Quality Improvement Final

What is physician profiling?

The collecting of provider-specific and practice-level data used to analyze physician profiling, utilization of services, and outcomes of care

What are the goals of physician profiling?

To:

Improve physician performance through accountability and feedback

Decrease practice variation through adherence to evidence-based standards of care

What does physician profile development enable?

A physician's treatment pattern to be assessed

What are provider registries?

An electronic system for uniform collection of information used to evaluate specified outcomes for a patient population defined by a particular disease, condition, or exposure

Can be:

-Lists

-Dashboards

-Scorecards

-Tables

What is a list?

An ordered collection of elements of a single data type. Elements added to a List are assigned an implicit index, and therefore, Lists can contain non-unique values (i.e. elements can be duplicated within a List).

What are dashboards?

Real time process and outcome measures that guide operational and management decision making

What are scorecards?

Outcome measures of past performance that may be useful for leadership tracking of strategic deployment, external comparison and benchmarking, and overall organizational performance benchmarking

What are tables?

An arrangement of data made up of horizontal rows and vertical columns.

What's interesting about the U.S in terms of healthcare system performance?

They rank last, while having by far the highest costs

What is the physician's role in improving quality?

-Adhere to clinical guidelines and best practices

-Address unexplained clinical variation in healthcare

What does physician profiling give providers the opportunity to do?

Make changes to their practice patterns and to improve patient outcomes.

What is the provision in healthcare in the U.S increasingly associated with?

A greater emphasis on value.

What is value?

The relationship between quality and cost

What are private insurers now following?

The government's lead by providing financial incentives for high-quality care

What are healthcare organizations now moving towards?

Value-based purchasing

What is value-based purchasing?

Payment method that rewards quality of care through payment incentives and transparency.

As stakeholders, what must large employers encourage their employees to select?

High-quality care providers identified through profiling of hospitals and providers

What is "Physician Compare"

CMS' profiling of physicians' performance on certain quality metrics.

What do payers use scorecards for?

To look at elements of quality and costs

Based on the results of scorecard, what is applied?

Financial bonuses or penalties

Scorecards may be used to compare what?

Performance at the individual provider level or at the practice level

What is benchmarking?

A concept that uses a standard against which to compare a physician's performance on a quality measure.

How is benchmarking often represented?

As the "goal" on the scorecard, which is ideally rsk-adjusted

When compared to the best of their peers, what are underperforming physicians more inclined to do?

Change their practice patterns to match.

What should a quality improvement commmite do?

-Identify the areas most appropriate for profiling and the areas in which it wants to improve performance

-Identify the techniques it will use to gather and disseminate data

-Develop an objective and appropriate way to interpret the results

-Communicate the results in a way that will be most valuable for physicians

-Schedule meetings on a monthly or quarterly basis so that physician have the opportunity to provide input on how the profiling system is working

What the keys for success in regards to physician profiling and benchmarking?

-Working closely with physicians

-Involving many different specalists

-Determining a time frame for all physicians to review the information before the profile becomes an official tool of the organization

-Organize multiple educational sessions

-Provide physicians with incentives

-Use a profile system that is not threatening

What are the challenges regarding physician profiling?

-No consensus exists at to what constitutes a profile, what it should measure, and the groups to which the information should be targeted.

-Different stakeholders have different preferences for what should be measured

-Many physicians are skeptical of profiling

-Profiling may have unintended consequences

There have been many attempts made to constrain what?

The rapid growth in healthcare spending

An increasing emphasis on value has led to the creation of what?

Numerous quality and value-based programs

What did the CMS spearhead in 2006?

Physician Quality Reporting System (PQRS)

What followed the PQRS?

The Electronic Health Record Incentive Program and the Value-Modifier

In 2015, what became law?

The Medicare Access and CHIP Reauthorization (MARCA), which established the Quality Payment Program (QPP)

What is a key component of MACRA?

