If You Can Measure It... the Rest Will Come

Transcription

1 If You Can Measure It... the Rest Will Come By C. Edward McBride III, M.D., FAAFP, CPE, and Valerie Hensley, L.P.N. Benjamin Franklin once said, If you can measure it, you can improve upon it. This has been the premise of the Summit Medical Group Quality Department since 2008, when we began benchmarking our diabetic care processes with the National Committee for Quality Assurance (NCQA) Diabetic Recognition Program (DRP). Summit Medical Group strives to continuously improve the quality of care we provide to our patients. With the move to value-based health care, patients, employers, and insurers are demanding greater levels of transparency in the quality of care being delivered. In response to this demand, Summit performed a market analysis to measure quality reporting needs both internal and external to our organization. Our analysis revealed that patients prefer an independent third party validator of quality over either claims-based payer reporting or physician clinical quality reporting. As a result, Summit s physician leadership chose NCQA to serve as that independent third party to measure our performance. Summit Medical Group s physician leadership chose NCQA to serve as an independent third party to measure performance. Our physicians participate in several NCQA recognition programs, including those for patient centered medical home, heart stroke, and diabetes. Adopting and implementing these programs was particularly challenging, given Summit s structure. Summit is a physician-owned primary care group with over 53 clinics operating in 11 counties around Knoxville, Tennessee. Given our diverse care delivery settings, we believe our experiences are directly applicable to other organizations, both large and small, with a need to measure their quality improvement progress. While NCQA typically confers recognition on a three-year cycle in each of its programs, Summit s experience with its first NCQA DRP audit revealed an opportunity to work with physicians seeking continuous quality improvement (CQI). As a result, Summit adopted the DRP program as an annual internal audit to leverage quality improvement, both for contracting with payers and public quality reporting. Using the processes outlined below, we have created a systematic approach focused on CQI which enables us to incorporate effective coordination of care and collaboration between medical professionals across the continuum of care. This Chronic Care Model also plays an important role in providing evidence-based, patient-centric guidelines focused on overall population health. 52 GROUP PRACTICE JOURNAL FEBRUARY 2013

2 Mind the Gaps! Our CQI team works with onsite management, individual physicians, and their staffs to identify clinical quality care gaps and establish processes to close them. Our team benefits from having a common framework in which to shape the improvement process. We use a proven approach called the FOCUS (Find a problem, Organize a team, Clarify the problem, Understand the problem, Select an intervention) Rapid Cycle PDSA (Plan, Do, Study, Act) model. Throughout the CQI project, good data collection is essential. Data provides our teams with ongoing feedback and support to engage further in opportunities to close gaps. Within a single practice, several physicians and their support team often operate in smaller units or pods. Changes to workflow are implemented one pod at a time. Early on, we name a Process Improvement Champion to help the CQI team roll out the process to our entire practice community. We find that we achieve better buy-in with this method. When Summit first implemented CQI in 2008, most of our practice sites were still using paper charting. With only a small portion of our sites operating in an electronic environment, we decided we could be most effective by adapting and reverting to a paper diabetic checklist. The appropriate care team member used paper charts to prepare for the patient s visit and conduct the rooming procedure performed on arrival. The completed checklist was scanned into the patient s medical record, filed in the chart, or incorporated into the physician s progress notes. Our diabetic Rapid Cycle PDSA improvement process spawned other areas of best practice (outside of clinical measures) that could be implemented system-wide. Our diabetic checklist included several barrier metrics that we identified across our organization including: annual eye exams, annual foot exams, and annual screening for renal disease. The approach to closing these CQI gaps varied depending on the gap itself. Foot Exam Model Template Documentation of annual diabetic foot exams is one area of opportunity which lent itself to standardized documentation, as well as a standardized rooming procedure. As a critical mass of physician practices moved onto our electronic health records (EHR), a

