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Working smarter and safer for quality improvement

To spearhead successful QI efforts, hospitalists say you need the right project—and a versatile team

From the September ACP Observer, copyright 2005 by the American College of Physicians.

By Paula S. Katz

CHICAGO—When the hospitalists at the University of San Diego wanted to reduce their patients' incidence of venous thromboembolism (VTE), they knew they had to do more than just talk about the importance of screening patients and providing prophylaxis.

"Quality improvement is not saying, 'You guys just aren't getting it done. You've got to work harder. You've got to be smarter and work safer,' " said Gregory A. Maynard, ACP Member, chief of the division of hospital medicine and associate professor of clinical medicine at the university.

Instead, Dr. Maynard pointed out, what was needed was a way to identify interventions that would boost screening, streamline treatment—and improve the quality of care. The answer was to create a VTE-prevention team that set specific goals to help physicians assess patients' VTE risk on admission and at frequent intervals, and match prophylaxis to their risk level.

At the annual meeting of the Society of Hospital Medicine in Chicago earlier this year, Dr. Maynard and Lakshmi Halasyamani, ACP Member, associate chair of the department of medicine at Saint Joseph Mercy Hospital, in Ann Arbor, Mich., outlined quality improvement strategies to help physicians increase quality and lower costs. While their tips were geared to a hospitalist audience, they can apply to physicians planning quality improvement projects in either the inpatient or outpatient setting.

Creating the ideal QI team

When it comes to implementing a quality improvement initiative, the first step is to choose a project. While that may sound obvious, Dr. Halasyamani said the initiative you choose will have long-ranging effects on your project's success.

She suggested tackling an issue that is a priority of a regulatory agency—or a strategic growth area for your organization, such as heart failure or inpatient glycemic control.

"Think about a process that requires re-doing or is done differently by each physician who performs it," Dr. Halasyamani explained. Or consider revamping a process that is a hassle or of questionable value.

When assembling a team, you'll need physicians to fill a number of different roles. The team leader should set the schedule and agenda and report to management, while a facilitator will enforce the ground rules. You'll also need team members who have fundamental knowledge of the problem being addressed.

"Don't just choose all your friends," Dr. Halasyamani said. "You want to choose the best critical thinkers."

In Dr. Maynard's case, the VTE-prevention team included a hospitalist leader, a hospitalist/analyst facilitator, another hospitalist, a critical care/pulmonary VTE expert, a pharmacist, a nurse who handled data, a nursing supervisor, two front-line nurses, and leaders from orthopedics and surgery.

Because the team is the engine that drives any quality improvement project, Dr. Halasyamani said, it needs to function in a safe environment with clear ground rules.

To start, those rules should state that all team members—and their opinions—are equal. "Any hierarchies that may exist outside the team are left at the door," she said.

Other ground rules should be that team members can discuss, analyze or attack the problem, not people; they should speak freely and in turn; and they need to understand that silence equals agreement. "If you have an issue," Dr. Halasyamani said, "you need to speak up."

Setting aims and measures

Once you've assembled the team, you need to set aims and establish measures, then select and test the changes. (These are all elements in the Institute for Healthcare Improvement's plan-do-study-act cycle, which is available online.) Drs. Maynard and Halasyamani offered the following suggestions:

  • Set achievable aims. The project's aim statements should be aggressive yet achievable, relevant and time-sensitive, said Dr. Maynard. At his facility, for example, the VTE-prevention team used two aim statements:

    • Ninety-five percent of patients will be on a VTE-prophylaxis regimen appropriate for their level of VTE risk, as defined by our protocol. (Each institution, Dr. Maynard said, needs to create a protocol that includes a VTE risk assessment model and a definition of acceptable prophylactic options for each risk level.)

    • Within 12 months, we will cut the number of hospital-acquired VTE in half.

  • Pick useful measures. It's important to select measures that physicians can integrate into their daily routine, Dr. Halasyamani said. It's also important to use qualitative and quantitative data and sampling, and to plot data over time.

    A quality improvement project can use one or more of several different types of measures:

    • outcomes measures track specific patient outcomes, such as the number of days to an appointment;

    • process measures track different processes of care, such as the average daily clinician hours available for appointments, and

    • balancing measures, which look at trade-offs between outcomes. Dr. Halasyamani gave this example of balancing measures: If you decrease inpatient length of stay, do you increase the rate of hospital readmission?

    In San Diego, the VTE-prophylaxis team measured outcomes by tracking the number of hospital-acquired VTE per 1,000 patient days. It also focused on process measures by tracking the percentage of patients on a recommended VTE prophylactic regimen. And the team included balancing measures by looking at post-operative bleeding complications and incremental cost of low-molecular-weight heparin preparations.

  • Rally the troops. Select the changes that will most likely result in improvement—and standardize them, Dr. Halasyamani advised. "Simplifying the process leads to improvement," she said. "It also leads to a much happier team."

    The QI-project members in San Diego motivated physicians by presenting some compelling data: Of 420 patients diagnosed with VTE, 186 would be hospital-acquired. Of those, half of those cases would be potentially preventable, at a potential savings of $20,000 per case. "That helps you sell the program," Dr. Maynard said.

    The interventions the VTE team put in place include:

    • A VTE risk assessment model that boosts screening and schedules regular assessments every 72 hours.

    • Screening for prophylaxis contraindications.

    • A menu of acceptable prophylactic options, with the most preferred option presented as the default order.

    • The ability to track variations from the protocol to identify outliers.

    • Automated platelet-count monitoring when pharmacologic prophylaxis is ordered.

  • Test changes. You also need to test changes in the real world to observe the results, and act on what is learned. In San Diego, for example, the VTE risk-assessment model and order set are being piloted on a small scale. Feedback is then being used to make these interventions more effective and user-friendly. In fact, Drs. Maynard and Halasyamani pointed out, you can expect to test dozens of ideas for change during a single project.

Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.

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