Value-based purchasing

What are physician reimbursements directly tied to?

Performance on quality metrics

What will remain the focus of healthcare in the foreseeable future?

Pay-for-performance programs

What does the Institute for Healthcare Improvement (IHI) suggest regarding reliability around healthcare?

It is a three part cycle of:

-Failure prevention

-Failure identification

-Process redesign

What does the literature suggest healthcare organizations using IT for healthcare quality and safety do instead?

Replace the "process redesign" with action, making the cycle:

-Failure prevention

-Failure identification

-Action

Regarding Health IT's "Best Fit", what should be implemented?

Clinical decision support and alerts, which have been shown to yield the best return on investment

How should CDSS be implemented?

-Keeping in mind the challenge of culture and interface design

-Spearheaded by internal champions

What does early success help?

Change culture

Who should be involved as soon as possible when it comes to implementing health IT?

Interface designers. Do not wait, get them involved when the project is being conceived

When it comes to prevention, what must health IT do?

Make it possible to understand how to prevent poor-quality care AND how to prevent safety events from occurring

Alerts are most often used to do what?

Improve care quality and prevent a safety event

Clinical decision support creates what kind of enviornment?

Where algorithms provide clinical assistance for the clinician.

What are customized health IT solutions created to do?

As an array of specialized solutions to increase quality for a specific issue

What are automated reminders and alerts useful in?

Providing important information that supports safe and effective clinical decisions

Automated reminders and alerts in the EHR are a common mechanisms for the use of health IT as what?

Prevention of potential missed quality and safety events

Are immunization alerts effective?

Yes, they have led to a 12% increase in well child and a 22% increase in sick child immunization administration

Are drug alerts effective?

Yes, they have been associated with a 22% decrease in medication prescription errors

What is prevention in Health IT?

Understanding how to prevent poor-quality care and how to prevent safety events from occuring

Can alerts be overridden?

Yes, and when they are- they no longer prevent events from occuring.

In this case, they are most often used to identify events

CDS provides suggestions, but not absolutes, which means?

CDS is also often used to identify events

Customized health IT solutions are often put in place to understand what?

The prevalence of potential quality and safety events

Health IT can be used to expose certain populations of what kind of patients?

Patients who may be deemed by payers to have received unnecessary care.

An example of a proper idenitifcation of issue would be?

Optimal length of stay for hospitalized patients

What should be considered regarding reducing hospital length of stay?

Unintended negative outcomes, such as unintended readmissions

What is a hard-stop alert?

An alert that prevents the user from moving forward with an order or intervention that would be potenitally dangerous to a patient.

This is a method of preventing safety events

What can hard stops allow?

They may allow the continuation of the process, but only if significant required action is taken by the user, including calls to or consultations with experts (such as a pharmacist or a medical specalist)

When appropriately designed, what are hard stops shown to do?

Be more successful in changing an unsafe plan or preventing a potentially dangerous intervention

What is a soft-stop alert?

An alert that can provide key information about a potential quality or safety issue, offering an alternative choice, but still allowing the user to proceed (upon acknowledgement)

What are the issues regarding soft-stop alerts?

They may be ignored or overridden because of alert fatigue, poor implementation, or poor interface design

What is "Action" regarding Health IT?

This is when an event has already occurred, and health IT has not prevented it. In this case, health IT is used for action

What is documentation necessary for?

Understanding the entire cycle of the quality and safety event

What is implementation?

Once health IT is developed, it needs to be implemented. Involving users in the design and testing will help with implementation

Culture is a critical component for implementing health IT in what aspects?

For:

-Prevention

-Identification

-Action

For the quality and safety of the clinical enviornment

What is important regarding documentation?

It is important to "test drive" a solution on paper before implementing in the EHR.

Involving health IT in the development of the paper version of the visual algorithm allows for improved implementation within the EHR.

What happens when you embed and algorithm-driven dashboard in the EHR?

