Quality … and How Doctors Achieve It

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Cover Story - April 2009  

Tex Med . 2009;105(4):16-25.  

By Ken Ortolon
Senior Editor  

Skeptics who think quality measures don't reflect real-world medicine or don't have an immediate payoff need only to look at the Baylor Health Care System. The Dallas-based hospital system saw a dramatic decline in its risk-adjusted mortality rate in only four years after stepping up its quality measures.

Quality has been an important organizational value for Baylor since founding its first hospital in Dallas in 1903, says allergy and immunology specialist Don Kennerly, MD, PhD, vice president for patient safety for Baylor. But during the past decade, Baylor made an even stronger commitment to quality and patient safety. It invested in an electronic medical record (EMR) system, developed standardized order sets for several illnesses and conditions to ensure consistency of care, and fostered teamwork among the medical staff, nurses, and all other allied health professionals who care for patients.

The results - a 30-percent drop in mortality between 2004 and 2008 in Baylor's 21 owned, leased, or affiliated hospitals throughout the Dallas-Fort Worth area - are impressive, says Dr. Kennerly. He added that the decision to emphasize quality rested with the system's senior leadership and stemmed from a belief that the organization's purpose was "to benefit our patients and community. So as a result, you might want to look at it from the Golden Rule perspective. We want to provide health care that we'd like to receive."

Baylor is just one example of successful quality and patient safety initiatives in physician offices, clinics, hospitals, and large health care systems across the state. Texas Medical Association President Josie R. Williams, MD, says such physician-led programs are essential in an era in which attempts to measure quality are becoming a driving force in health care reform.

To highlight the quality and patient safety initiatives in Texas, Dr. Williams directed the TMA Councils on Scientific Affairs and Socioeconomics to develop a report highlighting national health care trends and key concepts of initiatives from across Texas. A Texas Medical Association Case Studies Report: Achieving Quality and Patient Safety in the Delivery of Health Care for All Texans found four key themes that appear to be common to all successful quality initiatives:

  1. A commitment to quality,
  2. A philosophy of teamwork,
  3. An attitude of change, and
  4. Tracking, measuring, and reporting data. 

Highlighting Quality  

Dr. Williams says her goal with the case studies report was to highlight the quality and patient safety work already under way in Texas and encourage more physicians to pick up the torch.

"I know that change is coming, and I am a firm believer that the only way any change will be successful is if it's led by physicians," Dr. Williams said. "There are many physicians in this state who not only hold that belief but who also have begun the journey."

Dr. Williams says physicians must get out in front of the quality train because private health plans, as well as government initiatives, are pushing reforms that likely will include adoption of health information technology, pay for reporting or performance, quality measures, and public reporting.

"The Texas Medical Association remains committed to advocating, at both state and federal levels, use of fair methodology in the measurement of a physician's professional performance in the delivery of care to his or her patients," TMA's case studies report concludes. "However, the time has come for all of organized medicine to recognize that whether it be by federal mandate or third-party requirement, programs to track individual clinical performance or to direct the way health information is conveyed are here to stay. To be clear, 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."

As part of the case studies report, 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. (See " Case Studies in Quality.")   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." 

Keys to Success  

The first essential to creating and sustaining a successful culture of safety and quality is a commitment to quality, which must begin at the top of the organization.

Dr. Kennerly says Baylor's current focus on quality really began when David Ballard, MD, PhD, came on board in 1999 as chief quality officer. At that time, the Baylor system created an Institute for Health Care Research and Improvement. Then in 2000, the Baylor Board of Trustees adopted a resolution making quality improvement a formal goal of the organization.

"The resolution was quite clear that performing at a rate that was average or slightly above was not acceptable," Dr. Kennerly said. "We aspire to perform at a very high level."

In 2004, Baylor took the additional step of creating an Office of Patient Safety, which Dr. Kennerly heads. The board then adopted a further resolution setting goals for reducing risk-adjusted inpatient mortality rates.

