By Laura Gruber, Senior Director, Administration, Strategy and Education, University of Florida Health Physicians; Ted Singer, BA, CHCP, President, PVI, PeerView Institute for Medical Education Inc.; and Marvin Dewar, MD, JD, Senior Associate Dean and CEO, University of Florida Health Physicians
Editor’s Note: This article is the final installment of a three-part Almanac series focused on the implementation of an asthma-focused quality improvement project at two different medical practices in Gainesville, Florida. One project site focused on adult patients and the other focused on pediatric patients. The first two segments of the series appeared in the November 2015 and June 2016 issues of the Almanac.
Competency 8.1: Integrate into the design and assessment of educational activities/interventions a systems-based approach to identifying and closing gaps in healthcare by
- Evaluating quality and performance gaps for systems-based issues (e.g., structures and processes) that can be addressed within CEhp activities/interventions
- Addressing systems-based issues that are barriers to change and implementation of new knowledge and skills
- Assessing improvements in team performance
- Developing CEhp content that supports collaborative practice within the interprofessional health care team
When this quality initiative began in spring of 2015, the two participating practices, pediatric and adult, were essentially at the starting line together. However, as described in the last article of the series, their progress pace was vastly different. The pediatric practice had implemented a new asthma screening tool and was waiting to see if it had improved performance against the identified asthma quality measures. The adult practice was still trying to finalize a screening tool that would work with its patient population. Now, months later, we revisit each practice and see where the project stands.
Pediatric Practice – “Down the Backstretch They Come!”
As Table 1 indicates, the quality project resulted in considerable improvement in asthma quality measures at the pediatric practice over the course of six months.
The practice was quite pleased with these results and ascribes them to successful implementation and utilization of the new screening tool. For the one measure where no improvement was noted (documented provision of an asthma action plan) the team suspects that while the action plan was integrated into the EHR architecture, they had not had sufficient time to educate providers and staff on where to find it and how to use the materials. Over time, with additional education, they expect an increase in utilization of the asthma plan tool and a corresponding improvement against that measure.
An ensuing review of lessons learned during the project revealed numerous best practice strategies for Almanac readers to consider when designing and implementing their own QI efforts:
- Practice leadership is important.
As mentioned in earlier installments, the pediatric practice had an established history of successful QI efforts through multiple projects. The physician champion was committed to driving the process and was teamed up with a practice manager who served as a key lieutenant. Before starting, they knew the effort involved and believed in the process. As a result, their practice bought in to the project and goals and achieved great improvement.
- There are no “QI vacations.”
From kick-off through post chart audit, the pediatric practice discussed the QI project at each weekly departmental meeting. This frequency of contact kept the project top-of-mind, allowed for important adjustments to the methodology and tools, and monitoring of staff response to the project over time.
- Coordinate between clinical and non-clinical staff.
While involvement of all members of the health delivery team is vital to a successful QI project, it is important to emphasize that regular and effective communication among team members is key if the goal is to maximize team performance. While the pediatric practice designed a great asthma screening tool, it would have been an underused asset if the QI team had not worked hard to determine optimal workflows to implement the tool, which included EHR integration and efficient handoffs from front office staff to clinical staff. These handoffs were honed over time through trial and error. The front office staff needed to understand why asthma patients needed to be flagged and the screening tool included as part of the chart before the clinician entered the room. The clinicians needed to understand that identifying the correct patients to be screened was not an easy intuitive task that the front office staff could execute without training. Everyone on the delivery team needed to better understand the roles and responsibilities of each member for improvement to occur.
- Scan the environment to see what already works.
There are a ton of QI tools and strategies in the public domain, and there are probably some that exist within your own system. The pediatric practice adapted their asthma screening tool from a format already utilized with ADHD patients in their practice, and borrowed ideas for their revised “Asthma Action Plan” template from one used with their pulmonary patients.
- Get (and give) credit for the project.
The pediatric physician champion was successful obtaining American Board of Pediatrics MOC Part IV credits for the relevant participating clinicians on the team. The specialty boards seem to be more open than ever to supporting their diplomates in practice improvement activities. The process of gaining board approval for your MOC project might not be as complicated or time consuming as you think, and it’s definitely worth investigating, especially during the planning stages when adjustments to accommodate board requirements can still be included.
