Musings on using evidence to guide CQI efforts toward success: the computerized firm system as primary care microunit

The attempt to transfer classic industrial CQI (continuous quality improvement) theory into the clinical arena has proved to be more difficult than originally promised. A new "computerized firm system" approach to incorporating CQI efforts into mainstream practice settings, which has been able to obviate many of these shortcomings, is described.

To make it easier for CQI efforts to be successful, the scope of activities undertaken in completing the Shewhart cycle popularly referred to as PDSA (plan change, do change, study results, act on results) was delimited. Rather than plan the intervention themselves, staff worked with experts on tailoring a preselected change idea with already established efficacy--a computerized reminder system. Because the clinic was divided into two small group practices known as firms, a controlled time-series trial (CTST) design was used by initially turning the reminders on for one firm but not the other. The clinic was thereby also relieved of the responsibility of conducting a study to determine whether the intended improvement in quality had been achieved. In essence, one clinic was asked to do just DA (that is, do-act).

This approach engendered the successful completion of a streamlined Shewhart cycle in a busy clinic setting at remarkably low cost. The compelling nature of controlled evaluation results aided leadership in rapidly disseminating the reminder system to the remaining 11 primary care clinics associated with the university's 2 academic medical centers.

Computerized firm systems can be developed to conduct CTSTs as part of streamlined CQI cycles guided by both published and local evidence, and they are worth developing.