During 2006–2007, 41 teams from 37 teaching hospitals participated in the ETS. The response rate for participating in the ETS was 87%. The 1,145 narrative entries provided a window into how collaborative participants care for patients with chronic illness, work as part of a team, and teach.
Several themes emerged from the analysis of the qualitative data. The six most frequent themes from the ETS responses were (1) mindfulness of patient care, (2) changes in work attributed to the ACCC experience, (3) greater focus on patient education, (4) multi-disciplinary team function, (5) mindfulness of learner interactions, and (6) reflection on action (e.g. the ability to have new understanding based on a reflection of a recent experience).
The themes from the ETS narrative entries for teams focusing on improving diabetes care were then linked to the quantitative clinical outcomes that were submitted as part of the monthly reports that were required from participants in the ACCCs.9
We used the Assessment Scale for Collaboratives to rank the team performance on a scale of 1 to 5.20
This scale evaluates participating teams for evidence of (a) implementing the CCM for the patient population of focus, with at least one change implemented for each of the six components of the Care Model, (b) making significant improvement in two of three required outcome measures (percent of population with HbA1c <7, LDL <100, blood pressure ≤130/80), (c) reaching at least 50% of goal for all required process measures (percent of patient population with up-to-date retinal examinations, foot examinations, and establishment of patient self management support), (d) planning for spread of improvement efforts; and (e) monitoring at least 90% of the population of focus using a disease registry. A score of 4 served as the cut-off for high performance, which is defined as “Significant Improvement”. Specific results of collaborative measures are reported elsewhere.9
To consider whether there were any differences, as indicated by the qualitative themes, related to different levels of quantitative performance, we compared the sites that scored the highest on the assessment scale to those that scored the lowest. Five sites met criteria for high performance, using a score of “4” or “significant improvement” as the cut-off. The five sites ranking the lowest on the scale were grouped as low performing sites. The themes between the two groups were the same, except for one theme that emerged in the higher performers—professional work satisfaction (i.e. a sense of “joy in work”)—and two themes that emerged exclusively in the poorer performers which reflected the effect of providing care in difficult institutional environments—“lack of professional satisfaction” in work as evident by interference with ability to deliver good chronic illness care and awareness of “system failure” within the microsystem. Themes and illustrative verbatim quotations are described in the following sections.
“Mindfulness of Patient Care,” where the respondent identified and described an event from the day that was directly related to patient care, was the most frequent theme that emerged.
Took care of a pt. who was here with syncopal episodes, bradycardia and SOB. This is 89 year old pt. with a H/O CHF, HTN and several other problems. She had to have several tests done and she ended up being admitted on a tele floor for further evaluation. I spent about 90 minutes plus my lunch hr with this pt. The whole team- RN, MA, the collaborating physician, the pt. and her spouse was involved with everything we did. It was a group effort to get her to floor. This was a very satisfying visit, since I felt I could do something for her and reli[e]ve some of her symptoms. [Physician]
“Changes in Work” was the second most frequent theme, and provided the Collaborative faculty insight into real-time changes that were occurring in response to the Collaborative.
The group visit attracted two patients who had not been seen recently in the clinic and were due for a routine doctor visit. Their resident physician has graduated. I was able to assign new doctors for these two Change Team patients today. Appointments are being arranged with residents who will be trained in the chronic care model during next month's rotation. This will ensure planned visits will be scheduled for residents during the month. Not only does this promote continuity of care with the nurse practitioners providing team based care with the residents, it also provides residents with patient who need updated care. [Member of the Administrative Staff]
The next most frequent theme was “Patient Education”:
Per MD request, met with a 21 yr old type 1 DM who has been non compliant with diet, exercise, blood sugars...plus drug usage. I was able to utilize knowledge of young adults in approaching her to establish rapport and goal setting. She has agreed to weekly f/u with me for teaching and coaching. Patient open to teaching. [Nurse]
In the theme, “Multidisciplinary Team Function,” the respondent identified and described an event from the day that was related to working as part of a multidisciplinary team to provide chronic illness care.
