Impact of policies and performance measurement on development of organizational coordinating strategies for chronic care delivery.

OBJECTIVE To examine the impact of policy directives and performance feedback on the organization (specifically the coordination) of foot care programs for veterans, as mandated by public law within the Department of Veterans Affairs Health Care System (VA). STUDY DESIGN Case study of 10 VA medical centers performing diabetes-related amputations. PATIENTS AND METHODS Based on expert consensus, we identified 16 recommended foot care delivery coordination strategies. Structured interview protocols developed for primary care, foot care, and surgical providers, as well as administrators, were adapted from a prior study of surgical departments. RESULTS Although performance measurement results for foot risk screening and referral were high at all study sites over 2 calendar years (average 85%, range 69% to 92%), the number of coordination strategies implemented by any site was relatively low, averaging only 5.4 or 34% (range 1-12 strategies). No facility had systematically collected data to evaluate whether preventive foot care was provided to patients with high-risk foot conditions, or whether these patients had unmet foot care needs. CONCLUSIONS Although foot care policies and data feedback resulted in extremely high rates of adherence to foot-related performance measurement, there remained opportunities for improvement in the development of coordinated, technology-supported, data-driven, patient-centered foot care programs.

[1]  R. Hayward,et al.  Department of Veterans Affairs' Quality Enhancement Research Initiative for Diabetes Mellitus. , 2000, Medical care.

[2]  S. Kaplan,et al.  Foot infections in diabetic patients. Decision and cost-effectiveness analyses. , 1995, JAMA.

[3]  M. Charns,et al.  Health Care Organizations, a Model for Management , 1983 .

[4]  K W Kizer,et al.  Quality Enhancement Research Initiative (QUERI): A collaboration between research and clinical practice. , 2000, Medical care.

[5]  Alastair Baker,et al.  Crossing the Quality Chasm: A New Health System for the 21st Century , 2001, BMJ : British Medical Journal.

[6]  L T Cotton,et al.  Improved survival of the diabetic foot: the role of a specialized foot clinic. , 1986, The Quarterly journal of medicine.

[7]  D. Bild,et al.  Reduction of Lower Extremity Clinical Abnormalities in Patients with Non-Insulin-Dependent Diabetes Mellitus , 1993, Annals of Internal Medicine.

[8]  James S. M. Tan.  Foot Infections in diabetic patients , 2004, Current infectious disease reports.

[9]  C. Patterson,et al.  Joint Commission on Accreditation of Healthcare Organizations. , 1995 .

[10]  K. Kizer.  The "New VA": A National Laboratory for Health Care Quality Management , 1999, American journal of medical quality : the official journal of the American College of Medical Quality.

[11]  G. Young,et al.  Best practices for managing surgical services: the role of coordination. , 1997, Health care management review.

[12]  A. V. D. Ven,et al.  Determinants of Coordination Modes within Organizations , 1976 .

[13]  M P Charns,et al.  Patterns of coordination and clinical outcomes: a study of surgical services. , 1997, Health services research.

[14]  Gary J. Young,et al.  Validating risk-adjusted surgical outcomes: site visit assessment of process and structure1 , 1997 .

[15]  S. H. Mansbridge.  ORGANIZATION THEORY AND PRACTICE , 1961 .

[16]  Liane Ginsburg,et al.  Factors that influence line managers' perceptions of hospital performance data. , 2003, Health services research.

[17]  West Td.  Comparing change readiness, quality improvement, and cost management among Veterans Administration, for-profit, and nonprofit hospitals. , 1998 .

[18]  S M Shortell,et al.  Physician-System Relationships: Stumbling Blocks and Promising Practices , 2001, Medical care.

[19]  D. Armstrong,et al.  Functional status of persons with diabetes-related lower-extremity amputations. , 2001, Diabetes care.

[20]  D. Berwick.  A user's manual for the IOM's 'Quality Chasm' report. , 2002, Health affairs.

[21]  J. Newhouse.  Why is there a quality chasm? , 2002, Health affairs.

[22]  Donald R. Miller,et al.  Who has diabetes? Best estimates of diabetes prevalence in the Department of Veterans Affairs based on computerized patient data. , 2004, Diabetes care.

[23]  J Larsson,et al.  Towards less amputations in diabetic patients. Incidence, causes, cost, treatment, and prevention--a review. , 1995, Acta orthopaedica Scandinavica.

[24]  S. Shortell,et al.  Physician-System Alignment: Introductory Overview , 2001, Medical care.

[25]  Martin P Charns,et al.  The relationship between provider coordination and diabetes-related foot outcomes. , 2003, Diabetes care.

[26]  S M Shortell,et al.  The Performance of Intensive Care Units: Does Good Management Make a Difference? , 1994, Medical care.

[27]  Brian T. Austin,et al.  Organizing care for patients with chronic illness. , 1996, The Milbank quarterly.

[28]  Jay R. Galbraith.  Designing Complex Organizations , 1973 .

[29]  Joan C. Woodward.  Industrial Organization: Theory and Practice , 1966 .