the selection of strategies of control directed at the performance of given tasks, and (2) to what extent performance or nonperformance of clinical tasks is influenced by congruence, or "consonance," between, on one h and , strategies of control directed at task performance and , on the other, the characteristics of the task and the attitudes of the clinic's staff about the strategies themselves. The study focused on eleven clinical tasks associated with five common conditions or diagnoses in internal medicine, gynecology, and pediatrics. Data were obtained from sixteen outpatient clinics in five delivery sites located in two counties in the Midwest. Task performance data, obtained from another, concurrent study on the assessment of ambulatory care, were supplemented with interviews of clinical personnel to obtain information on the presence of organizational strategies of control and on staff attitudes about strategies of control and about the tasks themselves. The strategies of control directed at tasks fell into two categories: (1) bureaucratic strategies of control (including "reminder" forms, explicit policies, and assignment of task performance to a specific person), and (2) feedback controls (supervision, formal audits, and rewards and disciplinary actions). It was hypothesized that the more a task is routine the more likely it is for bureaucratic strategies of control to be directed at that task; the findings suggest instead that task routineness is a necessary but not sufficient condition for the presence of bureaucratic strategies. Similarly, it was found that the "consonance" or fit between task routineness and bureaucratic strategies is a sufficient but not necessary condition for high performance. That finding is consistent with the notion that, while high performance on routine tasks can be achieved through bureaucratic strategies of control, other factors and mechanisms can yield equally good results for such tasks. No support was found for the hypothesis that the presence of feedback controls is related to the visibility of the task. That result, however, can be attributed to the low variability in the measures used for testing the hypothesis. The attitudes of those who perform tasks and the decisions made by clinic chiefs reflected a strong awareness that bureaucratic strategies of control are appropriate only for routine tasks. At the same time, however, clinic chiefs did not see it as imperative that bureaucratic strategies be directed at every routine task; rather, for such tasks they perceived bureaucratic strategies of control as only one of the optional mechanisms available for achieving high performance.Ph.D.Health care managementUniversity of Michiganhttp://deepblue.lib.umich.edu/bitstream/2027.42/157869/1/8017404.pd

Kidney Transplantation: A Simulation Model for Examining Demand and Supply

In most regions of the United States there is a serious imbalance between the number of kidneys donated for transplantation and the number of persons wishing to receive a transplant. This not only affects the quality of life of those unable to obtain a transplant, but it also has important repercussions on the large and rapidly growing federal expenditures for the treatment of end-stage renal disease by transplantation and dialysis. A simulation model was constructed to assess the impact that changes in the number of cadaveric kidneys donated in Michigan would have on the waiting list of potential kidney transplant recipients in the state. The model represents the process of matching donated kidneys to people on the waiting list, taking into account the compatibility of the donor with the potential recipient's blood type and the tissue compatibility of the recipient to the donor as estimated by cytotoxicity. We describe the structure and data needs of the model, and we discuss the results obtained for Michigan. It was found that, under the current conditions, the waiting list would continue to grow rapidly. The number of donors needed to compensate for this growth would have to be disproportionately large: as the number of donations increases the effect of each donation in reducing the waiting list is less. The approach is applicable to other regions and it should also be adaptable to other types of organ transplants that require tissue compatibility, once such transplants become common enough to warrant regional coordination of the matching of recipients with donors.health care: kidney transplantation, simulation: applications

An observational study of the effectiveness of practice guideline implementation strategies examined according to physicians' cognitive styles

Abstract Background Reviews of guideline implementation recommend matching strategies to the specific setting, but provide little specific guidance about how to do so. We hypothesized that the highest level of guideline-concordant care would be achieved where implementation strategies fit well with physicians' cognitive styles. Methods We conducted an observational study of the implementation of guidelines for hypertension management among patients with diabetes at 43 Veterans' Health Administration medical center primary care clinics. Clinic leaders provided information about all implementation strategies employed at their sites. Guidelines implementation strategies were classified as education, motivation/incentive, or barrier reduction using a pre-specified system. Physician's cognitive styles were measured on three scales: evidence vs. experience as the basis of knowledge, sensitivity to pragmatic concerns, and conformity to local practices. Doctors' decisions were designated guideline-concordant if the patient's blood pressure was within goal range, or if the blood pressure was out of range and a dose change or medication change was initiated, or if the patient was already using medications from three classes. Results The final sample included 163 physicians and 1,174 patients. All of the participating sites used one or more educational approaches to implement the guidelines. Over 90% of the sites also provided group or individual feedback on physician performance on the guidelines, and over 75% implemented some type of reminder system. A minority of sites used monetary incentives, penalties, or barrier reduction. The only type of intervention that was associated with increased guideline-concordant care in a logistic model was barrier reduction (p Conclusion Guidelines implementation strategies that were designed to reduce physician time pressure and task complexity were the only ones that improved performance. Education may have been necessary but was clearly not sufficient, and more was not better. Incentives had no discernible effect. Measurable physician characteristics strongly affected response to implementation strategies.</p

An observational study of the effectiveness of practice guideline implementation strategies examined according to physicians' cognitive styles-0

<p><b>Copyright information:</b></p><p>Taken from "An observational study of the effectiveness of practice guideline implementation strategies examined according to physicians' cognitive styles"</p><p>http://www.implementationscience.com/content/2/1/41</p><p>Implementation science : IS 2007;2():41-41.</p><p>Published online 1 Dec 2007</p><p>PMCID:PMC2219964.</p><p></p