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Quality Improvement in Primary Care Clinics
In an unstable, hi$ly competitive, a d uncertain environment, change management skih could prove valuuble, perhaps even necessary fbr survival.
Quality Improvement in Primary Care Clinics LUCYROSEFISCHER,PHD LEIFI. SOLBERG,MD THOMAS E. KOTTKE, MD, MSPH
T
he concepts of continuous quality improvement (CQI) and total quality management have been used extensively to improve quality and costefficiency in the production of goods and services. In the past several years, interest in applying quality improvement (QI) initiatives in medical settings has increased in an effort to provide similar benefits to health care.'" However, few scientific studies have tested the effectiveness of such initiatives in any industry. This article presents a qualitative study of primary care clinics participating in the first randomized
controlled trial to evaluate the effectiveness of CQI in primary care-Project IMPROVE.4-6Case studies of a sample of clinics in the IMPROVE trial's intervention arm offered an unusual opportunity to examine the feasibility of applying CQI concepts in primary care medical settings.
Project IMPROVE IMPROVE (IMproving PRevention through Organization, Vision & Empowerment) was a four-year study that was started in July 1993 and designed to
Lucy Rose Fischer, PhD, is Senior Research Investigator, Magnan, MD, Jiom Blue P h , who helped in the overall and Leif I. Solberg, MD, is Clinical Director of Research, coordination of Project IMPROW and contributed to the Healthpartners Research Foundation, Minneapolis, and a design of the case study protocol; Carolyn Calomeni, MS, member of The Joint Commission Journal on Quality Katherine Giles, MA, and Kathleen Conboy, RN,Jiom Improvement j Editorial Advisory Board Thomas E. Kot- Healthpartners, who along with Shirley Conn, RN,from tke, MD, MSPH, is Professor of Medicine, Mayo Clinic, Blue Plus, were core members of the IMPROE research team andprovided data and insightsfar the qualitative study; and Rochester, Minnesota. Thisproject was supported by giantsJiom Group Health Milo Brekke, PhD, and Arnold Kaluzny, PhD, who were Foundation and the Blue Cross and Blue Shield Foundation. consultantsfor Project IMPROW and also provided advice We express our thanks to the six clinics that a p e d to be part and commentayfor the qtutlitative study. The IMPROW project was supported by Grant No. of the case studies and to the team members and other staf who were interviewed and shared their perspectives. Project R01 HS08091 Jiom the Agency far Health Care Policy and IMPROE was successfilly implemented in primary care Research. Please address correspondence to Lucy Rose Fischer, PhD, clinics because of the commitment and hard work of many Research Founddtion, 8100 34th Avenue Healthpartners dedicated p r o f e s o d in each clinic that partz'n'pated in the IMPROE demonstration. We are gmtej%lfor insightsJiom South, PO Box 1309, Minneapolis, M N 55440; phone a number of others, including thef i k i n g researchers: Sanne 612/883-5001; fdx 612/883-5022; e-mail Lucy.R.Fischer @HealthPartners,com. Ccwright Q 1998 by the Jdnt Cornmiasion on kmedkalkm of Healthcare Organizations
test the hypothesis that primary care clinics can increase their preventive service delivery rates by learning and applying CQI concepts to the development of prevention systems. The 44 primary care clinics volunteering to participate in the project were randomly divided into 22 comparison sites (that is, left alone) and 22 sites that received an intervention from the IMPROVE project beginning in September 1994. The intervention consisted of a program of leadership facilitation, training, consultatiop, and networking. Each of these program elements was designed to facilitate a CQI process focused on eight ;P$Ulrpreventive services: mammograms, breast examinations, Papanicolaou (Pap) smears, tobacco use, hypertension, hypercholesterolemia, and influenza and pneumonia shots. These systems generally consisted of methods for consistently identifying the prevention needs of individual patients as they visited the clinic, reminding clinicians about which preventive services each patient needed, and ensuring that those needs were met in a comprehensive way. Two persons (a team leader and a facilitator) Erom each clinic were invited to participate in six group training sessions that lasted four hours each and were conducted during a six-month period. The training consisted of a series of modules to teach the skills and tasks needed to implement an improvement process and develop systematic prevention processes.
During the training process, each team leader and facilitator met biweekly with an interdisciplinary team within their own clinic to define their goals and current process, gather and analyze data on needs and problems, develop and implement systems to increase preventive service delivery rates, and evaluate the systems' effectiveness. Throughout a 2 1-month period, both the clinic and team leaders had access to regular consultation with IMPROVE traihers. In addition, bimonthly networking sessions for team leaders and facilitators offered opportunities to share ideas, materials, and experiences with other clinics participating in the intervention. The intervention was designed as a trainingconsultation model that could be implemented by any external organization (such as a health maintenance organization [HMO] or preferred provider organization) able to help clinics improve their preventive service delivery rates. Each clinic team, although offered substantial information and advice through Project IMPROVE, made its own decisions about how to proceed and what specific form of prevention system to implement."
A Study of Social Change The relatively recent introduction of CQJ into health care settings represents a particular form of social change, This is a process of cultural dz&ion as CQI
'
methods and concepts developed in other settings are subsequently introduced into health care organizati on^.^ Q I constitutes an administrative innovation, which tends to be more difficult to transmit than is technologic change.'zs The CQI process also entails directed innovation. In Project IMPROVE, the process is initiated by an external change agent (the researchconsultation team) that presented a systematic ideology, strategy, and protocol for change.' To date there has been little research on the experience of directed innovation in general and almost no empirical studies on how health care organizations change.lO-l2 This qualitative study of Project IMPROVE was intended to examine the process of change in medical settings and thereby contribute to the research literature on social change and the diffusion of innovation.
Research Questions This study focused on the relationship between the QI process and the external and internal environments of primary care clinics. The study, conducted in a region that has seen an enormous amount of change in both these environments, addresses three specific questions: 1. How does change in the health care environment affect a QI process? 2. How does clinic organization influence a QI process? 3. What is the impact of a QI process on clinic organization?
