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AGA CENTER FOR QUALITY IN PRACTICE Best Practices: Academic Gastroenterology Practices STEPHEN J. BICKSTON,* JEAN ALLEY, and DEBORAH P. ROBIN § *Division of Gastroenterology & Hepatology, University of Virginia, Digestive Health Center of Excellence Performance Improvement Team, UVA Health System, Charlottesville, Virginia; and the § AGA Institute, Bethesda, Maryland T his is the second of 2 articles produced by the AGA Center for Quality in Practice (CQIP), a program of the AGA Institute. These articles describe best practices related to quality improvement, implementation of quality measure- ment, enhancing high-quality care, and developing patient safety initiatives. The first article focused on a community- based practice. This article focuses on a clinical academic practice. These articles fulfill the goal and intent of the CQIP, to identify and disseminate best practices of physicians/groups with respect to quality and related initiatives. This article outlines various management strategies to enhance quality, including those used in an academic practice in Virginia. The objectives for this article are as follows: first, to increase the understanding of quality improvement (QI) mechanisms and activities to evaluate, measure, and enhance care in an academic gastroenterology practice; second, to identify the best clinical, safety, and QI practices within this setting, and, third, to increase reader awareness of national trends in assigning value to quality of care. The Practice This practice is based in an eastern university medical school. The school itself was established in 1901, supplanting the Anatomical Hall of 1836. It has a 565-bed hospital and serves a wide multistate area. The hospital has 29,000 admis- sions annually. It has a level I trauma center and its nursing environment puts it in the 3% of hospitals in the nation who have earned Magnet Recognition. The current Digestive Health Center of Excellence was established in 1997. The model of a specialized digestive health unit with inpatient, endoscopy, and clinic space shared by surgeons and gastroenterologists devel- oped as a collaboration of several departments. Faculty and staff from gastroenterology, surgery, radiology, pathology, and nutrition are invested and have a voice. There is collaboration by telephone, e-mail, and in conference, but shoulder-to-shoul- der cooperation is a core component. The dedicated inpatient digestive health unit admits patients for gastroenterological, surgical, and interventional radiologic care. The outpatient ar- eas of the clinic, endoscopy, and motility are located centrally in a contiguous space. This practice is staffed only by full-time faculty and provides a full range of inpatient and outpatient gastroenterology and hepatology services including an inflammatory bowel disease (IBD) clinic shared by colorectal surgeons and gastroenterolo- gists. An on-site infusion area allows administration of intra- venous fluids, iron, and biologic therapies. The practice also includes a bariatric and laparoscopic surgery service, and a motility service. A pancreaticobiliary team shares a clinic in the Cancer Center. This is staffed by a specialized surgical team, consisting of interventional endoscopists and oncologists, with weekly meeting to review management of patients at a confer- ence known as Tumor Board. The program trains residents, interns, midlevel providers, and other health care professionals in the science and care of gastroenterologic conditions, proce- dures, and diseases. The practice uses an integrated electronic medical record in both the inpatient and outpatient care environments. The cen- ter has converted much but not all of its documentation from paper to electronic. The practice and center continue to move in that direction not just for documentation but also for data collection and reporting of quality management information. As the move toward connectivity and electronic health record occurs nationally, the practice takes all appropriate opportuni- ties to use electronic records, data acquisition, and documen- tation in an electronic environment. Quality Improvement Culture and Structure The structure of the relationship between an academic gastroenterology practice and its affiliated medical center varies. The relationship will sometimes add a bureaucratic burden to the practice’s QI process, but it also can reduce work if efforts are integrated and the philosophy and approaches of each subunit are shared. For example, the metrics required for the Joint Commission for Accreditation of Healthcare Organiza- tions (JCAHO) and national patient safety goals are embraced throughout the institution. This means that endoscopy staff need not perform separate assessment/paperwork for these goals for inpatients. Similarly, because there is an institutional process for monitoring outcomes in conscious sedation, the endoscopy laboratory did not have to create its own process. The host medical system has a system-wide movement to standardize QI processes wherever feasible. This emphasis is largely embraced by department chairs, division chiefs, and clinical staff. Data are compared with those from appropriate Abbreviations used in this paper: CQIP, Center for Quality in Practice; ER, emergency room; GI, gastrointestinal; IBD, inflammatory bowel disease; JCAHO, Joint Commission for Accreditation of Healthcare Organizations; LOS, length of stay; NSQIP, national surgical quality improvement program; QI, quality improvement. © 2006 by the AGA Institute 1542-3565/06/$32.00 doi:10.1016/j.cgh.2006.09.001 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2006;4:1415–1418

