Quality improvement in health care today requires a comprehensive approach. Improvement efforts led by patients, payers, regulators, or health care providers face many barriers. Obstacles include selecting measures with clinical value, building physician acceptance, establishing routine and efficient measurement, and resolving competing clinical demands and work flow impediments. To meet these challenges, the Brigham and Women's Hospital Department of Medicine created a grassroots quality program guided by four main principles: improvement is led by frontline clinicians who select measures important to their patients, performance measurement is automated and accurate, appropriate resources are provided, and interventions are system based and without financial incentives for individual providers.The quality program has engaged the department's physicians from the start. Given the flexibility to define their own metrics according to their patients' needs, clinicians have selected measures related to prevention and wellness, which are often based on national standards. The central quality team facilitates measurement and reporting while providers focus on patient care. The subsequent production of meaningful, actionable data has been instrumental in building physician acceptance and in providing clinicians the opportunity to evaluate and monitor performance. The program's largest challenges have been in capturing meaningful data from electronic systems. The program's system-based focus encourages providers to develop solutions within the existing framework of clinic resources, primarily targeting work flows and processes, while minimizing large expenditures on additional staffing.
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