Culture, Processes, Data, and Motivation: Keys to Quality Improvement

Each physician has to determine areas where there is room for improvement and the potential return on changes made.
Each physician has to determine areas where there is room for improvement and the potential return on changes made.

Quality in healthcare is difficult to define and quantify. So how does a practice embark on a program of quality improvement? A good starting point for those new to quality improvement may be to take a broad stroke approach. Knowing a pathway to make changes in an office provides a template for improving quality in ways that work best for them.

Start small

John Haughom, MD, a senior advisor at Health Catalyst in Salt Lake City, Utah, said it is best to crawl before walking when it comes to quality improvement. “Take 1 condition and learn how to do it based on 1 narrowly scoped project,” he said. “When you show you can improve process and outcomes over time, then move to next one.”

Instead of setting expansive, long-term goals out of the gate, he recommends goals that bring quick results and are easily measured.

“The surest way you can lose interest is to set a goal that you can't achieve for 9 months to a year,” he said.

Establish a quality culture

To improve something, you first have to admit that it isn't perfect. Not all doctors are comfortable doing this. Amy Mullins, Medical Director of Quality Improvement at the American Academy of Family Physicians, said a culture that is safe for people to voice problems is requisite. A physician has to be willing to accept feedback and invite the staff into the process.

“You need buy-in from the whole team and give them permission to identify areas for you,” she said. “They can often see where things are falling short before the provider does.”

Prioritize goals

Quality for many physicians can be nebulous. Many groups offer quality outcomes to measure, but they may not be relevant to, or feasible for, your office. Each physician has to determine areas where there is room for improvement and the potential return on changes made. Haughom recommends focusing on the “big money conditions,” or those that are large drivers of quality and cost in a particular office.

“If I stop a urologist and ask what 3 conditions they treat most frequently, they should know what they are,” he said. “Money is in big conditions so they need to start by focusing on those.”

Mullins said it might be wise to choose 1 clinical area and 1 functional area in the office (length of time waiting for a physician or time it takes to call in a prescription).

William Lynagh, MD, Chief Medical Officer of Crimson, part of The Advisory Board Company, which has its headquarters in Washington, D.C., said physicians should keep in mind the concept of processes versus outcomes. Doctors tend to measure things like readmission rates, which is an outcome. But processes, he said, can be just as valuable. Giving proper post-hospitalization instructions are what lead to reduced readmission rates.

Collecting and analyzing data

“Quality improvement is all about data ultimately,” Haughom said. “It always has been, we just didn't have good access to it before.”

Reliable data is the only way to measure improvement. Practices with IT support have an advantage, but even those without IT support can measure change. A practice using electronic health records (EHRs) should be able to query those records to find out, for instance, which patients have unmanaged A1C levels. Over time, that number can be tracked.

Some data can be manufactured. If you want to measure the time it takes for patient turnaround, set up a system in which patients sign in when they arrive and sign out when they leave. Their movement through the office can also be tracked on EHRs.

Physician's role

The heavy lifting of quality improvement work is typically not performed by the physician, but the team surrounding him or her. The physician's job is to lead the process, but someone else should champion the work. A doctor's job is to go over the project with the staff, map out the work, and meet with the team every few weeks to get status updates.

“They need to show they are supportive of the process and backing all of it,” Mullins said. “Everyone is going to look to the physician for that.”

Communicating results

The medical field is flush with intelligent people committed to the work they perform. Doctors, in particular, want to be “A” students, Haughom said. When they start looking at quality data, they often feel like they are getting Bs or Cs. Use this as motivation.

“You want to capture that energy to be the best and get them focused in on the process,” he said. “If you can get to that point, they start feeling like what they went to school for – to be “A” students.”

Most places go after the outliers for improvement – those whose marks aren't on par with everyone else. But Lynagh said it's important to mix in good data. Congratulate physicians who achieve the shortest hospital stays and then ask them about the areas where they might want to grow.

“Let them come up with a data point to review after you have made it safe,” he said. “Use the data for learning and not judgment.”

Getting an easy win upfront and celebrating that victory is good for team spirit, Mullins said. Take the staff that worked on the project to lunch or put a blue ribbon on their jacket or a star on their desk.  “It doesn't take a lot for people to feel good,” she said.

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