Best Practices: Academic Gastroenterology Practices

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CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2006;4:1415–1418

GA CENTER FOR QUALITY IN PRACTICE

est Practices: Academic Gastroenterology Practices

TEPHEN J. BICKSTON,* JEAN ALLEY,‡ and DEBORAH P. ROBIN§

Division of Gastroenterology & Hepatology, University of Virginia, Digestive Health Center of Excellence Performance Improvement Team, UVA Health System,harlottesville, Virginia; and the §AGA Institute, Bethesda, Maryland

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his is the second of 2 articles produced by the AGACenter for Quality in Practice (CQIP), a program of the

GA Institute. These articles describe best practices related touality improvement, implementation of quality measure-ent, enhancing high-quality care, and developing patient

afety initiatives. The first article focused on a community-ased practice. This article focuses on a clinical academicractice. These articles fulfill the goal and intent of the CQIP,o identify and disseminate best practices of physicians/groupsith respect to quality and related initiatives. This articleutlines various management strategies to enhance quality,ncluding those used in an academic practice in Virginia.

The objectives for this article are as follows: first, to increasehe understanding of quality improvement (QI) mechanismsnd activities to evaluate, measure, and enhance care in ancademic gastroenterology practice; second, to identify the bestlinical, safety, and QI practices within this setting, and, third,o increase reader awareness of national trends in assigningalue to quality of care.

The PracticeThis practice is based in an eastern university medical

chool. The school itself was established in 1901, supplantinghe Anatomical Hall of 1836. It has a 565-bed hospital anderves a wide multistate area. The hospital has 29,000 admis-ions annually. It has a level I trauma center and its nursingnvironment puts it in the 3% of hospitals in the nation whoave earned Magnet Recognition. The current Digestive Healthenter of Excellence was established in 1997. The model of a

pecialized digestive health unit with inpatient, endoscopy, andlinic space shared by surgeons and gastroenterologists devel-ped as a collaboration of several departments. Faculty andtaff from gastroenterology, surgery, radiology, pathology, andutrition are invested and have a voice. There is collaborationy telephone, e-mail, and in conference, but shoulder-to-shoul-er cooperation is a core component. The dedicated inpatientigestive health unit admits patients for gastroenterological,urgical, and interventional radiologic care. The outpatient ar-as of the clinic, endoscopy, and motility are located centrally incontiguous space.This practice is staffed only by full-time faculty and provides

full range of inpatient and outpatient gastroenterology andepatology services including an inflammatory bowel disease

IBD) clinic shared by colorectal surgeons and gastroenterolo-ists. An on-site infusion area allows administration of intra-

enous fluids, iron, and biologic therapies. The practice also

ncludes a bariatric and laparoscopic surgery service, and aotility service. A pancreaticobiliary team shares a clinic in theancer Center. This is staffed by a specialized surgical team,

onsisting of interventional endoscopists and oncologists, witheekly meeting to review management of patients at a confer-

nce known as Tumor Board. The program trains residents,nterns, midlevel providers, and other health care professionalsn the science and care of gastroenterologic conditions, proce-ures, and diseases.

The practice uses an integrated electronic medical record inoth the inpatient and outpatient care environments. The cen-er has converted much but not all of its documentation fromaper to electronic. The practice and center continue to move inhat direction not just for documentation but also for dataollection and reporting of quality management information.s the move toward connectivity and electronic health recordccurs nationally, the practice takes all appropriate opportuni-ies to use electronic records, data acquisition, and documen-ation in an electronic environment.

Quality Improvement Cultureand StructureThe structure of the relationship between an academic

astroenterology practice and its affiliated medical center varies.he relationship will sometimes add a bureaucratic burden to

he practice’s QI process, but it also can reduce work if effortsre integrated and the philosophy and approaches of eachubunit are shared. For example, the metrics required for theoint Commission for Accreditation of Healthcare Organiza-ions (JCAHO) and national patient safety goals are embracedhroughout the institution. This means that endoscopy staffeed not perform separate assessment/paperwork for theseoals for inpatients. Similarly, because there is an institutionalrocess for monitoring outcomes in conscious sedation, thendoscopy laboratory did not have to create its own process.

