• Quality Improvement (QI)

    • Measure of Success

       How Physician Quality Measures Are Developed  

      If physicians measure the care they deliver, the improvements will come. So goes the thinking when it comes to reforming the health care system. But who actually builds those doctor quality measures, and how?

      As it turns out, practicing physicians themselves largely drive the metrics they are accountable for as health care inches toward a value-based payment system that factors in both costs and care improvement. Keeping a seat at the quality table will be even more important as measures become more sophisticated and less voluntary, Texas Medical Association leaders say.

  • You are in a unique position to improve medical care in our nation.

    TMA has developed tools to assist you. Please see the menu to the left for available resources on clinical effectiveness, patient experience, performance improvement programs, and related topics.
  • What is quality improvement?

  • What are some difficulties within quality improvement?

    • The following are a few of the complexities related with quality improvement on the whole.

       

      Complexity of disease process. Many health care issues are very complex. The disease process may be chronic or acute. As intended consequences may be difficult to measure, a measurable process in place of one that is tougher to get at (a proxy measure) or an evaluation of a process, rather than an outcome may be used.

      Complexity of data. For example, physicians may be interested in how effective the practice is in counseling for smoking cessation. Since details of that are embedded in free text in medical records, to enable a practice to make use of computer records, a practice may choose instead to look at:

      • How many patients had “tobacco abuse” coded as a diagnosis
      • How many received prescriptions for Zyban or nicotine replacement


      Complexity of attribution. Correctly and systematically attributing patients and certain aspects of care to individual physicians when increasingly complex patients and conditions require teams of care is difficult. Yet, answering this question is critical for improving individual physician performance, as well as ensuring a fair credentialing process.

      Complexity of systems. Quality of care may not be high due to medical, patient or system reasons. Oftentimes, this is difficult to indicate within quality implementation programs.

      • Medical reasons include: the patient already assessed, measures are contraindicated, etc.
      • Patient reasons include: patient declined, social or religious reasons
      • System reasons (eg, resources to perform not available, insurance coverage/payer-related limitation, information not currently captured in Health Information Technology (HIT).
  • What are the quality provisions in health system reform?

    • The Affordable Care Act includes many quality components

       

      TMA staff has prepared the following report, which captures those parts of the Affordable Care Act that impact quality measurement and performance.

  • What is the TMA position on quality improvement?

    • An August 2008 TMA Quality of Care Survey found that Texas physicians are ripe for education on the benefits of current quality-of-care programs, including the use of patient satisfaction surveys to assess performance and quality.

        

      The survey also found that the vast majority of physicians do not see that federal or commercial initiatives to measure quality lead to improvements in their patient care, and prevention of "never events" and medication errors have the highest physician participation. 

      TMA Past President Josie Williams, MD said the survey results indicate that it is time for physicians "to think about how you are going to implement electronic health records, when are you going to implement them, and how they will help you improve care. This also will give you the information you need to compare your data with what you're going to be getting from hospitals, from Centers for Medicare and Medicaid Services (CMS), and from insurance companies so you can either disagree, prove wrong, or agree."  

      Among the survey's key findings:

      • Half of physicians do not conduct patient satisfaction surveys in their offices.
      • Thirty percent participate in the CMS Physician Quality Reporting Initiative (PQRI).
      • Fewer than 10 percent participate in the Bridges to Excellence (4 percent) or National Committee for Quality Assurance (NCQA) Physician Recognition program (9 percent).
      • Just one-fourth of physicians have used a practice improvement/performance practice module as part of their maintenance-of-certification requirement for certification renewal. 
      • Of physicians who are participating in quality improvement programs, the following percentages reflect physician opinion about their improvements in patient care:
        • Educational efforts tied to maintenance of certification for board renewal, 54 percent;
        • PQRI, 45 percent;
        • Some form of pay for performance, 38 percent;
        • The NCQA Physician Recognition program, 62 percent; and 
        • Bridges to Excellence, 22 percent. 

