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The Changing Face of Quality Improvement

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.

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