Community Health Center Quality Improvement: A Systematic Review and Future Directions for Research

Purpose

• 1 This article provides context for community leaders and policymakers involved with improving the caliber of care offered by the Community Health Center (CHC) program. It describes the current situation of this growing federal program, which provides primary health care to more than 15 million vulnerable people nationwide. With an annual budget of about $1.5 billion, the CHC program faces a huge challenge; that is to continually improve the quality of the care that it provides despite mounting numbers of both uninsured and underinsured people.
  
  Quality improvement (QI) efforts may help the program achieve its ambitious goal of eliminating ethnic disparities in health care. The last review of CHC quality dates to 1998. Since that time, many efforts to foster QI have occurred within the CHC setting and have been duly documented.
  
  The article offers community leaders and policymakers a fair appraisal of the effectiveness of these quality improvement efforts within the Health Centers. Only with such an appraisal, can they make informed decisions about QI investments and evaluate future research activities.

• 2 Specifically, the article does the following five things:

  1. 3 Identifies published studies of quality improvement interventions within Health Center settings

  2. 4 Describes key features of the quality improvement interventions in these studies

  3. 5 Reviews the quality of the studies that evaluate these interventions

  4. 6 Summarizes conclusions supported by this literature

  5. 7 Outlines 10 important areas for future research about quality improvement within Health Centers. These areas for further study reflect both a literature review and direct input from the CHC community.

Recommendations for Policy and Practice

Health Center personnel, leaders, and policymakers should:

• 8 Continue to consider quality improvement as an effective strategy to improve the quality of care in Health Centers

• 9 Recognize that effective quality improvement is likely to require significant efforts from Health Center leaders, providers and staff

• Strive to provide the financial and/or technical support needed for proper implementation of changes to enhance the quality of care

• Anticipate the existence of barriers to the long-term sustainability of quality improvement efforts and take steps to address such barriers

• Support a research agenda that answers basic questions about the following matters:

  • The best models for quality improvement

  • The best methods for implementing and sustaining improvements

  • Global positive and negative effects of QI

  • Ways to make such interventions financially viable and sensible from the perspectives of both the Health Center program and of society

How Findings Support Recommendations for Policy and Practice

Coming almost 10 years after the last comprehensive review of the literature about Health Center quality, this article makes several new and important contributions to that literature. It describes trends in QI interventions and outcomes, and it sets an agenda for future research.

The literature review portion of this article demonstrates that:

• The literature about this subject is small.

• QI interventions can take many different forms.

• Most evidence supporting the effectiveness of QI interventions is observational.

• Such efforts have focused upon 13 different clinical conditions and have targeted up to 4 conditions at once. To date, quality improvement efforts within Health Centers have proven most effective for improving diabetes care and cancer screening.

• QI interventions have used as many as 14 different tactics; those using 6 or more tactics appear to be more effective than those using smaller numbers.

• QI efforts backed by sufficient financial and/or technical support are likelier to succeed.

• QI interventions that have worked in Health Centers that have qualities predisposing them to success may not work as well in less fortunate Health Centers.

This article posits a set of 10 key questions for future study. Having answers to these questions would improve our understanding of how and when quality improvements within Health Centers prove most effective (from clinical, organizational and financial standpoints). The 10 questions are:

1. . What is (are) the best model (models) for quality improvement in Health Centers?

2. . Can the elements of successful interventions that have involved multiple components be prioritized?

3. . How should interventions be tailored to different Centers?

4. . How can such interventions...