For the pediatric practice, the asthma QI project built an infrastructure for improvement that should continue over time for projects involving other diseases. They identified measures that align with their patient population, established documentation processes that “close the paper quality gap” on reporting on all care that gets delivered, and mobilized the existing staff to collaborate better around improvement.
So what’s next for the pediatric asthma QI team? The dynamic physician champion/practice manager team has a few ideas:
- More EHR Integration
The pediatric practice implemented their QI project in an EHR-naive manner so that the lack of EHR integration would not slow them down. As a result, many of their tools were developed and implemented first on paper with plans to integrate into the EHR as the resources to do so become available. This increased their project implementation speed but left them with a follow-up project: seamless integration within the working EHR environment to reduce documentation burdens and support sustained improvement.
- Individual Physician Performance Dashboards
Making performance data available to team members via personalized dashboards that clinicians can access on-demand is viewed as a potentially powerful behavior change agent.
- Focus Shift to Outcome-Based Measures
This project was focused on closing documentation gaps to improve performance against process measures. Now that this first stage has been completed, the practice is interested in expanding its view to outcome-based measures such as reducing hospital admissions, ER visits and asthma exacerbations.
Adult Practice – “Last out of the Gate but Trying to Hit Its Stride”
For every success story, there is a cautionary tale, and the adult practice is a bit of a counterweight to the smooth functioning pediatrics group. While the pediatric practice was able to develop and implement their screening tool within five months of project kick-off, it took the adult practice over a year to do so. As a result, “post” implementation data is not available for this final update. But, just as every successful QI project produces a series of best practice examples, projects that struggle create learnings about obstacles and pitfalls that impede progress.
A review of the obstacles impacting the adult QI project supports the following observations:
- Within four months of kick-off, the adult practice physician champion had to take a medical leave of absence that lasted for several months. The lack of a regularly present physician champion severely impeded progress.
- The adult practice’s physician champion did not have a dedicated practice manager partner but rather a shared resource whose wide-ranging responsibilities made it difficult to focus on this QI project.
- Without other successful recent QI projects to develop a higher level of performance improvement expertise, the search for an adaptable adult screening tool took a longer time than in the more QI savvy pediatric site.
- The adult practice had more EHR-development resources to draw from, but this paradoxically extended the implementation timeline. The decision to seek changes to the electronic infrastructure at project outset resulted in delays due to required reviews and approvals of changes to the EHR. The pediatric practice’s initial reliance on paper-based tools was a lot faster by comparison.
- The adult practice also had some competing QI projects ongoing, including projects related to smoking cessation and colorectal cancer screening. The physician champion was worried about overwhelming the staff with too many EHR-based prompts.
All of the above considerations contributed to the slower start of the asthma project at the adult practice. However, the adult practice ultimately developed a screening tool that was integrated in their EHR. They announced the initiative to the relevant physicians within the practice and even provided an “EHR Tips and Tricks” how-to guide for utilizing the new tool. The biostats team is currently working to gather “post” data to share with the practice and is working with the EHR team to assess usage of the new tools and forms.
It would be easy to score the pediatric project a success and the adult project a failure, but such a conclusion is likely premature. By all accounts, the pediatric practice was a model of consistent leadership, vision and execution with impressive results. However, it was also a much smaller practice with fewer complexities. The adult asthma QI project, after almost failing to get out of the starting gate, eventually managed to implement a new asthma screening tool in the EHR, and has potential to see significant improvement in care as a result. While the goal of having both practices moving at the same pace and learning from each other’s work wasn’t realized, the adult practice will ultimately benefit from the pediatric practice’s work and, hopefully, will develop a QI culture of its own. Ultimately, each practice has to run its own QI race, while at the same time looking for ways to leverage the collective wisdom of the local and national QI community to make it a more efficient and effective journey.
Points for Practice:
- QI culture is built over time, through trial and error. When multiple practices are participating in the same QI project, some will succeed faster than others based on previous QI experience, leadership, size of practice and diversity of the patient population.
- For improvement to occur, everyone on the delivery team, including clinicians and non-clinical staff, needs to better understand the roles and responsibilities of each member of the team.