Engaging in Quality Improvement Efforts

The Medicare Access and CHIP Reauthorization Act (MACRA) is poised to transform the health care system by paying participating providers based on quality of care. Under MACRA, a percentage of physician payment is based on value, and high-value care is measured by several factors, including quality.

Quality improvement (QI) efforts are critical for physicians who participate in MACRA. In fact, failure to report improvements can mean a reduction in Medicare reimbursement payments. The following steps can help physician practices successfully plan and execute QI initiatives.

QI should be part of a practice’s mission, according to Kevin Shah, MD, an internist and the medical director of Primary Care Innovation and Improvement at Duke. “Practices need to look at improvement as their business,” he says.

However, improvement shouldn’t be limited to a single task or project. “If you’re a practicing group and you’re not constantly asking yourself, ‘How do we do it better? How do we evolve to make our care better?’ I think there’s a conversation there about what’s the culture of that practice and how do we change that culture,” Shah notes.

Improvement isn’t just a physician-focused activity, either—everyone working at a practice should be involved in QI efforts. For instance, a medical assistant in Shah’s clinical practice observed that the existing protocol for administering flu shots caused significant delays and, in some cases, resulted in patients leaving because the office was so backed up. Based on that observation, Shah’s clinic changed its flu shot program, and medical staff now administer flu shots before patients see providers.

After an organization commits to focusing on QI efforts, the next step is determining potential areas for improvement and developing measurable and time-specific goals.

Jackie Coult, a health care consultant and member of the National Society of Certified Healthcare Business Consultants, advises physicians to review the established QI measures put forth by the Centers for Medicare & Medicaid Services and their health insurance payers and then select the measures that are appropriate for their goals. “Once [physicians] inventory that, they can identify the [measures] that will actually really help them in their quality outcomes,” Coult says.

Many hospitals and larger medical groups have their own set of quality measures in place. For example, Duke Primary Care has explicit measures for its more than 200 providers, Shah explains. These include a composite of several quality measures for diabetes and coronary disease, as well as breast cancer screening.

After identifying QI goals, practices can begin data collection and analysis. According to Shah, it is crucial to determine the kind of data and information to collect and choose a capture method that accurately measures effects on patients and is meaningful to providers.

The American Academy of Family Physicians (AAFP) states that data collection and analysis lie at the heart of QI. In its guide to the basics of QI, the AAFP explains that data can help physicians understand how well systems work, identify potential areas for improvement, set measurable goals, and monitor the effectiveness of change. The guide also notes that it is important to collect baseline data before embarking on a QI project, commit to regular data collection, carefully analyze results at the end of the project, and then make decisions based on that analysis.

However, data capture and storage often pose a workflow issue, and inefficient systems can frustrate health care providers and staff and place an additional burden on an already overworked health care team. Although technology and electronic health records (EHRs) have come a long way, not every EHR vendor includes data collection features to facilitate QI efforts. Outsourcing data collection is one option for physicians, Coult says. Practices with data collection hurdles might find it beneficial to join an accountable care organization or even merge with a larger management organization to handle those concerns, she adds.

Technical issues don’t have to hinder QI efforts, though. If a practice’s goal is to increase mammogram screenings, front-office staff can make outreach calls to patients to schedule mammograms and record the number of scheduled screenings on a paper or electronic spreadsheet.

Analyzing data and making decisions based on that analysis is a skill that all providers should develop in order to keep up with the ever-changing health care industry. “Being able to look at data and then develop systems to improve upon that data—that is quickly becoming the core business of health care,” Shah says.

Improving patient outcomes is the goal of many QI projects, and it’s important to communicate priorities, actions, and results to staff members and patients. Additionally, take time to acknowledge and celebrate a project’s success, which can boost staff and patient morale. For instance, when Shah and his team were working on improving breast cancer screening rates, patients were impressed that their providers were analyzing data outside of their visits. Patients also appreciated the support they received from Shah’s team during QI efforts focused on reducing hospital readmissions and improving transitions of care.

“We [strive to] practice great medicine, but there’s always room for improvement,” Shah says. “I think most physicians would agree with that, and actually being able to look at your own data and ask, ‘How much improvement can be made?’ is a really important and critical piece of information.”