Using Continuous Quality Improvement to Increase Preventive Services in Clinical Practice—Going Beyond Guidelines 1 LEIF I. SOLBERG, M.D.,* ,2 THOMAS E. KOTTKE, M.D.,† MILO L. BREKKE,PH.D.,‡ CAROLYN A. CALOMENI, M.A.,* SHIRLEY A. CONN, M.S.N.,§ AND GESTUR DAVIDSON,PH.D.¶ *Group Health Foundation, Minneapolis, Minnesota 55440; †Mayo Clinic and Foundation, Rochester, Minnesota 55905; ‡Brekke Associates, Minneapolis, Minnesota; §Blue Plus, St. Paul, Minnesota 55164; and ¶Minneapolis, Minnesota Background. Even the most uniformly accepted pre- vention guidelines do not by themselves lead to imple- mentation or to adequate rates of preventive services in medical practice. Although much has been learned about the office systems that seem to be needed for major change in a busy clinical practice, there are still no examples of a model for developing, implementing, and sustaining those office systems in a nonacademic practice. Methods. IMPROVE, the first large randomized con- trolled trial of CQI (continuous quality improvement) in any industry, is providing a scientific test of the hypothesis that HMO sponsorship of a CQI-based in- tervention can lead to sustained organizational change, implementation and maintenance of office systems, and improved rates of adult preventive ser- vices in contracted private primary care clinics. The 22 clinics assigned to the intervention arm of the study are receiving training, consultation, networking, and reinforcement for internal multidisciplinary teams as they work through a structured process to understand and improve their clinic’s process for providing pre- ventive services. Rates and quality of eight preventive services in these clinics are being compared over time with those in 22 matched comparison clinics. Results. The 44 clinics needed for the trial have been recruited and randomized, and baseline comparisons show no significant differences between the two groups. Nine months into the trial, 21 of 22 interven- tion clinics have completed training and are pursuing a systematic improvement process for preventive ser- vices. Conclusions. With external training and consulta- tion, many private primary care clinics will voluntar- ily engage in a lengthy multidisciplinary team effort to use CQI techniques to study and systematically im- prove their entire process for providing preventive services. © 1996 Academic Press, Inc. Key Words: Preventive services; quality improve- ment; managed care; CQI. INTRODUCTION Both public policymakers and primary care physi- cians appear to agree that delivery of clinical preven- tive services is important. Despite that, even most of those preventive services with widespread support in the medical community are not currently being pro- vided at optimal rates, even to patients visiting medi- cal practices. In fact, most comparisons of physician attitudes and self-reported preventive behavior against services reported by patients or recorded in charts have shown a wide discrepancy between reality and physician desire/perception. 1,2 Why is this? It certainly can no longer be blamed on the absence of clear guidelines. Healthy People 2000 and the U.S. Preventive Services Task Force have helped greatly to clarify which services are most im- portant, what the actual guidelines should be, and the importance of an evidence basis for guidelines. 3,4 How- ever, even if one focuses on those areas where there is widespread agreement (e.g., mammography between the ages of 50 and 75), rates are surprisingly low. 5 Clearly, guidelines alone are necessary but not suffi- cient. There is now widespread agreement that the key issue is how to implement guidelines. We have very little evidence that anyone has learned how to do this well. 6–8 Lack of reimbursement is not a sufficient excuse ei- ther, as the Katz and Hofer article comparing preven- tive services rates between the United States and Canada demonstrates. 9 Instead, this deficiency ap- pears to be primarily due to the realities of medical practice 10–12 : 1. Time. Physicians and staff in most primary care clinics are overwhelmingly busy responding to the problems and requests of their patients. 1 This project was supported by Grant RO1 HS08091 from the Agency for Health Care Policy and Research. 2 To whom correspondence and reprint requests should be ad- dressed at Group Health Foundation, 8100 34th Avenue South, P.O. Box 1309, Minneapolis, MN 55440-1309. E-mail: Leif.I.Solberg@ HealthPartners.com. PREVENTIVE MEDICINE 25, 259–267 (1996) ARTICLE NO. 0055 259 0091-7435/96 $18.00 Copyright © 1996 by Academic Press, Inc. All rights of reproduction in any form reserved.