Quality Care Improvement Program in a Community-Based Participatory Research Project: METHODS

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The CQIP used a one-group pre- and post-test design. The target population included African-American residents of southeast Raleigh, the historical center of Raleigh’s African-American community. The DC component was initiated in August 1996; the ongoing intervention is at its institutionalization phase. The North Carolina State University, Wake Forest University, and CDC Institutional Review Boards approved Project DIRECT protocols during the study.

Study Population

By November 1995, the DC Workgroup (DCW), composed of DIRECT staff, community volunteers, physicians, and other healthcare providers, obtained and reviewed a list of providers in Wake County, from the three local hospital systems and compiled a list of healthcare providers in the county who were likely to serve patients with diabetes in the target area. The physician census in Wake County was 390 primary care physicians (93 family physicians, 15 general practitioners, 127 general internists, 65 obstetrician/gynecologists and 90 pediatricians) who are in active practice. Also, mid-level providers (i.e., 46 nurse practitioners and 55 physician assistants) practicing in Wake County were also eligible.
This is the population of providers from which a convenience sample of 30 providers was targeted for participation. The sampling was relaxed from random process to opportunity sampling. Because physicians know one another and have contact through various hospitals and other affiliations, they have first-hand knowledge about providers in the southeast Raleigh area serving African Americans. Recruitment of providers and practices commenced with the DCW physicians personally contacting providers and practices on the list with whom they are familiar. The contacts occurred through phone calls, office visits, and/or more informally via meetings or grand rounds. The goal of each encounter was to include discussion about the goals and objectives of Project DIRECT, the medical record review process, and the time commitment involved in participation. If the practices were interested, the recruiter assessed eligibility based on the following criteria.
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The inclusion criteria were a Wake County practice location; >10% of clients who were African Americans and southeast Raleigh residents; and a healthcare provider who practiced general, family, or internal medicine, or obstetrics and gynecology. Providers signed a consent form stating their willingness to participate in the CQIP and chart review.

Forty-seven providers, accounting for approximately 12% of primary care providers in Wake County at the project’s inception, agreed to participate and were included in the study at baseline.

The Intervention: Continuous Quality Improvement Plan

Once providers were recruited, they completed the baseline survey instrument about provider and patient population demographics and current diabetes management. The DIRECT staff also conducted a baseline chart review. These initial data were analyzed by the North Carolina Center for Urban Affairs and Community Services and compiled as provider’s performance profiles (snapshots) that were later returned so providers could set new performance goals during the October 1996 orientation session.
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The DIRECT staff conducted orientation sessions so each practice could establish a CQIP plan, adapted with permission from the Minnesota Diabetes Control Program. During the orientation session, participants completed a “planning worksheet” that included selection of a DIRECT office coordinator who was committed to the diabetes program; assessment of how to incorporate DIRECT office resources into their practices; identification of a patient education system either on-site (provide patient education and distribute, display, reorder, and stock materials), or by referral (initiate, track, and document the referral and to whom and how often); and determination of ways to implement the CQIP in their practices. They were then given a practice resource and provider quality improvement manuals and told about the Record Review Abstraction Form. They also received several diabetes reminder systems to select or adapt. By December 1996, all practices had chosen CQI coordinators and completed planning worksheets and summaries.

The Retention Plan

The retention plan included two major components: an education component with interactive feedback during regular and periodic follow-up visits, and diabetes-pertinent material distribution. Education programs included in-service training in the practices, grand-round sessions, and education programs with Continuing Medical Education credits organized in collaboration with diabetes experts from the University of North Carolina and Duke University, and a quarterly newsletter. Education sessions were first conducted collectively (conferences and grand rounds) and based on general diabetes topics; later, providers asked that sessions be held onsite and tailored to practice needs and based on snapshot results. As a result, during the second year, programs on nephropathy testing and foot exam and a traveling nursing education program accredited by Wake Area Health Education Center were developed. The former consisted of in-service programs, including providers’ training in foot care and microalbuminuria testing and distribution of kits and tools, teaching tools, patients’ education and providers’ education materials; seven practices made time for this learning session. The latter was based on the one-hour program, “Survival skills for the nurse providing diabetes education in the primary care setting” and was run in six practices. A county-specific resource directory was developed, updated annually, and freely distributed to participating providers. Contacts were established through monthly phone calls and periodic visits. suhagra 100