In This Issue

June 2011 | Bradford H. Gray

By now we all know that the checklist idea borrowed from aviation safety can improve outcomes in medical care (Gawande 2009). The experience of one hundred Michigan hospitals that used checklists to reduce central line infections to zero and to sustain that result may be the best-known health services research finding of recent years (Pronovost et al. 2006, 2010). But the familiar joke about whether something that works in practice can also work in theory contains truth, particularly when a complex intervention is involved.

Use of a checklist may seem like a simple idea, but in a complex organization, instituting a change that requires adjustments in work flow, tools, rules, incentives, and communications can be difficult. Replicating a successful intervention may be more likely, however, if we understand how and why it worked, not just that it did. The first article in this issue, “Explaining Michigan: Developing an Ex Post Theory of a Quality Improvement Program,” by Mary Dixon-Woods, Charles Bosk, Emma Louise Aveling, Christine Goeschel, and Peter Pronovost, uses the Michigan checklist project to illustrate the usefulness of theory. Space constraints and publication norms of clinical journals generally permit little explication of theory, but theory is no stranger to the pages of The Milbank Quarterly (See Grol et al. 2007 for a good example.)

“Explaining Michigan” is a collaboration between two of the leaders of the Michigan checklist project (Pronovost and Goeschel) and three social scientists (Dixon-Woods, Bosk, and Aveling) interested in applying theory to the case. Contemporaneous fieldwork would have been ideal for understanding the social processes involved in this case, but the authors argue that theory can nevertheless be useful in understanding what happened even in the absence of such fieldwork. They use six different theory-derived insights to help explain different aspects of the Michigan project, ranging from why the hospitals participated to why surgeons accepted new arrangements in which nurses were empowered to halt a surgical procedure. The authors acknowledge that explaining an outcome after it occurs always is easier than predicting it in advance. However, the theories they describe are available for testing in future research.

The importance of theory to the evaluation of interventions also is the topic of the next article in this issue, “Assessing the Evaluability of Complex Public Health Interventions: Five Questions for Researchers, Funders, and Policymakers,” by David Ogilvie, Steven Cummins, Mark Petticrew, Martin White, Andy Jones, and Kathryn Wheeler. In analyzing a case study of a community intervention program to improve health in England, the authors argue for testing theories rather than interventions, and they propose five questions that should be helpful in setting the priorities for evaluation. Among these are whether an evaluation of the particular intervention is likely to affect policy decisions, whether an evaluation can be carried out in a time frame that would make it useful, and whether the findings would enhance the existing scientific evidence.

The next article in this issue is “How Health Care Organizations Are Using Data on Patients’ Race and Ethnicity to Improve Quality of Care.” Authors Ruth Thorlby, Selena Jorgensen, Bruce Siegel, and John Ayanian report on how eight U.S. organizations (hospitals, health plans, and community health centers) identified and addressed disparities in care related to patients’ race and ethnicity. These organizations took different approaches and encountered different difficulties in grappling with such questions as what categories to use, how to collect the needed data, what factors to control for when analyzing data to document possible racial and ethnic differences, and what magnitude of difference signifies a problem.

Thorlby and her colleagues also provide several examples of how these organizations sought to improve care when their data analyses signaled disparities or deficits in quality. They conclude from their case studies that it is both feasible and productive for health care organizations to collect, analyze, and use information about their patients’ race and ethnicity to reduce disparities and improve quality of care.

The need to improve primary care is an important policy issue in many countries, particularly the United States and Canada (Blendon et al. 2002; Hutchison, Abelson, and Lavis 2001; Schoen et al. 2006, 2007). The next article in this issue, “Primary Health Care in Canada: Systems in Motion,” by Brian Hutchison, Jean-Frédéric Levesque, Erin Strumpf, and Natalie Coyle, describes reforms in primary care that took place over the past decade following a major investment by Canada’s federal government.

