AHRQ Summit—Improving Health Care Quality for All Americans
Promising Quality Improvement Initiatives
Reports From the Field
Panel 1
G.A. Carmichael Family Health Center
Janice Bacon, M.D.
Director of Clinical Services
| The experience of the Carmichael Family Health Center in Canton, MS, demonstrates that consistent measurement of clinic-wide data and close management of patients can improve health care outcomes.
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The Carmichael Family Health Center's service area covers three towns in rural Mississippi. Ninety-two percent of the patients are African American, and 40 percent are uninsured. Thus they are working with a population that represents some of the people with the highest risk factors and lowest health outcomes in our Nation. The Center is governed by a Community Board of Directors, 80 percent of whom are users of the Center's services.
The Center established a quality management strategy
As part of a health disparities collaborative sponsored by the Health Resources and Services Administration, the Carmichael Family Health Center established a quality management strategy focused on:
- Promoting positive health outcomes.
- Developing an informed team that interacts with a proactive patient.
- Building capacity for quality improvement.
- Redesigning systems.
- Building stronger risk management.
Quality improvements for chronic and disabling conditions were targeted
To address some of the most important chronic and disabling conditions affecting their service community, the Center specifically targeted quality improvements for diabetes and asthma prevention, treatment, and detection.
In order to assess these conditions and determine the magnitude of the problem, the Center built a registry to collect baseline data on both of these conditions. The goal of the registry was to help determine not only rates of diabetes, but also how well patients were managing their condition.
The Center worked with the State diabetes prevention office, the State cardiovascular division, and eye care provider groups to set a quality management strategy, including targeted patient management, based on clear, evidence-based guidelines for treatment. They worked in partnership with local providers, churches, and other community resources to help increase awareness of the program, do outreach, and ensure that patients would be able to get to the health care center.
Since these quality improvement measures have been in place, the Center has seen improvements in HbA1c levels, which at baseline were on average twice the recommended rate, while expanding the number of patients entered into the diabetes registry. The asthma data have shown large improvements in the use of anti-inflammatory medications and in the use of patient self-management tools.
With consistent measures and guidelines along with targeted patient management, the Center has experience improved outcomes. As a result, it has garnered increasing support from local providers, including those who were reluctant to participate in these programs.
Community-wide support is critical
Community-wide support has been critical to the implementation and successes of the Carmichael Family Health Center's quality improvement initiative.
Many of the most important lessons and successes to come from this initiative are directly related to the Center's level of outreach and support with the local community and with provider organizations across the State:
- The Carmichael Family Health Center worked with State-level offices and providers to set standards.
- They invited local officials such as mayors and sheriffs to attend health fairs, boosting the profiles of these events.
- The Center brought in specialists such as nephrologists and cardiologists (usually accessible only in major cities) for onsite evaluations.
- They worked with local churches, the Ministerial Alliance, daycare centers, schools, and other organizations to address health barriers and to institute programs promoting healthy behaviors (e.g., dance exercise classes for students, parents, and teachers).
Centers must work with State and local partners and provider organizations
Lessons learned from the Carmichael Family Health Center experience include:
- Centers cannot function in isolation and must reach out.
- Centers must keep trying, be proactive, and remember "it never hurts to ask."
- It is important to be creative and to use both traditional and nontraditional partners.
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Strong Memorial Hospital
Robert J. Panzer, M.D.
Chief Quality Officer
| By focusing on quality improvement and instituting specific procedures, this high-volume hospital has achieved strong positive outcomes, particularly related to ventilator-associated pneumonia (VAP).
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Strong Memorial Hospital operates 739 beds and serves a region of Upstate New York with a population of 1.7 million. The hospital has experienced enormous growth and operates at 94 percent of capacity.
The hospital's goals for success and improvement involve doing things right the first time to avoid errors as well as optimizing safety, satisfaction, costs, and clinical outcomes.
To meet these goals, the hospital instituted new procedures, including:
- Daily goal sheets for each patient.
- New protocols and standards for the care team.
- Monthly safety walkarounds for senior leaders.
- Clear guidelines for flow in and out of the intensive care unit.
New protocols were instituted to reduce risk of ventilator-associated pneumonia
As a result of these new prevention protocols, Strong Memorial experienced a significant and rapid improvement in results for ventilator-associated pneumonia (VAP):
- There was a reduction in VAP from 6 percent to less than 1 percent.
- This translated to a 27.5-percent reduction in VAP morbidity and 14-percent reduction in excess mortality from VAP.
- Since the estimated cost of a VAP ranges from $5,000 to $27,000, the cost savings each year from the reduced number of VAPs was between $137,000 and $742,500.
Computer technology was initiated to reduce risk of venous thromboembolism
Strong Memorial Hospital also joined with four others in the Rochester Regional Thromboembolism Collaborative to institute a computerized provider order entry (CPOE) technology; its aim was to reduce the risk of venous thromboembolism. The CPOE technology was adapted to be user friendly for hospital staff and more convenient than the old paper system.
The electronic form offers both risk assessment and prophylaxis choices, and it is used as a routine part of admission orders for all patients. As a result of this initiative, the appropriate use of prophylaxis was significantly improved over a 14-month period across each of the participating hospitals.
A focus on quality improvement can lead to positive outcomes relatively soon
By instituting clear, simple, and relatively inexpensive procedures, we can achieve the following within a remarkably short period of time:
- Improved communications.
- Fewer errors.
- Significantly increased positive outcomes.
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Lumetra (San Francisco, CA)
Jo Ellen H. Ross, M.N.A.
President and CEO
| The 2-year Doctors Office Quality-Information Technology (DOQ-IT) project fosters use of an electronic health records system instead of a paper-based structure to promote efficiency and improve quality.
