Improving care and lowering costs in the medical field are of the utmost importance. "Quality improvement initiatives are essential in every aspect of healthcare delivery because we will never be as good as we can be without additional monitoring and improvement of performance," says Thomas Deas, Jr., MD, MMM, FASGE, of Gastroenterology Associates of North Texas in Fort Worth. Dr. Deas, Brett Bernstein, MD, medical director of East Side Endoscopy in Manhattan, N.Y., and American Society for Gastrointestinal Endoscopy Quality Assurance committee member, and Jeffrey Fine, MD, chief of gastroenterology at Medical and Surgical Clinic of Irving and a gastroenterologist at Star Medical Center in Plano, Texas, establish QI project framework and identify some of the best opportunities for gastroenterologists.
Implementing a QI project
Outcomes, safety and patient experience are the three cores of quality improvement projects. "Another issue is ensuring that the QI projects you engage in are substantive and
impactful, but not overly complex," says Dr. Bernstein. There are a number of ways to approach QI projects. Dr. Bernstein begins by asking three questions from the Institute for Health Improvement project model.• What are you trying to accomplish?
• How do you know that change will lead to improvement?
• What change can we make that will lead to improvement?
"This is followed by performing PDSA (Plan, Do, Study and Act) cycles," he says. QI project leaders identify an area for improvement and measure how much improvement that area needs. Develop a way to improve that area, test it on a small scale and then evaluate the change. "If improvement is achieved, full implementation of the change is made and progress is measured over time," says Dr. Bernstein.
Project ideas
There are many established benchmarks that can be tracked and used as the basis of QI projects. For example Gastroenterology Associations of North Texas work on:
• Reporting colonoscopy measures such as cecal intubation, adenoma detection rate, prep quality, patient discharge recommendations to the GI Quality Improvement Consortium.
• Patient satisfaction monitoring
• Tracking of complications, transfers, falls wrong site surgery, bleeds, perforations and admissions within 14 days of a procedure
• Monitoring of scope reprocessing in accordance with guidelines
• Monitoring that all pathology reports are reviewed
• Peer review of medical records for appropriate documentation
"The potential for future QI projects is infinite," says Dr. Bernstein. As healthcare transitions to a value-based payment system, the importance of QI projects will only grow. For example, Dr. Fine focuses on all the standard measures such as cecal withdrawl time, adenoma detection rates, complication rates, patient satisfaction, fall precautions, center infections and bowel preparation quality. He suggests approaching each patient as an individual, taking into consideration medical history such as diabetes or irritable bowel syndrome and outlines recommendations to make each bowl prep optimal. "At least 25 percent of bowel preps are suboptimal, and could be improved easily," says Dr. Fine.
Dr. Fine sees a large opportunity for the development of a new set of benchmarks. "Current colonoscopy guidelines are all based on adequate bowel prep," he says. "If a patient doesn't have a good prep, when should physicians bring them back in?" Some institutions suggest bringing the patient in the next day, but this is often unrealistic. There is potential to build a QI project around inadequate bowel prep patients and the timeline for rescreening. Data collection and analysis
QI projects are built upon data, which can take a significant amount of time to gather and analyze. The advent of electronic medical records, if used correctly, has eliminated some of the time required. An EHR can pull data from patient medical history and billing systems for physicians. GIQuIC has also contributed to a streamlined process. At Dr. Deas' practice, a quality nurse oversees much of the data collection and processing. Physicians gather quarterly for medical executive and QI committee meetings to review trends and areas deserving improvement.
Looking past physician involvement can not only ease the work load, but also create a culture of quality in a physician practice. "What was most gratifying about the process was involving the staff at all levels in the process and watching how dedicated they became as a result of being enfranchised to participate in the improvement process," says Dr. Bernstein.
Embracing quality improvement
Physicians have sought to improve patient care throughout the history of healthcare. Quality improvement projects are the next step forward. Though QI initiatives take both time and money, placing additional strain on busy physicians facing tight schedules and reimbursement decline, they push providers to hone their skills and offer the patients the best possible care. These projects also have the potential to prepare physicians for the future of healthcare.
"There may be meaningful economic incentives in the future," says Dr. Deas. "If we evolve to a more transparent system, our quality performance will be available to patients/consumers making healthcare much more competitive on both price and quality."
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