The host medical system has a system-wide movement totandardize QI processes wherever feasible. This emphasis isargely embraced by department chairs, division chiefs, andlinical staff. Data are compared with those from appropriate

Abbreviations used in this paper: CQIP, Center for Quality in Practice;R, emergency room; GI, gastrointestinal; IBD, inflammatory bowelisease; JCAHO, Joint Commission for Accreditation of Healthcarerganizations; LOS, length of stay; NSQIP, national surgical quality

mprovement program; QI, quality improvement.© 2006 by the AGA Institute

1542-3565/06/$32.00

doi:10.1016/j.cgh.2006.09.001

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1416 BICKSTON ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 4, No. 11

eer institutions from the University Hospital Consortium witholucient data (Solucient, Evanston, IL) and with other bench-arks. The institutional emphasis encouraging the collection

nd tracking of quality data is timely; it is inevitable thatutside entities involved in credentialing and third-party payersill measure practice performance in our specialty.

The practice’s cooperative relationship with the hospital isiewed as a key to its success. Operationally this relationshipas led to an effective and efficient integrated care system.

ncorporating other specialists into the practice who are dedi-ated to the care of the patient with a digestive disease such asastrointestinal (GI) radiologists and colorectal surgeons pro-ides for integrated care across clinical settings and has beenssociated with reduced costs, reduced length of stay (LOS), andreserved clinical outcomes.1

Best Practices Regarding QualityImprovement/Management ProgramsThere are a number of organizational behaviors that

oth reflect and support the culture of quality. The currentocietal push toward measurements and rankings for healthare means that performance in digestive care will be measured.he reader should consider his or her own practice and how

hese overarching best practices may be applied to their partic-lar circumstances.

Quality Indicators/Performance MeasuresAre Assessed for Inpatient, Outpatient, andIndividual Physician Levels of CareThe importance of measuring metrics related to the

erformance of health care services for purposes of enhancingare, gaining efficiencies, and managing one’s practice is wellocumented.2– 4 This practice continually measures admissionnd re-admission rates, and procedural and sedation-relatedomplications. These quality metrics are collected and analyzedor both the clinic and procedure areas. Hospital-wide processesuch as point of care testing also are incorporated. Findings areistributed monthly or quarterly to key committees on whichhe practice is represented and at staff/unit meetings for dis-ussion. Barriers to quality identified through these reports areiscussed and potential actions to improve the quality are

dentified.The Digestive Disease Performance Forum meets quarterly

o review quality, safety, and care coordination efforts. Mea-ures/performance metrics for care in both inpatient and out-atient settings are reported. Measures developed by medicalocieties such as the AGA Institute’s polyp surveillance mea-ures are included. These data are analyzed as compared withast and current results at the level of the practice, the institu-ion, and the nation (where data are available). The focus is onpportunities to improve patient outcomes. An action plan isroduced with each meeting.

Responsibility to Monitor and Follow Upon Quality and Measures Data Is AssignedReporting of quality and safety data promotes learning

nd monitoring for improvement.5 The institution has createdn online QI reporting system that is available on all clinicalomputer workstations around the clock. This allows any care-

iver to enter and track adverse events. The online prompts s

ontain questions that help channel reports to individual ser-ices (eg, engineering for broken equipment) or to several ap-ropriate groups (eg, engineering, pharmacy, or clinical unit forroken pump causing a problem with drug administration).he entries also are reviewed by the Department of Quality anderformance Improvement. Reports that indicate that a pa-ient’s outcome may have been affected adversely are reviewedeekly by a quality report review committee chaired by theedical director and administrator for QI. This group can

ecommend further actions including departmental review andoot-cause analyses. The customizable online product was pur-hased commercially. It generates quarterly online reports on0 –12 quality indicators including medication errors and pa-ient satisfaction. Each clinical area including the practice candd measures for data collection. The results of these measuresre included in the work of the Digestive Disease Performanceorum.

A Cooperative Relationship Betweenthe Division and the Health SystemIs MaintainedOpen communication is a key to an effective, dynamic

erformance improvement program. As detailed earlier, thehysical structure of the practice afforded by the medical centerllows clinicians to share information daily. With the exceptionf a managing administrator, all members of the practice’s QIrocess (other than patients) are working clinicians; this helpsvoid an us-vs-them mentality.

Integration of Institutional Qualityand Safety ProcessesA designated nurse quality manager for the practice

llows for timely continual monitoring and communicationithin the practice regarding quality issues. This managerorks closely with her facility counterparts so that communi-

ations are consistent with those of the facility quality andafety programs. The process of complying with accreditationnd regulatory requirements provides opportunities to estab-ish quality and safety programs. Application of these require-

ents, such as reporting sentinel events, to the practice’s am-ulatory services and its inpatient unit supports quality andafety across the spectrum of gastrointestinal care. This is anxample of where both the letter and spirit of the law can beelpful.

