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How QI Saved My Bottom and Bottom Line

David M. Adelson, MD MS Associate Professor of Dermatology; Oregon

Health and Science University Chief, Dermatology Service, VA Portland Health

Care System

My views and opinions expressed herein do not necessarily state or reflect those of the United States Government, and shall not be used for advertising or product endorsement purposes. I have no conflicts of interests

Bottoms up!

Quality Improvement

QI Targets Defective Care

Inefficient Care

Underuse Care

Overuse Care

Patient Centered

Care

First Principle of Defective Care

To err is human and errors occur because

dermatology care is provided by humans

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IOM Report on Diagnostic Errors: How big a problem?

•  5% of patients annually experience a diagnostic error

•  10% of patient deaths •  Leading cause for malpractice claims

Slow vs Fast Thinking •  SLOW: Logical/Computational

–  Margins on excision –  Isotretinoin dosing –  Baysian logic calculated

•  Fast: –  Pattern recognition –  guestimation

Umpires

•  Binary decisions

•  Accuracy 92-94% •  Think they are more

accurate than they are •  CDM: ball path + strike zone

knowledge (subconscious) •  Detractions: stress, fatigue,

bias •  QuesTec system feedback

Physicians

•  1000s of diseases but reasonable choices < 10

•  Accuracy 90% •  Think they are more

accurate than they are •  CDM: pattern recognition

(subconscious) •  Detractions: stress, fatigue,

bias •  DST, feedback, cognitive

de=biasing

Question

What is more likely? P(A) OR P(AUB)

Kahneman: 3 heuristics can mislead

•  Availability •  Representativeness •  Anchoring and adjusting

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Cognitive Debasing Strategies

•  Consider alternatives •  Feedback •  Cognitive forcing strategies •  Specific training •  Awareness •  Metacognition •  Decrease reliance on memory

Acad. Med. 2003;78:775–780.

Mnemonics Cognitive Failure Can Screw A Medical Doctor

Second Principle of Defective Care

Systems should be designed to prevent, identify and limit

the effect of errors

Process Errors Sam came in for a follow up visit for his rosacea He leaves with a TB skin test and an order for a CBC

Wrong Patient Errors Process Errors

•  Mislabeling specimens •  Wrong site surgery •  Verbal Order miscommunication

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Forcing Function •  Hypertonic saline in cabinet with Normal saline–

dilution error risk •  E Prescribing list: Doxycycline next to Doxepin,

Methotrexate next to Metronidazole

Standardization •  Verbal order read backs •  Check lists •  Digital images of biopsy anatomic site •  Equipment location •  Medication monitoring guidelines

Resilience Engineering •  Concept of a complex adaptive system •  Proactive– what is likely to occur and how will it be

detected and mitigated? •  VA– teledermatology within a workforce designed

for low complexity/high volume •  Transparency of provider Press Ganey scores

Principle of Inefficient Care

Efficiency brings better patient outcomes, happier

staff and better returns

Business Case: Bottom Line •  Efficiency, cost, quality and trust are closely related •  No trade off between quality and productivity

(assuming waste is targeted) •  40% of health care dollars are waste

Reducing Process Inefficiency Waste

•  Fax/Scan workflow: Paperless fax –  Estimated saved 8 hours of staff time per week

•  VA referrals to community

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Process Improvement: Removing paper faxes from the

workflow Increase Free Time: Exercise (tone your bottom)

•  Leveling– messages and refills done between patients appointments –  2 patients 2 phone calls

•  Preclinical huddles and preparation

Principle of Underuse Care (Saving your ethical bottom)

Patients deserve the care they

need.

Care Disparities: Access

•  Hospitalized or nursing home patients •  Insurance •  Age •  Geography

Quality Improvement and Teledermatology

AccessDerm ECHO E- Consults E- Visits

Principles of Overuse Care

Patients deserve the care they need. Nothing less but

nothing more Care with no benefit can only

cause harm

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Helping patient choose care…. •  Supported by evidence •  Not duplicative of other tests

or procedures that have already been performed

•  Free from harm •  Truly necessary

Choosing Wisely •  Do not routinely use topical antibiotics on a

surgical wound. •  Do not routinely use microbiologic testing in the

evaluation and management of acne. •  Do not routinely prescribe oral antibiotics for

inflamed epidermal cysts

Mohs Choosing Wisely: Mohs micrographic surgery should not be used to treat uncomplicated, nonmelanoma skin cancer particularly less than 1 centimeter on the trunk and extremities.

Shared Decision Making •  Treatment of basal cell carcinoma •  Psoriasis treatment options •  Skin cancer screening in low risk populations

Quality

•  Vigilance •  Celebrate a safe environment •  Consider all: Defective, inefficient, underuse,

overuse care