Primer on Quality Improvement and Integrating MOC into my Practice. Erik Stratman, MD

Transcription

1 Primer on Quality Improvement and Integrating MOC into my Practice Erik Stratman, MD

2 PRIMER ON QUALITY IMPROVEMENT AND INTEGRATING MOC INTO MY PRACTICE DISCLOSURE I, Erik Stratman, MD FAAD have no relevant financial relationships with industry that are relevant to the content of this presentation Erik Stratman, MD Chairman, Marshfield Clinic Dermatology Wisconsin Dermatological Society Summer Meeting July 20, 2012 I am a Director for the American Board of Dermatology OBJECTIVES 1. Define Quality 2. Describe Basic Methods of Quality Improvement 3. Describe Examples of In-Office Quality Improvement activities that could be relevant to dermatologists 4. Describe MOC-qualifying Quality Improvement activities for dermatologists 5. Describe how Patient Surveys and/or Peer Surveys can be used to trigger Quality Improvement Activities WHY DISCUSS QUALITY? Mission Moral imperative for Our patient s health Economics Our patients Our Clinic Society Quality Improvement projects are part of MOC for dermatologists QUALITY - DEFINED The right care for the right person at the right time. Carolyn Clancy Medical Director AHRQ QUALITY TERMINOLOGY Quality assurance the process of ensuring compliance to specifications, requirements, or standards and implementing methods for conformance. (inspection, correction) Quality improvement an organized structured process that selectively identifies improvement teams to achieve improvements in products or services (change process, improve outcomes) 1

3 ISSUE 1: CARE IS DISCREPANT AND NON-STANDARDIZED Medicare Spending per Capita in the United States, by Hospital Referral Region, 2003 ISSUE 1: CARE IS DISCREPANT AND NON-STANDARDIZED Percent of recommended care received $7,200 to 11,600 (74) 6,800 to < 7,200 (45) 6,300 to < 6,800 (55) 5,800 to < 6,300 (60) 4,500 to < 5,800 (72) Not Populated Source: Source: The Commonwealth Fund, calculated from McGlynn et al., The Quality of Health Care Delivered to Adults in the United States, The New England Journal of Medicine (June 26, 2003): IS THIS HAPPENING IN DERMATOLOGY? ISSUE 2: PROJECTIONS OF FEDERAL EXPENDITURES AS A PERCENTAGE OF GDP CARE IS COSTLY. Percent of GDP 27.5 COSTS ARE RISING TO UNSUSTAINABLE LEVELS COST OF CARE NOT ASSOCIATED WITH QUALITY OF CARE Source: Congressional Budget Office (2003), The Long-Term Budget Outlook (Supplemental Tables), Available at as reported in R. Friedland and L. Summer, Demography Is Not Destiny, Revisited, The Commonwealth Fund, March

4 BUT WE ARE A VERY SMALL FIELD. WE AREN T MANAGING HYPERTENSION, DIABETES, AND CHRONIC KIDNEY DISEASE IS THIS ISSUE RELEVANT IN DERMATOLOGY? Source: The Commonwealth Fund, from G. Anderson and J. Horvath, Chronic Conditions: Making the Case for Ongoing Care (Baltimore, MD: Partnership for Solutions, December 2002) WHICH OF THE FOLLOWING IS THE MOST COSTLY SKIN DISEASE BY DIRECT MEDICAL COST? 1. Acne 2. Contact dermatitis 3. Cutaneous fungal infections 4. Herpes zoster and simplex 5. Skin ulcers/wounds Bickers, et al. The burden of skin diseases: 2004 Journal of the American Academy of Dermatology - Volume 55, Issue 3. September THE MORE I SPEND TO HELP A PATIENT, THE BETTER CARE I DELIVER TO THE PATIENT ISSUE 3: WE ALL ENCOUNTER ERRORS, AND MANY ERRORS ARE AVOIDABLE. Percent Patients Reporting Any Error by Number of Doctors Seen in Past Two Years, Sicker Adults, 2005 RIGHT?? WRONG Source: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults. 3

