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The Changing Face of Quality Improvement

From: The Hospitalist, November 2008

Hospitalists take on QI challenges in facilities large and small

by Barbara Dillard

At Emory University School of Medicine in Atlanta, Jason M. Stein, MD, and his team are working on a quality improvement (QI) strategy they hope will transfer to any hospital, anywhere. “That is where QI research lives right now,” says Dr. Stein, co-director of Emory’s hospital medicine quality improvement research program and co-chair of the department of medicine’s quality committee.

The Emory “blueprint” lays out what ideal care looks like and how physicians can provide that care. Dr. Stein’s team already has completed three successful pilot projects: preventing hospital-acquired venous thromboembolism (VTE); reducing catheter-related bloodstream infection; and improving management of hyperglycemia. “We are a mile down the road in the QI marathon,” Dr. Stein says.

Everywhere—not just in large academic medical centers, but in community hospitals and hospital medicine groups, as well—hospitalists are responding to an increased demand from government regulators, payers, and consumers to show demonstrated quality improvements. Even hospitalists on the sidelines are watching closely the experiences of others, in the hopes of marshaling their own resources and working collaboratively.

“The patient experience needs to improve at a pace we haven’t seen before in healthcare,” says Lakshmi Halasyamani, MD, vice president of quality and systems improvement at Saint Joseph Mercy Health System in Ann Arbor, Mich. Hospitalists, she says, are uniquely qualified to meet these demands.

The New Look of QI

The existence of hospitalists has changed the dynamic of QI research, Dr. Stein explains. “Before hospitalists, almost never was a clinician in charge of improving quality hospitalwide. Now, we have hospitalists who can generate and implement quality research.”

For hospitalists, QI research is rewarding and a good career move, he says. “If you fix something that’s broken today, it won’t be broken tomorrow. It’s doing something that makes a difference on a scale that’s way beyond what you normally do every day.” Plus, he adds, the demand for hospitalists with experience in quality improvement will continue to increase as more hospitals try to demonstrate their improvement efforts.

However, the increased demand could, in some cases, be a barrier to research, says hospitalist program consultant Ken Epstein, MD, MBA, former director of medical affairs and clinical research at IPC: The Hospitalist Company in North Hollywood, Calif. “There is more clinical work for hospitalists than there is time in the day, or that there are enough hospitalists to handle,” he explains. “Many hospitalists would like to do QI research, but are too busy clinically.”

That can change, but only with the support of employers. For example, academic medical centers build in time away from clinical duties and provide staff and information systems support. That’s harder to come by in community hospitals.

Funding is an issue, too. More medical schools are competing for a rapidly decreasing pool of research dollars, Dr. Stein says. That means it will be necessary to get more help from private foundations and drug companies to adequately fund quality improvement. Some hospitals are digging into their operating budgets to fund QI research.

Hospitalists in Action

Despite the barriers, hospitalists are changing the course of QI research in a variety of settings. Dr. Stein’s team at Emory is just one example. In Michigan, Saint Joseph Mercy Health System is creating a multidisciplinary practice council with teams established to study heart failure, acute coronary syndrome, and glycemic control—taking the first steps in its research efforts. “When we think about improving care, we need to think in teams, so you don’t have folks wanting to take care of one intervention that creates issues for another member of the team,” Dr. Halasyamani says.

IPC: The Hospitalist Company is focusing on post-discharge issues. The organization’s research has revealed patients with new or worsening symptoms after discharge were no more likely to make follow-up appointments than those who felt well, and that patients given five or more prescriptions at discharge were more likely to have trouble filling them than those who received less than five. Those with insurance or HMO coverage were more likely to fill the prescriptions than those without.

Dr. Epstein also published quality improvement research showing that patients’ hospital stays increased incrementally with the number of physicians seen at the hospital. In addition, the location of hospitalists when they spoke with patients—whether they were in the hospital round the clock or took calls from home—had little effect on patient satisfaction.

HMG Experience

At Northern Colorado Hospitalists in Fort Collins, Colo., hospitalists began their QI efforts by implementing and studying the research of the SHM VTE Collaborative. “The resource room on the SHM Web site gives you a cookbook for implementing QI research,” says Christine Lum Lung, MD, medical director of the 10-hospitalist group. “It can be implemented in any hospital, of any size, and should be.”

The key is for one hospitalist to take responsibility for seeing it through. Dr. Lum Lung did just that. Using the SHM resource room and mentors, she headed a team that developed and implemented a practice protocol for prevention of VTE for Poudre Valley Hospital in Fort Collins and Medical Center of the Rockies in Loveland, Colo. The group gathered background data and built a consensus to come up with the protocol, then measured the preliminary outcomes and improved on the process.