Method Case studies were conducted in a sample of 6 of the 22 clinics participating in the intervention arm of the IMPROVE trial. The case studies' purpose was to provide a qualitative analysis of theprocess of developing and implementing a CQI process in primary care clinics. Sample. A stratified random sample of intervention clinics was selected for in-depth case studies: three large clinics (employing eight or more physicians) and three small clinics (employing seven or fewer physicians). When one clinic from each size category declined to participate as a case study site because of concern about time demands, two additional names were drawn randomly from the remaining clinics. Characteristics of the six case study clinics are shown in Table 1 (p 364). Project IMPROVE was initiated in September 1994. The case study inter-
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views were conducted from January through June 1996, approximately 16 months later, at a time when most of the clinics had already implemented systems for improving prevention services. Data. The case study data consisted of results of open-ended interviews with "informants" and observations of CQI team meetings. The informants included two to four members of each CQI team plus other non-team members knowledgeable about the project. Altogether, 30 interviews were conducted with clinic staff, and five team meetings were observed from January through June 1996. Detailed notes were transcribed for each interview and meeting observation. The interviews, each approximately 30-45 minutes long, examined the process of participating in this QI initiative, focusing on informants' accounts of the history of the clinic's involvement in the project and their perceptions about the team experience. In addition, IMPROVE researcherslconsultants contributed to the qualitative study their accumulated documentation on the clinics and teams. Concern about intrusion and additional burden on the clinics arose because participation in Project IMPROVE required substantial amounts of clinic time. To lessen some of the time involved, whenever possible data were drawn from existing IMPROVE sources. IMPROVE researchers also were interviewed and provided their own observations and insights for the qualitative analysis. Analysis. The data were analyzed in five ways. First, each interview or set of observations was studied to identify themes and generate concepts. Second, data from each "case" (each cliniclteam) were reviewed to assess and compare the experiences and perspectives of multiple informants. Third, all the open-ended data were coded and organized for a thematic analysis. The coding involved an iterative process: initial coding to identify themes, grouping data by themes, refining the codes, regrouping, and so forth. Throughout this process each unit of data was assigned an identifier so the context could be recalled for validation. Fourth, a conceptual framework was developed, stimulated by relevant research and theory literature. Finally, other analysts (including IMPROVE researchers) provided feedback and insights on preliminary analyses and interpretations.13-l6 Limitations. Three factors limit generalizability from the case studies. First, the 44 Project IMPROVE
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Table 1. Characteristicsof Six Case Study Clinics*
clinics. The HMO introduced a number of technologic improvements across clinic sites, such as a new telephone system and a personal computer with software designed to be compatible with the HMO's. The team leader commented,
were collected m 1994, when Project IMPRO
clinics do not constitute a nationally representative sample: They are all located in the same HMOdominated region, within 60 miles of the Twin Cities, in the metro area and nearby towns in Minnesota and Wisconsin. Although the clinics varied in size, none is really large and none is a solo practice. Second, the case examples are not necessarily representative of the full sample of IMPROVE clinics inasmuch as they constitute a small sample selected randomly from a small pool. Finally, the interview and observation data reflect the perceptions of a limited number of informants at a particular time. Perceptions about a team process might diier not only among individuals but also over time, reflecting events and changing circumstances.
Discussion How Does Change in the Health Care Environment Affect a QI Process? During the intervention phase of Project IMPROVE, two-thirds of the clinics were involved in some form of substantial reorganization, including mergers and acquisitions (Table 2, p 365).17Thus, CQI was introduced to the clinics as a method for innovation within the context of turmoil and rapid change in the health care envir~nment.'~ As Table 2 shows, all the smaller clinics in the case study sample allied with large conglomerates of health care organizations during the study period. In the process, each clinic essentially lost much of its independence. The mergers led to changes in staff, procedures, equipment, location, and administrative structures. For example, when Project IMPROVE was initiated, Clinic D was independent and affiliated with several other clinics, all located in small towns within the same regi0n. the project was launched, a large HMO bought out the affiliation of
It's a stressful time because of changes in the environment. It's stressful for everyone, not just me or the providers. The positive part is that it's an opportunity. We're on the same learning curve, learning the computer and the phone, together. It's a time to problem solve and share and teach each other.
Another small clinic, Clinic E, aborted its IMPROVE project and never actually developed or implemented a comprehensive prevention system. This clinic had undergone what it described as "huge changes" in administrative organization. Before IMPROVE was launched, the clinic had belonged to a loose afKliation of small clinics. This group of clinics was bought out by a much larger health care network, which then centralized most administrative services. The physician team leader commented: "From the point of doing our original chart audits, there have been so many external changes that they would have dwarfed anything we could have done through the IMPROVE project. . . . Our system has lost to entropy." One of the larger clinics, Clinic B, merged with another clinic. The top management wanted to put the project "on h o l d while they were in'the throes of the merger. It was only through the insistence of the physician team leader and other team members that the project continued. Even so, the merger complicated the IMPROVE project. For example, the IMPROVE team had developed a system for sending reminder letters to patients who had not had recent mammograms. After the merger, the system for documenting mammograms was at risk of filling apart because staff in the radiology department had come from the other (nonIMPROVE) clinic site and did not understand the new protocol. In a general sense, team members were worried about loss of influence in their organization, which was now much larger and involved a merger of cultures. A team member complained, with the old group, it was easy to get things set up and going. NOW we have to go through committees and it takes too long. ~t'simportant to get going; the committees can be a big holdup. . . To get that many doctors to do something will be impossible. Good ideas will be droppec-so two years ofwork may go down the tubes. If everybody doesn't buy in, it goes by the wayside.
