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Transformational change, or reengineering, is a tough assignment for any organization. The pay-off, however, can be huge: happier patients, reenergized staff, and increased productivity. This article describes the team-based Apollo 11 project at Southeast Health Center in Indianapolis. Although this redesign effort took 7 months of extraordinary team effort, it resulted in a 54% reduction in patient encounter time, a decrease of more than 40% in per-visit cost, and improved patient and staff satisfaction. This article summarizes the background and dynamics of Apollo 11, shares some initial project results, and summarizes the lessons learned, so that other healthcare organizations can successfully tackle the reengineering challenge.

While electronic medical records (EMRs) have long held the promise of improved efficiency and quality, they have not yet made significant inroads into ambulatory care. One reason may be attempted EMR implementation in "old paradigm" clinic models. Southeast Health Center (SEHC) in Indianapolis, Indiana, began by reengineering its clinic procedures; only then did staff look for a computerized record. Because the new clinic model meshed nicely with the design of a relatively new EMR, a joint project was undertaken to test this EMR in SEHC's unique environment. This article details the reengineering, EMR implementation, project dynamics, results, and lessons learned.

This article on creating a world-class culture in primary care stresses the importance of customers. The concept of patients as external customers is addressed; the emphasis, however, is on healthcare professionals' responsibilities toward one another as internal customers.

It is recognized that in primary care, the staff is at the heart of the healing community. Primary care, which recognizes the wholeness of patients, cannot be successful unless the organizational culture also recognizes the wholeness of the staff. The effectiveness of total quality management (TQM) in an organization depends on a staff that is healthy and whole. This article relates how the creation of a culture that fosters the staff's health and wholeness is the most important factor in the implementation of a TQM program.

When asked to produce convincing evidence of quality, 281 ambulatory healthcare professionals suggested 98 different components of an ambulatory program. Obviously no overwhelming majority exists, nor is there a clear focus on what constitutes quality in the ambulatory setting. This demonstrates and highlights both the diversity of ambulatory care and the difficulty of defining quality in the ambulatory environment. We all feel that we know what quality is and that we provide quality care in our organizations. Quality is high priority, yet when asked for the most important demonstrator of quality, ambulatory care professionals gave 98 different answers. Based upon the Pareto diagram's top five categories as shown in Figure One, we can put together a composite definition. This composite would present the combined judgment of nearly 80% of the 281 seminar attendees. Quality ambulatory health care--meets the expectations (pleases) the patients, is enhanced and demonstrated by an effective quality assurance program, is the achievement of desired outcomes for patients, is dependent upon the excellence of the provider staff, and is enabled by an accurate, timely, and complete medical record system. The message for those of us in ambulatory care is that the process of working toward the definition of quality may be just as important as the actual definition of quality. A consensus on a definition of quality in the ambulatory setting is unlikely as there is too much diversity. It is important that each of our ambulatory centers should set out to determine its own definition of quality. The process itself is useful because it will help us to focus on the dimensions of quality. (ABSTRACT TRUNCATED AT 250 WORDS)

The electronic medical record in the ambulatory setting will be a force to be reckoned with during the 1990s. The increased quality of the medical record will lead to an increased quality of patient care at a fairly level cost (no long-term increase). With the new and increasing excitement about continuous improvement in health care, the electronic medical record can be a cornerstone of our quality assurance program and our quality improvement program. The electronic medical record needs to be taken seriously.

In ambulatory health care, patient records are important for assuring continuity of care. The diagnostic summary, or problem list, and the medication record are particularly useful for providing an overview of patients' significant diagnoses and treatments. If well-structured, reliable, and consistent, they can also contribute substantially to the quality of patient care.

Recognition of the need to document and track corrective action plans led to the development in 1980 of the quality improvement plan (QIP). The QIP form includes ten categories such as quality assurance (QA) assessment and initiator's recommendation; it helps provide information for the hospital QA committee and the QA program. The QIP form has helped identify 50 current QA concerns at the Methodist Hospital of Indiana, Inc., in Indianapolis indicating its successful implementation.

Assessing the quality of ambulatory care is difficult because practitioners see patients for only a short time and because the goals of care are not always clearly defined. The ambulatory care department of Methodist Hospital of Indiana, Inc, has developed a system, called ambulatory care parameters, that helps ambulatory health care professionals sort through the complexities of ambulatory care. The ten parameters provide a framework for evaluating the care provided.