Carlos Cárdenas, MD, board chair for Doctors Hospital at Renaissance in Edinburg, says his facility also had a top-down commitment to quality from its inception in 2003.á

"I knew from the very beginning when we embarked on this journey that we were going to need to be able to measure ourselves and say that we're doing a good job," said Dr. Cárdenas, who is also a member of the TMA Board of Trustees. "And not just say that we're doing a good job, but know that we're doing a good job."

The 500-bed physician-owned and operated hospital was an early participant in the American College of Surgeon's National Surgical Quality Improvement Program, which collects and reports risk-adjusted event data for surgical services. The hospital also uses state-level data on hospital quality of care from the Texas Department of State Health Services and other agencies to compare its performance against other facilities.

It measures its performance on core measures set out by the U.S. Centers for Medicare & Medicaid Services, Dr. Cárdenas says.

He says buy-in from hospital leadership, however, is not the only key factor. "You have to have buy-in not only of the general but you have to have buy-in of the foot soldier. You have to be able to manage from the bedside to the boardroom.   It has to be patient-centered care. There's no other way to get to where we want to go." 

Building a Team  

While physicians have traditionally been the captains of the health care ship, all of those interviewed for the case studies report say developing a philosophy of teamwork is essential to successful quality improvement.

"Quality is all about teams who communicate well without fear of retribution and have strong support at every level," the case studies report concluded. "Standardized algorithms and standing protocols are two of the ways that can empower team members to proactively implement processes that will result in safer practices."

Frank Villamaria, MD, associate professor of anesthesiology at Texas A&M University College of Medicine and former medical director for quality at Scott & White in Temple, says his organization has really focused on teamwork in the past five to 10 years. The concept of teamwork has been difficult for some physicians to accept, he says, because that is not how they were trained.

"They were trained to be captains of the ship. They weren't trained in teamwork skills or understanding the dynamics of a team," said Dr. Villamaria, who also serves on the TMA Council on Scientific Affairs.        

Still, Scott & White has used several methods to improve teamwork among its physicians, nursing staff, and other allied health personnel. One is the use of "time outs," a concept he says was borrowed from aviation. Much like a flight crew goes through a preflight checklist before take-off, time outs allow operating room personnel to go through their own checklist before surgery. That list can include making sure you have the right patient and the necessary equipment and blood supply to do the procedure, that everyone on the team understands the nature of the surgery and any possible complications, and that antibiotics are administered on time.

"It's really a pause right before you start surgery," Dr. Villamaria said. "Everybody on the team stops, and you focus."

He says there was some grumbling among the medical staff when the time-out policy was adopted, but there is now broad support for it. 

Getting Simulated  

Jose Pliego, MD,medical director for clinical simulation at Scott & White, says the organization also uses multidisciplinary team training in its clinical simulation laboratories to improve teamwork, particularly in using rapid response and Code Blue teams.

In 2006, Scott & White received a two-year, $300,000 grant to study whether clinical simulation training could improve resuscitation team response. Using that grant, Scott & White set up simulation labs in two intensive care unit rooms. They also use a simulation center set up in conjunction with A&M at Temple College for additional training.

Scott & White pays RNs and LVNs to undergo simulation training during off-shift hours, and it has trained all floor nurses in the hospital not only on when to call the rapid response teams, but also how to participate in that response.

"One of the problems that we had with our nurses was defining their roles and responsibilities," Dr. Pliego said. "When this happens, what is it that I am supposed to do?"

In the past, floor nurses might have taken a crash cart into a patient's room when a Code Blue was called, then gotten out of the way as the response team did its work. Now, the floor nurse not only takes in the crash cart, but also opens it and hooks up the monitors, and begins cardiopulmonary resuscitation.

"The nurses really liked the fact that we spent time and effort for education, that we're making it in a way that is friendly to them," Dr. Pliego said. "They feel more confident with their ability to participate during a code."

