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"Development of a Practice
Improvement Plan for a New
Radiation Oncology
Department"
Molly Gabel, M.D.
Associate Professor
Radiation Oncology
Robert Wood Johnson University Hospital
The American Board of Radiology
August 19, 2006
Resources for Quality Improvement
• Agency for Healthcare Research and Quality
• Institute for Healthcare Improvement
• National Association for Healthcare Quality
• Joint Commission on Accreditation of Healthcare Organizations
• Institute of Medicine
The American Board of Radiology
August 19, 2006
Quality Assurance
Quality Improvement
Clinical Value Compass : Sorted Monitors
Functional Health Status:
Physical function
Pain/Symptom Relief
Mental function
Quality of life
Satisfaction:
Clinical Outcomes:
Morbidity
Safety
Patient, staff, Referring MD
Access to care
Respect, trust
“I got what I want and need when I wanted it and needed it”
Mortality
Survival
Costs:
Direct medical
Indirect/social
Market share and volume
Insurance carriers
The American Board of Radiology
August 19, 2006
Quality Improvement circa 2000
• Compass encouraged multifaceted quality improvement
• Outcomes data encouraged
• Success defined as 5-10% improvement over baseline
The American Board of Radiology
August 19, 2006
Quality Improvement after 2001
• Result of the Institute of Medicine’s report “Crossing the
Quality Chasm: A New Health System for the 21st Century
(2001)”
•
Health care industry should hold itself to same standards
as other industries
• Recommended complete redesign of delivery systems,
based on data
• Zero defects, “perfect care”
The American Board of Radiology
August 19, 2006
Ten “Simple” Rules for Redesign of Care
Adapted by Donald M. Berwick, MD,
from IOM, Crossing the Quality Chasm, 2001
Old Way
1. Care is based primarily on visits.
New Rules
1. Care is based on continuous healing
relationships.
2. Professional autonomy drives variability.
2. Care is customized according to patient
needs and values.
3. Professionals control care.
3. The patient is the source of control.
4. Information is a record.
4. Knowledge is shared freely.
5. Decision making is based on training and
experience.
5. Decision-making is evidence-based.
The American Board of Radiology
August 19, 2006
Ten “Simple” Rules for Redesign of Care
Adapted by Donald M. Berwick, MD,
from IOM, Crossing the Quality Chasm, 2001
New Rules
Old Way
6. “Do no harm” is an individual
responsibility.
7. Secrecy is necessary.
6. Safety is a system property.
8. The system reacts to needs.
8. Needs are anticipated.
9. Cost reduction is sought.
9. Waste is continuously decreased.
10. Preference is given to professional roles
over the system.
10. Cooperation among clinicians is
expected.
7. Transparency is necessary.
The American Board of Radiology
August 19, 2006
2001: Raising the Bar for Healthcare Quality:
Pursuing Perfection Initiative
Joint Grant Process with RWJF and IHI
challenging health care systems to aim for zero defects
Six Aims For Improvement that evolved from those rules:
1.
Safe
Avoids injuries to patients from care that should help
2.
Effective
Matches science to care, avoids overuse of ineffective, under-use of effective care
3.
Efficient
Continually reduces waste
4.
Timely
Involves less waiting, for patients and for providers
5.
Patient-centered
Honors individual preferences and values, respects choice
6.
Equitable
Closes gaps based on race-ethnicity and other demographic variables
The American Board of Radiology
August 19, 2006
Pursuing Perfection:
Process of Outcome Measurement
• Define “perfect” care
– Absolute value (e.g., zero defects, 100% accessibility)
– Best possible level (specific non-zero target)
• Define baseline performance
• Define timeline for “perfect” - 24 months
• Set ambitious interim targets
– Define between end goal and “current” performance
– Close gap by half every six months
The American Board of Radiology
August 19, 2006
RWJUH Department of Radiation Oncology
First Performance Improvement Meeting
•
Brand new department
•
No chart rounds (physician peer
review)
• No documentation of multi-tiered
patient education
• No documentation of staging,
performance status or fall risk
•
No M&M
•
No tracking of timeliness
•
No documentation in chart of pain
management
•
No documentation of treatment
variances
• No standardized satisfaction
survey
• No clinic enhancements planned
The American Board of Radiology
August 19, 2006
Performance Improvement Plan :
Simple Example
RWJUH Initiatives
Correlation with Six P.P. Aims
