Quality Improvement and EBM Mindy Smith MD MS

Quality Improvement and EBM Mindy Smith, MD, MS

Why incorporate EBM into practice? ¬Improves physician ability to provide effective care ¬Provides data for educating patients ¬Provides information for informed joint decision making ¬May improve health outcomes

How to incorporate EBM into practice? ¬Read the evidence (primary/secondary) ¬Have evidence available at point of care ¬Use electronic medical records (data collection, prompts, tracking, handouts) ¬Create teams/systems of care ¬Collect practice information (interviews, chart audits, summary data, surveys) ¬Use information to improve practice ¬Monitor quality of care

Quality improvement ¬Iterative process of improving patient health by improving the care provided – Best completed by involving all the “stakeholders” – Important to maintain a learning environment and blame-free culture – Critical to make the process transparent and the outcome explicit

What is the big deal? ¬Ample evidence of quality problems – Variation in services – Underuse of services – Overuse of services – Misuse of services – Disparities in quality

Further motivation ¬ You and your practice are and will continue to be monitored on quality indicators ¬ Board certification requires evidence of quality which will become more rigorous ¬ You will be paid for improving quality of care

Helpful partners ¬ IOM report, Crossing the Quality Chasm: A New Health System for the 21 st Century (2001) (www. iom. edu) ¬ AHRQ is also dedicated to developing, testing, and disseminating information on strategies to improve the quality of care (www. ahrq. gov)

Steps for quality improvement ¬Decide on a problem to address ¬Collect baseline data ¬Design an intervention ¬Implement the intervention ¬Collect follow-up data ¬Disseminate and discuss outcomes ¬Determine if additional work is needed

The EBM/QI Exercise ¬Overall goal: To provide the basic tools needed to perform QI in your practice ¬Objectives: – Learn the process of QI – Locate and assess practice guidelines – Practice designing a chart audit instrument, complete a audit, and analyze the data – Discuss potential practice interventions based on the results of the analysis

Example: Asthma care ¬First step: Identify the problem

Asthma care problems ¬Forget to provide prevention (vaccination) ¬Patients lack understanding of their disease ¬Poor patient compliance with peak flow meters and medications ¬Poor documentation in records ¬Inadequate prescribing ¬Lack of providing education

Are there guidelines? ¬ Where to look – www. guideline. gov – National institutes and organizations – Local initiatives ¬ How to judge – Evidence based? – Agreement with other guides? – Makes sense clinically?

Pitfalls in using Guidelines as Quality Measures ¬Lack of evidence of effectiveness ¬Severity of illness not considered ¬Creators often specialist oriented ¬Patient preference not assessed ¬Physician judgment undervalued

Guidelines to consider for asthma care ¬Key clinical activities for quality asthma care: recommendations of the National Asthma Education and Prevention Program (CDC) ¬Global strategy for asthma management and prevention (NHLBI) ¬Diagnosis and management of asthma (Institute for Clinical Systems Improvement (ICSI))

Designing the audit tool ¬ Simple ¬ Easy to complete and enter information ¬ Contain most important quality indicators based on evidence

Sample audit tool: asthma Assessment and monitoring Presence of spirometry report (>5 years old): Severity classification present Evidence of efforts to control triggers Smoking Animal dander Y Y N N Evidence of efforts to prevent/treat comorbid conditions Influenza vaccination (past year) Y N Pneumovax (ever) Y N

Your assignment ¬Pick a clinical problem important to the group ¬Find appropriate guidelines ¬Choose quality indicators ¬Create a practice audit tool by 9/15/06 ¬Use the tool to audit 5 -10 of your patient’s charts and bring to the next session