Hutchison and his colleagues focus on several key initiatives that were implemented in different ways at the provincial level: the development of interprofessional primary care teams, the encouragement of group practices, patients’ enrollment with a primary care provider, different payment methods, new governance arrangements, expansion of the primary care workforce, implementation of electronic medical records, and enhanced quality improvement methods. They describe these initiatives, summarize the available evidence regarding their effects, and discuss the ongoing challenges faced by the need to improve primary care.

The last article in this issue is “An Economic History of Medicare Part C,” by Thomas McGuire, Joseph Newhouse, and Anna Sinaiko. Part C was added to the Medicare law in the early 1980s with two stated goals: to give beneficiaries the option of enrolling in private managed care plans as an alternative to traditional Medicare and to save money for the Medicare program. The plans were expected to attract beneficiaries by providing more coordinated care and more comprehensive benefits than in traditional Medicare. The savings for Medicare were to come by paying these plans only 95 percent of the average local Medicare costs.

Tensions built into the program have played out over the years. For example, if enrollees were healthier and less expensive than the average Medicare patient, the program could increase rather than reduce Medicare’s overall costs. Although Medicare could address this problem by reducing its payments to Part C plans, this might drive the plans out of the market, thereby defeating the goal of increasing enrollees’ options. Over the past twenty-five years, all these scenarios have played out in both the research literature and the political process. McGuire, Newhouse, and Sinaiko describe in detail the research evidence regarding the program’s operation, as well as the various modifications that have been made to address its problems. They conclude by discussing the need for additional changes in the payment rules for Part C plans (now called Medicare Advantage) in order to encourage the plans to participate and also to save Medicare money.

Bradford H. Gray
Editor, The Milbank Quarterly


Blendon, R.J., C. Schoen, C.M. DesRoches, R. Osborn, K.L. Scoles, and K. Zapert. 2002. Inequities in Health Care: A Five-Country Survey. Health Affairs 21(3):182–91.

Gawande, A. 2009. The Checklist Manifesto. New York: Metropolitan Books.

Grol, R.P.T.M., M.C. Bosch, M.E.J.L. Hulscher, M.P. Eccles, and M. Wensing. 2007. Planning and Studying Improvement in Patient Care: The Use of Theoretical Perspectives. The Milbank Quarterly 85(1):93–138.

Hutchison, B., J. Abelson, and J. Lavis. 2001. Primary Health Care in Canada: So Much Innovation, So Little Change. Health Affairs20(3):116–31.

Pronovost, P.J., C.A. Goeschel, E. Colantuoni, S. Watson, L.H. Lubomski, S.M. Berenholtz, D.A. Thompson, D.J. Sinopoli, S. Cosgrove, J.B. Sexton, J.A. Marsteller, R.C. Hyzy, R. Welsh, P. Posa, K. Schumacher, and D. Needham. 2010. Sustaining Reductions in Catheter Related Bloodstream Infections in Michigan Intensive Care Units: Observational Study. BMJ 340:c309.

Pronovost, P., D. Needham, S. Berenholtz, D. Sinopoli, H. Chu, S. Cosgrove, B. Sexton, R. Hyzy, R. Welsh, G. Roth, J. Bander, J. Kepros, and C. Goeschel. 2006. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. New England Journal of Medicine355(26):2725.

Schoen, C., R. Osborn, M.M. Doty, M. Bishop, J. Peugh, and N. Murukutia. 2007. Toward Higher-Performance Health Systems: Adults’ Health Care Experiences in Seven Countries. Health Affairs 26(6):w717–34.

Schoen, C., R. Osborn, P.T. Huyn, M.M. Doty, J. Peugh, and K. Zapert. 2006. On the Front Lines of Care: Primary Care Doctors’ Office Systems, Experiences, and Views in Seven Countries. Health Affairs web exclusive 25:w555–71.

Author(s): Bradford H. Gray

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Volume 89, Issue 2 (pages 163–166)
DOI: 10.1111/j.1468-0009.2011.00631.x
Published in 2011