Quality Improvement and EBM Mindy Smith, MD, MS

Why incorporate EBM into practice? Improves physician ability to provide effective care Provides data for educating patients Provides information for informed joint decision making May improve health outcomes

How to incorporate EBM into practice? Read the evidence (primary/secondary) Have evidence available at point of care Use electronic medical records (data collection, prompts, tracking, handouts) Create teams/systems of care Collect practice information (interviews, chart audits, summary data, surveys) Use information to improve practice Monitor quality of care

Quality improvement Iterative process of improving patient health by improving the care provided Best completed by involving all the “stakeholders” Important to maintain a learning environment and blame-free culture Critical to make the process transparent and the outcome explicit

What is the big deal? Ample evidence of quality problems Variation in services Underuse of services Overuse of services Misuse of services Disparities in quality

Further motivation You and your practice are and will continue to be monitored on quality indicators Board certification requires evidence of quality which will become more rigorous You will be paid for improving quality of care

Helpful partners IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century (2001) (www.iom.edu) AHRQ is also dedicated to developing, testing, and disseminating information on strategies to improve the quality of care (www.ahrq.gov)

Steps for quality improvement Decide on a problem to address Collect baseline data Design an intervention Implement the intervention Collect follow-up data Disseminate and discuss outcomes Determine if additional work is needed

The EBM/QI Exercise Overall goal: To provide the basic tools needed to perform QI in your practice Objectives: Learn the process of QI Locate and assess practice guidelines Practice designing a chart audit instrument, complete a audit, and analyze the data Discuss potential practice interventions based on the results of the analysis

Example: Asthma care First step: Identify the problem

Asthma care problems Forget to provide prevention (vaccination) Patients lack understanding of their disease Poor patient compliance with peak flow meters and medications Poor documentation in records Inadequate prescribing Lack of providing education

Are there guidelines? Where to look How to judge www.guideline.gov National institutes and organizations Local initiatives How to judge Evidence based? Agreement with other guides? Makes sense clinically?

Pitfalls in using Guidelines as Quality Measures Lack of evidence of effectiveness Severity of illness not considered Creators often specialist oriented Patient preference not assessed Physician judgment undervalued

Guidelines to consider for asthma care Key clinical activities for quality asthma care: recommendations of the National Asthma Education and Prevention Program (CDC) Global strategy for asthma management and prevention (NHLBI) Diagnosis and management of asthma (Institute for Clinical Systems Improvement (ICSI))

Designing the audit tool Simple Easy to complete and enter information Contain most important quality indicators based on evidence

Sample audit tool: asthma Assessment and monitoring Presence of spirometry report (>5 years old): Y N Severity classification present Y N Evidence of efforts to control triggers Smoking Y N Animal dander Y N Evidence of efforts to prevent/treat comorbid conditions Influenza vaccination (past year) Y N Pneumovax (ever) Y N

Your assignment Pick a clinical problem important to the group Find appropriate guidelines Choose quality indicators Create a practice audit tool by 9/15/06 Use the tool to audit 5-10 of your patient’s charts and bring to the next session