O

The clinical microsystem

Disease activity (DAS) over ten years at initial consultation and at 6 and 12 months in recent onset rheumatoid arthritis

Das (median)

2 | | | | | | | | 1994 1996 1998 2000 2002 2004 2006 2008

2 | | | | | | | | 1994 1996 1998 2000 2002 2004 2006 2008

Figure 5 The Swedish rheumatology register. Source: Courtesy of Staffan Lindblad, MD, PhD, Karolinska Institute, Stockholm, Sweden.

activity data over a 12-year period from patients with adult rheumatoid arthritis detailed in Figure 5.

A pedagogic tool for illustrating measurements in multiple dimensions is the "Clinical Value Compass" (12). In adolescent rheumatology examples of measures in the different directions are illustrated in Figure 6.

A registry can give clues if and why health disparities occur about groups of patients and between geographic locations. An interesting study from Cinncinati Children's Hospital Medical Center (Cinncinati, Ohio, U.S.) using a prospective disease registry showed that children with Medicaid status who had been diagnosed with juvenile idiopathic arthritis had significantly lower health-related quality of life and higher disability than children with the same severity of disease and private insurance. The difference was present in spite of similar overall resource utilization. However, children with Medicare status were more likely to visit the emergency department and had fewer magnetic resonance images (17).

Knowledge of Psychology of Work and Change

The performance of a system can be attributed to multiple causes, including understanding health-professional behavior. Seeking knowledge about what nurtures curiosity and learning, joy, and pride in health care professionals can support leaders who are interested in engaging staff in change and improvement. Change theory and leading change knowledge is an important leadership responsibility.

A pediatric rheumatology value compass

■ Child health assessment questionnaire (CHAQ)

■ Child health questionnaire (Quality of life, CHQ)

Function and risk status

Biological status

■ Number of active joints

■ Number of joints with limited range of motion

■ Acute exacerbations

■ Systemic side effects from medications

A pediatric rheumatology value compass

■ Child health assessment questionnaire (CHAQ)

■ Child health questionnaire (Quality of life, CHQ)

Function and risk status

Satisfaction vs. need

■ Needed treatments given

■ Prepared to prevent problems

■ Access to care as needed

■ Trust in doctor and nurse

■ Costs affordable

Costs

1 ED visits/hospitalizations

■ Diagnostic test costs

■ Laboratory tests

■ Medication costs

■ Lost work time for family

Satisfaction vs. need

■ Needed treatments given

■ Prepared to prevent problems

■ Access to care as needed

■ Trust in doctor and nurse

■ Costs affordable

Costs

1 ED visits/hospitalizations

■ Diagnostic test costs

■ Laboratory tests

■ Medication costs

■ Lost work time for family

Figure 6 The clinical value compass: An example for adolescent rheumatology. Source: Adapted from Ref. 12.

Theory of Knowledge for Change

When we link theory and action we have the potential for learning and building knowledge, which forms the basis for continual improvement. This model is how clinicians work with patients, with a diagnosis as a theory and the tests with some treatment as the action—and then measurement and evaluation together with the patient to see if it was effective. The new knowledge built in that cycle can be used to the next decision. A useful method based on the idea of theory and action is the Plan-Do-Study-Act (PDSA) cycle (Fig. 7) (13,14). How the PDSA model can help us to work on improvement in health care in our own setting is further explored in the second part of this chapter.

An illustration of how the different knowledge systems need to be put together for improvement is the following equation suggested by Batalden and Davidoff (9):

Generalizable scientific evidence + Particular context ^ Measured performance improvement

The context is in this case is the adolescent rheumatology clinic.

The "+" in the equation represents the variety of methods available for connecting evidence to the particular context, degree of agreement, and priorities for implementing the scientific evidence, while the arrow symbolizes your strategy and execution plan for making improvements in the particular context (Fig. 8).

This equation provides a framework for the second part of this chapter, which provides practical advice on how to gain deeper knowledge of your particular context—the clinical microsystem of adolescent rheumatology. Suggestions on how to get started in your work to improve performance measures and outcomes with and for patients and families is illustrated.

Arthritis Joint Pain

Arthritis Joint Pain

Arthritis is a general term which is commonly associated with a number of painful conditions affecting the joints and bones. The term arthritis literally translates to joint inflammation.

Get My Free Ebook


Post a comment