1. Quality Improvement and EBM
Mindy Smith, MD, MS

2. 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

3. 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

4. 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

5. 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

6. 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

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

8. 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

9. 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

10. Example: Asthma care
First step: Identify the problem

11. 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

12. 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?

13. 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

14. 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))

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

16. 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

17. 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