Increasing Clinical Prevention Efforts in a Family Practice Residency Program Through CQI Methods

As primary care physicians develop ongoing relationships with their patients, each contact provides another opportunity for primary, secondary, or tertiary prevention activities. In 1991 an interdisciplinary prevention project team using continuous quality improvement (CQI) principles was established to improve family practice residents’ provision of such services. For a random sample of 60 patient charts, abstractors looked for documentation of 23 clinical preventive services, including nursing screens, physician on-site and off-site implemented services, lifestyle education (diet, tobacco use), and self-screening education. After the chart review, the physicians, nurses, residents, and clinical staff used a fishbone analysis to identify physician-, clinic system–, and patient-centered factors contributing to the lack of conformance with clinical prevention guidelines. The residency program began a series of didactic sessions on clinical prevention and instituted a procedures rotation to teach prevention procedure skills such as flexible sigmoidoscopy, stress testing, and colposcopy. On the CQI team’s recommendation, a checklist developed by physicians and staff which itemized age- and gender-specific clinical prevention services was placed at the front of all patient charts. Clinic-system and patient factors were also addressed. The 1993 postintervention chart review showed significant improvements for 17 (81%) of the 21 targeted services. Providing educational sessions on prevention, permitting residents to select the areas of prevention on which to focus, and giving feedback on resident and staff performance through ongoing, nonpunitive monitoring resulted in increased provision of clinical prevention services in a family practice residency training center. Providers at a family practice center had adopted the same mentality as the patients in addressing only urgent, acute, or emergency problems at physician visits. To change this crisis mentality, physicians and nurses participated in ongoing didactic sessions on clinical prevention and were encouraged to try to include a bit of prevention at every visit, even urgent care visits.