Stratman Quality Primer and MOC Handouts - Marshfield Clinic · RAPID CYCLE QI: DMAIC D: Define the Problem Statement M: Measure where we are at baseline ... Microsoft PowerPoint

Primer on Quality Improvement and Integrating MOC into my

Practice

Erik Stratman, MD

07/17/2012

1

Erik Stratman, MDChairman, Marshfield Clinic Dermatology

Wisconsin Dermatological Society Summer Meeting

July 20, 2012

PRIMER ON

QUALITY IMPROVEMENT AND

INTEGRATING MOCINTO MY PRACTICE

DISCLOSURE

I, Erik Stratman, MD FAAD have no relevant financial relationships with industry that are relevant to the content of this presentation

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)

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ISSUE 1: CARE IS DISCREPANT AND NON-STANDARDIZED

Source: www.dartmouthatlas.org.

$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

Medicare Spending per Capita in the United States, by Hospital Referral Region, 2003

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): 2635–2645.

Percent of recommended care received

ISSUE 1: CARE IS DISCREPANT AND NON-STANDARDIZED

IS THIS HAPPENING IN DERMATOLOGY?

ISSUE 2:

CARE IS COSTLY.

COSTS ARE RISING TO UNSUSTAINABLE LEVELS.

COST OF CARE NOT ASSOCIATED WITH QUALITY OF CARE

PROJECTIONS OF FEDERAL EXPENDITURES AS A PERCENTAGE OF GDP

Source: Congressional Budget Office (2003), The Long-Term Budget Outlook (Supplemental Tables), Available athttp://www.cbo.gov/showdoc.cfm?index=4916&sequence=0 as reported in R. Friedland and L. Summer, Demography Is Not Destiny, Revisited, The Commonwealth Fund, March 2005.

Percent of GDP

7.79.4

12.7

17.4

22.3

27.5

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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)

BUT WE ARE A VERY SMALL FIELD. WE AREN’T MANAGING HYPERTENSION, DIABETES, AND CHRONIC KIDNEY DISEASE…

IS THIS ISSUE RELEVANT IN DERMATOLOGY?

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/woundsBickers, et al. The burden of skin diseases: 2004 Journal of the American Academy of Dermatology - Volume 55, Issue 3. September 2006.

THE MORE I SPEND TO HELP A PATIENT, THE BETTER CARE I DELIVER TO THE PATIENT…

RIGHT??

WRONG

Patients Reporting Any Error by Number of Doctors Seen in Past Two Years, Sicker Adults, 2005

Percent

Source: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults.

ISSUE 3: WE ALL ENCOUNTER ERRORS, AND MANY ERRORS ARE AVOIDABLE.

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INEFFICIENT, POORLY COORDINATED, UNSAFE CARE

Percent of adults reporting a time theyexperienced each event in the past two years

Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2006.

Ordered a test that hadalready been done

Failed to provide importantmedical history or test results

to other doctors or nurses

Any of the above

Recommended unnecessarycare or treatment

Medical, surgical, medication,or lab test error

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

TOOLS IN THE QUALITY TOOLKIT

• EMR-based Quality Tools

• LEAN Methodology

• Rapid Improvement

• DMAIC

• PDSA

ILIST (INTERVENTION LIST) Melanoma

Annual Full Body

Skin Exam

Contacted Primary Care about Plan

Clinical Staging before Re-excision

Sun Protection Education

Self-Exam Counseling

Guideline-based Management

National Cancer Registry Completion

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07/17/2012

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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

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EXAMPLE PDSA: PSORIASIS AND SMOKING

• Psoriasis + Smoking is bad cardiovascular risk

• We weren’t identifying which psoriasis patients smoke

• 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.

Plan• Identify issue• Baseline data

CHART REVIEW DESIGN

2 Stelara

3 No visit

6UVB

3IL injections

106 patients

92 included14 excluded

• 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

DOCUMENTATION OF TOBACCO USE FOR PSORIASIS PATIENTS: THEN AND NOW

0%

20%

40%

60%

80%

100%

BaselineCurrent

Study

• Chart review• Comparison

TOBACCO CESSATION COUNSELINGCurrent

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

E 0 n/a

F 2 100%

G 4 100%

H 2 50%

Department 16 63%

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)

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PDSA CYCLEPlan• Identify issue• Baseline data

Do• Comorbidity stamp• Tobacco cessation tools• Department education• May 3-June 15

Study• Chart review• Comparison

Act• Expansion to other comorbidities• Frequency of comorbidity

documentation• Tobacco cessation vs. Tobacco

cessation counseling

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 provide compared to peers and national benchmarks and then apply the best evidence or consensus recommendations to improve that care using follow-up assessments.

Plan

Do

Study

Act

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

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FUTURE DIRECTIONS:

INSTITUTIONAL MOC(IMOC)

INSTITUTIONAL MOC

• Local relevance

• Lead time / Lag time

• Boards grant local institutions oversight of board-recognized 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

Quality Improvement Cycle: Plan, Do, Study, Act (PDSA)

© 2010 Marshfield Clinic. Quality Improvement and Care Management

Name of Project:

Division: Project Lead:

Center: Team Members:

Department:

Start Date:

End Date: QICM Member:

SITUATION KEY COMPONENTS

Improvement Opportunity:

BACKGROUND

Aim: How good? By when?

Measure(s): Outcome Process

Baseline Data:

Changes: Actions to achieve aim



1. PLAN

4. ACT 2. DO

3. STUDY



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



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: http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/testingchanges.htm

Stratman Quality Primer and MOC Handouts - Marshfield Clinic · RAPID CYCLE QI: DMAIC D: Define the Problem Statement M: Measure where we are at baseline ... Microsoft PowerPoint

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