by Dr. Moises Auron MD, FAAP, FACP
It is certain that since the seminal publication of the Institute of Medicine “To Err is Human,” physicians and society in general have pursued a legitimate effort to gain perspective and understand the incredibly complex system which is the healthcare system. The increased focus on the degree of quality of healthcare delivery has even yielded into the incorporation of quality metrics that impacts on hospital revenue by CMS. This has prompted healthcare institution to implement changes in practice in order to achieve compliance with the measures and avoid financial penalties. This affects physicians’ practice as they need to have enhanced mindfulness around a large number of quality metrics that don’t necessarily impact the patients’ outcome. The need for change and for creating mindfulness around the quality metrics and performance, has even evolved in the creation of formal quality curriculum for trainees of different specialties. And now, even junior faculty need to be involved in quality improvement efforts as an expectation for their professional development.
The main issue is that this has been such a rapid change in the paradigm, that a majority of trainees and young faculty have not had the time to fully grasp the understanding of a formal concept of quality improvement as well as of the involved processes – the so called PDCA cycles. Multiple factors contribute to this gap in knowledge: lack of formal training in quality at medical school until recently, as well as the fact that the training in quality improvement was a “silo” discipline that required a particular motivation to pursue such training. However, beyond any degree of training, the more relevant aspect to ensure sustainability in the understanding and knowledge of the process of quality improvement is the active engagement in “real time” quality improvement.
When a trainee or a junior faculty expresses interest regarding engaging in formal quality improvement projects, I try to have them reflect on their own practice – find out areas of opportunity – so called “burning platforms” – and have them identify the need for change. This has substantial relevance as the identification of own areas of opportunity usually yields in a more genuine involvement. The provider can focus on simple things, for example:
• Improve the rate of hand washing for a single hospital unit
• Improve the rate of medication reconciliation on admission
• Decrease the use of “GI prophylaxis”
• Decrease phlebotomy episodes per patient
• And more.
At a larger level, top institutional priorities can also mandate where to focus efforts in areas like minimizing readmissions, decreasing mortality, minimizing healthcare acquired conditions, etc.
I’ll share an example. I aimed that for my next inpatient rotation, all the patients should have a formal PCP appointment prior to discharge, and that we communicate the PCP office about the patients’ admission. Currently, there is no enforcement of patient’s accountability in their own care; therefore, engaging the patient is to me a key concept in improving the overall quality of care. We’ll ask them on the day of admission to provide their PCP’s name and phone number (if they don’t have one, or don’t remember – it could be a marker of high risk for overall poor transitions of care), and also to have them call their PCP to schedule an appointment in about a week to 10 days from admission (which can be postponed shall the patient remains admitted). This provides several benefits: the patient will have a real appointment (schedule by him/herself), which will promote a patient’s engagement and accountability in the transitions of care, and we will have accurate information of the PCP’s data. We can measure a baseline data of current patients having formal appointments with a PCP within a day of admission for a given hospital unit, and then measure it a week or two after implementation of the project.
The previous is a SMART project – simple, measurable (rate of patients who know their PCP vs. not), attainable, reproducible, time oriented. In the era of focusing efforts in decreasing readmissions, attempting a genuine effort to enhance transitions of care is fundamental, and this can become a single resident’s team “project for the rotation”. The learning outcome that trainees will have is:
1) Understanding the compelling need for improvement
2) Experiencing the active process of implementing a change
3) Measuring the results of the intervention
4) Developing a constant mindset focused on how to everyday “Do what’s right when nobody is watching.”
For the teacher, the learning outcome will be always discovering different perspective from the trainees. Perhaps gain awareness of more creative and low cost ways to implement a change. As a teacher, of course you will become a better quality improvement expert with the more experience you gain in helping others understand quality improvement – acknowledging that every day we can improve further. The individual caregiver hardwiring of skills and behaviors that will render in continuous improvement overall and a better and safer healthcare environment with better patient outcomes, is the prize for the effort.
Dr. Moises Auron is an academic Med-Peds hospitalist at the Cleveland Clinic in Cleveland, Ohio. He is an Associate Professor of Medicine and Pediatrics at the Lerner College of Medicine of Case Western Reserve University and a core faculty of the Internal Medicine Residency Training Program. His interests are medical education, acute and perioperative medicine and quality and patient safety. He is the Quality and Patient Safety Officer of the Department of Hospital Medicine at the Cleveland Clinic. He has been a member of the Quality and Pediatrics committees at SHM, and is currently a member of the SHM Public Policy committee. Dr. Auron is the Chair-elect of the Council of Early Career Physicians of the American College of Physicians.