A Practice Change Model for Quality Improvement in Primary Care Practice,
Deborah Cohen, Reuben R. McDaniel, Jr., Benjamin F. Crabtree, Mary
C. Ruhe, Sharon M. Weyer, Alfred Tallia, William L. Miller, Meredith A.
Goodwin, Paul Nutting, Leif I. Solberg, Stephen J. Zyzanski, Carlos R.
Jaén, Valerie Gilchrist, and Kurt C. Stange
a rapidly changing healthcare environment, primary care practices often
have to change how they provide medicine. Yet change is difficult, and
the process by which practice improvement can be understood and facilitated
has not been well elucidated. Therefore, we developed a model of practice
change using data from a quality improvement intervention that was successful
in creating a sustainable practice improvement. A multidisciplinary team
evaluated data from the Study To Enhance Prevention by Understanding Practice
(STEP-UP), a randomized clinical trial conducted to improve the delivery
of evidence-based preventive services in 79 northeastern Ohio practices.
The team conducted comparative case-study analyses of high- and low-improvement
practices to identify variables that are critical to the change process
and to create a conceptual model for the change.
The model depicts the critical elements for understanding and guiding
practice change and emphasizes the importance of these elements' evolving
interrelationships. These elements are (1) motivation of key stakeholders
to achieve the target for change; (2) instrumental, personal, and interactive
resources for change; (3) motivators outside the practice, including the
larger healthcare environment and community; and (4) opportunities for
change-that is, how key stakeholders understand the change options. Practice
change is influenced by the complex interaction of factors inside and
outside the practice. Interventions that are based on understanding the
four key elements and their interrelationships can yield sustainable quality
improvements in primary care practice.
Keeping Patients Safe: An Analysis of Organizational Culture and Caregiver
Training, Kathie Johnson
and professional publications, such as the Institute of Medicine reports,
have brought to the attention of both healthcare providers and consumers
the importance of the issue of patient safety. In this article, we describe
the study conducted by one hospital to improve patient safety within its
culture. The study included the development and use of a culture survey
tool. Key learnings from this survey are presented here as well. The article
also states the limitations of the study and offers recommendations for
The work of improving both the culture and processes of healthcare institutions
to reduce error and promote safety is ongoing. The findings from this
study add to the growing body of knowledge on successful patient-safety
strategies and tools.
The Impact of Nursing Care and Other Healthcare Attributes on Hospitalized
Patient Satisfaction and Behavioral Intentions, Koichiro Otani
and Richard S. Kurz
organizations in the United States are struggling to find ways to survive
in their uncertain and competitive environments. One of the survival strategies
used by those organizations is to increase patient satisfaction. This
article presents research on factors that influence hospitalized patients'
satisfaction and their intention to return to and recommend the hospital.
The first objective of this study was to find out, using a comprehensive
set of healthcare attributes, which attributes play a more important role
in increasing patient satisfaction and behavioral intentions. The second
objective was to analyze the relative importance of those attributes and
the nature of the relationships across the values of the attributes. More
specifically, this study attempted to identify any existing curvilinear
relationships among these variables. If any curvilinear relationships
exist, do they show an increasing or a decreasing marginal-utility function?
Included in this article is an example, featuring a hospital-discharged
patient, that explains the importance and uniqueness of this curvilinear
This study found that among six attributes, nursing care showed the largest
parameter estimate for the patient satisfaction and behavioral intentions
models. Thus, simply improving the nursing care attribute seems to be
the most effective manner to enhancing patient satisfaction and behavioral
intentions. However, nursing care also showed a diminishing marginal-utility
function for both models. To assess the effect of this diminishing marginal-utility
function, the impact of nursing care was computed for each unit of improvement
together with other attributes. The finding from this study provides information
needed to increase patient satisfaction and behavioral intentions and
should result in more effective and efficient healthcare management.