In this edition, Colleen Morton, MBBCh, MS, talks about teaching quality improvement. Dr. Morton will also be discussing quality improvement in the changing U.S. health-care system at the 2016 ASH Annual Meeting (read more here).
As clinicians, we are charged with providing patient care, and we also have a duty to improve care. Quality improvement – though it is probably most commonly thought of in terms of cost-containment – is essentially an opportunity to improve patient care. While cost-containment is certainly a goal, improving the full patient experience is always our objective. What more reason do we need to make quality improvement a part of training?
Quality is quickly becoming a larger part of our lives as hematologists. Programs from the Centers for Medicare & Medicaid Services (CMS) like Hospital Value-Based Purchasing, the Physician Quality Reporting System, and the Merit-Based Incentive Payment System, are changing the way we practice.
Right now, these measurements don't include many hematologic parameters, but it is the way we're all moving. We have to prove that we are delivering quality care more and more.
Historically, quality has not been a standard part of the training curriculum. Quality improvement – an evolving cycle of identifying a problem, planning a solution, executing that plan, and evaluating its progress – is a new concept for medical educators.
Learning to Teach Quality
Randy Hurley, MD, head of the Department of Hematology and Oncology at HealthPartners, and I joined other University of Minnesota faculty in completing a Teaching For Quality Program (Te4Q). The Te4Q program, sponsored by the Association of American Medical Colleges, trains clinical faculty on how to effectively teach quality improvement.
We learned what we needed to have in place to implement a quality improvement training program for our hematology/oncology fellows, how to evaluate trainees, and, in turn, how to have the trainees evaluate us.
The biggest hurdle to overcome, though, was actually getting people to understand the value of this kind of training! Our residents and fellows have been raised at academic institutions, where the emphasis has always been placed on research and publishing. Quality improvement hasn't been thought of in the same way as research.
I only started to appreciate the value of quality improvement when I participated in a Quality Improvement Advanced Training Program at the Park Nicollet Institute and realized that the quality improvement project I planned had failed miserably.
In an effort to reduce inappropriate testing for heparin-induced thrombocytopenia (HIT) at my institution, I developed an electronic medical record (EMR)-based decision support that asked clinicians to calculate patients' 4Ts score before ordering the HIT test. My goal was to reduce the number of HIT tests ordered and to reduce inappropriate testing. At first, the numbers suggested that the project was successful: the number of tests ordered was reduced by 17 percent and the number of positive tests increased by 50 percent.
But, when I looked deeper into the orders and medical records and followed the proper quality improvement process, I discovered that, in reality, I had accomplished nothing! Half the tests ordered were still inappropriate, and a survey of clinicians revealed that two-thirds of providers were not using the decision tool or the 4Ts score. Furthermore, 25 percent of patients who had a positive HIT result did not receive treatment.
Following the quality improvement process, I re-evaluated the project to determine what went wrong. The flaw of the protocol was that clinicians could ignore what I added into the EPIC system to try to alter practice. Also, we didn't track the use of the tool or of the 4Ts score, but just assumed that people would embrace it.
Today we have a newly designed tool that forces clinicians to run the 4Ts score and, when placing the order for the HIT test, it directs clinicians in how to administer therapy.
This project taught me a basic principle of quality improvement: You don't know what you're doing until you can measure it properly.
How We Teach Quality Improvement
While our program is still in its infancy, we are lucky to have access to a training program for fellows and residents from Park Nicollet. This includes an online training component and lectures. With faculty support, we also require the fellows to execute a quality improvement project, so it's a hands-on approach in which learners apply knowledge to real-world clinical practice.
This is a crucial element, because if trainees don't go through the process themselves, they aren't likely to understand the value of quality improvement training. Having trainees design and implement their own projects helps them grasp the reasons behind quality improvement, the importance of these efforts, and how to use these tools in their clinical practice going forward.
When we work with fellows, we help design the project, implement it, and then collect and analyze the data. The fellows are welcome to come up with their own projects, but we also have a list of potential projects that we think would be good for the fellows to tackle. We meet with a statistician during the initial planning stages so that we can have his or her input from the beginning, to ensure that we'll end up with usable, relevant data to determine if the project was successful. Even if a project is unsuccessful, we still learn about other aspects that might have been overlooked in the initial stages.
How Our Fellows Are Tackling Quality Improvement
I am working with four fellows on their quality improvement projects. One is looking at improving fibrinogen testing in patients who receive massive transfusions. As part of a Transfusion Committee review, we discovered that only 20 to 30 percent of patients who received a massive transfusion had fibrinogen activity tested.
Fibrinogen, of course, is crucial for clotting, so if a patient's fibrinogen level is low, he or she won't clot. We also discovered that 38 percent of the patients in whom fibrinogen was measured had low fibrinogen levels. Of these patients, 40 percent did not receive cryoprecipitate to increase their fibrinogen levels.