•
Access to care: time to initial consultation
•
Timely care
•
Treatment Variances
•
Safety
•
Physician peer review
– Done within one week
– Recommendations acted upon
•
Safety
•
ECOG, fall risk, pain all documented, followed and
acted upon in chart
•
Safety
•
Extensive patient education documented in chart
•
Effective, patient-centered
•
Translation of teaching materials to Spanish
•
Patient-centered
•
Written discharge instructions upon completion
•
Effective, efficient, patient-centered
•
Documentation/update of medications throughout
treatment
•
Effective, patient-centered, safety
•
Development of unique satisfaction survey
•
Patient-centered
The American Board of Radiology
August 19, 2006
RESULTS
Timeliness of consultation
100
80
Em e r ge nt % < 1 day
60
Ur ge nt % < 2days
40
Routine % < 2 w e e k s
20
0
Goal
1Q
2005
2Q
2005
3Q
2005
4Q
2005
1Q
2006
2Q
3Q
2006 2006
4Q
2006
Safety: Treatment Variances
0.2
0.15
0.1
Tre atme nt Variance s (% total
fie lds tre ate d)
0.05
0
Goal
1Q
2Q
3Q
4Q
1Q
2Q
3Q
4Q
2005 2005 2005 2005 2006 2006 2006 2006
The American Board of Radiology
August 19, 2006
Safety: Physician Peer Review for each new field
100
98
96
94
92
90
88
86
84
82
Charts re v ie we d within first
we e k of tre atme nt
Goal
1Q
2Q
3Q
4Q
1Q
2Q
3Q
4Q
2005 2005 2005 2005 2006 2006 2006 2006
Safety, Efficacy: Performance status, pain and risk of fall documented in consult and on-treatment visit notes
100
100
93
93
80
60
% cases documented at consult
40
% cases assessed and documented
weekly during treatment
20
0
Goal
1Q
2Q
3Q
4Q
1Q
2Q
3Q
4Q
2005 2005 2005 2005 2006 2006 2006 2006
The American Board of Radiology
August 19, 2006
Efficacy, Patient-Centered, Efficiency:
Multi-tiered education documented in chart (at consult and in separate post-simulation teaching session by nurses)
100
98
96
94
92
% Patie nts with docume ntation
of supple me ntal nursing
e ducation
90
88
86
84
Goal
1Q
2Q
3Q
4Q
1Q
2Q
3Q
4Q
2005 2005 2005 2005 2006 2006 2006 2006
Effective, Patient-Centered: Written discharge instructions
100
90
80
70
60
50
40
30
20
10
0
Documentation of
written discharge
planning before
completing radiation
follow up appointment
documented
Goal
2Q
2005
4Q
2005
2Q
2006
4Q
2006
The American Board of Radiology
August 19, 2006
A More Complex Example…..
Pursuing Perfection in Prostate Cancer Care:
Transforming a Healthcare System
• From the six aims, we (40 physicians) made
enhancements to our prostate cancer practice:
– Multidisciplinary prostate cancer clinic
– Educational DVD co-written by urologists and
radiation oncologists, post –test at end
– Clinic note via EMR to all providers, same day
– Patient follow up card
– Patient advisory board
– Rigorous patient follow up (comprehension, treatment,
satisfaction, morbidity and status)
Note: above with the assistance of a very robust electronic medical record
The American Board of Radiology
August 19, 2006
Pursuing Perfection in Prostate Cancer Care:
Results
Fig. V.8: Patients Treated According to
NCCN Guidelines
100
Percent
99
98
97
96
95
94
Baseline
4Q01
1Q02
All Patients
2Q02
3Q02
PCOP Patients
4Q01 results due to 2 patients’ mortality (>75 undergoing surgery)
The American Board of Radiology
August 19, 2006
4Q02
1Q03
Target
Pursuing Perfection in Prostate Cancer Care:
Results
Fig. V.5: Patient Plans Communicated to PCP
100
90
80
60
50
40
30
20
10
0
4Q01
1Q02
All Patients
2Q02
3Q02
PCOP Patients
4Q02
1Q03
Target
Fig. V.7: High Risk Patients
Treated with Surgery
2
2
1.5
Number
Percent
70
1
0.5
0
0
0
0
0
Baseline
4Q01
All Patients
The American Board of Radiology
August 19, 2006
1Q02
2Q02
3Q02
PCOP Patients
4Q02
Target
1Q03
Pursuing Perfection in Prostate Cancer Care:
Results
- Administered 6 months post-treatment
- >80% response rate
100
99
98
97
96
95
94
93
92
4Q01
1Q02
PCOP Patients
2Q02
3Q02
4Q02
Fig. V.2: Patients Scoring "Perfect" 100%
on Delayed Post Test
1Q03
Target
Percent
Percent
Fig. V.1: Patients "Delighted with Care"
100
95
90
85
80
75
70
65
60
4Q01
1Q02
2Q02
PCOP Patients
The American Board of Radiology
August 19, 2006
3Q02
4Q02
1Q03
Target
Coded by race:
No variation
M.O.C. Guidelines
• May be easier for physicians in hospital-based
department (with Performance Improvement
policy and reporting in place)
• But…….RWJUH experience gives example of
simplified version of practice improvement easily
translated to smaller practice setting
• Offer consultation/training on national level
• Consider incorporating practice improvement
into residency training
The American Board of Radiology
August 19, 2006