Table 2. Overview of Project IMPROVE in the Six Case Study Clinicsn
IMPROVE. The team has argued that the project wil
A physician with a strong interest in preventive the team leader; a nurse is the facilitator. Both actively engaged in the project, along with other te members. Despite major upheaval in the clinic as t result of a merger, the project has proceeded and
The physician team leader commented, "We have good working relationships with physicians at -Clinic, but their systems are different, so there's a lot to be worked out." The change in the workplace environment increased the stress level. The physician team leader added, "If it had been implemented at a different time than [after] the merger, it would have
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been better. . . . It was a little overwhelming. There were all these new forms-just learning how to use a new voice mail. And then we had to learn the flow sheets. . . ." The relationship between environmental instability and Project IMPROVE is complex, however. On one level, the stress associated with environmental
Table 2. Ovewiew of Project IMPROVE in the Six Case Study Clinics (continued)
which the interv~ewswere conducted, team members were concerned that the project was losing steam, an
change and uncertainty constitutes an obstacle to QI. But from another perspective, Project IMPROVE was a response to an environment of uncertainty. It was designed for an environment where change not only is widespread but also may connote desirable improvement. In essence, many of the clinics were motivated to
participate in Project IMPROVE became they exist in an unstable, highly competitive, and uncertain environment where change management skills could prove valuable, perhaps even necessary for ~ u r v i v a l . ' ~ . ' ~ ~ Project IMPROVE offered an ideology of change and adaptation and a systematic methodology
for QI. In this sense, the project provided an appealing solution to the problem of environmental uncertainty. As Flood and Fennel have stated: The adoption of expensive wst systems and CQI techniques can be explained as an example of mimetic pressure, the pressure to mimic seemingly successful organizations. This pressure stems from the need to "do something" when conditions become uncertain. When successful adaptation is not well understood, an easy path is to copy or mimic what other organizations have done, particularly those which appear to be doing well. . . . New forms of management are ado~ted,not because chey are known '0 help the ~ r ~ i z a t i obut n, because they reflect current norms and beliefs about what modern 161) managers do.lO(p
cultural compatibility. The relative lack of resources in the smallest clinics made the QI process more difficult. In addition, the formal QI process, as developed by Project IMPROVE, seemed inept and awkward in
the
A number of studies have found that access to slack resources" is a key predictor of ability to innoThe case how having relatively easy access to funds and personnel time can facilitate a &ange process whereas, conversely, lack of available funds (worrying about survival) is a serious impediment. The project successfully recruited primary care One of the large clinics, Clinic A, invested subclinics (for the scientific trial) on the basis of the perstantial resources in the IMPROVE initiative. For ceived potency of process improvement methodology. example, this was the only site (out of the six case When asked why his clinic agreed to be part of Project study clinics) that provided lunch for members during IMPROVE, a physician at Clinic D said, "We jumped their noon meetings to compensate team members for at the chance. It is exciting to improve care to patients; giving up their lunch hour. The clinic administration this includes preventive services." All the clinics made also allocated paid coverage for time staff spent away a business decision in committing staff time to Project from their departments working on the IMPROVE IMPROVE. Participation offered a potential compet- team. Moreover, the clinic hired a chart auditor to itive advantage associated with being an early adopter identify needed prevention services of scheduled of process improvement in the r e g i ~ n . ~ patients as part of the new prevention system. Its investment was, in large part, motivated by an expecHow Does Clinic Organization Influence a QI tation that in a fee-for-service context, augmenting Process? preventive services would generate increased revenues: A recent study of QI in hospitals reported that "We estimated the clinic could earn up to $1.6 millarger hospitals, tending to be more hierarchical, are less lion more." The decision to hire an additional clerical effective in implementing QI efforts than smaller hospi- person was based on this calculation. "It was unusual tal~.'~.'~ Our qualitative analysis of Project IMPROVE that they approved [hiring the chart auditor]. . . . At also suggests that clinic size is an important factor in the meeting one of the doctors [not on the team] said shaping a QI process. In contrast to the hospital QI 'Is there any question about this?' and the whole thing study, however, the three larger clinics in our case study took three minutes to approve." sample appeared to absorb the process improvement iniClinics B and C, the other large clinics, were tiative with the most ease, whereas the QI process somewhat more cautious about direct monetary seemed to overwhelm the three small clinics. The study expenditures for IMPROVE. Even so, they brought settings are different, of course-hospitals versus primasubstantial resources to the project: meeting time for ry care clinics-so these observations are not necessarily six to ten clinic employees, supplies, and expertise (for mutually contradictory. Moreover, both our qualitative example, experience with chart audits and research). study of IMPROVE and results from the hospital QI Although the larger clinics, including Clinic A, were survey underscore the importance of organizational feaconcerned about the project's cost, they were able to tures. Social theorists and management consultants have invest in their future, knowing that monies spent on argued that organizations need to be adaptive and flexi- the project would eventually increase revenues. ~ ~ ~ ' the smaller clinics (D, E, and F) were ble to survive in a rapidly changing e n v i r ~ n m e n t ~ ~ ~ ' ~ ~In~contrast, the implication being that the ability to adapt is, at least more constrained in their ability to invest in future in part, related to organization factors. potential earnings. The team leader at Clinic D lamentOur analysis suggests that clinic size is associated ed, "Size is the major issue. There is no one to relieve peowith two underlying factors: access to resources and ple to [work on the team]." In general, resources were
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tight. The clinic did not have appropriate meeting space (team membershad to use a meeting room in an adjacent building), and it lacked equipment and special expertise. The clinic had only one transcriptionist, who did almost all the typing and copying for the team, taking her hours away fiom her regular job. Because no funds were available to cover st& for their time on the team, some of the cost for doing the project was borne by team members contributing their own time. This was especially true of the team leader, who contributed a large number of hours of her own time. She reported that her husband also spent about 30 hours working at home with her on a spreadsheet: "It's hard not to be envious of the larger clinics-all the resources they have, like an IS [Information Services] department that can help them collect and analyze data. We don't even have a PC, and where we do have some equipment, we don't have the skills." The team leaders at Clinic E, which terminated its IMPROVE initiative, blamed the project's failure on their clinic's size and lack of resources: It's harder in a small dinic. . . . We have 2%doctors and about seven or eight employees. We're small and still getting off the ground. . . . The clinic started about 8% years ago. We don't even have time for cleaning or stocking. . . . We have no administrative time in our schedules,so everything we do comes out of clinic time, our working time.
Theoretically, small size should facilitate innovation. Compared with large clinics, a small clinic might have a more cohesive staff and fewer bureaucratic hurdles, as Shortell and colleagues concluded in their study of QI in hospitals.23Even so, a QI process requires an investment in infhstmcture, and to a large degree entails a fixed cost, i e v e of clinic size. Thus, the cost is likely to be espeually burdensome for small d i c s with little capital. Clinic size is also related to another factor: the compatibility of a particular culture and specific change process. In his classic book, Dzfiion of Innovations, -Rogers argued that innovation is most likely to be accepted when it is consistent with the experience and values of a cult~re.~ The larger clinics were organized into departments or units. The IMPROVE project recommendation that teams be composed of representatives born a cross-section of units or personnel positions made sense withii this type of organization. Moreover, these clinics frequently organized committees to address various problems or tasks. Committee work is always expensive and takes staff time away fiom rwenue-generating activities. Even so, the formal structure of IMPROVE was compatible with these clinics' tradition and experience.
In c o n m , the miii&aders in the smallest clinics, Clinics E and F, amplained that ~rojedt IMPROVE did not fit well within their organizations; they had only a handfd of st& who interacted with one another informally virtually every day, so that the formal meeting process seemed awkward and inappropriate. A physician in Clinic E asserted, "It's difficult to make something that will work in all sites."
