Performance Improvement Projects

1. Performance Improvement Projects Core Principles of Project Acceptability Richard Tejedor, MD EQUIPS Forum May 14, 2013

2. Objectives • Define the need for a set of principles that determine acceptability of a QI project • Propose a set of principles • Define when these principles should be applied • Discuss how education of core principles will assist physician trainees in their career

3. QI – Reasons for Prominence • Medical Errors – prominent reports in the literature. • Institute of Medicine 1999 – “To Err is Human” • 98,000 deaths in hospitals yearly – preventable errors • Huge Media Stir – Driver for huge changes

4. QI – Reasons for Prominence Subsequent intense criticism of this report • Flawed statistical handling • Subjectivity in determining definition of “medical error” • Subjectivity in determining which deaths were due to medical error • Erroneous assumption that 100% of patients would have survived 

5. QI – Reasons for Prominence • Healthcare disparities • US has best care in the world if the metric is recovery from disease, but: • Large disparities in care exist • US not well ranked at preventable diseases • Medicare as a government program • Laws signed by President Clinton • Sparked development of numerous agencies

6. How are physicians affected? • Quality metrics – motivators • Resulted in proliferation of guidelines • In order to measure you need a metric (guideline) • Centralized Control of Healthcare • An important corollary to the use of metrics • Inconsistent “buy in” to metrics

7. Good reasons to get involved • Physicians are in a good position to see problems and improve healthcare. • Improvement requires change. Not all change is good. • Unintended consequences

8. VAComprehensive care management program (CCMP) • 426 patients randomized to usual care vs CCMP • CCMP • COPD education in individual and group sessions • Scheduled telephone calls by a case manager • PRN prednisone and antibiotics, with a written action plan

9. VAComprehensive care management program (CCMP) • Findings: • Plan – enroll 960 patients • At 426 patients — Trial stopped when an excess of deaths was observed in the intervention group • 28 deaths from all causes in the COPD comprehensive care group vs. 10 in the usual-care group. Most deaths related to COPD

10. Unintended Consequences

11. Unintended Consequences • Increased costs related to adherence without demonstrable improvement in outcomes • Complex clinical decision making abrogates to formulaic care • Pathways may have inadequate consideration of comorbid conditions • Patient preferences • Undue influence of “Scoring” • Inappropriate use of medications to “score well” • Avoidance of sicker patients

12. Residency Initiative • All residents must be involved in QI. • Patient safety, quality and value of care goals • In defining involvement, what are the goals of resident involvement? • What values or skill sets will be learned? • What do we hope to achieve through acquisition of these skill sets?

13. Goals for Residency Quality Curriculum • A basic curriculum – education on: • Background • Patient safety • Methodology • Learn principles of acceptable quality initiatives – core principles • Knowledge – for improvement of existing initiatives • - empower to create acceptable projects

14. Study to define core principles • Hypothesis: A meaningful set of Core principles can be defined based upon lessons learned from the national experience on quality initiatives. • Methods: Literature review focusing on a number of key phrases related to quality metrics. An appropriate set of articles were selected based upon relevance.

15. National experience has identified problems with: • Scientific acceptability • Widespread applicability • Problems of undue influence • Problems of feasibility • An explosion of quality initiatives – burden to the system

16. Study to define core principles • Findings: • Core principles needed when: • A QI project acts within a system as a “prescription” for patient care and/or • Provider is “measured” to influence care • High risk of adverse unintended consequences • System resources will be used

17. CORE PRINCIPLES Importance Scientific Acceptability Feasibility (Usability) Absolute Performance

18. CORE PRINCIPLES • Importance • Is there a performance gap? • Is the focus of potentially high impact? • Is an intervention likely to improve health outcomes?

19. CORE PRINCIPLES • Scientific Acceptability • Evidence should be weighted as to quality. • Endorsed national quality initiatives are preferred • (1) Use GRADE system or similar • (2) Expert opinion should generally not be used. • 2. May need IRB review as research

20. CORE PRINCIPLES • Feasibility – Is the plan actionable? • Use electronic data • Target population identifiable? • Data elements should be routinely generated • Exclusions should be readily evident within the data sources.

21. CORE PRINCIPLES • Recognize absolute performance • Potential of unintended consequences • Scoring • Undue influence on decision making • Avoid high risk patients • VA COPD initiative

22. CORE PRINCIPLES • Recognize absolute performance • 2. Appropriate for all entities? • Race, sex, age and comorbid conditions? • 3. Outcome measures preferred over process measures • Attention to adherence to a process without looking at outcomes can be associated with perverse consequences

24. SUMMARY • An important component of QI is physician engagement • Core principles should be applied when QI projects involve: • A prescription for care • Significant system resources • Knowledge of principles will empower physicians to interact with the purveyors of quality initiatives