We designed an EMR-based tool that automatically orders labs (including fibrinogen activity testing) as part of the massive transfusion protocol (MTP). The EPIC tool is built with a best-practice alert: If the results of the labs show the fibrinogen activity is low, the clinician is alerted to order two units of pooled cryoprecipitate. This is an ongoing project; we are collecting data (including patient demographics, lab results on admission, anticoagulant use, use of blood and other products), and plan to analyze the effect that this amended protocol has on fibrinogen testing, cryoprecipitate use, and outcomes.
In another example, a fellow is examining the placement of inferior vena cava (IVC) filters in non-trauma patients. Inappropriate use of IVC filters is a problem; the devices themselves are expensive and, in most cases, unnecessary. Again we have developed an EMR-based tool that requires the clinician to select an indication for the IVC filter placement (i.e., a patient with venous thromboembolism [VTE] who cannot be anticoagulated, a patient with pulmonary embolism and hypotension, or a peri-operative patient who cannot receive anticoagulation for a recent VTE). The protocol also requires a consult with an interventional radiologist. By implementing this process, we are hoping that we can reduce inappropriate use and ensure that IVC filters are eventually removed. (For more on the IVC debate, see the Drawing First Blood debate: Should IVC Filters Be Inserted into Thrombosis Management Guidelines?)
Many of our fellows' quality improvement projects involve simple measures such as adding a prompt in the IT and EMR system that makes it easier for clinicians to do the right thing.
Making Room for Quality Education
Quality improvement, in theory, sounds simple, so why isn't it a commonplace practice?
There are multiple reasons. First, faculty members need to be trained in quality improvement. Second, they need to have the time and resources to train residents and fellows. Scarcity of time, as with every aspect of clinical practice, is a barrier. Luckily, quality improvement projects usually do not require much funding – aside from the necessary resources to pay for statistical work, data collection, and information technology time. However, depending on the amount of data collection and analysis needed, it could be conducted by the fellow who is in charge of the project.
Each institution is different, of course, and some won't have the resources to establish a formal teaching program. We are fortunate to be a part of an organization where we have a quality improvement training program for faculty and trainees, but there are other options available to educators and learners, such as online modules and training programs. For instance, the Institute for Healthcare Improvement Open School program offers courses in quality, cost, and value that are free of charge to residents and fellows. Giving faculty and trainees access to this type of training is an important first step.
Next, you have to provide trainees with opportunities to act on what they learned. Come up with a variety of projects; involve them in the process, have them troubleshoot, ask them to think of ideas of what can be done, and help them implement the plan and measure the outcomes.
Overall, our mission is to raise awareness about the importance of quality improvement. There's a misconception that publishing papers about quality improvement initiatives is difficult, but quality improvement is scalable: it can be very small or very big.
Depending on how the analysis is performed and the amount of data collected, a quality improvement project can evolve into a full-fledged research project. And, if one institution has discovered a problem, there is almost certainly another institution with the same problem. Sharing the data we gather can help us learn best practices from each other.
In my opinion, quality improvement is a fun and enjoyable process that can produce results rather quickly. A quality improvement project like the ones our fellows are working on can have a turnaround time of three months, compared with a research project that can take years to show any tangible results. It's a satisfying process and something that a fellow can easily do in a short period of time.
And, regardless of the perceptions, these projects produce publishable data. Leading one of these efforts also looks good on your resume. When quality starts becoming a larger part of our daily lives as clinicians, what institution doesn't want someone who knows how to improve quality?
Importantly, quality improvement training can be incorporated at every level of the hospital and at any academic institution or private organization. Our internal medicine residents are actively conducting these types of projects, and it has become a fundamental part of their training curriculum. Still, this type of training isn't widespread and recognized as a valuable part of hematology/oncology training. That needs to change.
Major and ongoing changes in the U.S. health-care system have made quality a larger part of caring for patients. In response to these changes, hematologists – particularly those specializing in non-malignant blood diseases – are exploring an innovative, sustainable new role: the "systems-based hematologist."
The role of the systems-based hematologist is still being defined, but an ASH report published in March 2015,1 highlights multiple areas where involving the systems-based hematologist would lead to cost-effective decision-making. At this year's ASH annual meeting, the systems-based approach will be the focus of an Education Spotlight Session, in which Dr. Morton will discuss the role of the systems-based hematologist in a community-based, health-care system.
Read below for some details – and make sure to add it to your annual meeting agenda in December.
- Systems-Based Hematology: A New Career Path for Hematologists
Chair: David Garcia, University of Washington, Seattle, WA, United States
- Why Systems-Based Hematology? (Community-Based System)
Colleen Morton, Regions Hospital, Saint Paul, MN
Janice Lawson, Tallahassee Memorial Hospital, Tallahassee, FL
- Why Systems-Based Hematology? (Academic-Based System)
Marc Zumberg, University of Florida, Gainesville, FL
Nathan Connell, Brigham and Women's Hospital, Boston, MA
- Why My System Supports a Systems-Based Hematologist
Brian Rank, HealthPartners, Bloomington, MN
Thomas Staiger, University of Washington Medical Center, Seattle, WA
- Wallace PJ, Connell NT, Abkowitz JK. The role of hematologists in a changing United States health care system. Blood. 2015;125:2467-70.