That, he says, is good because no one in the hospital knows more about the patient than the floor nurse.

Scott & White also uses the simulation labs to train resident physicians on events that may occur infrequently during their training, as well as assessing how the residents, nurses, and others work as a team.

"Those events don't occur very frequently, but when they occur they occur in a setting that is not very conducive to teaching. Everybody is working, and you don't have time to stop and reflect," Dr. Pliego said.

Experiencing those situations in a simulated environment makes the residents more comfortable that they know the steps that need to be taken.

"That's been very helpful, and the feedback we've gotten from the residents has been very positive," he said. 

Standardizing Care  

Dr. Kennerly says Baylor also has an extensive program to use standard protocols and order sets to improve quality of care and teamwork. Unlike other hospitals, Baylor pays its medical staff to participate in developing standardized order sets designed specifically to fit Baylor's needs. Baylor will soon have as many as 160 standardized orders for a variety of illnesses and conditions, ranging from heart attack to pneumonia.

While Dr. Kennerly says Baylor doesn't want its physicians practicing "cookbook medicine," the standardized orders have had a dramatic impact on consistency of care.

"If a patient is admitted with pneumonia, we have a standard order set. And the physician just goes through that order set and checks things off. They're all there for him so he won't forget anything," Dr. Kennerly said. "Now, if he feels like a given order is not appropriate for a patient, he can absolutely take it off. But what we want to do is start from the point of some consistency."

Dr. Williams also sees value in standing protocols and order sets. Not only do they help physicians remember what to do at times when they might be distracted, but also they improve the timing of recommended care.

"What we've learned about optimal timing is that it can improve our response time very dramatically and actually decrease the time the patient spends in the hospital because we did it appropriately and on time," she said.

Dr. Williams also says standardization must allow physicians to make appropriate changes to fit specific patients' needs. "The good protocols always allow the physician to be the physician, to think about where the patient may differ, and what should be changed, based on the patient's profile, that may not be appropriate for the patient." 

Measuring Quality  

Physicians generally have been unhappy with government and private health plan attempts to measure the quality of their care, but Dr. Williams says performance measurement is here to stay. Dr. Cárdenas 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.

"There's no question in my mind that we're going to have to have control of the data that we generate as physicians because it is going to be our best defense," he said. "That's our data. It's up to us to find a way to demonstrate what it is we do, measure it in a way that we can look at the outcomes and determine if we're doing a good job or a bad job, and have that as our evidence as we move forward."

While Doctors Hospital uses an EMR system to collect some quality data, it is still looking for the optimal system that it can use hospital-wide, Dr. Cárdenas says.

Dr. Villamaria, however, says Scott & White has invested in a Web-based EMR system that can generate quality reports, plus give physicians instant access to patient and medical information.

"That may be one of the biggest improvements in quality - immediate access to medical information and medical data," he said. "It helps you to make better decisions quicker."

Scott & White's EMR system allows it to generate quality reports that physicians can use to assess their own quality of care. Department chairs and division directors also see those reports and use them for feedback and discussion with their medical staffs, Dr. Villamaria says.

Quality reporting is not just for large hospitals or hospital systems. Physician practices must measure their quality data, as well.

Family physician Sidney Ontai, MD, runs three telemedicine clinics in the Texas Panhandle from his solo practice in Plainview. Using an EMR system he purchased through a grant from the U.S. Department of Agriculture, he sends his quality data to the Medical University of South Carolina. Officials there analyze it and send back reports comparing his data with other participating practices across the country, as well as national baseline benchmark data on some 50 different measures, such as depression screening, measuring blood pressure, and mammogram rates.

Dr. Ontai uses the data to show his staff how the practice is doing on the various quality measures, and he enlists them in improving overall performance measures.

"It's gratifying to see how when I show my staff this data and we're all pitching in, we can really make the numbers move," he said. "It's kind of motivating."

Dr. Ontai also is helping other Texas physicians learn about and adopt these kinds of programs as chair of TMA's Council on Practice Management Services. 

