Article Figures & Data
Figures
- Figure 1.
Microsystems approach to implementing and sustaining healthcare change. Reproduced with permission from Little GA, Hammond CS. International perspectives: the Kosovo-Dartmouth Alliance for Healthy Newborns. NeoReviews 2008;9:e233–41.9 Copyright 2008 by the AAP.
- Figure 2.
Improving primary health care using a Microsystems approach.
- Figure 3.
Gjakova family medicine centers antenatal care clinical and educational service indicators.
Tables
Improvement Workgroup Aim Outcome Training Continuously increase the knowledge and skills of health providers at the MFMC 94% (61 of 65) doctors and 97% (152 of 156) nurses trained and demonstrating competency for blood pressure measurement and HTN management, including patient education
Ongoing monthly CPD programs led by and for staff doctors and nurses; clinical topics selected by group consensus
Patient flow To have most functional flow of patients through the MFMC Redesigned use of space with clearly designated areas for registration, patient waiting, screening, clinical care, and medical records
Increased patient satisfaction from March through October 2003
CPG Develop, adapt, and use guidelines for doctors and nurse to identify and manage HTN in patients at the MFMC CPG for HTN created by and for team of doctors and nurses (baseline, no HTN CPG)
HTN CPG used at MFMC
144 hypertensive patients identified and followed with new protocol including medical record
HTN CPG adopted by MoH for use throughout Kosovo
Data Design and use data forms and databases in order to improve the care of patients with HTN Forms created and in use: medical record for HTN; patient HTN “passport”; daily patient registration datasheets, patient and staff surveys (baseline, 0 medical records or passports)
Registration data collected for more than 40,000 patient visits during year 1 (baseline, 0)
Data shared and used to inform and improve care via data display in patient areas and routine reporting to leadership group
Patient education Provide the best health education (about HTN) for the population of Gjilan Nurses provide patient education for all patients found at screening to have high blood pressure or be at risk for HTN (baseline, no nurse-led patient education)
Patient education brochures created and distributed at individual appointments and in waiting area (baseline, no available materials)
Patient education videotapes available for various health topics
LRC Increase knowledge and skills of the MFMC staff through better use of information systems (computer, Internet, library resources) 5 computers with Internet connection available at MFMC for medically related use by staff and interested community members (baseline, no LRC)
Doctors and nurses trained by LRC staff: 117 in computer use, 56 in basic Internet searching, 15 in evidence-based medical searching
1 Clinical Practice Standard Review completed on hypertensive crisis (baseline, 0)
Patient access Improve quality of care by having patients get their care at the MFMC in their own community Increase in Monday staffing in response to higher volume
24% decrease (31% in November 2002 to 7% in October 2003) of patients seen at MFMC rather than family medicine center in their own community
52% decrease in visits resulting in antibiotic injection (average of 268 per week in November 2002 to 139 per week in March 2003)
Community outreach Use hypertension screening as a vehicle to build a good relationship between the MFMC and the community 10 community screenings for HTN held in 8 months; provided screening for 860 individuals; counseling and referral for appropriately identified patients
Ongoing patient education radio and TV spots for various common health topics, including HTN
Patient education posters for HTN in community settings
AIHA, American International Health Alliance; MFMC, main family medicine center; CPD, Continuing Professional Development; CPG, clinical practice guideline; HTN, hypertension; LRC, learning resource center (a tool promoted and supported by AIHA partnerships); MoH, Minstry of Health.
162 family medicine doctors and nurses completed antenatal care training
9 family medicine centers implemented antenatal care in Gjakova municipality (100%); staggered roll-out over 10 months
172 women received 254 antenatal care visits at family medicine centers (7% of population)
25% early, appropriate identification of risk and referral to specialist (consistent with WHO-model expectations)
28% of eligible women returned for postpartum visits
Antenatal care included clinical and educational care (see Figure 3)
Patient education highly valued by both patients and staff
Staff found provision of care “very rewarding”
Staff formed good relationships with patients
Staff developing relationships with obstetric colleagues
WHO, World Health Organization.
Change in culture from specialty care to primary care will take time and attention from the Ministry of Health.
Time lags for funding impact project momentum, supply chain, and reinforcement of new practice patterns.
Lack of system-wide health statistics on which to base our outcome data makes true outcome data very difficult to collect and rely on.
Care processes that do not include systematic follow-up or preventive care reflect ongoing cultural change challenges that will take time and attention from providers and the healthcare system of the country.
Changes in leadership within the family medicine centers led to interruption of progress in improvements made and threatened to move the family medicine centers back to previous standards.
Lack of funding for the healthcare system overall, including for supplies and professional salaries, has had a tremendous impact on the project. Professionals are unable to live at current salary levels and must have second/third jobs to survive. This had led to many requests for additional payment for work done within the project and increased tension. It has also led to a lack of basic supplies of equipment and medications necessary to care for the population.
