1. High Value Quality Improvement Fellowship HVC Curriculum 2016-2017 Presentation 7 of 7

2. Learning Objectives Explain the rationale for engaging in HVC QI projects Explore one commonly used model for quality improvement Review high value care project ideas Select a quality improvement project focused on a high value care theme Promote a high value care institutional culture

3. Steps Toward High Value Care 1 Step one: Understand the benefits, harms, and relative costs of the interventions that you are considering Step two: Decrease or eliminate the use of interventions that provide no benefits and/or may be harmful Step three: Choose interventions and care settings that maximize benefits, minimize harms, and reduce costs (using comparative-effectiveness and cost-effectiveness data) Step four: Customize a care plan with the patient that incorporates their values and addresses their concerns Step five: Identify system level opportunities to improve outcomes, minimize harms, and reduce health care waste

4. Why is this important? HVC QI is an opportunity for you to: 1.Impact the quality, safety, and efficiency of care at your institution 2.Make care more patient-centered through improved communication and coordination 3.Work collaboratively with quality and safety officers, finance, and other health system leaders 4.Learn and practice leadership skills 5.Publish or present your results at a national meeting

5. Small Group Session: HVC QI Project Ideas HVC themes: reducing waste, minimizing harm, improving communication Subspecialty society Choosing Wisely lists: http://www.choosingwisely.org/clinician-lists/ http://www.choosingwisely.org/clinician-lists/ MKSAP Choosing Wisely Recommendations by specialty: https://hvc.acponline.org/clinrec_mksap.html https://hvc.acponline.org/clinrec_mksap.html

6. Problem Statement Current Condition Root Causes Sample QI Framework: A3 Roadmap Target / Aim Propose and Test Countermeasure Metrics Implement Successful Countermeasures

7. Reduce Unnecessary Preoperative Testing Internal Medicine Resident at NYU Collaborative project among medicine, cardiology, and anesthesiology Goal to decrease use of unnecessary pre-op cardiac testing for average-risk patients undergoing low-risk procedures Current condition step (chart review) identified pre- colonoscopy testing was a major contributor Root cause analysis underway….

8. Improve Vaccination Rates Objective: Assess vaccination rates in our HIV clinic and compare to national targets (Healthy People 2020) Methods: Demographic information and vaccine data from the past 10 years was imported from the EMR for all HIV+ patients seen in the clinic from Jan 2014 to June 2015 Results: 1762 HIV+ patients were seen during the study period. The vaccination rates were: Pneumovax 65% (goal 60%), Pneumovax in ≥ 65 yo 73.2% (goal 90%), Prevnar13 35.5% (goal 60%), Tdap 53.6%. Conclusions: The vaccination rate in our HIV patients is lower that the national targets for most of the vaccine types Possible Interventions: Use influenza vaccination “season” to update vaccination in our HIV patients; incorporate a vaccine “dot phrase” in every follow-up note to assess vaccination status; provide quarterly feedback to providers; initiate an annual nurse appointment for vaccination review

9. Reduce Unnecessary Daily Labs Hematology-Oncology fellow at University of Penn 87% of Internal Medicine Residents said they order routine daily labs regardless of how they alter management Root cause analysis identified several causes: cut and paste habit, no cost transparency, and concern attending will ask for them Housestaff-led initiative across all departments at UPENN has led to a decrease in wasted daily CBC’s and BMP’s by 9% over the past 6 months

10. Improving Follow-up among Patients Living with HIV Problem A subset of patients followed in the HIV clinic fail to follow up despite uncontrolled HIV infection Goal Improve retention in care, increase ART use, and achieve viral suppression in patients with uncontrolled HIV infection Intervention Identify patients with detectable VL (7/1/14 - 12/31/14) who did not have a scheduled follow-up as of 3/1/15 and contact them to make an appointment Results Of 96 patients with detectable VL, 28 had no scheduled follow-up More patients with scheduled follow-up had seen a social worker within the past year After 3 months, 17 (61%) scheduled, 9 (32%) attended, 4 (15%) declining VL, 1 suppressed VL Conclusions More intensive outreach involving social work and clinicians is needed in this subset of patients Automatic social work intervention at appointments for patients with a history of being lost to follow-up

12. Next Steps Identify stakeholders Build a team and assign roles Define the problem and the aim of the project with input from key stakeholders Clarify timeline for projects and mentorship plan

13. References 1.Adapted from Owens D et al. High-Value, Cost-Conscious Health Care: Concepts for Clinicians to Evaluate the Benefits, Harms, and Costs of Medical Interventions. Ann Intern Med. 2011;154:174- 180 2.Landon BE et al. Improving the management of chronic disease at community health centers. N Engl J Med. 2007;356:921-934 3.Djuricich AM et al. A continuous quality improvement curriculum for residents. Acad Med. 2004;79(10 suppl):S65-S67 4.Holmboe ES et al. Teaching and improving quality of care in a primary care internal medicine residency clinic. Acad Med. 2005;80:571-577 5.Shojania KG et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Vol 1. Rockville, MD: Agency for Healthcare Research and Quality. 2006:14-18