1. QUALITY CARE IS IT ATTAINABLE? Bashar S. Amr, MD Haseeb Nawaz, MD

2. SIU Internal Medicine Quality Improvement Project 2015  Introduction  Background  Methods  Chart Prep Process  Results over the year  Behavior Change  Chart Prep Literature  Obstacles  Resident Feedback

3. Introduction - Institute of Medicine  To Err is Human: Building a Safer health System 1  44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented  Adverse drug events, improper transfusions, surgical injuries and wrong-site surgery, falls, burns, pressure ulcers, and mistaken patient identities, etc.  Between $17 billion and $29 billion per year in hospitals nationwide  Errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them

4. Introduction - Institute of Medicine  Crossing the Quality Chasm 2  Calls for improvements in six dimensions of health care performance: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity  Asserts that those improvements cannot be achieved within the constraints of the existing system of care  Framework for redesigning health care system at four levels: patients’ experiences; the “microsystems” that actually give care; the organizations that house and support microsystems; and the environment of laws, rules, payment, accreditation, and professional training that shape organizational action  Ten Rules to redesign and improve healthcare  The system should anticipate patient’s needs, strive to decrease waste, and the patient in control

5. Introduction – Quality Improvement  Quality improvement (QI) has become an integral aspect of medicine residency training  2005-2009 FM graduates surveyed: 75% had QI training 3  87% of QI trained residents where active in at least 1 QI project in their current practice 3  Periodic patient care data review, Specific quality improvement projects, and Disease specific activities

6. Introduction – QI Impact  Having nurses and staff to lead QI efforts probably provides structure and demonstrates investment in QI activities

7. Introduction – QI Impact  The Agency for Healthcare Research and Quality (AHRQ) looks at improving patient clinical outcomes 4  Project to increase anticoagulation therapy for Medicare beneficiaries who have suffered from a stroke, lead to increase in anticoagulation therapy from 58.4 to 71.1%  The Centers for Medicare and Medicaid Services (CMS) estimates that this improvement has prevented up to 1,300 strokes

8. ACGME Requirements

11. Background  Each year the Internal Medicine residents participate in quality improvement projects, often in teams  Different goals, different time lines and ambiguous  This year, it was determined that we would launch one large quality improvement effort to create a united vision within our General Internal Medicine clinic  “The Smart Efficient Clinic Machine or SECM.”

12. Background  We have yet to make a significant and long term impact on metrics relevant to the care of our general internal medicine patients (specifically in preventive care)  Barriers to success that are identified:  limited time to capture all targeted services during visit  new learners adjusting to system  addressing patient concerns and preventive care  Patients with multiple significant comorbidities  Project Goal: To improve patient outcomes related to common preventative services through thoughtful pre-visit planning or “chart prep”

13. Methods  Kicked off on October 15, 2014 during a multidisciplinary meeting of residents, faculty and staff.  Monthly multidisciplinary meetings: modifications and adjustments to the processes for pre-visit planning in a collaborative manner  For each patient visit, resident would complete a “chart prep” document  Capturing most recent: advanced directive status, BMI, HgbA1c, influenza vaccination, pneumovax vaccination, mammogram, colonoscopy, and hospitalization.

14. Methods  The “chart prep” document is to be completed two weeks prior to the patient’s visit  The patient’s chart is updated where gaps exist and the general plan of care for preventative services and chronic disease is documented  Identified labs or other orders are communicated with the nursing staff, who then work with the patient to obtain testing prior to the clinic visit  Document allows for residents to type in notes and familiarize with patients

15. Chart Prep Process

20. Chart Prep - Goals  Evaluate the impact of the pre-visit planning process on rates of preventative services provided for our patients  This initiative involves such a significant change in workflow for our residents and staff  Though our goal is to observe a change in preventative services provided to our patients, we anticipated a noticeable change may not occur for approximately 6-9 months  Thus, we are measuring compliance rates with completing a “chart prep” document and collecting anecdotal experiences, positive and negative in nature

21. The Financial Aspect

22. Primary Care Reactive Chaotic 1.Proactive 2.Organized Institute of Medicine: Crossing the Quality Chiasm (2001) The U.S. health care delivery system does not provide consistent, high quality medical care.