What Is the Impact of a QI Process on Clinic Organization? Project IMPROVE introduced a new paradigm to primary care clinics in a double sense: the CQI approach and the focus on prevention systems. CQI, offering a systematic change process and emphasizing continuous improvement rather than a one-time "fix," is intended to change the perception about management. Furthermore, it undermines the traditional hierarchical method of decision making and introduces a more interpersonally complex operational method. Concurrently, IMPROVE created H new paradigm for preventive services-not only emphasizing the importance of prevention but also encouraging clinics to integrate prevention into routine medical care. In his book The S m r e of Scientifi RevoZutions, Thomas Kuhn described the concept of paradigm shift in science: "Led by a new paradigm. . . . It is rather as if the professional community had been suddenly transported to another planet where familiar objetts are seen in a different light.""(pllO)For clinic IMPROVE leaders and team members alike, acceptance of the IMPROVE paradigm entailed a conversion experience expressed in seved ways. First, &th in the project was emphasized: "People on the committee uuly believe in this." Second, an insistence on the uniqueness of this commitment-that IMPROVE is qualitatively different fiom other committees-was evident. Third, the ideology was suggested by a shared language code associated with IMPROVE concepts. For example, team members insisted that quick solutions to problem solving are "just Band-Aids." Another example is the fact that a number of informants at different sites repeated the phrase, "xtles are dropped at the door." Although case study observations suggested that the physician title tended to be used in team meetings, it appeared that the ideology of equal participation was an accepted and shared concept. A number of theorists have discussed the importance of perception, belief, or faith in adopting
i n n o v a t i ~ n . ~ Faith .'~.~~ in a new paradigm is a critical factor because the change process is difficult and expensive.I2In all the case study clinics, expressions of faith in their new CQI paradigm were heard. In this sense, Project IMPROVE appears to have had a qualitative impact on each of the clinics. However, diffusion of an administrative innovation, such as a QI process or a prevention system, is much more difficult than a technologic or material inno~ation.'.~ Whereas the relative advantage of the latter tends to be clear, administrative change is often complex and difficult to understand. Our case studies illustrate the difficulty and tenuousness of administrative innovation. For example, the CQI process was often slow and timeconsuming. A member of the team in Clinic A commented, "We never made fast progress. . . . The whole process is tedious. As individuals we would like to see things solved quickly I felt frustrated when some doctors were asking What are we accomplishing? and I couldn't produce anything just yet." The project in that clinic seemed to operate in stops and starts, going for long periods with no team meetings. Although a productive meeting was observed in January 1996, the team had not met since October 1995 (they were waiting to hire a chart auditor who would play a key role in the project). A related problem was the time needed to implement the prevention system. A nurse in Clinic C said, "We room six patients an hour. If a nurse adds additional questions and it takes one minute more, for 36 patients, that's an additional half hour. So that's a problem." Most of the clinics indicated that they were not able to implement their new prevention system at all times and with all patients. A nurse at Clinic F commented, "There are days when scheduling is horrid and we just don't use the IMPROVE form. Our 's heart doctors are overwhelmed since Dr attack. . . . [On some days] I get yelled at if I try to get them to counsel about prevention services." Time was also a factor in the issue of clinics' innovative systems over time. The concern of team members at Clinic D about recidivism, for example, was evident in comments such as "now people are backing off from using [the prevention tool] that was being filled out here and there. A lot of stuff isn't being done." Finally, getting buy-in from other staff at the clinic was, at best, a formidable challenge. All the case study teams confronted substantial resistance from some individuals or groups within the clinics. In most of the clin-
ics, a process of rejection and negotiation helped other staff feel empowered in the change process. For example, when physicians and nurses were uncomfortable using a prevention form developed by the team, they were given an opportunity to revise it. This feedback mechanism helped other staff to feel empowered in the change process. The teams used various "trickle in" methods for communicating with other clinic staff and implementing a change process. For example, Clinic B's team initially attempted to put prevention stickers on every chart that came through the clinic. After it became apparent that this effort was too burdensome, the team designated no more than six new charts a day per clinician for the new prevention system. In effect they succeeded in "breaking down" a complex system so that dissemination became more feasible and ~alatable.~ Despite these difficulties, our qualitative analysis indicates that Project IMPROVE had two substantive impacts on the clinics. First, the project enhanced awareness about preventive services, for both the patients and the professional staff. The increased emphasis on prevention was noticeable on entering the clinics, most of which displayed postures and brochures on improvement in their preventive services. A member of Clinic B's team remarked, "The patients are getting more educated. . . . I sit by the lab control desk, so I overhear more people scheduling proctos. And I've seen a lot of patients in the lobby reading the boards." (A quantitative analysis of the impact on preventive services will be reported elsewhere.) Second, one of the findings noted in the case studies was that in all these clinics, the CQI method was being applied to other problems and issues. A team member from Clinic A, for example, reported, "Now they're beginning to talk about a process for Peds [Pediatricsl-the Peds doctors are interested. It's exciting that Peds found out what we're doing and wants to be part of it." Similarly, a team member at Clinic B commented, "It taught us a lot about CQI-how usell it is. . . . We have some spin-off projects now-like in UC [Urgent Care]-it takes it out of the personality conflicts, gives us a problem-solving approach." All the clinics had examples of applying the change concepts and methods to other areas and needs.
SUmmary and lmplications An Unstable and Uncertain Environment Our case study analysis suggests that environmental change has a paradoxical effect. Environmental instability
complicates an improvement process, yet the changing environment also forces changes - to be made and stimulates improvement. To survive in an uncertain, unstable, and highly competitive environment, an organization needs to change and adapt. Thus, the application of QI methods is essentially a way to respond to an environment of "perpetual re~olution."~' One implication is that environmental change is not necessarily a sole reason to delay QI efforts. To the contrary, leaders in HMOs or other change agents in regions wrestling with change might want to encourage QI in medical clinics as an appropriate and potentially rewarding response to competition and change. Of course, an organization in chaos, uncertain of its very survival, might be unable to launch an orderly improvement process. So a balance between sufficient strength and stability to sustain operations, and environmental competition and change to motivate improvement, is necessary. Organization and Culture Our case studies of the smallest clinics suggest that an elaborate change process may be too costly for clinics with few resources. Although the improvement process and change concepts were useful, in the very smallest clinics a large team structure was awkward and seemed to be incompatible with the organization struc-
ture and culture. The lesson learned was that one format does not fit all situations. Thus, the CQI process needs to be flexible, adaptable, and variable.
The QI Process and the Impact on Clinics A QI approach in medical clinics appears to have a number of qualitative benefits that are difficult to quantify. For example, the approach creates a crossdepartmental functioning team useful for addressing various organizational problems and tasks. All the case study clinics found the CQI process useful and applied it to other problems and tasks, thus creating an apparent ongoing diffusion of the change process. Moreover, involvement in a QI effort raises awareness about important issues in providing health care. Participation in Project IMPROVE increased the focus on preventive services, with discussions in staff meetings, posters in lobbies and examination rooms, and educational materials all emphasizing the importance of these services. Finally, another significant benefit of the project was an enhanced awareness about the importance of, and techniques for, improvement. In effect, the IMPROVE teams, by all their activities in the clinics, increased sensitivity about specific needs for change and also promoted the concept that clinics can and should improve their systems of care.
