PowerPoint Presentation

Core Principles of Project Acceptability

Richard Tejedor, MDEQUIPS ForumMay 14, 2013Performance Improvement ProjectsObjectivesDefine the need for a set of principles that determine acceptability of a QI projectPropose a set of principlesDefine when these principles should be appliedDiscuss how education of core principles will assist physician trainees in their careerQI Reasons for ProminenceMedical Errors prominent reports in the literature.Institute of Medicine 1999 To Err is Human98,000 deaths in hospitals yearly preventable errorsHuge Media Stir Driver for huge changesQI Reasons for ProminenceSubsequent intense criticism of this reportFlawed statistical handlingSubjectivity in determining definition of medical errorSubjectivity in determining which deaths were due to medical errorErroneous assumption that 100% of patients would have survived

Healthcare disparitiesUS has best care in the world if the metric is recovery from disease, but:Large disparities in care existUS not well ranked at preventable diseasesMedicare as a government program Laws signed by President Clinton Sparked development of numerous agenciesQI Reasons for ProminenceHow are physicians affected?

Quality metrics motivatorsResulted in proliferation of guidelinesIn order to measure you need a metric (guideline)Centralized Control of Healthcare An important corollary to the use of metricsInconsistent buy in to metricsGood reasons to get involved

Physicians are in a good position to see problems and improve healthcare.Improvement requires change. Not all change is good.Unintended consequencesVA Comprehensive care management program (CCMP)

426 patients randomized to usual care vs CCMP

CCMPCOPD educationin individual and group sessions

Scheduledtelephone callsby a case manager

PRNprednisone and antibiotics, with a written action planVA Comprehensive care management program (CCMP)

Findings:Plan enroll 960 patients

At 426 patients Trial stopped whenan excess of deaths was observed in the intervention group

28 deathsfrom all causes in the COPD comprehensive care group vs.10in the usual-care group. Most deaths related to COPDUnintended Consequences

Unintended ConsequencesIncreased costs related to adherence without demonstrable improvement in outcomesComplex clinical decision making abrogates to formulaic carePathways may have inadequate consideration of comorbid conditionsPatient preferencesUndue influence of ScoringInappropriate use of medications to score wellAvoidance of sicker patients

Residency Initiative

All residents must be involved in QI. Patient safety, quality and value of care goals

In defining involvement, what are the goals of resident involvement?What values or skill sets will be learned?What do we hope to achieve through acquisition of these skill sets?Goals for Residency Quality Curriculum

A basic curriculum education on:BackgroundPatient safetyMethodologyLearn principles of acceptable quality initiatives core principlesKnowledge for improvement of existing initiatives - empower to create acceptable projectsStudy to define core principles

Hypothesis: A meaningful set of Core principles can be defined based upon lessons learned from the national experience on quality initiatives. Methods: Literature review focusing on a number of key phrases related to quality metrics. An appropriate set of articles were selected based upon relevance.

National experience has identified problems with:Scientific acceptabilityWidespread applicabilityProblems of undue influenceProblems of feasibilityAn explosion of quality initiatives burden to the system Study to define core principles

Findings: Core principles needed when: A QI project acts within a system as a prescription for patient care and/orProvider is measured to influence careHigh risk of adverse unintended consequences System resources will be usedCORE PRINCIPLES

ImportanceScientific Acceptability Feasibility (Usability) Absolute PerformanceWe will be looking at these principles in order to screen initiatives17CORE PRINCIPLESImportance Is there a performance gap? Is the focus of potentially high impact? Is an intervention likely to improve health outcomes? CORE PRINCIPLES

Scientific Acceptability

Evidence should be weighted as to quality. Endorsed national quality initiatives are preferred(1) Use GRADE system or similar(2) Expert opinion should generally not be used.2. May need IRB review as research

Performance initiatives would be guidelines converted to metrics that have already been evaluated for adherence to principles 19CORE PRINCIPLESFeasibility Is the plan actionable?

Use electronic data Target population identifiable? Data elements should be routinely generated Exclusions should be readily evident within the data sources.CORE PRINCIPLESRecognize absolute performance Potential of unintended consequencesScoringUndue influence on decision makingAvoid high risk patientsVA COPD initiativeCORE PRINCIPLESRecognize absolute performance 2. Appropriate for all entities?Race, sex, age and comorbid conditions?3. Outcome measures preferred over process measures Attention to adherence to a process without looking at outcomes can be associated with perverse consequences

SUMMARY

An important component of QI is physician engagementCore principles should be applied when QI projects involve:A prescription for careSignificant system resources Knowledge of principles will empower physicians to interact with the purveyors of quality initiativesTable 1Donabedian Dichotomy for Health Outcome MeasuresOutcome Measure CategoriesType of OutcomeDeathtechnical outcomeDiseasetechnical outcomeDisabilitytechnical outcomeDiscomforttechnical or interpersonal outcomeDissatisfactioninterpersonal outcome