The impact of a quality improvement program on systems, processes, and structures in medical clinics

OBJECTIVE:: We sought to assess whether participation in a quality-improvement collaborative changed care processes, systems, and organization of outpatient human immunodeficiency virus (HIV) clinics. METHODS:: We surveyed clinicians, medical directors, and HIV program administrators before and after an 18-month quality improvement collaborative at 54 intervention and 37 control clinics providing HIV care. Surveys assessed clinic structures, processes, systems, and culture. During the collaborative, a clinicianĝ€"administrator team from each intervention clinic attended 4 2-day sessions on quality improvement techniques. Conference calls, a website, and an e-mail list provided support and facilitated communication among collaborative participants. RESULTS:: Survey response rates were 85% or greater. Six of 54 organizational measures differed significantly between baseline and follow-up. Intervention clinicians reported greater computer availability (82% vs. 67%, P ≤ 0.03) and use (3.13 vs. 2.68, P ≤ 0.02; 4-point scale), attended more local (14.2 vs. 8.6, P < 0.01) and national (4.1 vs. 2.9, P ≤ 0.01) conferences, and rated leadersĝ€™ ability to implement quality improvement higher (3.8 vs. 3.4, P ≤ 0.01; 5-point scale). Intervention directors were more likely to compare quality data to other clinics (79% vs. 54%, P ≤ 0.04). For the set of 54 measures, intervention clinics were more likely to have higher post-intervention scores than controls (sign test, mean ≤ 14.5, P < 0.0001). CONCLUSIONS:: A quality-improvement collaborative for HIV clinics resulted in modest organizational changes. Achieving greater change may require more focused and/or intensive interventions, greater resources for participating clinics, and better developed information technology.