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Quality Improvement in Primary Care Clinics LUCYROSEFISCHER,PHD LEIFI. SOLBERG,MD THOMAS E. KOTTKE, MD, MSPH
T
he concepts of continuous quality improvement (CQI) and total quality management have been used extensively to improve quality and costefficiency in the production of goods and services. In the past several years, interest in applying quality improvement (QI) initiatives in medical settings has increased in an effort to provide similar benefits to health care.'" However, few scientific studies have tested the effectiveness of such initiatives in any industry. This article presents a qualitative study of primary care clinics participating in the first randomized
controlled trial to evaluate the effectiveness of CQI in primary care-Project IMPROVE.4-6Case studies of a sample of clinics in the IMPROVE trial's intervention arm offered an unusual opportunity to examine the feasibility of applying CQI concepts in primary care medical settings.
Project IMPROVE IMPROVE (IMproving PRevention through Organization, Vision & Empowerment) was a four-year study that was started in July 1993 and designed to
Lucy Rose Fischer, PhD, is Senior Research Investigator, Magnan, MD, Jiom Blue P h , who helped in the overall and Leif I. Solberg, MD, is Clinical Director of Research, coordination of Project IMPROW and contributed to the Healthpartners Research Foundation, Minneapolis, and a design of the case study protocol; Carolyn Calomeni, MS, member of The Joint Commission Journal on Quality Katherine Giles, MA, and Kathleen Conboy, RN,Jiom Improvement j Editorial Advisory Board Thomas E. Kot- Healthpartners, who along with Shirley Conn, RN,from tke, MD, MSPH, is Professor of Medicine, Mayo Clinic, Blue Plus, were core members of the IMPROE research team andprovided data and insightsfar the qualitative study; and Rochester, Minnesota. Thisproject was supported by giantsJiom Group Health Milo Brekke, PhD, and Arnold Kaluzny, PhD, who were Foundation and the Blue Cross and Blue Shield Foundation. consultantsfor Project IMPROW and also provided advice We express our thanks to the six clinics that a p e d to be part and commentayfor the qtutlitative study. The IMPROW project was supported by Grant No. of the case studies and to the team members and other staf who were interviewed and shared their perspectives. Project R01 HS08091 Jiom the Agency far Health Care Policy and IMPROE was successfilly implemented in primary care Research. Please address correspondence to Lucy Rose Fischer, PhD, clinics because of the commitment and hard work of many Research Founddtion, 8100 34th Avenue Healthpartners dedicated p r o f e s o d in each clinic that partz'n'pated in the IMPROE demonstration. We are gmtej%lfor insightsJiom South, PO Box 1309, Minneapolis, M N 55440; phone a number of others, including thef i k i n g researchers: Sanne 612/883-5001; fdx 612/883-5022; e-mail Lucy.R.Fischer @HealthPartners,com. Ccwright Q 1998 by the Jdnt Cornmiasion on kmedkalkm of Healthcare Organizations
test the hypothesis that primary care clinics can increase their preventive service delivery rates by learning and applying CQI concepts to the development of prevention systems. The 44 primary care clinics volunteering to participate in the project were randomly divided into 22 comparison sites (that is, left alone) and 22 sites that received an intervention from the IMPROVE project beginning in September 1994. The intervention consisted of a program of leadership facilitation, training, consultatiop, and networking. Each of these program elements was designed to facilitate a CQI process focused on eight ;P$Ulrpreventive services: mammograms, breast examinations, Papanicolaou (Pap) smears, tobacco use, hypertension, hypercholesterolemia, and influenza and pneumonia shots. These systems generally consisted of methods for consistently identifying the prevention needs of individual patients as they visited the clinic, reminding clinicians about which preventive services each patient needed, and ensuring that those needs were met in a comprehensive way. Two persons (a team leader and a facilitator) Erom each clinic were invited to participate in six group training sessions that lasted four hours each and were conducted during a six-month period. The training consisted of a series of modules to teach the skills and tasks needed to implement an improvement process and develop systematic prevention processes.
During the training process, each team leader and facilitator met biweekly with an interdisciplinary team within their own clinic to define their goals and current process, gather and analyze data on needs and problems, develop and implement systems to increase preventive service delivery rates, and evaluate the systems' effectiveness. Throughout a 2 1-month period, both the clinic and team leaders had access to regular consultation with IMPROVE traihers. In addition, bimonthly networking sessions for team leaders and facilitators offered opportunities to share ideas, materials, and experiences with other clinics participating in the intervention. The intervention was designed as a trainingconsultation model that could be implemented by any external organization (such as a health maintenance organization [HMO] or preferred provider organization) able to help clinics improve their preventive service delivery rates. Each clinic team, although offered substantial information and advice through Project IMPROVE, made its own decisions about how to proceed and what specific form of prevention system to implement."
A Study of Social Change The relatively recent introduction of CQJ into health care settings represents a particular form of social change, This is a process of cultural dz&ion as CQI
'
methods and concepts developed in other settings are subsequently introduced into health care organizati on^.^ Q I constitutes an administrative innovation, which tends to be more difficult to transmit than is technologic change.'zs The CQI process also entails directed innovation. In Project IMPROVE, the process is initiated by an external change agent (the researchconsultation team) that presented a systematic ideology, strategy, and protocol for change.' To date there has been little research on the experience of directed innovation in general and almost no empirical studies on how health care organizations change.lO-l2 This qualitative study of Project IMPROVE was intended to examine the process of change in medical settings and thereby contribute to the research literature on social change and the diffusion of innovation.
Research Questions This study focused on the relationship between the QI process and the external and internal environments of primary care clinics. The study, conducted in a region that has seen an enormous amount of change in both these environments, addresses three specific questions: 1. How does change in the health care environment affect a QI process? 2. How does clinic organization influence a QI process? 3. What is the impact of a QI process on clinic organization?
