title: Infrastructure for large-scale quality-improvement projects: early lessons from North Carolina Improving Performance in Practice.
abstract: BACKGROUND
  Little is known regarding how to accomplish large-scale health care improvement. Our goal is to improve the quality of chronic disease care in all primary care practices throughout North Carolina.
  
  
  METHODS
  Methods for improvement include (1) common quality measures and shared data system; (2) rapid cycle improvement principles; (3) quality-improvement consultants (QICs), or practice facilitators; (4) learning networks; and (5) alignment of incentives. We emphasized a community-based strategy and developing a statewide infrastructure. Results are reported from the first 2 years of the North Carolina Improving Performance in Practice (IPIP) project.
  
  
  RESULTS
  A coalition was formed to include professional societies, North Carolina AHEC, Community Care of North Carolina, insurers, and other organizations. Wave One started with 18 practices in 2 of 9 regions of the state. Quality-improvement consultants recruited practices. Over 80 percent of practices attended all quarterly regional meetings. In 9 months, almost all diabetes measures improved, and a bundled asthma measure improved from 33 to 58 percent. Overall, the magnitude of improvement was clinically and statistically significant (P = .001). Quality improvements were maintained on review 1 year later. Wave Two has spread to 103 practices in all 9 regions of the state, with 42 additional practices beginning the enrollment process.
  
  
  CONCLUSIONS
  Large-scale health care quality improvement is feasible, when broadly supported by statewide leadership and community infrastructure. Practice-collected data and lack of a control group are limitations of the study design. Future priorities include maintaining improved sustainability for practices and communities. Our long-term goal is to transform all 2000 primary-care practices in our state.
authors.affiliation: Department of Family Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7595, USA. warren_newton@med.unc.edu
authors.forename: Warren P
authors.initials: WP
authors.lastname: Newton
authors.forename: Ann
authors.initials: A
authors.lastname: Lefebvre
authors.forename: Katrina E
authors.initials: KE
authors.lastname: Donahue
authors.forename: Thomas
authors.initials: T
authors.lastname: Bacon
authors.forename: Allen
authors.initials: A
authors.lastname: Dobson
mesh_terms: D001249:Asthma / Q000628:therapy; D002908:Chronic Disease; D003299:Cooperative Behavior; D003920:Diabetes Mellitus / Q000628:therapy; D004502:Education, Medical, Continuing; D005240:Feasibility Studies; D006265:Health Care Coalitions; D006801:Humans; D009042:Motivation; D009657:North Carolina; D011320:Primary Health Care / Q000592:standards*; D011785:Quality Assurance, Health Care / Q000379:methods*; D012955:Societies, Medical; D013219:State Government