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CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2006;4:1292–1295

GA CENTER FOR QUALITY IN PRACTICE

est Practices: Community-Based Gastroenterology Practices

OHN I. ALLEN,* MARY IGO,* and DEBORAH P. ROBIN‡

Minnesota Gastroenterology, St. Paul, Minnesota; and ‡AGA Institute, Bethesda, Maryland

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The PracticeThis is 1 of 2 articles produced by the AGA Center for

uality in Practice (CQIP) that will describe best practiceselated to quality improvement, implementation of quality

easurement, enhancing high-quality care, and developing pa-ient safety initiatives. This article focuses on a community-ased practice, and the second article will focus on clinicalcademic practices. These articles fulfill the goal and intent ofhe CQIP, to identify and disseminate best practices of physi-ians/groups with respect to quality initiatives to foster thexamination and improvement of quality and safety in allastrointestinal practices. This article outlines various manage-ent strategies to enhance quality including those used in a

arge Midwest community-based practice.The objectives of this article are as follows: (1) to increase the

eader’s understanding of quality-improvement mechanismsnd activities to evaluate, measure, and enhance care deliveredn a large community-based gastroenterology practice, and (2)o identify the best clinical, safety, and quality in practicesithin a community-based practice setting.

This practice was established in 1996 with the merger of 3ndependent gastroenterology practices. The practice provides aull range of gastroenterology and hepatology ambulatory andnpatient care and treatments and procedures for adult andediatric patients. Outpatient clinics are operated in 6 locationsith adjacent endoscopy centers and 2 infusions centers. Oneffice is designed and dedicated especially to pediatric gastro-nterology services. This practice adopted quality measurementnd quality improvement as its number one business strategy in004. This effort was promoted internally as a key strategicove in anticipation of expanding consumer-driven health care

nd the perception that various pay-for-performance initiativesould be forthcoming from various national and regional pay-

rs. Two fundamental steps in quality improvement were be-ieved to be needed: (1) the development of measurement toolsithin an electronic medical record (EMR) and (2) internal

hanges in the culture of practice from production based touality based.

The Minnesota Gastroenterology practice began convertingo an EMR in late 2003, and the effort continues. The initialonversion process focused on practice management, and theecond phase focused on the development of endoscopy report-ng, which supports and allows for the collection and analysisf information related to quality of care. The EMR has been aollaborative effort of the clinicians and administration. Theystem network allows referring providers to send referrals andccess information on the status of their patients cared for by

embers of the practice.

Quality data collection and measurement are supported byhe EMR. It has been designed to search data that are recordedn a menu-driven format, which allows for the combination oflinical and financial data and reporting on the value of aervice. In this system, value is defined as incremental qualitymprovement divided by cost—an equation that reflects thetakeholder value of a service. Others have defined the value ofare as quality/price.1 The focus on value has been essential toaintain an emphasis on both quality and cost.Opportunities to design the clinical centers incorporate in-

ut from multiple disciplines and levels of the organization.hysicians, midlevel providers, nurses, administrative staff, andatients, through patient-satisfaction surveys, participate inesign processes.

Quality Improvement Culture andStructureMeasurement and the use of data are a necessary com-

onent of any quality program. Therefore, a practice mustccept the concept that aspects of care provided will be mea-ured. The main driver in efforts to build a quality measure-

ent and improvement effort is the recognition that enhancingalue (see earlier) will be the single most important businesstrategy for a practice to succeed in an environment of dimin-shing resources and conversion to a consumer-driven healthare market. In this practice the adoption of quality as part ofts culture began initially as a business strategy. That is, theractice knew, and accepted, that quality needed to be mea-ured to ensure long-term financial success. However, as theyegan to explore measurement it became clear that first educa-ion about quality, its value to care, and the bottom-line waseeded. That education led to a shift of quality from a man-gement idea to a true part of the practice culture.

A formal governance structure that aligns with incentivesives authority to the culture of quality. This, of course, re-uires a willingness to invest in quality and decrease produc-ion.2 The development of such governance grew quickly forhis practice as the culture shifted. For example, leadershipgreed to fund a quality department, including a designatedhysician medical director for quality, the inclusion of servicend clinical quality measurement, and reporting of quality data.

