Texas Institutions Spread Quality Improvement
Quality Feature – September 2012
Tex Med. 2012;108(9):45-47.
By Ken Ortolon
In 2002, the Baylor Health Care System (BHCS) in Dallas and The University of Texas M.D. Anderson Cancer Center in Houston sent several key physicians and other leaders to Salt Lake City to learn quality improvement techniques at Intermountain Healthcare.
Intermountain, a large hospital system serving Utah and Idaho, is a pioneer in applying quality improvement techniques developed for the manufacturing industry to health care. For nearly 20 years, Brent James, MD, chief quality officer for Intermountain, has taught health care leaders from around the country and the world how to use those same techniques.
Ronald Walters, MD, associate vice president for medical operations and informatics at M.D. Anderson, says eight people from his institution, including six physicians, attended Intermountain's Advanced Training Program in 2002.
"We used that as a seed, then built up our own version of the course internally at M.D. Anderson," Dr. Walters said. Since 2005, 18 classes completed the M.D. Anderson Clinical Safety and Effectiveness (CS&E) course, based heavily on the Intermountain course. Its success led three other UT System institutions to launch similar programs.
Similarly, BHCS officials used their early training at Intermountain to create a quality improvement course for physicians, other clinicians, and administrators in its multihospital system in the Dallas area.
"We decided that if we really wanted to move our organization forward [in quality improvement], we needed to come up with one of our own courses," said Cliff Fullerton, MD, vice president for chronic disease and care redesign for BHCS.
BHCS uses the Accelerating Best Care course to train its own leaders in quality improvement and takes the show on the road. It presented the course at rural hospitals across Texas as part of a federally funded research project and in Pennsylvania, as well as at Sentara Healthcare in Norfolk, Va., and to groups of physicians and others in Mexico, Italy, and Honduras.
Until now, the BHCS and UT courses targeted physicians, other key clinicians, and administrators within those systems and a limited number of outsiders, as space permitted. But UT and BHCS hope to partner with the Texas Medical Association Council on Health Care Quality to offer a condensed version – perhaps as short as four hours – of their courses to physicians in private practice who may not be able to spend several days away from their practice or afford the more comprehensive courses, such as Intermountain's, that can cost several thousand dollars.
"We have to get some interested people in the small practices or even the larger small practices interested in doing some sort of project," Dr. Walters said. "It really doesn't matter what it is. It can be anything that's important that they're having a problem with. And then we need to establish a mechanism to communicate those results and to spread those results across practices."
While discussions of this effort are still in the formative stages, that could involve a TMA-sponsored quality event each year at TexMed, TMA's annual meeting, he says.
The focus on using industrial practices to improve quality in health care began at Intermountain in the late 1980s after physicians there received a grant to study whether a new approach to ventilator care could help treat acute respiratory distress syndrome. The success of that study led several Intermountain departments to begin quality improvement efforts of their own, and Intermountain eventually developed the Advanced Training Program to spread the concept to other health care systems.
Frank Villamaria, MD, former medical director for quality at Scott & White Healthcare in Temple, took the course in 1997. He describes it as a "very extensive" program that combines didactic information about quality and quality improvement with a hands-on experience in actually conducting a quality improvement project.
That, he says, gets participants involved in actually putting what they're learning into practice.
Dr. Walters says some of the industrial concepts included in the course involve the so-called "lean" methodology – a process Toyota and other manufacturers use to focus on eliminating waste – and a process called Plan, Do, Check, and Act (PDCA). He describes PDCA as a "classic" methodology that stresses identifying a problem, planning how to make improvements, deciding how to measure improvement, and implementing the plan, and then measuring its impact.
The Intermountain course involves four five-day sessions spread over four months and includes instruction in developing guidelines and protocols; health services research methods; health policy and economics; cost-based accounting medical informatics; severity of illness measurement; and total quality management and continuous quality improvement. The course also stresses the role of interprofessional teams in quality improvement.
Participants must carry out a quality improvement project and present its results to graduate. Tuition for the course is $9,000 per participant.
Dr. Villamaria says the concept of total quality management is very important. "Quality improvement is not just crunching numbers but understanding how to manage change," he said. "If you're going to improve anything, you've got to change it. That's sometimes the biggest challenge: to get people comfortable with change."