Method Case studies were conducted in a sample of 6 of the 22 clinics participating in the intervention arm of the IMPROVE trial. The case studies' purpose was to provide a qualitative analysis of theprocess of developing and implementing a CQI process in primary care clinics. Sample. A stratified random sample of intervention clinics was selected for in-depth case studies: three large clinics (employing eight or more physicians) and three small clinics (employing seven or fewer physicians). When one clinic from each size category declined to participate as a case study site because of concern about time demands, two additional names were drawn randomly from the remaining clinics. Characteristics of the six case study clinics are shown in Table 1 (p 364). Project IMPROVE was initiated in September 1994. The case study inter-
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views were conducted from January through June 1996, approximately 16 months later, at a time when most of the clinics had already implemented systems for improving prevention services. Data. The case study data consisted of results of open-ended interviews with "informants" and observations of CQI team meetings. The informants included two to four members of each CQI team plus other non-team members knowledgeable about the project. Altogether, 30 interviews were conducted with clinic staff, and five team meetings were observed from January through June 1996. Detailed notes were transcribed for each interview and meeting observation. The interviews, each approximately 30-45 minutes long, examined the process of participating in this QI initiative, focusing on informants' accounts of the history of the clinic's involvement in the project and their perceptions about the team experience. In addition, IMPROVE researcherslconsultants contributed to the qualitative study their accumulated documentation on the clinics and teams. Concern about intrusion and additional burden on the clinics arose because participation in Project IMPROVE required substantial amounts of clinic time. To lessen some of the time involved, whenever possible data were drawn from existing IMPROVE sources. IMPROVE researchers also were interviewed and provided their own observations and insights for the qualitative analysis. Analysis. The data were analyzed in five ways. First, each interview or set of observations was studied to identify themes and generate concepts. Second, data from each "case" (each cliniclteam) were reviewed to assess and compare the experiences and perspectives of multiple informants. Third, all the open-ended data were coded and organized for a thematic analysis. The coding involved an iterative process: initial coding to identify themes, grouping data by themes, refining the codes, regrouping, and so forth. Throughout this process each unit of data was assigned an identifier so the context could be recalled for validation. Fourth, a conceptual framework was developed, stimulated by relevant research and theory literature. Finally, other analysts (including IMPROVE researchers) provided feedback and insights on preliminary analyses and interpretations.13-l6 Limitations. Three factors limit generalizability from the case studies. First, the 44 Project IMPROVE
.
Table 1. Characteristicsof Six Case Study Clinics*
clinics. The HMO introduced a number of technologic improvements across clinic sites, such as a new telephone system and a personal computer with software designed to be compatible with the HMO's. The team leader commented,
were collected m 1994, when Project IMPRO
clinics do not constitute a nationally representative sample: They are all located in the same HMOdominated region, within 60 miles of the Twin Cities, in the metro area and nearby towns in Minnesota and Wisconsin. Although the clinics varied in size, none is really large and none is a solo practice. Second, the case examples are not necessarily representative of the full sample of IMPROVE clinics inasmuch as they constitute a small sample selected randomly from a small pool. Finally, the interview and observation data reflect the perceptions of a limited number of informants at a particular time. Perceptions about a team process might diier not only among individuals but also over time, reflecting events and changing circumstances.
Discussion How Does Change in the Health Care Environment Affect a QI Process? During the intervention phase of Project IMPROVE, two-thirds of the clinics were involved in some form of substantial reorganization, including mergers and acquisitions (Table 2, p 365).17Thus, CQI was introduced to the clinics as a method for innovation within the context of turmoil and rapid change in the health care envir~nment.'~ As Table 2 shows, all the smaller clinics in the case study sample allied with large conglomerates of health care organizations during the study period. In the process, each clinic essentially lost much of its independence. The mergers led to changes in staff, procedures, equipment, location, and administrative structures. For example, when Project IMPROVE was initiated, Clinic D was independent and affiliated with several other clinics, all located in small towns within the same regi0n. the project was launched, a large HMO bought out the affiliation of
It's a stressful time because of changes in the environment. It's stressful for everyone, not just me or the providers. The positive part is that it's an opportunity. We're on the same learning curve, learning the computer and the phone, together. It's a time to problem solve and share and teach each other.
Another small clinic, Clinic E, aborted its IMPROVE project and never actually developed or implemented a comprehensive prevention system. This clinic had undergone what it described as "huge changes" in administrative organization. Before IMPROVE was launched, the clinic had belonged to a loose afKliation of small clinics. This group of clinics was bought out by a much larger health care network, which then centralized most administrative services. The physician team leader commented: "From the point of doing our original chart audits, there have been so many external changes that they would have dwarfed anything we could have done through the IMPROVE project. . . . Our system has lost to entropy." One of the larger clinics, Clinic B, merged with another clinic. The top management wanted to put the project "on h o l d while they were in'the throes of the merger. It was only through the insistence of the physician team leader and other team members that the project continued. Even so, the merger complicated the IMPROVE project. For example, the IMPROVE team had developed a system for sending reminder letters to patients who had not had recent mammograms. After the merger, the system for documenting mammograms was at risk of filling apart because staff in the radiology department had come from the other (nonIMPROVE) clinic site and did not understand the new protocol. In a general sense, team members were worried about loss of influence in their organization, which was now much larger and involved a merger of cultures. A team member complained, with the old group, it was easy to get things set up and going. NOW we have to go through committees and it takes too long. ~t'simportant to get going; the committees can be a big holdup. . . To get that many doctors to do something will be impossible. Good ideas will be droppec-so two years ofwork may go down the tubes. If everybody doesn't buy in, it goes by the wayside.
