How to Institute Quality Improvement Initiatives In Your Practice Gil Y. Melmed, MD, MS Cedars-Sinai...

How to Institute Quality Improvement Initiatives In Your Practice

Gil Y. Melmed, MD, MSCedars-Sinai Medical CenterCCFA Advances in IBDOrlando, FL 2014

What is “Quality” in Healthcare? (Institute of Medicine, 1990)

• “The degree to which health services for individuals and populations increase the likelihood for positive health outcomes and are consistent with current professional knowledge”

In other words…

“Quality of care” is a mechanism to ensure that the best new research and ideas do not get left behind in journals, but get applied equally to all patients

Corey Siegel, DHMC

Mission: The improve the quality of care DELIVERED to patients with IBD

Crohn’s and Colitis Foundation of America: Goals of Quality of Care for IBD

Steps Define the standards of care for IBD Develop an implementation program to

measure and deliver this care Continuous evaluation and refinement of

this process Measure and improve the impact on

patient outcomes

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Today’s “Opportunities”(care falls short of theoretic potential)

1. Significant variation in practice2. Inappropriate care (risk>benefit)3. Preventable complications4. Waste and high costs

All are true for IBD All are probably true in an individual practice!

Brent James, 2011

Variation in Care in the United States

Proportion of patients with Crohn’s disease using biologics by Zip Code

David G, et al. Geographic variation in care of patients with IBD suggests unequal quality of care in the United States. Presented

at DDW 2013, Orlando, FL

What Quality Improvement Initiatives are out there to help me in my practice?

Quality Improvement Initiatives

• Quality Measures• AGA – Digestive Health Registry Program• CCFA• ImproveCareNow (Pediatric)• ABIM MOC• Care Pathways / Algorithms

• Checklists

• Others – don’t need a “program”, just need to start improving!• Know your denominator

Define quality measures

Pilot testing in the “real world”Demonstrate feasibility

Widespread implementationDemonstrate improved outcomes

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Quality Improvement for Adults With IBD: Where Are We Going?

Quality Indicators

• “specific, measureable elements of care for which there is evidence or consensus that can be used to “assess the quality of care provided and hence change it.”

• offer uniform, minimally acceptable level of care to all patients (i.e. the floor, not the ceiling)

Campbell SM et al. BMJ 2003;326:816-19. MacLean CH et al. Arthritis Rheum 2004;51:193-202

CCFA Quality Indicators Process Measures

Prof Ed. QI subcommittee

Electronic voting + in-

person RAND panel

•Literature review (>2000 articles with 21 reviewers)

•Electronic voting + 2nd in-person RAND panel

Multidisciplinary Panel: •Physicians/Surgeon•AGA, ECCO, ACG•Nurse•Patients

CCFA “Top Ten” Process Measures

• Test for TB before anti-TNF therapy• Test for C. difficile in flares • Flex sig. for CMV in steroid-refractory hospitalized UC• Check TPMT before starting thiopurines• Recommend steroid-sparing agents if >4m steroids• Recommend colectomy or close surveillance for low-

grade dysplasia in colitis• Recommend smoking cessation if smoker with CD• Educate patients regarding vaccinations

Melmed, et al. Inflamm Bowel Dis, accepted 2012. Melmed GY et al. IBD 2013

CCFA “Top Ten” Outcome Measures

Steroid-free clinical remission

Days lost from work/school

Days hospitalized

ED visits

Malnutrition

Melmed, et al. Inflamm Bowel Dis 2013

Anemia

Narcotic use

Incontinence

Normal health related QOL

Nighttime BMs or leakage

We’ve defined measures. Now what?

UK Clinical Audit: Ulcerative Colitis

Courtesy of Richard Driscoll




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CCFA Adult Quality of Care 1-year Pilot Program

CCFA – Pilot Implementation Study“IBD QI Collaborative Network”

key measuresmonthly reports and webinarscoached model for improvement

CCFA – Pilot Implementation Study“IBD QI Collaborative Network”

CCFA Pilot Implementation StudyMonthly Measures Report

Checklists, Templates, and Tools

Can “checklists” actually help?

• World Health Organization Safe Surgery Saves Lives

• October 2007 to September 2008

• 8 hospitals in 8 countries

- Jordan, India, Philippines, Tanzania, New Zealand, Canada, USA, England

• Introduced the Surgical Safety Checklist

• Measured post-operative complications and deaths in first 30 days

• 3700 operations before checklist, 3900 operations after checklist

Haynes AB et al. New Engl J Med 2009;360:491-9

Outcomes before and after checklist

11%11%

6.2%6.2%

1.8%1.8%

7%7%

3.4%3.4%

0.8%0.8%

Any complicationp <0.001

Infectionp <0.001

DeathP=0.003

Haynes AB et al. New Engl J Med 2009;360:491-9

Before

After

Every system is perfectly designed to get the results that it gets

To improve results, you must redesign your system. Simply trying harder at your old system won’t work.

“It’s better to do it the same than to do it right”




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CCFA Next steps:A Registry Enabled Care & Learning System

Feed ForwardPRO Data

Feed Forward Clinical Data

Learning Health System For More Effective Action by Patients, Providers, and Researchers

Shared Information Environment

Partnership forCo-production

Aim: We aim to build a learning health system where patients, providers, and researchers partner to co-produce optimal health and high value care.

Key Mechanisms: A registry enabled care and learning system that integrates: data feed forward systems, patient-centered clinical decision support “dashboards”, meaningful reports available to patients and providers, patient and provider networks, and multi-stakeholder learning collaboratives.

Electronic Health RecordsCollaborative Improvement Networks

Personal Health RecordsPatient Facilitated Networks

Registries

Patient & Family

Provider & Care Team

Optimal Health and High Value Care for Patients and Populations

© 2014 Trustees of Dartmouth College and Karolinska Institutet

Do you know your denominator?

• How many patients with IBD did I care for in 2014?• How many are in remission right now?• How many are on steroids right now?• How many are on narcotics right now?• How many are anemic at their last CBC?• How many went to the ER this year?

• On MONDAY –figure out your denominator!• Billing records• EMR ICD9 diagnosis codes

Start with ONE area to improve…

• Patient outcomes – CCFA 10 outcome measures to choose from

• Patient management – phone calls, timeliness of appts, tracer, p

• Process measures• CCFA Processes• AGA Process measures – DHRP• Cornerstones checklist

Envisioning the Future:Start Small, Think Big

• Globally relevant quality measures• Minimized variation in care • Linked registries of patient metrics / outcomes• Regional and global learning health systems to improve

quality metrics for patient care

How to Institute Quality Improvement Initiatives In Your Practice Gil Y. Melmed, MD, MS Cedars-Sinai...

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