QUALITY CAREIS IT ATTAINABLE?

Bashar S. Amr, MD Haseeb Nawaz, MD

SIU Internal Medicine Quality Improvement Project 2015

Introduction Background Methods Chart Prep Process Results over the year Behavior Change Chart Prep Literature Obstacles Resident Feedback

Introduction - Institute of Medicine

To Err is Human: Building a Safer health System1

44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented

Adverse drug events, improper transfusions, surgical injuries and wrong-site surgery, falls, burns, pressure ulcers, and mistaken patient identities, etc.

Between $17 billion and $29 billion per year in hospitals nationwide

Errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them

Introduction - Institute of Medicine

Crossing the Quality Chasm2

Calls for improvements in six dimensions of health care performance: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity

Asserts that those improvements cannot be achieved within the constraints of the existing system of care

Framework for redesigning health care system at four levels: patients’ experiences; the “microsystems” that actually give care; the organizations that house and support microsystems; and the environment of laws, rules, payment, accreditation, and professional training that shape organizational action

Ten Rules to redesign and improve healthcare The system should anticipate patient’s needs, strive to

decrease waste, and the patient in control

Introduction – Quality Improvement

Quality improvement (QI) has become an integral aspect of medicine residency training

2005-2009 FM graduates surveyed: 75% had QI training3

87% of QI trained residents where active in at least 1 QI project in their current practice3

Periodic patient care data review, Specific quality improvement projects, and Disease specific activities

Introduction – QI Impact

Having nurses and staff to lead QI efforts probably provides structure and demonstrates investment in QI activities

Introduction – QI Impact

The Agency for Healthcare Research and Quality (AHRQ) looks at improving patient clinical outcomes4

Project to increase anticoagulation therapy for Medicare beneficiaries who have suffered from a stroke, lead to increase in anticoagulation therapy from 58.4 to 71.1%

The Centers for Medicare and Medicaid Services (CMS) estimates that this improvement has prevented up to 1,300 strokes

ACGME Requirements

Background

Each year the Internal Medicine residents participate in quality improvement projects, often in teams

Different goals, different time lines and ambiguous

This year, it was determined that we would launch one large quality improvement effort to create a united vision within our General Internal Medicine clinic

“The Smart Efficient Clinic Machine or SECM.”

Background

We have yet to make a significant and long term impact on metrics relevant to the care of our general internal medicine patients (specifically in preventive care)

Barriers to success that are identified: limited time to capture all targeted services during visit new learners adjusting to system addressing patient concerns and preventive care Patients with multiple significant comorbidities

Project Goal: To improve patient outcomes related to common preventative services through thoughtful pre-visit planning or “chart prep”

Methods

Kicked off on October 15, 2014 during a multidisciplinary meeting of residents, faculty and staff.

Monthly multidisciplinary meetings: modifications and adjustments to the processes for pre-visit planning in a collaborative manner

For each patient visit, resident would complete a “chart prep” document

Capturing most recent: advanced directive status, BMI, HgbA1c, influenza vaccination, pneumovax vaccination, mammogram, colonoscopy, and hospitalization.

Methods

The “chart prep” document is to be completed two weeks prior to the patient’s visit

The patient’s chart is updated where gaps exist and the general plan of care for preventative services and chronic disease is documented

Identified labs or other orders are communicated with the nursing staff, who then work with the patient to obtain testing prior to the clinic visit

Document allows for residents to type in notes and familiarize with patients

Chart Prep Process

Chart Prep Process

Chart Prep Process

Chart Prep Process

Chart Prep Process

Chart Prep - Goals

Evaluate the impact of the pre-visit planning process on rates of preventative services provided for our patients

This initiative involves such a significant change in workflow for our residents and staff

Though our goal is to observe a change in preventative services provided to our patients, we anticipated a noticeable change may not occur for approximately 6-9 months

Thus, we are measuring compliance rates with completing a “chart prep” document and collecting anecdotal experiences, positive and negative in nature

The Financial Aspect

Primary Care

Reactive

Chaotic 1.Proactive

2.Organized

Institute of Medicine: Crossing the Quality Chiasm (2001)

The U.S. health care delivery system does not provide consistent, high quality medical care.

HOW ???

Mayo Clinic (2011)

Pre-order preventive services tests 2 weeks prior

1.5 months61% abnormal testsPre-order (mean 2.2)

No pre-order (mean 3.08)87.8% completion

MORE TIME

Massachusetts General Hospital

Ambulatory Practice Pre visit labs

Reduced phone calls by 89%Reduced number of letters sent by 85%

Fewer revisits due to abnormal labs (61%)Saved $25/visit in physician and staff time