3 FIGURE 1 Plan, Do, Study, Act (PDSA) Model Score Outcomes FIGURE 2 SMG Physicians Meeting Annual NCQA DRP Provider E Provider D Provider C Provider B Provider A Year Post 2011 Post-PDSA 2010 Pre-PDSA # meeting criteria % meeting criteria ( = > 75 ) physician-led workgroup designed a diabetic foot exam template within the EHR. Nurses were trained to prepare patients for a foot exam prior to seeing the physician. In some cases, they were trained to perform a preliminary exam with subsequent follow-up by the physician as clinically indicated. As a result, many physicians who previously failed to perform and document this service were able to meet this CQI measure. The EHR also alerts physicians to the need for regular screenings such as an annual eye exam and annual nephropathy screening. Care guides were deployed that allow physicians to quickly place reminders and orders simultaneously. As discrete lab results flow back into the EHR, reminders are automatically updated with a next-to-be-done date. Measuring Improvements Figures 1 and 2 and Table 1 demonstrate the impact of this program. For example, members of the Quality Reporting and Improvement Division worked with Provider D (Figure 1) and staff to implement process improvements. These improvements included implementation of a standardized rooming procedure in which the staff reviews the patient s record, obtains any outstanding documentation of previously ordered studies, and prepares the patient for the physician exam. These changes enabled Provider D to improve from a score of 30 to a passing score of 90 in one year. The changes were implemented with minimal impact on the physician s workflow. In fact, they allowed the physician to spend more time centered on communicating with the patient rather than reviewing the patient medical record and searching for required test results and/or exams. table 1 Mandated PDSA for Never Passed Physicians* Participants SMG Score Score Score Score Score Location Participants SMG Score Score Score Score Score Physician 1 Site A Physician 2 Physician 3 Physician 4 Physician 5 Physician 6 Physician 7 Physician 8 Physician 9 Physician 10 Physician 11 Physician 12 Physician 13 Site B Site B Site C Site C Site D Site D Site E Site F Site G Site H Site I Site F *Summit Medical Group Physicians with annual Diabetic Recognition Program (DRP) audit scores below passing grade of 75 in 4 years prior to intervention (red) and 2012 scores post intervention (black). All 13 passed the audit after participating in the performance improvement initiative GROUP PRACTICE JOURNAL february 2013

4 Our quality reporting and improvement team experienced opportunities to learn from failure. In addition to our many successes, our quality reporting and improvement team also experienced opportunities to learn from failure. One such failure involved regression to prior behavior post PDSA. Provider E (Figure 1) and nurse performed very well as a team post PDSA in 2011 (score ). This nurse subsequently left the organization, and her knowledge was not passed along to her successor. This resulted in Provider E once again failing his annual audit in 2012 with a score of. Early in the rapid cycle improvement process, our teams worked diligently to avoid placing any undue burdens on physicians. Another learning moment occurred when we realized that it is imperative to involve clinicians in the performance improvement process, which allows them to take ownership and ensures that changes will last. The CQI team once again worked with site leadership to oversee the gains that had been achieved, and the sites built these enhanced processes into their care team orientations. Preliminary data show a favorable response to this initiative. When Summit s CQI process was introduced to the group in 2010, participation was voluntary. The early success of the quality reporting and improvement process led our Quality Committee and Board of Directors to mandate process improvement for any physician who had never received the NCQA DRP award. A process improvement team was assigned to work with 13 physicians who had never passed the DRP audit and whose 2011 DRP audit scores ranged from a low of 30 to a high of (Table 1). As a result, all 13 physicians subsequently received NCQA DRP recognition in The average increase in individual physician DRP scores post intervention was 31 points, with one physician seeing a -point increase.

5 Since 2010 when Summit began its mandatory quality reporting and improvement initiative, the number of physicians qualifying for the NCQA DRP increased from of 131 in 2008 to 136 of 149 physicians receiving recognition on our 2012 annual chart audit (Figure 2). Our most recent data tell us that 146 of 149 outpatient primary care physicians possess NCQA DRP recognition, and 20 physicians scored a perfect 100 on their 2012 annual audit. As significantly, the annual DRP audit process has created ongoing dialogue between physicians, their staffs, and the Quality Reporting and Improvement Division. Through use of CQI initiatives, Summit continues to create the vision, define the goals, provide the necessary support, and measure outcomes that sustain CQI across the continuum of care. Ben Franklin would be proud! C. Edward McBride, III, M.D., FAAFP, CPE, is medical director, quality and informatics, and Valerie Hensley, L.P.N., is manager, quality reporting and improvement at Summit Medical Group.