Table 2. Overview of Project IMPROVE in the Six Case Study Clinicsn
IMPROVE. The team has argued that the project wil
A physician with a strong interest in preventive the team leader; a nurse is the facilitator. Both actively engaged in the project, along with other te members. Despite major upheaval in the clinic as t result of a merger, the project has proceeded and
The physician team leader commented, "We have good working relationships with physicians at -Clinic, but their systems are different, so there's a lot to be worked out." The change in the workplace environment increased the stress level. The physician team leader added, "If it had been implemented at a different time than [after] the merger, it would have
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been better. . . . It was a little overwhelming. There were all these new forms-just learning how to use a new voice mail. And then we had to learn the flow sheets. . . ." The relationship between environmental instability and Project IMPROVE is complex, however. On one level, the stress associated with environmental
Table 2. Ovewiew of Project IMPROVE in the Six Case Study Clinics (continued)
which the interv~ewswere conducted, team members were concerned that the project was losing steam, an
change and uncertainty constitutes an obstacle to QI. But from another perspective, Project IMPROVE was a response to an environment of uncertainty. It was designed for an environment where change not only is widespread but also may connote desirable improvement. In essence, many of the clinics were motivated to
participate in Project IMPROVE became they exist in an unstable, highly competitive, and uncertain environment where change management skills could prove valuable, perhaps even necessary for ~ u r v i v a l . ' ~ . ' ~ ~ Project IMPROVE offered an ideology of change and adaptation and a systematic methodology
for QI. In this sense, the project provided an appealing solution to the problem of environmental uncertainty. As Flood and Fennel have stated: The adoption of expensive wst systems and CQI techniques can be explained as an example of mimetic pressure, the pressure to mimic seemingly successful organizations. This pressure stems from the need to "do something" when conditions become uncertain. When successful adaptation is not well understood, an easy path is to copy or mimic what other organizations have done, particularly those which appear to be doing well. . . . New forms of management are ado~ted,not because chey are known '0 help the ~ r ~ i z a t i obut n, because they reflect current norms and beliefs about what modern 161) managers do.lO(p
cultural compatibility. The relative lack of resources in the smallest clinics made the QI process more difficult. In addition, the formal QI process, as developed by Project IMPROVE, seemed inept and awkward in
the
A number of studies have found that access to slack resources" is a key predictor of ability to innoThe case how having relatively easy access to funds and personnel time can facilitate a &ange process whereas, conversely, lack of available funds (worrying about survival) is a serious impediment. The project successfully recruited primary care One of the large clinics, Clinic A, invested subclinics (for the scientific trial) on the basis of the perstantial resources in the IMPROVE initiative. For ceived potency of process improvement methodology. example, this was the only site (out of the six case When asked why his clinic agreed to be part of Project study clinics) that provided lunch for members during IMPROVE, a physician at Clinic D said, "We jumped their noon meetings to compensate team members for at the chance. It is exciting to improve care to patients; giving up their lunch hour. The clinic administration this includes preventive services." All the clinics made also allocated paid coverage for time staff spent away a business decision in committing staff time to Project from their departments working on the IMPROVE IMPROVE. Participation offered a potential compet- team. Moreover, the clinic hired a chart auditor to itive advantage associated with being an early adopter identify needed prevention services of scheduled of process improvement in the r e g i ~ n . ~ patients as part of the new prevention system. Its investment was, in large part, motivated by an expecHow Does Clinic Organization Influence a QI tation that in a fee-for-service context, augmenting Process? preventive services would generate increased revenues: A recent study of QI in hospitals reported that "We estimated the clinic could earn up to $1.6 millarger hospitals, tending to be more hierarchical, are less lion more." The decision to hire an additional clerical effective in implementing QI efforts than smaller hospi- person was based on this calculation. "It was unusual tal~.'~.'~ Our qualitative analysis of Project IMPROVE that they approved [hiring the chart auditor]. . . . At also suggests that clinic size is an important factor in the meeting one of the doctors [not on the team] said shaping a QI process. In contrast to the hospital QI 'Is there any question about this?' and the whole thing study, however, the three larger clinics in our case study took three minutes to approve." sample appeared to absorb the process improvement iniClinics B and C, the other large clinics, were tiative with the most ease, whereas the QI process somewhat more cautious about direct monetary seemed to overwhelm the three small clinics. The study expenditures for IMPROVE. Even so, they brought settings are different, of course-hospitals versus primasubstantial resources to the project: meeting time for ry care clinics-so these observations are not necessarily six to ten clinic employees, supplies, and expertise (for mutually contradictory. Moreover, both our qualitative example, experience with chart audits and research). study of IMPROVE and results from the hospital QI Although the larger clinics, including Clinic A, were survey underscore the importance of organizational feaconcerned about the project's cost, they were able to tures. Social theorists and management consultants have invest in their future, knowing that monies spent on argued that organizations need to be adaptive and flexi- the project would eventually increase revenues. ~ ~ ~ ' the smaller clinics (D, E, and F) were ble to survive in a rapidly changing e n v i r ~ n m e n t ~ ~ ~ ' ~ ~In~contrast, the implication being that the ability to adapt is, at least more constrained in their ability to invest in future in part, related to organization factors. potential earnings. The team leader at Clinic D lamentOur analysis suggests that clinic size is associated ed, "Size is the major issue. There is no one to relieve peowith two underlying factors: access to resources and ple to [work on the team]." In general, resources were
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tight. The clinic did not have appropriate meeting space (team membershad to use a meeting room in an adjacent building), and it lacked equipment and special expertise. The clinic had only one transcriptionist, who did almost all the typing and copying for the team, taking her hours away fiom her regular job. Because no funds were available to cover st& for their time on the team, some of the cost for doing the project was borne by team members contributing their own time. This was especially true of the team leader, who contributed a large number of hours of her own time. She reported that her husband also spent about 30 hours working at home with her on a spreadsheet: "It's hard not to be envious of the larger clinics-all the resources they have, like an IS [Information Services] department that can help them collect and analyze data. We don't even have a PC, and where we do have some equipment, we don't have the skills." The team leaders at Clinic E, which terminated its IMPROVE initiative, blamed the project's failure on their clinic's size and lack of resources: It's harder in a small dinic. . . . We have 2%doctors and about seven or eight employees. We're small and still getting off the ground. . . . The clinic started about 8% years ago. We don't even have time for cleaning or stocking. . . . We have no administrative time in our schedules,so everything we do comes out of clinic time, our working time.
Theoretically, small size should facilitate innovation. Compared with large clinics, a small clinic might have a more cohesive staff and fewer bureaucratic hurdles, as Shortell and colleagues concluded in their study of QI in hospitals.23Even so, a QI process requires an investment in infhstmcture, and to a large degree entails a fixed cost, i e v e of clinic size. Thus, the cost is likely to be espeually burdensome for small d i c s with little capital. Clinic size is also related to another factor: the compatibility of a particular culture and specific change process. In his classic book, Dzfiion of Innovations, -Rogers argued that innovation is most likely to be accepted when it is consistent with the experience and values of a cult~re.~ The larger clinics were organized into departments or units. The IMPROVE project recommendation that teams be composed of representatives born a cross-section of units or personnel positions made sense withii this type of organization. Moreover, these clinics frequently organized committees to address various problems or tasks. Committee work is always expensive and takes staff time away fiom rwenue-generating activities. Even so, the formal structure of IMPROVE was compatible with these clinics' tradition and experience.
In c o n m , the miii&aders in the smallest clinics, Clinics E and F, amplained that ~rojedt IMPROVE did not fit well within their organizations; they had only a handfd of st& who interacted with one another informally virtually every day, so that the formal meeting process seemed awkward and inappropriate. A physician in Clinic E asserted, "It's difficult to make something that will work in all sites."