The quality department is composed of the Medical Direc-or, physician committee chairs, chief operating officer, senior

Abbreviation used in this paper: EMR, electronic medical record.© 2006 by the American Gastroenterological Association (AGA) Institute

1542-3565/06/$32.00

doi:10.1016/j.cgh.2006.07.023

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October 2006 COMMUNITY–BASED GASTROENTEROLOGY PRACTICES 1293

irector of operations, director of quality, and 3 full-time nurseuality advisors. The work of the department is directed by theuality Steering Committee and is overseen by the administra-

ion. The Steering Committee is made up of representativesrom other key committees.

Three ideals that have driven the practice’s quality culturere its passion for customer-focused care, the incorporation ofhe Institute of Medicine’s 6 aims for improving health caresafety, effectiveness, equity, efficiency, timeliness, and patient-entered care),3 and a commitment to create a positive worknvironment for physicians and staff with accountability.

Physician accountability within the context of quality mea-urement required a compromise by individual physicians withegard to their personal autonomy. This fundamental shift inutlook was discussed thoroughly and required agreement byll providers. This buy-in and shift in culture is critical as aractice moves from a collection of providers to an integrateduality-driven organization.2,3

Best Practices RegardingQuality-Improvement/ManagementProgramsThere are a number of organizational behaviors that

oth reflect and support the culture of quality. These conceptsnd the resulting initiatives can be applied to most community-ased practices, although the scope may vary depending on theize and focus of the practice. The reader should consider his orer own practice and how these overarching best practices maye transferred.

Mission StatementEvery practice needs a clear understanding of where the

ractice is going and how the leadership wants to get there. Forxample, did the practice form to support each individualhysician’s practice or is there an overriding corporate goal thatupersedes a single individual’s prerogatives? At a provider level,his is addressed in one’s contract or employment agreement,efining the accountability to mission, vision, and type of careo be provided. The mission statement of the practice shouldddress and speak to quality of care. In this practice the qualityrogram works to provide a reporting system that sends aessage that is supportive of the mission statement.

Physician Leadership for QualityThe size and resources of the practice will certainly

mpact the structure of a quality program. At a minimum, thereeeds to be a designated physician lead or champion for qualityho is accountable for implementing quality initiatives andversight for compliance. Recently, many payers have included

anguage in their contracts to support and provide qualityirectives that also should be considered in structuring therogram and accountabilities.

Physician and Staff OrientationAll practices should provide physician and staff orien-

ation that addresses the accountability for quality, relatedolicies and procedures, and performance expectations. In theractice reported here, all new employees and physicians arerovided with a thorough orientation, including discussions

bout the quality program, its principles, and their accountabil- a

ties. The learning includes defining acceptable and unaccept-ble behavior standards and addressing how the quality culturempacts provider/staff performance of patient care. For those inlinical roles, the orientation process often is customized. Phy-icians are asked to sign a commitment to a Citizenship Phi-osophy designed by the physicians for the physicians. Thisompact outlines gives (responsibilities) and gets (benefits of theractice). Management and staff have similar pledges that are

ncorporated into the learning.

Compensation PackagesAs public and private payers explore and test various

alue-based payment options, all practices need to consider howuality/performance will be included in compensation calcula-ions. The recognition that a practice is committed to qualitymprovement means that physician and staff incentives must beligned together with this philosophy. In this practice, quality-erformance measures are incorporated into staff and physicianompensation packages. These goals relate to procedural out-omes, behavioral factors, and patient satisfaction. Staff incen-ives (bonuses) are tied to production and patient-satisfactionoals.

Customer ServiceAs patients assume more financial responsibility for

heir health care practices, physicians and staff need to beensitive to the patient care experience. Feedback about the carend service provided can be ascertained through patient surveyools administered by a practice or third party. For example,

ost payers (health plans) routinely survey their beneficiariesbout their satisfaction with provider care and services. In thisractice the customer service department captures complaintsnd compliments about staff and providers, regardless ofhether it is in the business or clinical area. Offering patients/

amilies an opportunity to complete satisfaction surveys isoutine and an ongoing process with regular, specific, physi-ian-level feedback reports. Service data are shared with physi-ians and staff as an opportunity for system learning. It alsorives process evaluation and changes and includes internalustomers (other staff/physicians). Open dialogue and localroblem solving is encouraged. The use of written, telephone,nd internet-based surveys has allowed this practice to collectore than 20,000 surveys per year (�35% of patient contacts).