With the backing of hospital administration, Dr. Lum Lung and her team performed their own chart audits, created spreadsheets, and went back to naysayers with data demonstrating their progress. Early results have been impressive. The initiative has increased compliance with appropriate measures, increasing VTE prevention from 58% to 85% from November 2007 through May 2008.

Dr. Lum Lung is convinced quality initiatives are the future of hospital medicine. “We need to stop being reactive to what the government is telling us we should do,” she says. “We should be leading the quality charge because we are the ones who see what works.” She’s drawing on her experience with VTE to create an infrastructure, so other hospitalists can take on their own QI initiatives. A project on glycemic control already is underway.

Dr. Lum Lung advises hospitalists to take time to educate themselves before jumping into the lion’s den. For her, it meant reading everything she could get her hands on about quality improvement and clinical developments. She also suggests understanding what must happen for behaviors to change. In the case of the VTE QI initiative, documentation was the key.

“When you’re asking physicians to change their practice standards, you have to have incredibly good documentation—and a thick skin,” she says. If you have documentation to back up your request, she explains, most healthcare providers are willing to give it a try.

For hospital care to improve, it’s essential hospitalists take the next step. “Quality improvement is an incredibly important responsibility we have as hospitalists in taking care of patients,” Dr. Lum Lung says. “If you start with that as your foundation, then the difficulties you encounter along the way are easier. You can find the time to do anything, if you’re passionate about it.”

The First Step

The future of QI research in community hospitals may depend on several things. To start, it’s essential to set up an infrastructure for support, Dr. Halasyamani says. Though this may be more difficult for community hospitals, all hospitals have some systems in place for research, she points out. And smaller hospitals also can participate in research collaboratives to get the support they need.

Saint Joseph’s funds its QI efforts from its operating budget. Researchers also are in discussions with the hospital’s development office about possible donor funding. “There may be people who are interested in leaving as their legacy improvements in care, rather than having their name on a building,” Dr. Halasyamani says.

Partnerships with academic medical centers may advance quality improvement, says David Meltzer, MD, PhD, associate professor and chief of hospital medicine at the University of Chicago Pritzker School of Medicine. He also is director of the program on outcomes research training and chair of SHM’s research committee. “Community hospitals could share their data with academic medical centers to look at quality measurers across multiple settings,” he suggests.

SHM’s research committee is working on strategies to develop networks of institutions, starting with academic medical centers and then broadening to community hospitals, Dr. Meltzer says. The goal is collaborative research. It’s a win-win for both settings. “Academics would like data on patients in community hospitals and community hospitals would like resources to do research,” says Dr. Epstein, who founded KRE‚ÄąConsulting, LLC.

Some institutions are receiving funding for just this purpose. The medical school at the University of Chicago Medical, for example, received a grant from the Agency for Healthcare Research and Quality to help community hospitals develop quality improvement teams. The funds will pay for hospitalists from across the country to visit the school for a summer program in outcomes research. The hospitalists will then return to their institutions to begin QI research.

Calls for Training

Initiatives, such as the summer program at the University of Chicago, are just one aspect of the education necessary to move QI forward. Some hospitalists also see a need for increased training during residency. Dr. Stein, of Emory, is working with other academics to create a core competency in QI research for hospitalists, looking at systems issues and quality tools. “Hospitalists have to feel like they have the expertise in QI research if they are to respond to the increased QI demands,” he says.

There are several programs dedicated to making that happen. The Robert Wood Johnson Clinical Scholars Program at the University of Chicago trains physicians on health policy and outcomes research, preparing them for academic careers. Dr. Meltzer thinks a similar program could be designed for community-based hospitalists who want to conduct quality improvement research.

Intermountain Healthcare in Salt Lake City, Utah, also offers training in QI research for practicing hospitalists that “jams a lot into 12- and 20-day programs,” according to Dr. Stein.

Hospitalists have to be willing to invest in themselves to get additional training in QI research, Dr. Meltzer says. Taking a job at a lower salary in exchange for time off for QI training, or paying for their own training, will lead to advancement opportunities in the future, he says.

For patients, the QI work done by hospitalists already is paying off by raising expectations about the quality of care, Dr. Epstein says. “When hospitalists are involved with a hospital to improve the system of care, it raises the bar for all patients, whether or not they are cared for by hospitalists.” TH


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