What Is the Impact of a QI Process on Clinic Organization? Project IMPROVE introduced a new paradigm to primary care clinics in a double sense: the CQI approach and the focus on prevention systems. CQI, offering a systematic change process and emphasizing continuous improvement rather than a one-time "fix," is intended to change the perception about management. Furthermore, it undermines the traditional hierarchical method of decision making and introduces a more interpersonally complex operational method. Concurrently, IMPROVE created H new paradigm for preventive services-not only emphasizing the importance of prevention but also encouraging clinics to integrate prevention into routine medical care. In his book The S m r e of Scientifi RevoZutions, Thomas Kuhn described the concept of paradigm shift in science: "Led by a new paradigm. . . . It is rather as if the professional community had been suddenly transported to another planet where familiar objetts are seen in a different light.""(pllO)For clinic IMPROVE leaders and team members alike, acceptance of the IMPROVE paradigm entailed a conversion experience expressed in seved ways. First, &th in the project was emphasized: "People on the committee uuly believe in this." Second, an insistence on the uniqueness of this commitment-that IMPROVE is qualitatively different fiom other committees-was evident. Third, the ideology was suggested by a shared language code associated with IMPROVE concepts. For example, team members insisted that quick solutions to problem solving are "just Band-Aids." Another example is the fact that a number of informants at different sites repeated the phrase, "xtles are dropped at the door." Although case study observations suggested that the physician title tended to be used in team meetings, it appeared that the ideology of equal participation was an accepted and shared concept. A number of theorists have discussed the importance of perception, belief, or faith in adopting
i n n o v a t i ~ n . ~ Faith .'~.~~ in a new paradigm is a critical factor because the change process is difficult and expensive.I2In all the case study clinics, expressions of faith in their new CQI paradigm were heard. In this sense, Project IMPROVE appears to have had a qualitative impact on each of the clinics. However, diffusion of an administrative innovation, such as a QI process or a prevention system, is much more difficult than a technologic or material inno~ation.'.~ Whereas the relative advantage of the latter tends to be clear, administrative change is often complex and difficult to understand. Our case studies illustrate the difficulty and tenuousness of administrative innovation. For example, the CQI process was often slow and timeconsuming. A member of the team in Clinic A commented, "We never made fast progress. . . . The whole process is tedious. As individuals we would like to see things solved quickly I felt frustrated when some doctors were asking What are we accomplishing? and I couldn't produce anything just yet." The project in that clinic seemed to operate in stops and starts, going for long periods with no team meetings. Although a productive meeting was observed in January 1996, the team had not met since October 1995 (they were waiting to hire a chart auditor who would play a key role in the project). A related problem was the time needed to implement the prevention system. A nurse in Clinic C said, "We room six patients an hour. If a nurse adds additional questions and it takes one minute more, for 36 patients, that's an additional half hour. So that's a problem." Most of the clinics indicated that they were not able to implement their new prevention system at all times and with all patients. A nurse at Clinic F commented, "There are days when scheduling is horrid and we just don't use the IMPROVE form. Our 's heart doctors are overwhelmed since Dr attack. . . . [On some days] I get yelled at if I try to get them to counsel about prevention services." Time was also a factor in the issue of clinics' innovative systems over time. The concern of team members at Clinic D about recidivism, for example, was evident in comments such as "now people are backing off from using [the prevention tool] that was being filled out here and there. A lot of stuff isn't being done." Finally, getting buy-in from other staff at the clinic was, at best, a formidable challenge. All the case study teams confronted substantial resistance from some individuals or groups within the clinics. In most of the clin-
ics, a process of rejection and negotiation helped other staff feel empowered in the change process. For example, when physicians and nurses were uncomfortable using a prevention form developed by the team, they were given an opportunity to revise it. This feedback mechanism helped other staff to feel empowered in the change process. The teams used various "trickle in" methods for communicating with other clinic staff and implementing a change process. For example, Clinic B's team initially attempted to put prevention stickers on every chart that came through the clinic. After it became apparent that this effort was too burdensome, the team designated no more than six new charts a day per clinician for the new prevention system. In effect they succeeded in "breaking down" a complex system so that dissemination became more feasible and ~alatable.~ Despite these difficulties, our qualitative analysis indicates that Project IMPROVE had two substantive impacts on the clinics. First, the project enhanced awareness about preventive services, for both the patients and the professional staff. The increased emphasis on prevention was noticeable on entering the clinics, most of which displayed postures and brochures on improvement in their preventive services. A member of Clinic B's team remarked, "The patients are getting more educated. . . . I sit by the lab control desk, so I overhear more people scheduling proctos. And I've seen a lot of patients in the lobby reading the boards." (A quantitative analysis of the impact on preventive services will be reported elsewhere.) Second, one of the findings noted in the case studies was that in all these clinics, the CQI method was being applied to other problems and issues. A team member from Clinic A, for example, reported, "Now they're beginning to talk about a process for Peds [Pediatricsl-the Peds doctors are interested. It's exciting that Peds found out what we're doing and wants to be part of it." Similarly, a team member at Clinic B commented, "It taught us a lot about CQI-how usell it is. . . . We have some spin-off projects now-like in UC [Urgent Care]-it takes it out of the personality conflicts, gives us a problem-solving approach." All the clinics had examples of applying the change concepts and methods to other areas and needs.
SUmmary and lmplications An Unstable and Uncertain Environment Our case study analysis suggests that environmental change has a paradoxical effect. Environmental instability
complicates an improvement process, yet the changing environment also forces changes - to be made and stimulates improvement. To survive in an uncertain, unstable, and highly competitive environment, an organization needs to change and adapt. Thus, the application of QI methods is essentially a way to respond to an environment of "perpetual re~olution."~' One implication is that environmental change is not necessarily a sole reason to delay QI efforts. To the contrary, leaders in HMOs or other change agents in regions wrestling with change might want to encourage QI in medical clinics as an appropriate and potentially rewarding response to competition and change. Of course, an organization in chaos, uncertain of its very survival, might be unable to launch an orderly improvement process. So a balance between sufficient strength and stability to sustain operations, and environmental competition and change to motivate improvement, is necessary. Organization and Culture Our case studies of the smallest clinics suggest that an elaborate change process may be too costly for clinics with few resources. Although the improvement process and change concepts were useful, in the very smallest clinics a large team structure was awkward and seemed to be incompatible with the organization struc-
ture and culture. The lesson learned was that one format does not fit all situations. Thus, the CQI process needs to be flexible, adaptable, and variable.
The QI Process and the Impact on Clinics A QI approach in medical clinics appears to have a number of qualitative benefits that are difficult to quantify. For example, the approach creates a crossdepartmental functioning team useful for addressing various organizational problems and tasks. All the case study clinics found the CQI process useful and applied it to other problems and tasks, thus creating an apparent ongoing diffusion of the change process. Moreover, involvement in a QI effort raises awareness about important issues in providing health care. Participation in Project IMPROVE increased the focus on preventive services, with discussions in staff meetings, posters in lobbies and examination rooms, and educational materials all emphasizing the importance of these services. Finally, another significant benefit of the project was an enhanced awareness about the importance of, and techniques for, improvement. In effect, the IMPROVE teams, by all their activities in the clinics, increased sensitivity about specific needs for change and also promoted the concept that clinics can and should improve their systems of care.
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