Doing What's Right  

In the end, Dr. Williams hopes disseminating the TMA case studies report will prompt more Texas physicians to take ownership of quality and patient safety. But she says it is sometime difficult to make the "business case for doing what's right" because of the costs involved.

"If it's good for the patient, then it ought to be good for physicians," she said. "That's not necessarily the case because sometimes it does cost to implement these programs."

Dr. Kennerly says quality can actually save more in the long run.

"It's good business to do things right the first time," he said. "We have data that show when things don't go well, then actually it costs the organization more. Having high quality, it may cost you money to spend on it but it saves you money in general."

Dr. Cárdenas agrees. "I think there's a definite connection between doing excellent work, having a high-quality product, and seeing the economic advantage that that brings. Quality and the thrust toward quality drive the economics of the organization, as well."

To read the entire TMA case studies report, visit the  TMA Web site.

Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at Ken Ortolon.


Share Your Quality Stories

Are you involved in quality improvement or patient safety initiatives in your practice, clinic, or hospital? If so, TMA would like to hear about it.

Please email stories about your quality efforts to Nancy Bieri, director of the TMA Clinical Advocacy Department. 


Case Studies in Quality

Several other physicians participated in TMA's case studies report on quality and patient safety. Here's some of what they had to say about the quality improvement activities in which they are involved:

Thomas Blevins, MD, founder of Texas Diabetes and Endocrinology, a small group practice in Austin and Round Rock, says his practice uses its electronic medical record (EMR) system to maintain patient medication records to help them avoid adverse drug interactions or other medication errors. Staff members work as a team to rigorously review these medication lists to make sure they are complete and up to date.

I.L. Balkcom, MD, chief of staff, Hopkins County Memorial Hospital, says his facility established quality improvement teams made up of physicians, nurses, and administrators to look at performance issues such as administration time of tissue plasminogen activator in stroke patients and screening for deep vein thrombosis. The hospital also has ongoing quality improvement projects that have cut door-to-needle times for patients suffering myocardial infarctions, boosted smoking cessation counseling to 100 percent, and reduced times for administration of antibiotics in pneumonia cases to less than two hours after admission.

Austin Diagnostic Clinic (ADC), a multidisciplinary practice of 118 physicians in 22 specialties, collects quality data and shares that information publicly on its Web site, says Ghassan Salman, MD, ADC's chief medical officer. Dr. Salman says ADC also evaluates physicians' performance annually to give them direct feedback. Sharing such information is essential so that the physicians know their baseline performance levels, he says.

Gilberto Handal, MD, professor of pediatrics at Texas Tech University Health Sciences Center at El Paso, says the school shares physician-specific quality reports and routinely addresses underperformance on patient care standards. In the outpatient setting, Tech measures utilization of consultations and laboratory and imaging requests to attain greater efficiency and effectiveness.

Austin internist Isabel Hoverman, MD, says her small group practice is doing without an EMR system, but is still gathering data and measuring quality. They have developed a form to help them track performance on such things as colon cancer screening, mammography, and prostate-specific antigen (PSA) tests. They recently used DocSite to compile and submit quality data to Medicare's Physician Quality Reporting Initiative (PQRI). TMA-endorsed vendor DocSite off­ers TMA members a simple, free way to satisfy the PQRI requirements and qualify for incentive payments. DocSite is one of 32 registries the Centers for Medicare & Medicaid Services (CMS) has approved to transmit clinical data to Medicare for payment. TMA has vetted this company and arranged for TMA members to register, track patient PQRI data, and submit the data to CMS for free through DocSite PQRI ( www.docsite.com ). TMA member physicians should use the following code: TMAPQRI. TMA will identify DocSite registrants who are TMA members and make sure they can use DocSite PRQI for free. If you have additional questions, contact the TMA HIT Helpline at (800) 880-5720.

