title: Fostering evidence-based quality improvement for patient-centered medical homes: Initiating local quality councils to transform primary care.
abstract: Although the patient-centered medical home endorses quality improvement principles, methods for supporting ongoing, systematic primary care quality improvement have not been evaluated. We introduced primary care quality councils at six Veterans Health Administration sites as an organizational intervention with three key design elements: (a) fostering interdisciplinary quality improvement leadership, (b) establishing a structured quality improvement process, and (c) facilitating organizationally aligned frontline quality improvement innovation.
  
  
  
  Our evaluation objectives were to (a) assess design element implementation, (b) describe implementation barriers and facilitators, and (c) assess successful quality improvement project completion and spread.
  
  
  
  We analyzed administrative records and conducted interviews with 85 organizational leaders. We developed and applied criteria for assessing design element implementation using hybrid deductive/inductive analytic techniques.
  
  
  
  All quality councils implemented interdisciplinary leadership and a structured quality improvement process, and all but one completed at least one quality improvement project and a toolkit for spreading improvements. Quality councils were perceived as most effective when service line leaders had well-functioning interdisciplinary communication. Matching positions within leadership hierarchies with appropriate supportive roles facilitated frontline quality improvement efforts. Two key resources were (a) a dedicated internal facilitator with project management, data collection, and presentation skills and (b) support for preparing customized data reports for identifying and addressing practice level quality issues.
  
  
  
  Overall, quality councils successfully cultivated interdisciplinary, multilevel primary care quality improvement leadership with accountability mechanisms and generated frontline innovations suitable for spread. Practice level performance data and quality improvement project management support were critical.
  
  
  
  In order to successfully facilitate systematic, sustainable primary care quality improvement, regional and executive health care system leaders should engage interdisciplinary practice level leadership in a priority-setting process that encourages frontline innovation and establish local structures such as quality councils to coordinate quality improvement initiatives, ensure accountability, and promote spread of best practices.
authors.affiliation: Susan E. Stockdale, PhD, is Research Health Scientist, HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Sepulveda, California; and Associate Research Sociologist, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles. Jessica Zuchowski, PhD, MPH, is Health Science Specialist, HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Sepulveda, California. Lisa V. Rubenstein, MD, MSHS, is Associate Director, HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Sepulveda, California; and Professor, David Geffen School of Medicine, University of California, Los Angeles; and RAND Corporation, Santa Monica, California. Negar Sapir, MPH, is Health System Specialist, HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Sepulveda, California. Elizabeth M. Yano, PhD, MPH, is Center Director and Senior Research Career Scientist, HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Sepulveda, California; and Adjunct Professor of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles. Lisa Altman, MD, is Associate Chief of Staff for Transformation and Innovation, VA Greater Los Angeles Healthcare System, Sepulveda, California; and Professor, David Geffen School of Medicine, University of California, Los Angeles. Jacqueline J. Fickel, PhD, is Research Health Scientist, HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Sepulveda, California. Skye McDougall, PhD, is VISN Director, VHA South Central VA Healthcare Network (VA Integrated Service Network 16), Ridgeland, Mississippi. Timothy Dresselhaus, MD, MPH, is Chief, Primary Care Service, San Diego VA Healthcare System, California; and Professor, Department of Medicine, University of California, San Diego. Alison B. Hamilton, PhD, MPH, is Research Health Scientist, HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Sepulveda, California; and Research Anthropologist, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles.
authors.forename: Susan E
authors.initials: SE
authors.lastname: Stockdale
authors.forename: Jessica
authors.initials: J
authors.lastname: Zuchowski
authors.forename: Lisa V
authors.initials: LV
authors.lastname: Rubenstein
authors.forename: Negar
authors.initials: N
authors.lastname: Sapir
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Yano
authors.forename: Lisa
authors.initials: L
authors.lastname: Altman
authors.forename: Jacqueline J
authors.initials: JJ
authors.lastname: Fickel
authors.forename: Skye
authors.initials: S
authors.lastname: McDougall
authors.forename: Timothy
authors.initials: T
authors.lastname: Dresselhaus
authors.forename: Alison B
authors.initials: AB
authors.lastname: Hamilton
mesh_terms: D019317:Evidence-Based Medicine; D006761:Hospitals; D006801:Humans; D007857:Leadership; D017146:Models, Organizational; D009936:Organizational Innovation; D018802:Patient-Centered Care / Q000379:methods / Q000592:standards*; D011320:Primary Health Care / Q000379:methods / Q000592:standards*; D011785:Quality Assurance, Health Care / Q000592:standards; D058996:Quality Improvement; D014481:United States; D014493:United States Department of Veterans Affairs