Step by Step: Proper Planning Essential for Quality Improvement
All medical residents are now required by the Accreditation Council for Graduate Medical Education (ACGME) to undergo training in continuous quality improvement (CQI). Many of us were taught this, to varying degrees, at some point in our medical education. And although many of us work on improving processes and methods of care delivery in our practices, we shortchange ourselves and our patients if we cut corners.
Fortunately, my training in CQI methods as a resident was excellent. Each third-year resident led a full clinical team in a project that covered the entire academic year. We had time each month dedicated to meeting with our team to work through the FOCUS-PDSA cycle, with didactics before each meeting to prepare us for the next steps.
The project I selected was designed to improve immunization rates in children younger than age 3 years. The process was not without difficulties, but our intervention was fairly simple. We determined that there were many missed opportunities for immunization during acute-care visits, and so we needed to remind our physicians and physician assistants to bring this up during those visits. Based on alarm fatigue associated with our electronic health record (EHR) system, we decided against an electronic reminder. Instead, we printed immunization records from the state database (which, unfortunately, does not communicate with our EHR) and had the medical assistant discuss it with the physician or physician assistant during the pre-session huddle.
By the end of the project, we were able to show a statistically significant improvement, with the rate of recommended vaccinations in this age group increasing from 66 percent to 91 percent for our population. I encountered the same issue with immunization rates when I entered practice, and I implemented a similar intervention. This time, rates for the recommended vaccines being given to adults and children in our practice improved from 55 percent to 87 percent.
My next project involved improving our process for processing requested medication refills, which also showed some success but not as much as I had hoped. Why hadn't it, I wondered? What were we missing?
I quickly realized that we had skipped some steps in the CQI process. We had not done a full analysis of the existing process, and because of this, I had a harder time getting buy-in from the medical assistants, who had the biggest role to play in the intervention. I had failed to follow what I had learned, which resulted in time wasted and only modest improvements.
More recently, in a follow-up to our immunization project, I realized our rates were starting to slip again. What was happening here? In this case, we failed to follow possibly the most important part of CQI: continuous. Any process requires ongoing follow-up to ensure that problems or kinks can be addressed. Realizing the errors in both of these projects, we were able to provide solutions that really worked and provided some improvement for our staff and patients.
CQI can be a bit onerous, particularly because it takes time and the efforts of many staff members. It can be frustrating, as I experienced, to miss some steps and realize that you have to start over. But based on estimates of vaccination benefits, we saved millions of dollars in direct and indirect medical costs to society and avoided multiple hospitalizations of the children who received immunizations -- and those they could have otherwise infected -- over their lifetimes.
We also saved time by providing refills more efficiently through medical assistant support of increasing refills during visits, making our patients happier at the same time. The time and effort were well worth it.
Following the proper steps, remembering what we have already learned and experienced in quality improvement, and addressing pressing needs in our practices provides big dividends, both in quality of care and, potentially, cost. These are essential steps, whether on a small scale in our practices or on larger population-based scales, to making our health care system the high-performing entity we know it can be.
Kyle Jones, M.D., is a faculty member at the University of Utah Family Medicine Residency Program in Salt Lake City. He is the director of primary care at the Neurobehavior HOME Program, a patient-centered medical home for those with developmental disabilities. You can follow him on Twitter @kbjones11.
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