CollaborationCollaboration in quality and safety initiatives is key to

upport, and minimize gaps, in knowledge.4 Collaboration is aalue integrated into the practice and is supported by the boardo the frontline staff. Although difficult to measure, collabora-ion can be experienced through the respectful exchange ofdeas and inclusion of all disciplines and levels of the organi-ation as various initiatives are developed and implemented.

Association With Regional StakeholderGroupsLinkage to and involvement with regional stakeholder

roups looking at quality improvement such as the nationallyecognized Institute for Clinical Systems Improvement andocal business groups can be a source of information and, moremportantly, an epicenter for synergies for improvement initi-

tives across organizations.

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1294 ALLEN AND IGO CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 4, No. 10

Practice GuidelinesAdoption of clinical practice guidelines can prompt

are and provide a common point of reference for the physicianegarding the management of a particular condition. Guide-ines are not intended to replace professional judgment, nor arehey a recipe to be applied to all patients with a particularondition. However, when based on evidence, they can be usedo guide care and educate patients regarding various aspects ofare such as ongoing monitoring required for their condition orelated to treatment, such as immunosuppressants.5 This prac-ice has adopted/developed internal clinical practice guidelinesnd policies for major treatments, procedures, and conditionsandled by the group. Such policies/guidelines also shouldddress areas of safety, such as universal precautions and latexensitivity. Guidelines are reviewed and updated as needed, butt least every 2 years.

Individual Physician Quality Data/FeedbackWhatever quality initiatives a practice undertakes,

hether process (appointment wait time) or clinical (cecumntubation rates), the members of the practice need feedback in

timely manner. The entire team should have access to aggre-ate data so all can be involved in identifying barriers to success,roblem solving, and supporting improvement activities. Dis-eminating physician-level reports is likely to result in mixedeactions. In this case, this practice initially experienced a de-ensive reaction at the time of the first disclosure of data.owever, as physicians began to understand what is behind theumbers, they have become more comfortable with the processnd the data, shortening the bell curve. The initial focus haseen on colonoscopy-quality indicators (based on current na-ional consensus recommendations), for which the data arehared individually and in aggregate form every 6 months.

Administrator CommunicationsCommunication and open dialogue is essential for a

ulture of safety2 and quality.6 Communication tools includeeam meetings, staff newsletters, and educational materialselectronic or paper). In this practice the chief executive officeregularly addresses questions and concerns related to the prac-ice, quality, or any other matters in a dedicated section of theractice intranet.

Best Practices Regarding SafetyAlthough many of the best practices identified later

peak to safety and quality in relation to colonoscopy, we havettempted to broaden their application to other areas of prac-ice as well. Therefore, the reader should consider his or herwn practice and how these overarching best practices may beransferred.

CredentialingEstablishing credentialing criteria allows a practice to

et a bar for competency. This practice requires that all endo-copists are board eligible or certified in gastroenterology orolorectal surgery, in accordance with national gastrointestinaltandards set out by the American Society for Gastrointestinalndoscopy. Similarly, each endoscopy center’s basic cardiac lifeupport– certified registered nurses is supported and encour-

ged to certify in gastroenterology. All endoscopy center staff u

re required to participate in an extensive training and orien-ation program to ensure compliance to basic practice stan-ards.

Facility credentials and accreditation also must be consid-red. These include any state licensure requirements, Medicareequirements, and quality standards of accrediting entities suchs the Accreditation Association for Ambulatory Health Carend the Joint Commission on Accreditation of Healthcare Or-anizations defined by the center governing board as require-ents.

Endoscope Disinfection and CleaningNational standards (American Society for Gastrointes-

inal Endoscopy, Society of Gastroenterology Nurses and Asso-iates, Association of Practitioners in Infection Control, Amer-can Society for Testing and Materials) should be applied tondoscope disinfection and cleaning processes and procedures.ompliance with such standards should be audited routinelynd may be required by local law and accreditation bodies. Thisractice evaluates staff competencies related to these processesuarterly in a formal manner, based on written tests and directbservation by trained educators.

Accuracy of Biopsy Specimen Labeling andFollow-Up EvaluationThis practice uses a multiple-check process for labeling

iopsy specimens, including an examination room check and 2ndependent checks before leaving the facility. Incorporation ofuch redundancies is known to reduce errors.6 A monthly near-

iss report is discussed at the staff and management levels toacilitate systems learning. This initiative has been extremelyaluable in reducing errors from double digits to �0.5 percentince implementation.