Lots happening today... Absolutely awesome Interdisciplinary Team Meeting with residents presenting complex patients. Great interchange between disciplines about patient barriers, medication adjustments and coordinating follow-up for continuity. Improvement in show rates for planned visits was also reported as a result of nurse practitioner telephone interventions. Residents discussed a team approach to patient care as a follow-up from the Team Meeting. [Physician]
“Mindfulness of Learner Interactions” emerged as a prevalent theme:
Worked with a 4th year medical student this afternoon in clinic and had a ton of no-shows (all acute visits), but the patients who did show up were all my chronic care patients, many of them diabetic. I was able to teach the med student about following DM trends with our clinic flowsheet and go through some self-management goal setting with the patient while med student was present. She thought it was fantastic and wishes she had been exposed to this earlier [Physician]
“Reflection-on-action” is a theme where the respondent described an event from the day that was related to his or her own reflections about caring for patients with chronic illness. This theme represents comments displaying consciousness about the future, goals, and how to improve care. The “reflective practitioner” is not a new concept and “reflection-in-action” and “reflection-on-action” were central to Schön’s efforts to describe what professionals do.21
Reflection-in-action is reflecting on the process while engaged in the process. Reflection-on-action is something that occurs later, after the event. Given the nature of our data collection process where the narrative entries captured the event of the day, post hoc, reflection-on-action best describes the category.
Today I saw a young patient with poorly controlled Type I diabetes. She has been very cooperative and enthusiastic about establishing care with me and getting her DM under control. Yet her A1c is 12.4. She has limited income and really would benefit from seeing an endocrinologist in the area. I’m excited to work with her, but sometimes I feel somewhat overwhelmed with the complexities of her care and the limited economic means she has. I know that if we get her DM under control that will be a huge achievement for her, myself, and the entire team. This event reminded me to share my frustrations with my residents, so that they see that attendings also have difficulties with their patients at times and we can all work to motivate each other. [Physician]
Whereas the previous six themes were the most frequent across all participating sites in the collaborative, separating the high performing teams from the lower performing teams based on clinical indicators resulted in two key differences. The high performing teams had an additional theme of “Professional Work Satisfaction” that could be best described as events that brought “joy” to the provider in their day-to-day work of providing care for patients with chronic illness. These ranged from simple to more complex interactions, but overwhelmingly described an enthusiasm resulting from the work, environment, and interactions that we termed “joy and work”.
A patient that we have been calling weekly to titrate insulin came today with perfect sugars. She was happy and so were we. We called the nurses in to look at her logbook! It takes a village to take care of a patient. [Physician]
In contrast to the theme of Professional Satisfaction, “Lack of Professional Satisfaction or Joy in Work” characterized events that resulted in frustration for the respondent.
Due to an overcrowded faculty meeting agenda I was unable to discuss the [collaborative] activities currently underway. We learned that another faculty member is leaving at the end of June. We are extremely short of physician faculty. In the face of these stresses, not being able to keep the [collaborative] activities in front of the faculty lets them drift [to] the background. When you are focused on just getting the essentials done, anything new seems less important. My limited time working on the [collaborative] in this residency give[s] me a Sisyphus-like experience. You push it to the top of the hill only to have it fall back to the bottom. [Physician]
“System Failures” describes events that can be characterized as trying to work within a larger system that sets up barriers that are perceived as insurmountable.
I created a new flow sheet for insulin titration in the clinic. It has evidence based guidelines built right in and it looks good. Now I have to turn it over to the forms committee and it will take months to be approved and patient care will suffer as a result. I think our forms committee is awful and causes unnecessary delays in patient care. What do you say to residents in systems like ours? Any good idea you have today will be delayed because of a draconian hospital committee? [Physician]