23. HOW ???

24. Mayo Clinic (2011)  Pre-order preventive services tests 2 weeks prior  1.5 months 61% abnormal tests Pre-order (mean 2.2) No pre-order (mean 3.08) 87.8% completion MORE TIME

25. Massachusetts General Hospital  Ambulatory Practice  Pre visit labs Reduced phone calls by 89% Reduced number of letters sent by 85% Fewer revisits due to abnormal labs (61%) Saved $25/visit in physician and staff time INCREASED PATIENT SATISFACTION

26. BENCHMARK

27. First Result – December

28. Second Result – January

29. Changing Physician Behavior Education Audit & Feedback Economic Incentives Local opinion leaders Printed educational materials Reminders Multifaceted approach

30. Achievable Benchmark – 80%  Better results  Provider perceptions and attitudes  Enhances feedback

31. Education Audit & Feedback Reminders

32. HAYES, SEAN267% CAVATAIO, ANTONINO180% AKOFU, ANOTA162% LIN, JUNZHI154% GRIMM, TRENTON150% VARNEY, JACOB144% IQBAL, MUHAMMAD123% SAEED ZAFAR, ZUBAIR116% STICH, ADRIENNE112% DABABNEH, EHAB111% BHATTI, KARAN110% CHANDRA, SIDHARTH106% MANDO, RUFAAT105% STONE, SCHUYLER104% IBRAHIM, YASMINE103% AQUINO, CINDERELLA100% SIDDIQUI, AHMER100% AMR, BASHAR93% PERVIN, NAJWA88% LEE, KRISTIN84% BALAGNA, JONATHAN82% NAWAZ, HASEEB81% AL OBAIDI, ZAINAB81% SAFI, JAVERYAH80%

33. Target 80%

35. Target 80%

36. Target 80%

37. Impact  Minnesota Pediatric Clinics (1996) Increase in immunizations from 53 to 86%  Seattle Primary Care Clinics (1998) Increased percentage of controlled hypertensive patients  Mayo Clinic, Diabetes Care (2002) Improvement in HbA 1C, HDL and smoking cessation

38. Measured BMI HTN BP > 140/90 DM A 1C ordered in last 12 months DM A 1C > 6.5 FluVax within 1 yr RED Nov 201464.7%24.6%8.9%14.5%4.1% April 201565.3%25.2%10.6%14.5%5.4% GREEN Nov 201457.8%24.6%8.1%15.1%2.3% April 201560.5%24.1%9.1%14.2%5.5% BLUE Nov 201461.9%22.4%8.4%13.2%3.6% April 201563.4%22.2%10.5%14.2%6.8%

39. TOTAL 7931 13.8%

40. Six Dimensions of Health Care Performance: Safety Effectiveness Patient-centeredness Timeliness Efficiency Equity

41. Obstacles  Lack of time  Lack of resident follow-through  Lack of staff follow-through  Unanticipated (Mail, Lab etc.)

43. Residents feedback/comments Adequate knowledge about patient beforehand makes clinic run faster and smoother. Discussing labs with attending during clinic reduces time spent calling patients later. It made me more prepared in clinic, more organized and time effective. Allowed me to spend more time with the patient rather than searching through the chart. It definitely improved patient care as well relationship. The contact and labs made patients feel involved and remembered before the appointment. Helps us be prepared and more comfortable with pt in clinic.

44. I had difficulty preparing the charts 2 weeks ahead my pt’s appt, takes too much time.

46. Time to Think… Less work later!!!

48. References  Kohn, Linda T., Janet M. Corrigan, and Molla S. Donaldson, eds. To err is human:: building a Safer Health System. Vol. 6. National Academies Press, 2000.  Corrigan, Janet M. "Crossing the quality chasm." Building a Better Delivery System (2005).  Moore LG. Escaping the tyranny of the urgent by delivering planned care. Fam Pract Manag. May 2006;13(5):37-40.  Diaz, Vanessa A., Peter J. Carek, and Sharleen P. Johnson. "Impact of quality improvement training during residency on current practice." Family Medicine-Kansas City 44.8 (2012): 569.  McGlynn, Elizabeth A., et al. "The quality of health care delivered to adults in the United States." New England journal of medicine 348.26 (2003): 2635-2645.  Hunt VL et al. Does pre-ordering tests enhance the value of the periodic examination? Study design – Process implementation with retrospective chart review. BMC Health Services Research 2011, 11:216.  Pre-visit planning. AMA Steps Forward, Oct 2014.  Mostofian F et al. Changing Physician Behavior: What Works? Am J Manag Care. 2015;21(1):75- 84.  Ghandi TK et al. Obstacles to collaborative quality improvement: the case of ambulatory general medical care. Int J for Quality in Health Care 2000; 12(2);115-123.  Kiefe CI et al. Improving Quality Improvement Using Achievable Benchmarks for Physician Feedback. JAMA, June 2001, Vol 285, 22, 2871.  Shortell SM et al. Assessing the impact of continuous quality improvement on clinical practice: What it will take to accelerate Progress. The Milbank Quarterly, Vol 76, 4, 1998, 593.