Preprocedure Physical and Informed ConsentPolicies and procedures for a brief physical examination

nd informed consent before the administration of consciousedation should be established.7 Regulatory agencies, accredi-ation bodies, and malpractice insurance requirements alsohould be explored to ascertain that such policies and proce-ures are comprehensive. This practice has established sucholicies and procedures and monitors compliance.

Compliance With Anticoagulation andAntibiotic GuidelinesGuidelines regarding the management of patients using

nticoagulants during endoscopy and those for preprocedurentibiotics should be used and compliance should be moni-ored.7

Monitor and Measure Unplanned Reversal ofSedation MedicationIn this practice ongoing monitoring of reversal agent

se is standard operating procedure at all endoscopy centers.hese data are reported quarterly to the Quality Steering Com-ittee. Rex et al7 have written about monitoring these partic-

lar indicators.

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October 2006 COMMUNITY–BASED GASTROENTEROLOGY PRACTICES 1295

Measure and Monitor Serious PostoperativeComplicationsThis practice monitors serious complications including

eath within 30 days, perforation, bleeding with transfusion,nd cardiac arrest. Ongoing monitoring and reporting is stan-ard practice. Rex et al7 have written about monitoring thesearticular indicators.

Reviewing Adverse EventsReviewing and reporting of adverse events and near

isses against those required by regulators and accreditingodies is another monitor of safety.6 A safe environment needso exist if the expectation is for the self-reporting of errors. Thisractice experienced significant resistance when the process wasrst implemented but, after a brief hiatus, the process has beenevamped to ensure educational, not punitive, opportunities forhe review.

Best Clinical PracticesMultidisciplinary Collaborative Approach toCareIt has been documented in the literature that a multi-

isciplinary collaborative approach supports safety and qualityare.2– 4 All levels and all committees and work groups address-ng quality in the practice include representation from acrossunctions—nurses, physicians, midlevel staff, and nonclinicaltaff engage in joint problem solving.

Use of Clinical Measures and MonitoringIdentifying and defining quality indicators are core

unctions of a quality program. For endoscopy this practice hasncluded effectiveness of bowel preparation, cecum intubationates, and adenoma removal rates for patients older than 50ears (effectiveness).7

ClosingIt is our hope that this discussion of best practices in a

arge community-based gastroenterology practice will help tonergize and stimulate gastroenterology practices of all typesnd sizes to examine quality and safety within their own setting.epending on the particular practice environment, the struc-

ure and activities of the quality program may vary. However, m

he key concepts that a practice must accept for a successfuluality program are as follows:

● Performance measurement is a part of the practice envi-ronment and operation.

● Accountability at all levels of the practice directed towardexcellence, service, and increased stakeholder value (inter-nal and external).

● Sacrifice individual physician autonomy for the sake ofquality.

● Willingness to invest in quality knowing it will impact andpotentially decrease individual production.

References

. American Gastroenterological Association. AGA Task Force onQuality in Practice: a national overview and implications for GIcare. Gastroenterology 2005;129:361–369.

. Amalberti R, Auroy Y, Berwick D, et al. Five system barriers toachieving ultrasafe health care. Ann Intern Med 2005;142:756–764.

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

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

. Lohr KN, Eleazer K, Mauskopf J. Health policy issues and applica-tions for evidence based medicine and clinical practice guidelines.Health Policy 1998;46:1–19.

. Institute of Medicine. Committee on Quality of Health Care inAmerica. In: Kohn LT, Corrigan JM, Donaldson MS, eds. To err ishuman: building a safer health system. Washington, DC: NationalAcademy Press, 1999.

. Rex DK, Bond JH, Winawer S, et al. Quality in the technical perfor-mance of colonoscopy and the continuous quality improvementprocess for colonoscopy: recommendations of the U.S. Multi-So-ciety Task Force on Colorectal Cancer. Am J Gastroenterol 2006;101:873–885.

Address requests for reprints to: John I. Allen, MD, MBA, Medicalirector, Minnesota Gastroenterology, 2550 University Avenue West,uite 423 South, St. Paul, Minnesota 55114. e-mail: JAllen@ngastro.com; fax: (612) 870-5807.Please note that specific equipment or services mentioned areentioned for illustration and in no way constitute a formal endorse-

ent by the AGA Institute.