      TMA again surveyed physician stakeholders and thought leaders to assess the needs of physicians regarding quality improvement. The latest report, in 2011, captured the following trends:

      • The Physician Quality Reporting Systems (PQRS, formerly PQRI) and ePrescribing Centers for Medicare and Medicaid Services (CMS) incentives remain undersubscribed by Texas physicians, even though reporting via a registry mechanism takes about three hours on average. 
      • Physicians are looking for centralized and simplified turn-key approaches for reporting and acquiring incentive bonus payments, not the current expansive centers of knowledge.
      • Quality efforts need to be linked with increased reimbursement to offset loss in productivity, IT investment, and increased staffing.
        • Variance from normal practice workflow to capture and report on program-eligible patients further compounds this barrier.
      • Many physicians are delaying efforts to implement EMRs in their practice due to the uncertainty of health reform and the future of Medicare and Medicaid reimbursement.
      • Availability of routinely prepared feedback reports and benchmarking tools to gauge practice improvement are integral to clinical quality improvement efforts.
      • It is paramount that the TMA provide actionable information to help physicians in their practice setting, and include close collaboration with county and specialty medical society efforts in quality.
  • How do I implement quality improvement in my practice?

    • A personal philosophy and professional commitment to the highest quality of patient care is only the first step. To make it work, a culture of quality must start at the top, no matter the size or complexity of the organization. That's the conclusion of a recent TMA case studies project .

        

      Interviews with Texas physician leaders revealed these keys to creating and sustaining a successful culture of safety and quality:

      Commitment to quality

      • Hands-on involvement of physician leaders,
      • Staff time and resources needed to get the job done right,
      • Regular meetings with everyone involved,
      • Continuous quality improvement as a basic expectation of the entire team, and
      • Accountability, through sharing information privately and publicly whenever possible.

      Philosophy of teamwork

      • A culture of collegiality and professionalism, based around a shared vision, that regards all team members as equals;
      • Communication without fear of retribution and with strong support at every level;
      • Standing protocols, standardized algorithms, and other clear guidelines that staff can rely on as various situations arise; and
      • Recognition of success, e.g., through rewards or incentives.

      Attitude of change

      • An attitude of learning and welcoming change that recognizes the importance of new  technologies, and
      • Use of refresher courses, simulation exercises, or other means to ensure competency.

      Tracking, measuring, and reporting

      • A system, either electronic or paper, for tracking patients and the actual care they are receiving, and
      • A mindset for using the information gathered to improve quality of care.
  • What is the background of health care quality improvement?

    • In 2001, the Institutes of Medicine published the landmark report Crossing the Quality Chasm: A New Health System for the 21st Century. The Chasm report described the current gaps in care and put forth six aims for improving America’s health care system, namely that health care should be safe, timely, effective, efficient, equitable, and patient-centered. It was these foci that established how quality is defined across the United States.

       

      Since long before then, Texas physicians have had the desire to provide the best possible care. This evolution is not new, but has been building steadily over the last decade or more. Physicians must prepare themselves and their practices for the increased accountability that surely will be demanded of them in the days ahead by those in both private and public sectors. Physicians generally have been unhappy with government and private health plan attempts to measure the quality of their care, but former TMA President Josie R. Williams, MD, says performance measurement is here to stay. TMA Trustee Carlos Cárdenas, MD, adds that measuring quality data not only will help physicians improve the quality of their care, but also will be their best defense against economic credentialing and pay-for-performance schemes.

      Texas physicians have a professional responsibility to provide evidence-based health care consistently while asking, "How can we do things better?"

      Now is the time to evaluate the daily practice of medicine and begin to implement those changes that will yield higher levels of patient safety and more effective, efficient care. Continuous quality improvement depends on physician leaders to nurture and drive teams sharing a common vision - one that is ultimately realized through the care provided every day, every time, and for every patient.

      As part of a case studies report to better understand this new arena of healthcare, TMA Clinical Advocacy Department staff interviewed a dozen Texas physicians in a variety of clinical settings about their efforts to improve quality in their practice or hospital. The settings ranged from solo practitioners in rural Texas to large multispecialty groups to physician-owned hospitals to large hospital systems. While the report found that larger organizations may have the economic infrastructure and necessary resources to effect big change, the presence of those factors alone is not enough to ensure a true culture of quality and patient safety. "Through our case studies and interviews, it became very apparent that adopting a personal philosophy and professional commitment to always provide the highest level of effective and efficient care is only the first step," the report stated. "To make it work, quality must be driven from the top down, no matter the size or complexity of the organization. And, it is essential for physicians to understand that they must objectively revisit and redefine their traditional authoritarian positions to allow all members of the team to be seen as valuable and vital to success."

  • Get the latest news on quality improvement.

  • Whom do I contact if I have more questions?