Integration of Patient/Family FeedbackInclusion of patient and family opinions into the qual-

ty-assessment process is valuable.4,6 This health system cap-ures feedback specifically regarding the patient/family carexperience with GI faculty, staff, and care processes. The instru-ent used for patient satisfaction is supplied by Press Ganeyssociates, Inc (South Bend, IN). This firm has created nationalatabases of comparative satisfaction information and is usedidely in the University Hospital Consortium. The practice’sultidisciplinary input was used to develop survey items spe-

ific to digestive conditions and the instrument used addressesll levels of care/care environments. The surveys are adminis-ered daily through mail and telephone by Press Ganey Associ-tes to a specified percentage of patients. Quarterly data are

hared institution-wide. Monthly data are available to manag-

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November 2006 ACADEMIC GASTROENTEROLOGY PRACTICES 1417

rs, faculty, and administrators. These data are used in evalua-ions for promotion and for financial rewards.

CollaborationCollaboration among caregivers in quality and safety

nitiatives helps to minimize gaps in knowledge.6 Whenevereasible, these initiatives should include patient input, particu-arly for patient safety6 and condition-specific4 initiatives. Thisacility had the opportunity to design its digestive disease cen-er with input from many disciplines and levels of the organi-ational structure; physicians, nurses, administrative staff, fac-lty, and patients all provided input. Bariatric patients are onepecific patient group that was included in the process. Theenter has specific examination rooms, stretchers, and otherquipment to accommodate the larger patient. With a patient’sdvice, all waiting area chairs now can accommodate substan-ial weight and couches are used to avoid difficulties with chairrms. The GI inpatient unit design process also included thisevel of multidisciplinary input.

Best Practices Regarding SafetyThe academic practice provides a wide range of care

cross numerous settings and intensities of care. Many of theest practices identified later speak to specific safety and quality

nitiatives, as appropriate, we have attempted to broaden theirpplication to other areas of practice as well. The reader shouldonsider his or her own practice and how these overarching bestractices may apply to their particular circumstances.

Compliance With Joint Commission forAccreditation of Healthcare OrganizationsNational Safety GoalsAnnually JCAHO reviews and updates its national

afety goals and incorporates them into its various accredita-ion program standards as applicable. In the academic environ-

ent, compliance is dictated by JCAHO accreditation and theedical staff by-laws. The incorporation of applicable safety

oals across all services and settings of gastroenterology care isssential to ensure quality in academic practice.

Quality Program Includes Regulatoryand Accreditation RequirementsSuch requirements provide opportunities to evaluate

uality and safety.4 Because accreditation standards are up-ated at least annually, maintaining compliance means that anccredited center continually will evolve. Medicare paymentequirements also can drive quality and safety. For example,ariatric center certification by the American College of Sur-eons as a level 1A Bariatric Surgery Center or by the Americanociety for Bariatric Surgery as a Bariatric Surgery Center ofxcellence is required for Medicare reimbursement.7 These so-ieties have their own standards. Their requirements includearticipation in the national surgical quality improvement pro-ram (NSQIP). The NSQIP prospectively collects data on 40reoperative risk factors, 20 postoperative complications, andortality on all patients undergoing major surgeries under

eneral, spinal, or epidural anesthesia. The data are collected,alidated, and transmitted by a highly trained surgical clinicalurse reviewer. Benchmark reports are available online. A more

omplete report is distributed to participating centers annually. e

hese reports allow the center to compare its volume, patient-isk profiles, and risk-adjusted outcomes with the nationalverage and with the averages in their peer group of hospitals.his system has been used successfully in non–Veteran’s Ad-inistration hospitals.8

Best Clinical PracticesMultidisciplinary Collaborative Approachto CareIt has been documented in the literature that such an

pproach supports safety and quality care.2,4,6 All levels and allommittees and work groups addressing quality in the practicenclude representation from across functions. Nurses, physi-ians, mid-level providers, and nonclinical staff engage in jointroblem solving. A comparison of cost, LOS, and 30-day re-dmission rates between an integrated inpatient model andeneral admissions for 9 major diagnoses showed that thisodel brings tangible benefits.1 In this study of 9 common

igestive diagnoses, meaningful decreases in cost and LOS wereeen for all but pancreatic disorders. When cohort-specific 30-ay readmission rates were adjusted, the pancreatic disorderatients had a 44% reduction in the 30-day re-admission rateompared with patients admitted under a traditional modelP � .0478). This speaks to improved outcomes. When all of thetudied diagnoses were pooled (including pancreatic disorders),he average cost savings was $268 (year 2000 US dollars) andhe decrease in LOS was .41 days. Efforts are underway toecrease costs for patients with pancreatic disorders. A protocolor prompt administration of appropriate enteral feeding isnder study.

