Robin R. Hemphill
In contrast to “patient safety,” which is concerned with those events that should never happen to patients as they interact with the healthcare system, quality improvement may be defined by concern about all the things that shouldhappen to patients to increase the likelihood of desired health outcomes and to meet their expectations. This goal is challenging to achieve because it is so broad. In Crossing the Quality Chasm, the Institute of Medicine (IOM) has offered a blueprint that identifies and classifies the elements of quality through six desired characteristics of quality care (1):
1. Safe: Care should be free from preventable harms (see Chapter 379).
2. Effective: Evidence should be applied to the delivery of care.
3. Efficient: Resource use should be assessed in achieving desired results and waste should be removed.
4. Timely: Waits and delays should be understood and minimized.
5. Patient centered: The health system should focus around the goals and needs of the patient and respect the decisions and preferences of the patient.
6. Equitable: Disparities in care should be removed.
To achieve these, administrative leaders require a set of skills that focus on patients, the use of data, and the engagement of the healthcare workforce.
QUALITY IMPROVEMENT PROCESSES
Industry has developed a variety of systems to guide quality improvement efforts, many of which can be applied in the emergency eepartment (ED) setting. The goal is to develop a system that consistently delivers the correct care to a patient at the best price in a manner that meets the patient’s expectations. A guiding principle is that one must understand the goal to be achieved before determining how to accomplish it. Specific methodologies for improving quality are summarized in Table 380.1. Each follows a procedure of repeated testing and intervention.
TABLE 380.1
Comparison of Improvement Process Methods
IMPROVEMENT PROCESS METHODS
Plan, Do, Study, Act (PDSA) Cycle
This is a method of trial and error carried out over a series of small cycles (2). Small tests of change are attempted before proceeding with broader implementation.
• Plan: In this phase it is helpful to consider three questions (3):
1. What are we trying to accomplish?
2. How will we know change is an improvement?
3. What changes might allow the desired changes to be achieved?
• Do: Carry out the plan on a small scale, identifying problems, and make other observations. Data analysis begins here.
• Study: Assess the effects of the initial change and compare them to those which were aimed for. Summarize the lessons learned and identify any further changes that appear to be needed.
• Act: Decide whether the cycle should be repeated with modifications or whether the initial goals have been achieved. Note any remaining gaps in desired performance and determine whether additional PDSA cycles should be undertaken.
Lean Methodology
Lean thinking focuses on improving flow and reducing cost by removing activities or processes that use resources but create no value. This is referred to generically as “waste.” This includes waste of over- and underproduction, waste of inventory (e.g., unused medications which may expire), waste of rework (e.g., redo of x-rays when poorly done), waste of motion (e.g., repeatedly checking to see if a patient has returned to a room after testing), waste of waiting (e.g., both providers and patients waiting on laboratory tests prior to disposition), waste of processing (e.g., decreasing steps of ED triage process), waste of transporting (e.g., excessive distance from the ED to the cath lab). Lean processes also focus on improving the delivery of services or products by aligning the best steps in the best sequence. Simplification of processes can result in less variation and more consistent output.
Six Sigma Methodology
Six sigma refers to a control process in which 99.99966% of outcomes are within the desired range of acceptability. Opportunities for improvement or for correction of problems are identified through a series of steps (DMAIC): Define the problem and the improvement objective, Measure each of the process steps, Analyze the collected data to provide insight into the process, Improve the process by developing solutions and changes, and Control the process if it is performing at the desired level, while continuing to monitor for unexpected events. This methodology is based on the idea that reduction of variation leads to both consistent output and improved efficiency.
QUALITY MEASUREMENT
Measures of performance are critical to the ability to improve. Appropriate quality measures are essential to improving care in the ED setting and increasingly there is an expectation that performance data will be made available to the public. Emergency medicine providers currently have a variety of externally imposed quality measures (some of dubious value) (4,5), and there is a need to develop measures that better reflect the quality of care that emergency physicians wish to provide. The Centers for Medicare and Medicaid now require reporting of a variety of performance measures. Examples relevant to emergency medicine providers are listed in Table 380.2.
TABLE 380.2
2013 PQRS Measures Relevant to Emergency Medicine
When determining what to measure it is important to take into account how such measures will be used. Measures developed to help understand performance may later become measures used to enforceperformance. This shift in use is unhealthy since it may induce providers to resist the development of other measures in the future.
Desirable characteristics of quality measures are listed in Table 380.3 (6).
TABLE 380.3
Desirable Characteristics of Quality Measures
APPROACHES TO IMPROVING QUALITY
• Meaningful engagement of physician leaders is critical if long-term gains are to be made in both quality and safety. Leaders give legitimacy to improvement efforts, tie them to strategic priorities, and can direct needed resources. Change will not be achieved by the efforts of only a few committed individuals on the front line. Quality and safety should be a part of every staff meeting.
• Emergency physicians should take part in the development of quality measures relevant to emergency practice. Performance data should be transparent and accessible. Decreasing practice variation may provide opportunities to improve patient care. Processes should be standardized when appropriate. This includes the use of clinical pathways.
• Initial ED improvement efforts should focus, whenever possible, on areas where there is widespread support for change.
• Patients and families may give physicians critical insight into ways they may improve the delivery of care in the ED.
• Develop strategies to understand and limit procedures and tests that are overused in the ED (7).
• A particular focus should be on improving transitions of care. This includes handoffs between emergency physicians during turnover, handoffs when admitting patients to inpatient settings, and the patient discharge process. Quality and safety are compromised by the limits of human cognition, particularly in the ED setting. A deeper understanding of how decisions are made may provide opportunities to recognize the limits of clinical judgment and to take this into account when designing ED protocols and procedures (8).
Common Pitfalls
• Failure of leadership. Just as leadership can support quality management, it can also obstruct it. The ED leader must constantly demonstrate visible support for the quality effort.
• Prioritizing physician autonomy over appropriate standardization of care.
• Using quality improvement measures as performance measures.
• Failure to develop meaningful performance measurements. Often things are measured because they are easy to measure, not because they matter.
• Failure to sustain gains made during improvement projects. It is important to cement gains that have been made before moving from one project to the next. Cooperation will wane if the work put into quality efforts does not result in long-term improvement.
REFERENCES
1. Institute of Medicine. Crossing the Quality Chasm: A new Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
2. Berwick DM. Developing and testing changes in deliver of care. Ann Intern Med. 1998;128(8):651–656.
3. Langley GJ, Nolan KM, Nolon TW, et al. The Improvement Guide. 2nd ed. San Francisco, CA: Jossey-Bass; 2009.
4. Pines JM, Isserman JA, Hinfey PB. The measurement of time to first antibiotic does for pneumonia in the emergency department: A while paper and position statement prepared for the American Academy of Emergency Medicine. J Emerg Med. 2009;37:335–340.
5. Silber SH, Garrett C, Singh R, et al. Early administration of antibiotics does not shorten time to clinical stability in patients with moderate to sever community acquire pneumonia. Chest. 2003;124:1798–1804.
6. Harrington L, Pigman H. Quality measurement. In: Varkey P. ed. Medical Quality Management: Theory and Practice. Burlington, MA: Jones and Barlet; 2010:
29–41.
7. Choosing Wisely Campaign. An Initiative of the ABIM Foundation. Available online at: http://www.choosingwisely.org/doctor-patient-lists/. Accessed May 30, 2013.
8. Kelly JJ, Thallner E, Broida RI, et al. Emergency medicine quality improvement and patient safety curriculum. Acad Emerg Med. 2010;17:e110–e129.