How Turning a QI Project into "Research" Almost Sank a Great Program

Abstract

Two years ago I had a great idea. I was able to put two disparate thoughts together in the same sector of my brain. One thought was that the low-income patients of my health center needed a place to exercise at no cost. The other was that the local YWCA, where I had been exercising for twenty years, offered institutional memberships to local agencies, like day care centers, which used these memberships as a staff benefit or incentive. My idea was to purchase institutional memberships for our patients as a new intervention that we could offer in the management of chronic disease. Institutional memberships cost the same as a membership for a family of four, but they allow any four members of an agency to use the cards whenever the facility is open. When a staff member comes from an agency to exercise, she swaps some form of identification for one of the assigned magnetic cards and then has use of all the exercise areas-pool, gym, strength room, aerobics classes, and so on. I checked with the membership coordinator about whether she would be open to offering YWCA institutional memberships to our patients, and she was happy to say, Yes, why not? The local community mental health center had recently made a similar arrangement for their patients. I immediately sent out a flurry of emails to every doctor and nurse practitioner at the health center. I also contacted residents who had graduated from our program and former faculty, asking them to send me money or checks written to the YWCA to buy these memberships. Each would cost $875, or only $850 if we paid the total up front. Within two weeks I had raised $1,700. I also wanted to be sure that health center employees would benefit from the project, so I decided to raise money for a staff membership as well. One former graduate called me and asked, How much money do you need, Luce? I told him I needed $850 for a staff membership, and he said, Hey, I blow that much at the track every week! No problem. The check was in the mail. So we started out with two institutional memberships for patients (eight cards) and one for staff (four cards). I had to work through the grants and contracts officer to get everything signed, but the deal was done. I emailed all the providers that they could start referring patients to the YWCA. All they had to do was give the patient a little blue Family Health Center registration card that, up till that point, had no real function. The plan was that each patient would go down to the YWCA and get an orientation, during which he or she would make an appointment for a one-on-one introduction to the strength training room. Patients could attend any aerobics class, and those who wanted to swim could get the pool schedule and start immediately. This process was like scattering bird seed in a public park. Pretty soon the pigeons were landing around me and crowding each other out. I had multiple phone calls from the YWCA, providers, and patients, sometimes all in the same day. We needed more cards. They needed more Spanish-speaking interpreters. The first version of our medical clearance form was inadequate. Patients missed appointments for the strength room orientation. Some people tried to use the room without the introduction. Some people brought their friends without a card. Some not yet sixteen years old--the cut-off for the strength room--tried to get in with a fake ID. At the end of the first month the YWCA sent me the original sign-in list of all the patients who had attended, but since the signatures were illegible, I had no way to decipher who had gone. We decided that patients should sign in with their medical record number, which was, after all, on the little blue card. At the end of the second month we had to buy an additional membership because when all the cards were in use, patients were having to wait to get in. We had more than eight patients wanting to exercise at the same time! By now, usable data was flowing in: hundreds of names and chart numbers of the patients who had exercised each day of the month. …