It creates a sustainable, predictable, processes for the end user.

How should algorithm-driven dashboards be designed?

Around the bedside workflow, in concert with a visible and visual display of the information

Understanding the frequency of the process you plan to improve is best done using what?

A pareto chart

Understanding data over time before and after an improvement is best achieved with a what?

A control chart

In complex healthcare delivery, what is often the more important issue?

To address not WHAT needs to be done but HOW to appropriately implement intended care in the most efficient way possible.

A thorough understanding of all steps in a process and the data related to those steps requries what?

A partnership between health IT and quality improvement

Early involvement and health IT and quality improvement produces what?

An improved workflow within the EHR

Including health IT in detailed process mapping allows for better what?

Better understanding of goals for the improvement

Analysis of data available in partnership with health IT allows optimal assessment of the what?

Extent of the current problem

Health IT and quality improvement must partner with key stakeholders in the process to accomplish what?

To streamline care delivery for any process

What is the 4 prong-approach to improvement?

1. Forming a team including all key stakeholders

2. Strong partnership between quality improvement and health IT

3. Analysis of current process performance gaps using detailed process mapping and baseline data

4. Appropriate prioritization of solutions for improved process and outcomes

What does culture require a focus on?

Developing a critical mass of leaders with expertise in quality improvement, patient safety, and change management.

A culture of quality develops how?

More slowly, and with buy-in from all levels of care providers within an organization.

When healthcare personnel trained in quality improvement and patient safety methodologies feel empowered to promote change and enact improvements in their enviornment, what happens?

They will be motivated to work toward more global changes that align with executives

What provides remarkable improvements in outcome?

When addressing HOW to deliver intended care; results are achieved by creating a practical, visual, algorithm of the desired process

Health IT can assist in monitoring what?

Monitoring multiple metrics within a desired overall outcome.

Timely antibiotic administration in sepsis is critical to what?

Survival

There should a level of what in healthcare simulation?

A level of fidelity

What are some educational delivery models for healthcare simulations?

-Task trainers

-Standardized patients

-High-fidelity options

-Low-fidelity options

What is debriefing?

Supporting a dialogue to encourage reflection

What are some evolutions and histories of healthcare simulation?

-Early training models in training programs

-Parallels with the aviation industry

-Crew resource management (CRM)

-To Err is Human

-Champions of simulation

-Professional societies and their development

What are some skills addressed with simulation?

-Clinical skills (e.g., physical examination)

-Procedural skills

-Communication skills

-Interprofessional skills

-Leadership skills

Who is in an undergraduate audience?

Medical shool, nursing school

Who is in a graduate audience?

Postgraduate trainees

Who are the stakeholders in simulation and educational programming?

Education and clinical leadership

What are the theoretical frameworks and paradigm shifts of simulation and educational programming?

-"See one, do one, teach one"

-Experiential learning

-Deliberate practice

What are the benefits of a simulation center?

-Control of scenario

-Less stress on educators & learners

-Logistical control

-Time

What are the benefits of an In-Situ design?

-Enviornmental Fidelity

-Teams & Systems evaluation

-Realism

What are some educational frameworks?

-Adult learning

-Learner-centered design

-Experiential learning

-David Kolb's cycles of learning

-Ericson's concept of deliberate practice

What is David Kolb's cycles of learning?

A 4-stage cyclical process emphasizes that learning is continuous and involves moving through these stages repeatedly to deepen understanding and knowledge.

What is the first step of Kolb's cycle of learning?

Concrete Experience: Engaging in a new experience or situation.

What is the second step of Kolb's cycle of learning?

Reflective Observation: Reflecting on the experience and observing what happened.

What is the third step of Kolb's cycle of learning?

Abstract Conceptualization: Formulating theories or concepts based on the reflections.

What is the fourth step of Kolb's cycle of learning?

Active Experimentation: Applying the new ideas to the world to see what happens.