engaging physicians in quality and performance improvement

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12 May - 1550 - Wendy Novicoff - Track H

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Engaging Physicians in Quality and Performance


Wendy M. Novicoff, Ph.D. Associate Partner, Creative Healthcare USA

Manager and Assistant Professor UVA School of Medicine

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ACGME Competency Related to Quality

According to the ACGME, to be qualified as competent physicians,residents must be able to investigate and evaluate their patient care

practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to:

analyze practice experience and perform practice-based improvement activities using a systematic methodology

locate, appraise, and assimilate evidence from scientific studies related to their patients health problems

obtain and use information about their own population of patients and the larger population from which their patients are drawn

apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic

effectiveness use information technology to manage information, access on-line medical

information; and support their own education facilitate the learning of students and other health care professionals

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Definition of Quality the degree to which health care services

for individuals and populations increases the probability of desired health outcomes and is consistent with current professional knowledge of best practice.

Institute of Medicine, 1990

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How Can Performance Improvement Impact Quality?

Three distinct parts: Using data and statistics to measure Using a proven problem-solving

methodology Employing a management philosophy

with quality as a fundamental goal

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Bringing in EBM and Guidelines

If we know a specific clinical process is a best practice leading to optimal outcomes, then variation in that process may constitute a quality deficiency

If we have no clear best practice, then seeking it, or eliminating ineffective practices are desirable goals

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The Purpose of EBM and Practice Guidelines

The purpose of Evidence-Based Medicine and practice guidelines is to provide a stronger scientific foundation for clinical work, to achieve consistency, efficiency, effectiveness, quality, and safety in medical care.

Timmermans and MauckHealth Affairs, 2005

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Definition of Clinical Guidelines

Clinical guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.

Institute of Medicine, 1990

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How is This Accomplished?Define best medical practice

Determine why variation occurs

Make changes in practices and procedures to support shift to best practice

Monitor the effects of the changes

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Financial Rationale for EBM?


Present Practice

Revenues Costs Revenues

Assure best practicesReduce needless variation

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Evidence-Based Medicine

involves managing processes of care


managing clinicians

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Supporters of EBM Standards will reduce costs, reduce

variability, and increase access to care Means to measure efficacy, effectiveness,

and efficiency of practice using data, not personal experience

Create better-informed patients and providers Can be used to make better health policy

decisions based on fact, not politics

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Critics of EBM Evidence is not always available or strong

enough to make sound guidelines Loss of autonomy of individual practitioner Disincentive for innovation and progress

(cookbook medicine) May lead to practitioners unprepared for

natural variation in patient populations

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Adherence to Guidelines Asthma example: surveys showed low

compliance with guidelines (between 35% and 68%)

Core Measures example: JCAHO and CMS require adherence to guidelines for care for pneumonia, AMI, and HF patients

Meta-analysis showed average compliance across conditions at about 50%

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Barriers to Adherence Lack of awareness of guideline Lack of familiarity with guideline Lack of agreement with guideline Inertia Autonomy and discretion inherent in

professional work Lack of incentive/disincentive to adherence

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Causes of Practice Variation

Complexity of modern medicine Insufficient evidence base for most

treatment choices Subjective judgment/uncertaintyExpert medical opinion often anecdotalPractice guidelines alone may not change


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Quality Improvement in Reducing Variation







Data Distributionbefore process improvement







Data Distributionafter process improvement


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Examples of Variation in Health Care

Time needed to get test results to MDs Actual time that 2 P.M. medication is actually

administered Number of transfers per month into ICU Number on medical records coded per hour Percent of surgery patients per month that

develop post-op fever/infection

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Must Break the Cycle of Fear

Fearmy patients are sicker than yours

Kill the messengerplace blame

defensive response

Filter the datagame the system, change methods, question data

Micromanagewasted activity & resources

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Lessons from Brent James 1. The core problem is variation in clinical practice.2. Real benefits accrue when inappropriate practice

variations decline.3. For most physicians, financial rewards are

secondary to good patient care. Efforts that emphasize patient care quality are much more successful, even for managing costs, than those that focus on costs alone.

4. Guidelines are nothing new to healthcare.


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Lessons from Brent James5. Control is a central issue.6. Implementing process management requires a

partnership between physicians, administrators, and other stakeholders

7. Local consensus is essential for implementing guidelines.

8. Effective guidelines require feedback on compliance and outcomes, using credible clinical data.

9. Physicians will lead guideline implementation ifvalues, structures, and realities are aligned

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How are Quality Problems Handled?

Problem: Last month Dr. Smiths patients had the highest complication rate following Cardiac cath.

Response: Have the head of the QA Committee send Dr. A a strongly worded letter.

Results: Next month Dr. Jones patients have the highest complication rate.

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How are Quality Problems Handled?

Problem: The Billing Office is overwhelmed by complaints about errors on patient bills and delays in billing.

Response: Replace the Nifty Version 3.0 automated system with the SuperCool Deluxe version 4.1.

Results: During the conversion period 2 weeks of bills are lost. Errors and delays continue.

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How are Quality Problems Handled?

Problem: a patient is upset because she had to wait 4 hours in the ER before being seen.

Response: A soothing phone call from a customer relations employee, followed by a written apology from an administrator.

Results: Customer relations requests 4 more FTEs to handle the increasing workload.

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10 Ways to Sell Change Perceived advantage (WIIFM) Compatible with current practice Simplicity of usage Can be tried one at a time Can be explained using existing lingo Reversible: can back out if it does not work Economy: time, money, effort Credibility of innovator Dependability Consequence of failure

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Stakeholder AnalysisStrongly






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Three Ds Matrix

Negative consequences if actions arent followed


Show how project will positively impact people and processes


Charts, graphs, statisticsData


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Preparing the Organization

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Elements for Successful Projects

High frequency events (hourly, daily, weekly)

Established measures and data collection Narrow scope Jurisdiction authority to make changes Significant business impact ($$,

satisfaction, growth etc)

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But What Is Really Needed?

Support from Management

Sponsor Owner The right team

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Problems In Project Identification

Having a predetermined solution Trying to make everything a project instead

of making reasonable or necessary changes (Just Do It)

Projects tha


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