Infrastructure for large-scale quality-improvement projects: early lessons from North Carolina Improving Performance in Practice

J Contin Educ Health Prof. 2010 Spring;30(2):106-13. doi: 10.1002/chp.20066.


Introduction: Little is known regarding how to accomplish large-scale health care improvement. Our goal is to improve the quality of chronic disease care in all primary care practices throughout North Carolina.

Methods: Methods for improvement include (1) common quality measures and shared data system; (2) rapid cycle improvement principles; (3) quality-improvement consultants (QICs), or practice facilitators; (4) learning networks; and (5) alignment of incentives. We emphasized a community-based strategy and developing a statewide infrastructure. Results are reported from the first 2 years of the North Carolina Improving Performance in Practice (IPIP) project.

Results: A coalition was formed to include professional societies, North Carolina AHEC, Community Care of North Carolina, insurers, and other organizations. Wave One started with 18 practices in 2 of 9 regions of the state. Quality-improvement consultants recruited practices. Over 80 percent of practices attended all quarterly regional meetings. In 9 months, almost all diabetes measures improved, and a bundled asthma measure improved from 33 to 58 percent. Overall, the magnitude of improvement was clinically and statistically significant (P = .001). Quality improvements were maintained on review 1 year later. Wave Two has spread to 103 practices in all 9 regions of the state, with 42 additional practices beginning the enrollment process.

Discussion: Large-scale health care quality improvement is feasible, when broadly supported by statewide leadership and community infrastructure. Practice-collected data and lack of a control group are limitations of the study design. Future priorities include maintaining improved sustainability for practices and communities. Our long-term goal is to transform all 2000 primary-care practices in our state.

MeSH terms

  • Asthma / therapy
  • Chronic Disease
  • Cooperative Behavior*
  • Diabetes Mellitus / therapy
  • Education, Medical, Continuing
  • Feasibility Studies
  • Health Care Coalitions*
  • Humans
  • Motivation
  • North Carolina
  • Primary Health Care / standards*
  • Quality Assurance, Health Care / methods*
  • Societies, Medical
  • State Government