The physical structure of a GI service in relation to othercademic departments, units, and services is important to sup-ort collaboration and efficiency in the delivery of high-qualityare. The degree to which a clinician can influence the physicaltructure will depend on facility cycles of design, redesign, and

aintenance, but we recommend that any opportunity to in-uence the physical layout should be taken. Despite techno-

ogic advances in imaging and electronic communication inecent years, there is no substitute for shoulder-to-shoulderollaboration. Proximity to surgeons, radiologists, and nutri-ionists should have a high priority for most practices; differentervices may take priority in other centers.

Specific areas in which this practice works to optimize carenclude the following.

Tube placement. The assignment of a certified phy-ician’s assistant (PA) to oversee outpatient percutaneous en-oscopic gastrostomy and jejunostomy tube placements andaintenance is one way to optimize care. A highly skilled

linician works with referring physicians of various specialtieso facilitate safe tube placement, appropriate nutritional con-ultation, and desired follow-up evaluation. The PA can addressube problems during office hours. This helps limit emergencyoom (ER) visits for such problems. Fellow physicians continueo handle after-hours problems.

Development of clinical pathways. An upper-GIleeding pathway was created collaboratively by interventionalndoscopists, endoscopy nurses, ER faculty, and Health Evalu-tion Science faculty. The initial effort centered on a researchroject examining the role of transnasal endoscopy for urgent

valuation.

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1418 BICKSTON ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 4, No. 11

Development of a computer-based protocol fornflammatory bowel disease patient monitoring. In thisractice clinic patients with IBD on immunomodulating ther-pies are monitored closely with an innovative system. Thisollaborative project was led by 2 specialized nurses and an IBDhysician, with administrative and technical support from theedical center. It replaces the clumsy “no laboratory, no refill”

pproach and provides a rational effective means to ensure thatatients are on appropriate dosages and are up to date onurveillance testing, vaccinations, and visits.

ConclusionsIt is our hope that this discussion of best practices in an

cademic gastroenterology practice will help to stimulate GIlinicians to examine quality and safety within their own set-ing. The key concepts to support a successful quality programre as follows:

● Collaboration as a part of the practice environment andoperation.

● Integration of patient and family input into a center’s plans.

● Recognition throughout the practice and host system thatQI measurements are valuable. This is critically important.As Peter Drucker said, “If you can’t measure it, you can’tmanage it.”9

● Alignment and integration of facility quality and safetyinitiatives should be established for all settings.

● Avoidance of paralysis by analysis. All QI programs requiremaintenance and refinement as regulatory and clinicalguidelines evolve.

References

. Arseneau KO, Yeaton P, Kahaleh M, et al. Effect of digestive health

care services integration on resource use and outcomes in pa- A

tients with digestive disorders. Clin Gastroenterol Hepatol2003;1:145–151.

. Dlugacz YD, Restifo A, Nelson K. Proceedings from the qualitycolloquium, implementing evidence-based guidelines and report-ing results through the quality metric. Patient Safety Qual Health-care 2005;2:40–42.

. Landon BE, Noemanad ST, Blumenthal D, et al. Physician clinicalperformance assessment prospects and barriers. JAMA 2003;290:1183–1189.

. Institute of Medicine. Crossing the quality chasm: a new healthsystem for the 21st century. Washington, DC: National AcademyPress, 2001.

. Leape LL. Reporting of adverse events. N Engl J Med 2002;347:1633–1638.

. Welsh A, Frost M, Weepie N. Patient safety simulators: driver ofcross functional collaboration. Patient Safety Qual Healthcare2005;1:26–28.

. Centers for Medicare & Medicaid. Medicare Coverage Database,decision memo for bariatric surgery for the treatment of morbidobesity (CAG-00250R). Available at http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id�160. Accessed September 2,2006.

. Fink AS, Campbell DA Jr, Mentzer RM Jr, et al. The NationalSurgical Quality Improvement Program in non-veterans administra-tion hospitals: initial demonstration of feasibility. Ann Surg 2002;236:344–354.

. Behn B. Resistence to measurement. Public Management Report2005;3:1–2.

Address requests for reprints to: Stephen J. Bickston, MD, AGAF,ssociate Chief, Division of Gastroenterology & Hepatology, UVAealth System, 800708 UVAHS, Charlottesville, Virginia 22908.-mail: [email protected]; fax: (434) 244-7511.Please note that specific equipment or services mentioned are for

llustration and in no way constitutes a formal endorsement by the

GA Institute.