Norman Chenven, MD, chief executive officer and founder of Austin Regional Clinic (ARC), says his group has a culture of quality improvement that is open and proactive. The 230-physician multispecialty group conducts monthly peer review committee meetings. Physicians are encouraged to send quality and patient safety issues to the committee, and physicians review each other's work quarterly. Dr. Chenven also says ARC's board approved a self-funded pay-for-performance program to promote quality improvement in diabetes care.

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Seton Says Program Virtually Eliminates Birth Injuries

When Seton Medical Center launched a project to reduce birth trauma in four of its Austin-area hospitals in 2003, some officials believed some of those injuries were unpreventable.

However, implementation of some highly standardized protocols, improved communications between doctors and nurses, and extensive training in clinical simulation laboratories to prepare the labor and delivery team for unexpected complications reduced the birth injury rate in Seton's Austin facilities to virtually zero. For that, The Joint Commission in 2007 awarded Seton its prestigious Codman Award, presented annually to hospitals that achieve exceptional performance improvement.

The Institute for Healthcare Improvement is promoting the best practices in preventing birth trauma developed by Seton.

"Up until the time we did our project, the consensus was if you deliver babies, eventually you are going to have some who are injured. It's just something that's inevitable," said Frank Mazza, MD, Seton's vice president for medical affairs and member of the Texas Medical Association Council on Scientific Affairs . "We basically were able to show that, if you adhere to a certain process you could get down very close or even completely to zero."

Seton launched its birth trauma prevention project in 2003 as part of a broader preventable injury and death reduction project of Ascension Health, Seton's parent organization. Seton was assigned as the alpha hospital to conduct the birth injury reduction program, while other Ascension hospitals studied ways to reduce such preventable conditions as ventilator-associated pneumonia, central line bloodstream infections, pressure ulcers, and falls. Unlike most of those conditions, there were no well-defined best practices for birth injury prevention, so Seton essentially had to start from scratch to develop its own.

Dr. Mazza says Seton's program relied heavily on standardized protocols and simulation training using high-fidelity mannequins that can be programmed to mimic various crisis situations during labor and delivery.

"It's all about process," Dr. Mazza said. "Highly standardized protocols that are very specific are a well-known, well-established element that you have to do any time you want to change a complex system and make it better."

Five key elements of the Seton program included putting a "hard stop" on elective induction of labor before the 39th week of pregnancy. Dr. Mazza says fetuses are not physically mature before the 39th week, but elective inductions were widespread because they were convenient for either the mother or the obstetrician.

"We empowered people who were at the sharp end of care - nurses, unit secretaries, others - to say no to scheduling those elective inductions unless there was a medical indication," Dr. Mazza said.

Seton also developed protocols for the use of oxytocin, a drug commonly used for induction and augmentation of labor, and required physicians and nurses to jointly review and discuss fetal monitor strips, and reach joint interpretations of them to reduce errors. The hospitals also implemented the SBAR (Situation, Background, Assessment, and Recommendation), a tool to improve communications in critical situations. SBAR is a highly structured, terse method of communicating critical information quickly.

Finally, Seton drilled its labor and delivery personnel extensively in its simulation labs.

"Our concept was that in the area of obstetrics almost always what you get is a healthy baby and a healthy mom," Dr. Mazza said. "But when things go wrong, they really go wrong."

A team can't function in a highly effective way unless it has experienced some of those rare complications that can occur, Dr. Mazza says.

"What we do is we mimic an emergency and then we study how well the team performs in that emergency," he said. "We do this over and over again so that when the real emergency happens, they are more likely to be effective in how they communicate and how they deal with it."

Dr. Mazza says Seton got its injury rate down to zero for 18 straight months. Now it occasionally sees birth injuries, but those usually are nonpreventable, he says.

He also says Seton continues to develop new best practices in birth trauma prevention implemented throughout the Ascension Health system. 


Study Finds Bypass Surgery Better Than Stents in Severe Coronary Artery Disease

Coronary artery bypass grafting (CABG) "remains the standard of care" in severe coronary disease, according to a study published in the Feb. 18 edition of the New England Journal of Medicine .