INCREASED PATIENT SATISFACTION

BENCHMARK

80%

First Result – December

11%

Second Result – January

16%

Changing Physician Behavior

Education

Audit & Feedback

Economic Incentives

Local opinion leaders

Printed educational materials

Reminders

Multifaceted approach

Achievable Benchmark – 80%

Better results

Provider perceptions and attitudes

Enhances feedback

EducationAudit &

FeedbackReminders

HAYES, SEAN 267%

CAVATAIO, ANTONINO 180%

AKOFU, ANOTA 162%

LIN, JUNZHI 154%

GRIMM, TRENTON 150%

VARNEY, JACOB 144%

IQBAL, MUHAMMAD 123%

SAEED ZAFAR, ZUBAIR 116%

STICH, ADRIENNE 112%

DABABNEH, EHAB 111%

BHATTI, KARAN 110%

CHANDRA, SIDHARTH 106%

MANDO, RUFAAT 105%

STONE, SCHUYLER 104%

IBRAHIM, YASMINE 103%

AQUINO, CINDERELLA 100%

SIDDIQUI, AHMER 100%

AMR, BASHAR 93%

PERVIN, NAJWA 88%

LEE, KRISTIN 84%

BALAGNA, JONATHAN 82%

NAWAZ, HASEEB 81%

AL OBAIDI, ZAINAB 81%

SAFI, JAVERYAH 80%

Blue Green Red MedPsych TOTAL0%

10%

20%

30%

40%

50%

60%

70%

80%

86%

45%

42%

22%

56%

Chart Prep Completion Rates by Color TeamsMarch

Target 80%

Baseline Jan-15 Feb-15 Mar-150%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

11%

16%

46%

56%

Chart Prep Completion Rates

Baseline Jan-15 Mar-15 Apr-15 May-15 Jun-150%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

11%

16%

56%

73% 78%

76%

Participation in Chart Prep Project Target80%

Blue Green Red MedPsych TOTAL0%

10%

20%

30%

40%

50%

60%

70%

80%

86%

45%42%

22%

56%

March

Target 80%

Blue Green Red TOTAL0%

10%20%30%40%50%60%70%80%90%

100%110%

78% 80%70% 76%

June

Impact

Minnesota Pediatric Clinics (1996) Increase in immunizations from 53 to 86%

Seattle Primary Care Clinics (1998) Increased percentage of controlled hypertensive

patients

Mayo Clinic, Diabetes Care (2002) Improvement in HbA1C , HDL and smoking

cessation

Measured BMI

HTNBP >

140/90

DMA1C

ordered in last 12 months

DMA1C > 6.5

FluVax within 1

yr

REDNov 2014 64.7% 24.6% 8.9% 14.5% 4.1%

April 2015 65.3% 25.2% 10.6% 14.5% 5.4%

GREENNov 2014 57.8% 24.6% 8.1% 15.1% 2.3%

April 2015 60.5% 24.1% 9.1% 14.2% 5.5%

BLUENov 2014 61.9% 22.4% 8.4% 13.2% 3.6%

April 2015 63.4% 22.2% 10.5% 14.2% 6.8%

TOTAL7931

13.8%

Six Dimensions of Health Care Performance:

SafetyEffectiveness

Patient-centerednessTimelinessEfficiency

Equity

Obstacles

Lack of time Lack of resident follow-through Lack of staff follow-through Unanticipated (Mail, Lab etc.)

Residents feedback/comments

Adequate knowledge about patient beforehand makes clinic run faster and smoother. Discussing labs with attending during clinic reduces time spent calling patients later.

It made me more prepared in clinic, more organized and time effective. Allowed me to spend more time with the patient rather than searching through the chart.

It definitely improved patient care as well relationship. The contact and labs made patients feel involved and remembered before the appointment. Helps us be prepared and more comfortable with pt in clinic.

I had difficulty preparing the charts 2 weeks ahead my pt’s appt, takes too much time.

Time to Think…

Less work later!!!

References

Kohn, Linda T., Janet M. Corrigan, and Molla S. Donaldson, eds. To err is human:: building a Safer Health System. Vol. 6. National Academies Press, 2000.

Corrigan, Janet M. "Crossing the quality chasm." Building a Better Delivery System (2005). Moore LG. Escaping the tyranny of the urgent by delivering planned care. Fam Pract Manag.

May 2006;13(5):37-40. Diaz, Vanessa A., Peter J. Carek, and Sharleen P. Johnson. "Impact of quality improvement

training during residency on current practice." Family Medicine-Kansas City 44.8 (2012): 569. McGlynn, Elizabeth A., et al. "The quality of health care delivered to adults in the United

States." New England journal of medicine 348.26 (2003): 2635-2645. Hunt VL et al. Does pre-ordering tests enhance the value of the periodic examination?

Study design – Process implementation with retrospective chart review. BMC Health Services Research 2011, 11:216.

Pre-visit planning. AMA Steps Forward, Oct 2014. Mostofian F et al. Changing Physician Behavior: What Works? Am J Manag Care.

2015;21(1):75-84. Ghandi TK et al. Obstacles to collaborative quality improvement: the case of ambulatory

general medical care. Int J for Quality in Health Care 2000; 12(2);115-123. Kiefe CI et al. Improving Quality Improvement Using Achievable Benchmarks for Physician

Feedback. JAMA, June 2001, Vol 285, 22, 2871. Shortell SM et al. Assessing the impact of continuous quality improvement on clinical

practice: What it will take to accelerate Progress. The Milbank Quarterly, Vol 76, 4, 1998, 593.