American College of Physicians: Internal Medicine — Doctors for Adults ®


How to stay ahead of the curve on quality improvement

To keep overhead costs from spiraling way out of control, practices must start small and embrace change

From the May ACP Observer, copyright 2006 by the American College of Physicians.

Michael A. Hennigan, FACP, a solo general internist in Decatur, Ala., estimates that his practice spent nearly $15,000 last year to do something unusual: exceed the standard of care, knowing those efforts wouldn't be reimbursed. His goal was to get completely up to speed on meeting pay-for-performance initiatives—when they arrive.

He spent those dollars reaching the American Diabetes Association's (ADA) standard of ensuring that 80% of diabetic patients had a documented eye exam within the past year. Cheaper efforts didn't work, according to his calculations. Just telling patients to get their eyes checked, for example, resulted in a 35% compliance rate.

Giving patients a check-off card with the name and phone number of a recommended eye doctor boosted that rate, but only to just over 50%. To reach the ADA's magic number, Dr. Hennigan had to pay staff to call ophthalmologists and make appointments for each of his 2,000 diabetic patients.

In return, his practice, Decatur Internal Medicine Associates, earned ADA recognition for its diabetes education program and the practice itself—also known as the Diabetes and Lipid Center—has grown significantly.

"We get to say that we're one of the few recognized ADA practices in Alabama, but there's no financial reimbursement for doing what is considered way above the standard of care," noted Dr. Hennigan, whose staff includes three nurse practitioners and two certified diabetic educators.

Like other physicians and group practices anticipating pay for performance, Dr. Hennigan decided to invest early so his office would be ready when insurers start mandating measurement and reporting. Because there are few financial incentives yet, early adopters need to gauge how much time and effort they can afford to put in, and which strategies—abandoning losing propositions and starting small—will work best.

Making it work

While it's difficult to implement quality improvement measures with limited staff, it's not impossible. The key, practitioners say, is having a flexible management style to identify problems and adapt workflow quickly.

That's especially true when your assumptions about an intervention don't pan out. Consider Jorge J. Scheirer, ACP Member, a general internist at the six-physician RPS Internal Medicine in Wyomissing, Pa. This January, he set out to improve the blood pressure and lipid scores of patients with coronary artery disease as part of his office's involvement in ACP's Closing the Gap: Cardiovascular Risk project. Within two weeks, the physicians' theory that patient compliance was the biggest stumbling block to improving those scores was proven wrong. (Also see "Implementing practice changes.")

"We did three or four different testing cycles—and found that compliance, while an issue, wasn't the only issue in our practice," Dr. Scheirer said. For example, differences in how doctors and nurses reconciled patients' own medication lists with the office's electronic health record was a more common problem than noncompliance.

The practice responded by shifting gears and beginning to target patients with blood pressures above goal, said Dr. Scheirer. The front desk identifies those patients before they arrive and alerts the clinician to the need for additional counseling. In the exam room, the doctor suggests behavioral interventions such as limiting sodium intake or starting a moderate exercise program. The nurse then asks patients for a commitment to try the interventions——and promises to call in one week to follow up and offer encouragement.

The initiative is still too new to tell whether it will improve outcomes but the point is to try new things until something works, said Dr. Scheirer. "You have a theory, but you may have to change your tactics midway through."

To stay flexible, said Michael S. Barr, FACP, the College's Vice President for Practice Advocacy and Improvement, everyone on the team has to be clear about what you're trying to accomplish and how to recognize when a change results in an improvement.

"Use small samples of data to inform the process and rapidly test new changes," advised Dr. Barr, who leads ACP's Center for Practice Innovation, which helps small and mid-sized practices make quality improvements. "Remember that these improvement strategies are not the same as large, randomized research projects."

James H. Baker, FACP, a general internist at the 23-physician CCOM Medical Group in Muskogee, Okla., for example, realized that routine 15-minute visits for diabetic care weren't achieving his desired results. Instead, he tried a new approach: focusing nurses on education and referrals so the physician could target hemoglobin A1c, LDL cholesterol and blood pressure levels in the exam room.