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Research indicates that among outpatient visits, 13.6 percent of essential patient information is missed.1 This includes such data as lab results, letters and dictation, radiology results, information on medications, history, and physical examination.
The goal of the DOQ-IT project is to use an electronic-based health records system to limit this problem and accelerate the rate of quality improvement in physicians' offices.
The DOQ-IT pilot study investigates barriers and opportunities for the adoption of electronic health records systems in physician's offices. Supported by the Centers for Medicare & Medicaid Services, this study has been undertaken by four quality improvement organizations (QIOs) located in California, Arkansas, Massachusetts, and Utah.
Other partners include:
- American Academy of Family Physicians.
- American Medical Association.
- American Academy of Family Practices.
- American Osteopathic Association.
- Medical Group Management Association.
- Medical Records Institute.
- Medical Records Institute.
An objective of the DOQ-IT project is to promote efficiency and improve safety
The pilot program targets small and medium-sized practices and aims to use the electronic health records technology to help develop and implement the QIO intervention model for improved chronic and preventive care management in primary care practices. The program's objectives are to help make physician's offices more efficient by using electronic patient records and to improve patient safety and outcomes.
The DOQ-IT project offers support to practices interested in adopting electronic health records in areas such as:
- Guidance on office redesign needs.
- Functionality requirements for the technology.
- Implementation planning.
- Interoperability considerations.
- Quality improvement processes.
- Choices of vendors.
- Preparation for pay-for-performance data collection.
It also provides advice regarding the types of culture and leadership changes that may need to accompany the adoption of this new technology.
Response to DOQ-IT has been higher than anticipated
Many physicians are very interested in adopting tools to improve quality and efficiency within their practices.
Participation in the DOQ-IT program is voluntary and free of charge, but it also requires that physicians' practices commit to the following:
- Completing a readiness assessment.
- Selecting and acquiring an electronic health records system.
- Making the necessary office redesign and systems changes to adopt the program.
Another important requirement of the program is that practices adopt a quality improvement project using this technology. This may include such things as creating a diabetes registry system, implementing patient self-management tools, or customizing visit templates for chronic diseases.
Improved quality and efficiency offer an important return on investment
Among the lessons learned from the DOQ-IT project are:
- Moving from a paper-based to an electronic records system is challenging because it requires cultural change, office redesign, and financial investment.
- The level of interest from physicians' practices is very high.
- The payoffs in terms of improved quality and efficiency offer an important return on investment.
- QIOs represent a great resource for physicians' practices.
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Sentara Healthcare
Gary R. Yates, M.D.
Chief Medical Officer
| To improve health care quality and patient safety, health care institutions must change their whole environment and create a new culture of quality that will serve as a foundation for progress and change.
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In order to improve quality and safety, health care organizations must develop a framework comprised of four critical dimensions:
- Technology—Incorporate important information and decision supports into processes at points of care. For example, the use of remote electronic links in the intensive care unit to add an extra level of offsite vigilance remotely has been shown to decrease mortality rates by 20 percent.
- Processes—Create more reliable processes built on principles of human factors research.
- People—Recruit, train, grow, and retain a capable and reliable workforce.
- Culture—Adopt a strong culture based on safety and excellence that will provide the foundation for improved quality and safety.
Changing the culture of health care is like reaching the high C in music—it is the hardest goal to achieve.
Health care can learn from other sectors
In looking for useful techniques and examples of how to change direction and accelerate the pace of improvement, the health care industry has much to learn from other business sectors.
Sentara (Norfolk, VA) searched beyond the health care sector for assistance and made use of some of the safety and quality approaches that have been developed for the nuclear power industry. They conducted a baseline analysis, with input from providers, of strengths and opportunities, identifying four key risk areas that contributed to 90 percent of problems:
- Inadequate communications, particularly during changes (e.g., shift changes, transfer of patients to different units).
- Inadequate attention to detail.
- Noncompliance with policy and procedures.
- Use of high-risk behaviors (often not recognized as such) in high-risk situations.
Changing the institutional culture requires clearly stated changes in processes, behaviors, and expectations. Staff and providers must be given the tools with which to change. It is not enough simply to tell them to do better.
Changing institutional culture requires clear, behavior-based expectations
To inculcate a culture of quality throughout the organization, Sentara established a new set of behavior-based expectations aimed at both general approaches and specific problem areas. These expectations were developed by a team of 25 members that included representatives from the medical staff, managers, and other employees.
Examples of some of these behavior-based expectations, designed to address the problem areas identified in the baseline review, include the following:
- Pay attention to detail—Sentara adopted the following technique, known as SAFE, from the nuclear power industry. It takes just over 3 minutes to implement:
- Stop.
- Assess.
- Focus.
- Evaluate.
- Have a questioning attitude—Verify and validate.
- Hand off effectively—Ensure that proper information is passed along when patients are transferred or provider shifts change. Use the five Ps:
- Patient.
- Plan.
- Purpose.
- Problems.
- Precautions.
- Assign a coordinating physician—This is the captain of the ship.
After instituting clear, quality-based guidelines with the behavior-based expectations, Sentara experienced the following:
- A 21-percent increase in effective handoffs.
- A 42-percent reduction in falls with injury.
- A 38-percent decrease in hospital-acquired pressure ulcers.
- Significant reductions in liability claims.
This experience suggests that with the institution of clear, consistent guidelines, we can accelerate the pace of improvement and build a solid organizational foundation based on quality and safety.
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Reference
1. Smith PC, Araya-Guerra R, Bublitz C, et al. Missing clinical information during primary care visits. JAMA 2005 Feb 2;293 (5):565-71.
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