5 INEFFICIENT, POORLY COORDINATED, UNSAFE CARE Percent of adults reporting a time they experienced each event in the past two years Ordered a test that had already been done Medical, surgical, medication, or lab test error Failed to provide important medical history or test results to other doctors or nurses Recommended unnecessary care or treatment CROSSING THE QUALITY CHASM (2001) Trying harder will not work. Get away from culture of Blame-And-Shame Quality improvement efforts need to focus on Minimizing variation in processes. Creating reproducible processes for reliable results Any of the above Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, TOOLS IN THE QUALITY TOOLKIT EMR-based Quality Tools LEAN Methodology Rapid Improvement DMAIC PDSA ILIST (INTERVENTION LIST) Melanoma Self-Exam Counseling Clinical Staging before Re-excision Sun Protection Education Contacted Primary Care about Plan Annual Full Body Skin Exam National Cancer Registry Completion Guideline-based Management 4

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8 RAPID CYCLE QI: PDSA RAPID CYCLE QI: DMAIC D: Define the Problem Statement M: Measure where we are at baseline A: Analyze gaps and barriers I: Improve through innovative solutions to fix and prevent process problems C: Control and monitor improvements to ensure continued success MARSHFIELD CLINIC DERMATOLOGY DEPARTMENT EXAMPLES OF RAPID CYCLE QI Psoriasis Comorbidities Screening and Primary Care Connection Prednisone Prescribing and Bone Protection Counseling Informing Primary Care Doctor of his/her patient s new Melanoma Diagnosis Hand hygiene use among dermatologists and staff 1

9 EXAMPLE PDSA: PSORIASIS AND SMOKING Plan Identify issue Baseline data CHART REVIEW DESIGN 106 patients Psoriasis + Smoking is bad cardiovascular risk We weren t identifying which psoriasis patients smoke 14 excluded 92 included Baseline data = 21% smoking hx documented When we DID identify smokers, we weren t providing those who smoke with resources to quit. Baseline data = Only once did we document providing smoking cessation information or counseling. 2 Stelara 3 No visit 6 UVB 3 IL injections Only counted one visit if patient had multiple appointments during 5/2-6/15 Included spot checks and add-on appointments if psoriasis also included in A&P Do Comorbidity stamp Tobacco cessation tools Department education May 3-June 15 Study Chart review Comparison 100% 80% DOCUMENTATION OF TOBACCO USE FOR PSORIASIS PATIENTS: THEN AND NOW 60% 40% 20% Baseline Current 0% TOBACCO CESSATION COUNSELING Current Provider Psoriasis patients who use tobacco (N) Patients with tobacco cessation counseling (%) A 0 n/a B 7 43% C 1 0% D 0 n/a In baseline data, tobacco use was identified in one patient and cessation counseling was documented Act Reflection on Success Expansion to other comorbidities Frequency of comorbidity documentation Tobacco cessation (outcome measure) vs. Tobacco cessation counseling (process measure) E 0 n/a F 2 100% G 4 100% H 2 50% Department 16 63% 2

10 PDSA CYCLE Act Expansion to other comorbidities Frequency of comorbidity documentation Tobacco cessation vs. Tobacco cessation counseling Plan Identify issue Baseline data Study Chart review Comparison Do Comorbidity stamp Tobacco cessation tools Department education May 3-June 15 HOW IS THIS RELEVANT TO MOC? COMPONENT 4: PRACTICE PERFORMANCE ASSESSMENT Physicians are evaluated in their clinical practice according to specialty-specific standards for patient care. They are asked to demonstrate that they can assess the quality of care they Plan provide compared to peers and national benchmarks and then apply the best evidence or consensus recommendations to improve that care using follow-up assessments. Act Study Do AAD CLINICAL PERFORMANCE ASSESSMENT TOOL (CPAT) Acne Atopic Dermatitis Melanoma ABMS QUALITY IMPROVEMENT IN PRACTICE Quality Improvement in Practice ($30) Patient Safety Improvement ($55) INSTITUTIONAL MOC 3

