Practice-based learning for improvement: the pursuit of clinical excellence

Physicians often seem to be paralyzed waiting for a health plan, a health maintenance organization, or an integrated health care system to bring about change or improvement in health care. But small changes in individual practices (microsystems) can have a profound impact on outcomes in an organization (microsystem). With simple graphical measurement tools, physicians can teach patients to measure and empower themselves to learn to improve both their health and their health care. At the same time, physicians can learn a great deal from their patient population data. When these measurement tools and a well-known and widely accepted method for clinical practice improvement called rapid cycle testing were used in a population of patients with diabetes, the average fasting blood sugar changed from 187 to 110 and the average hemoglobin A1c from 10.5 to 7.2. This article shows that measurement using specification charts and control charts in patient care can have a profound impact on patients, physicians, and organizations. Understanding these principles and using time-sequence measurement with graphical data feedback, physicians can engage in practice-based learning and can participate in improvement in the microsystems over which they have control.