The new workflow improved efficiency but wasn't enough to get key diabetic indicators to where he wanted them. That's when he brought a diabetic educator, obtained through a grant, into the clinic. The goal is to hold a once-a-week diabetic clinic with 20 patient visits.

"To me, the answer is to eventually have all these chronic care modules going on at the same time," said Dr. Baker, who envisions having different educators coming on separate days to see different patient populations, including those with asthma and congestive heart failure. "We know these chronic diseases require their own specific focus, and for us to think we can wind up doing it all ourselves is impossible."

Sometimes meeting patient needs can trump financial hardship. Natalie A. Doyle, ACP Member, a solo practitioner in Wilson, N.C., is finding her resources stretched thin as she tries to implement a smoking cessation program as part of the College's Closing the Gap program.

"I can't afford to increase my staff without some kind of financial incentive," said Dr. Doyle, who does not yet participate in any pay-for-performance programs. Steps she's taken to make the most of scarce resources include asking front desk staff to highlight the fee slips of smokers the day before their appointment so she will remember to stress cessation, and offering handouts to patients, referring them to smoking cessation classes at the local hospital.

Starting small

One cost-saving strategy is to make less risky micro-level changes. At the University of Oklahoma Health Sciences Center in Tulsa, for example, residents were divided into five teams of 12 residents and three faculty members. Each team was assigned a different goal as part of the College's diabetes and cardiovascular risk Closing the Gap projects.

"Our plan is to take a small group of residents within each team and try changes to improve quality," said Michael A. Weisz, FACP, program director of the internal medicine residency program. "If something works, we broaden it out to the rest of the team and if it keeps working we recommend that it be accepted by the other four teams." As soon as the team realizes something isn't working, they drop it and move on.

Dr. Weisz's team began with two diabetes goals: increasing appropriate aspirin use and the incidence of annual foot exams. One of the five teams, which spent one day a week in the clinic, initially focused on patient education, placing a colorful brochure in the waiting room with tips on what to ask the doctor.

But patients did not pick up the brochures, Dr. Weisz said. Instead, the team asked nurses to hand the pamphlets to appropriate patients before their visit. Most patients still didn't ask their doctor about the information, he said—but seeing patients holding the pamphlets prompted physicians to check their charts to see if they were in compliance with guidelines.

In a subsequent spot review of patient charts, Dr. Weisz found that compliance with aspirin use had risen to 100% for the charts reviewed on a given day. At the same time, the team had not invested too much time in the losing brochure-placement strategy.

"We are constantly looking at our initiatives, accepting—and to some extent celebrating—failure and moving on," Dr. Weisz said. That's crucial when time is a valuable commodity, he said, and because pay-for-performance incentives have not yet reached outpatient practices. "It tends to be a breakeven situation at best, even though it's the best thing to do medically."

Constant vigilance

Until reimbursement becomes a reality, quality improvement efforts can cost more than they yield financially. Besides having to foot the extra overhead costs, for example, Alabama's Dr. Hennigan lost two physician partners who "weren't willing to accept the higher overhead as part of the bargain," he said.

To help contain costs, physicians say they constantly monitor what's happening in their office to make sure they don't invest too much time and energy in ineffective strategies.

In the short term, however, better quality comes with a cost.

"Ten years ago, I was taking home as much or more money and seeing two-thirds the number of patients I see now," said Dr. Hennigan. "There's the advantage of having better outcomes, but for now that means higher overhead and more work."


Implementing practice changes

The College's Closing the Gap projects in diabetes and cardiovascular risk embrace the Institute for Healthcare Improvement's Plan-Do-Study-Act cycle. That cycle recommends testing changes in small increments in rapid cycles before implementing them in practice. Here are the plan's four basic elements:


  • Plan the test and how you will collect data.
  • State your objective.
  • Make predictions about the outcome.
  • Develop a plan to test the change.


  • Try out the test on a small scale.
  • Document problems.
  • Begin analyzing the data.


  • Set aside time to analyze the data and study the results.
  • Compare the data to your predictions.
  • Summarize what was learned.


  • Refine the change, based on what was learned from the test.
  • Determine what modifications should be made.
  • Prepare a plan for the next test.

Source: Institute for Healthcare Improvement


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