11 FUTURE DIRECTIONS: INSTITUTIONAL MOC (IMOC) INSTITUTIONAL MOC Local relevance Lead time / Lag time Boards grant local institutions oversight of boardrecognized approval for Component 4 MOC credit Institutions create quality project review process (Quality Project Review Task Force, Quality Review Board, etc) *Not Time-Avoiding, just makes the work more relevant KILLING 2 MOC BIRDS WITH ONE STONE MOC Component 4 currently has 3 requirements: Performance in Practice Assessment Patient Experience Surveys Peer Surveys It is acceptable to use an area of poor survey performance to trigger a performance improvement activity! OBJECTIVES 1. Define Quality 2. Describe Basic Methods of Quality Improvement 3. Describe Examples of In-Office Quality Improvement activities that could be relevant to dermatologists 4. Describe MOC-qualifying Quality Improvement activities for dermatologists 5. Describe how Patient Surveys and/or Peer Surveys can be used to trigger Quality Improvement Activities 4

12 Quality Improvement Cycle: Plan, Do, Study, Act (PDSA) Name of Project: Division: Project Lead: Center: Team Members: Department: Start Date: End Date: QICM Member: SITUATION KEY COMPONENTS Improvement Opportunity: Aim: How good? By when? BACKGROUND Measure(s): Outcome Process Baseline Data: Changes: Actions to achieve aim 2010 Marshfield Clinic. Quality Improvement and Care Management

13 Quality Improvement Cycle: Plan, Do, Study, Act (PDSA) 1. PLAN 4. ACT 2. DO 3. STUDY 2010 Marshfield Clinic. Quality Improvement and Care Management

14 Quality Improvement Cycle: Plan, Do, Study, Act (PDSA) Use this page to further explain your assessment of the results (expanded study section from PDSA cycle -- including lessons learned ) and any recommendations (expanded act section from PDSA cycle including next steps ) for this project. ASSESSMENT RECOMMENDATIONS 2010 Marshfield Clinic. Quality Improvement and Care Management

15 Quality Improvement Cycle: Plan, Do, Study, Act (PDSA) Background and Situation Identify an opportunity for improvement. Provide baseline data if available. Key Components Establish a precise aim (what is your goal, what is the timeframe i.e. how good, by when? ). Set performance measure(s) for the project. Identify changes (actions) that will accomplish the aim. Step 1: PLAN a Change Identify the processes that may prevent you from reaching the aim. Collect and analyze data related to the project. Verify or revise the original improvement opportunity statement. Verify or revise the performance measure. Step 2: DO Try the Change on a Small Scale A. Develop Changes Generate potential changes that will address root causes of any barriers to accomplishing the aim. Select a specific change or changes that can be implemented on a small scale and tested quickly to see if it (they) work(s). Identify anticipated results from this change. Plan how you will carry out the change, when and who will do it. This is your first change cycle. B. Implement a Change Implement the change on a trial or pilot basis. Step 3: STUDY Observe/Evaluate the Results of the Change Gather data on the change. Analyze the data on the change. Was the change carried out as planned? Did you obtain the anticipated results? What new knowledge did you gain as a result of this change cycle? Use the assessment box to further explain the results of the project, including lessons learned. Step 4: ACT Refine and Spread the Change List the actions that will be taken as a result of this change and evaluation cycle. If successful, spread the change more broadly. Identify any systemic changes and training needs for full implementation. Plan ongoing monitoring of the change. Continue to look for incremental improvements to refine the change. Look for another improvement opportunity. Use the recommendations box to further explain any recommended actions, including next steps for this project. The Plan-Do-Study-Act (PDSA) cycle is part of the Institute for Healthcare Improvement Model for Improvement, a simple yet powerful tool for accelerating quality improvement. Once a team has set an aim, established its membership, and developed measures to determine whether a change leads to an improvement, the next step is to test a change in the real work setting. The PDSA cycle is shorthand for testing a change by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method, used for action-oriented learning. For more information about using the PDSA tool, visit the Institute for Healthcare Improvement Web site: s/howtoimprove/testingchanges.htm 2010 Marshfield Clinic. Quality Improvement and Care Management