However, an Austin interventional cardiologist says that doesn't mean that bypass surgery is the correct choice for every patient with arterial blockages.

The "Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery" (SYNTAX) trial researchers randomly assigned 1,800 patients with three-vessel or left main coronary artery disease either to CABG or percutaneous coronary intervention (PCI) with drug-eluting stents. After one year, they found more patients undergoing PCI experienced major cardiac and cardiovascular adverse events, including death from any cause, than did those undergoing CABG.

Rates of repeat revascularization were higher with PCI, but patients were more likely to suffer stroke after CABG, the researchers found.

They concluded that "CABG proved to be superior."

Participants were from 85 centers in Europe and the United States. A stent manufacturer paid for and participated in the study.

"The results of our trial show that CABG, as compared with PCI, is associated with a lower rate of major adverse cardiac or cerebrovascular events at one year among patients with three-vessel or left main coronary artery disease (or both) and should therefore remain the standard of care for such patients," the authors wrote.

Austin interventional cardiologist Robert Wozniak, MD, a consultant to the Texas Medical Association Council on Scientific Affairs, says the study is important in that it continues to challenge accepted practices in cardiac care. But, he says, physicians need to avoid a "knee-jerk reaction that everybody should have bypass surgery if you have this type of blockage."

PCI may be more appropriate for some patients, particularly if they are older or have comorbidities that would make it more difficult for them to fully recover from major surgery.

"I don't take away from it the conclusion that everybody who has this type of blockage should all go to bypass," he said. "One-size-fits-all is not going to work. There's a role for bypass surgery, but there is obviously a role for using higher-risk stent procedures in those types of patients who would certainly benefit from it."

Dr. Wozniak says cardiologists and cardiovascular surgeons must work as a team to determine which procedure is most appropriate for a specific patient. And, he says, they must do a good job explaining the pluses and minuses of each procedure to the patient and have the patient play an active role in deciding which approach to use.

Writing in Journal Watch Cardiology , Howard Herrmann, MD, suggests that, in deciding which approach to use, "the newly defined SYNTAX score (measuring lesion complexity based on angiograms) used in both the randomized trial and a registry of excluded patients could help inform clinical decision making."

Dr. Hermann is professor of medicine and director of the Interventional Cardiology and Cardiac Catheterization Laboratories at the University of Pennsylvania Medical Center. 


TMA's Quality Resources

Texas Medical Association President Josie R. Williams, MD, says physicians must prepare themselves and their practices for the increased accountability that the private and public sectors will demand of them.

TMA has the resources to help.

TMA's Department of Clinical Advocacy is ready to help physicians measure and improve the quality of care. Visit the department's  Performance and Quality Improvement Resource Center  page on the TMA Web site for a list of resources, including clinical performance and prevention tools; performance improvement project templates; and TMA's quality report, A Texas Medical Association Case Studies Report: Achieving Quality and Patient Safety in the Delivery of Health Care for All Texans.

Contact Nancy Bieri, BSN, RN, at (800) 880-1300, ext. 1400, or (512) 370-1400 for more information.

TMA's Health Information Technology Department is your trusted advisor providing education, unbiased advice, resources, and consulting services. One of those resources is DocSite, an effective care improvement tool that offers the following functions in the office:

  • Visit planning - getting the right questions and answers in front of the patient and physician while they are together in the office;
  • Outreach and recall - offering a simple way to find out who needs follow-up care and making it simple to contact patients to bring them in;
  • Performance monitoring - measuring the consistency and effectiveness of the care you provide, and measuring it while you still have time to enhance the results, before someone else grades your care; and
  • Team communication - showing each member of the health care team what a patient needs.

For more information about DocSite, click here. For more information about TMA's health information technology services, log on to the TMA Web site. You also can call the TMA HIT Helpline at (800) 880-5720. 

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