M.D. Anderson and BHCS developed the courses with assistance from Dr. James at Intermountain, but both chose to implement a somewhat condensed version. The M.D. Anderson courses – as well as those at the UT Health Science Center at San Antonio (UTHSCSA), UT Health Science Center at Houston, and UT Southwestern Medical Center – include eight days of instruction with time for a quality improvement project.
Dr. Walters says each campus' version of the course varies. Some stress the lean principles, while others focus more on the PDCA approach.
Jan Patterson, MD, associate dean for quality and lifelong learning at UTHSCSA, says the San Antonio course differs from the others because it involves clinicians, administrators, and others from affiliated hospitals that are not actually part of the UT System.
More than 600 physicians and others have graduated from the various UT courses, and they have completed more than 260 quality improvement projects at their institutions.
The BHCS course has a similar design, but includes only five days of classroom instruction. BHCS also offers a one-day version of its program.
Neil Fleming, PhD, vice president and chief operating officer of BHCS's STEEEP Global Institute, said the BHCS course is also organized around the "six domains of quality" identified by the Institute of Medicine. They are Safe, Timely, Effective, Efficient, Equitable, Patient Centered care (STEEEPTM), which includes concepts such as cost-effectiveness and value.
Officials from both systems say they have seen demonstrable improvement in quality of care as a result of the projects initiated as part of the course.
"We've documented that in virtually every project, we've been able to show improvement," Dr. Patterson said." Many of those projects are sustained over time." Dr. Fleming added that "a key to the projects is that they involve multidisciplinary staff who develop teamwork and the necessary communication essential to addressing the increasing complexities facing health care providers and their patients."
Rapid Cycle Improvement
Dr. Villamaria says medical school and residency programs did not teach quality improvement a generation ago. While many schools now incorporate quality improvement into their curricula, he says, it is important for physicians already in practice to learn these techniques because the changing health care delivery environment – from pay-for-performance to accountable care organizations to outcomes measurement – drives the focus on quality. Also, many specialty boards now require physicians to complete quality improvement projects as part of the board recertification process.
Luci Leykum, MD, UTHSCSA associate dean for clinical affairs and a graduate of the CS&E course, agrees.
"It's critical for physicians to be active participants in improving the efficiency and quality of care we deliver," she said. "Training in process and quality improvement, such as that provided by the CS&E course, gives us the opportunity to become better able to contribute to those improvement efforts. It also enables us to look at the system of care delivery in a more critical way, to assess what processes could be optimized, and approach thinking about these types of issues."
UT-San Antonio otolaryngology professor Randal Otto, MD, also graduated from the course. He says its focus on "rapid cycle improvement" means significant improvements in quality can be achieved in many cases with very little effort.
"Physicians tend to think we have to go from point A to point B, with point B being perfection," he said. "And we can study it or dumb it to death and never really get anything done."
But if you focus on a series of small steps that move toward perfection, you can accomplish a great deal, he says.
As his project for the CS&E course, Dr. Otto looked at hiring translators to communicate with Spanish-speaking patients rather than pulling Spanish-speaking staff away from other tasks. Just spending more to hire translators saved time for the physicians and improved patient flow, he says.
"Health care is filled with those kinds of examples," he added. "So you can show substantial improvements and cost savings in very short periods of time by just thinking about the things we do – What are we doing? Can we be more efficient? What are the barriers to that? At the end of the day, that's what clinical safety and effectiveness is."
Learn More About Quality Improvement
Interested in learning more about quality improvement?
Baylor Health Care System (BHCS) offers its Advancing Best Care course to outside organizations, and The University of Texas System institutions offer slots in their Clinical Safety and Effectiveness (CS&E) course on a space-available basis.
Cost of the full BHCS course is $2,500 per participant. UT's M.D. Anderson Cancer Center charges only for course materials for outside participants in its CS&E course.
For information about the BHCS course, email Neil Fleming, PhD, at BHCS or call (214) 265-3601.
Physicians interested in the M.D. Anderson course should email Doris Quinn, PhD, or call (713) 745-2579.
And physicians interested in attending the UT Health Science Center at San Antonio CS&E course should contact Letti Bresnahan at the UTHSCSA Center for Patient Safety and Health Policy at (210) 567-4445.
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