Question 1:
When considering what effectively changes prescribing practice, a
variety of interventions have been systematically reviewed (i.e. practice
guidelines, CME, audit & feedback, patient-mediated strategies, academic
detailing, etc, etc). But no where have I seen CQI methods
systematically reviewed. Has anyone looked at this? Is anyone in the
process of looking at this? Does good evidence exist to suggest CQI
works to bring about meaningful and lasting change in practice?
Question 2:
Don Berwick, head of the Institute for Healthcare Improvement in Boston,
advocates using PDSA quick-cycle testing (i.e. Plan the change; Do the
change, Study the results, Act on the results) for measuring whether
changes in practice have lead to improvment. (See Ann Intern Med
1998;128:460-466) This quick-cycle testing produces rapid results at the
front-lines of medicine by advocating measuring small, representative
samples, avoiding long baseline collection periods, and striving for
practicality rather than perfection in data collection. Obviously, this
approach is far from the methodologic rigour we prefer, but Berwick's
point is that this approach is practical and gets physicians (and other
practitioners) measuring things and making changes in their practice that
otherwise would never get done. He purports that this method is
preferable to not doing anything at all. This quick-cycle approach has
been used by a variety of tertiary care institutions in the US, and has
resulted in "reducing costs of care while improving outcomes" under the
tutelage of Berwick and IHI.
I welcome your input on the merits and risks of this CQI approach to
improving prescribing practice.
Thanks in advance,
Janet Martin, PharmD
Evidence-Based Prescribing Guidelines Pharmacist
London Health Sciences Centre
London, Ontario
N6A 4G5
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