Making Strides in Quality Improvement

“Quality,” according to William Edward Deming, an icon of the quality movement, “is a never-ending cycle of continuous improvement.”

Historically, quality improvements within healthcare have been attempted through many incremental efforts, in both the inpatient and outpatient arena, with mixed success. The Southern California Permanente Medical Group’s (SCPMG) experience, however, has shown that only when physician groups work every individual piece of the system can they achieve the dramatic improvements in healthcare that physicians desire for patients. It is critical that physician groups and caregivers challenge the entire system process, stop what does not work, and not be afraid to try something new.

This article will look at several areas of quality improvement efforts by SCPMG including technological advances and patient care, as well as overall system challenges. The path to quality improvement is challenging, but required during this time of increasing demands for quality, affordable, and accessible healthcare.

The Changing Face of Healthcare Technology

The most substantial quality improvement effort for SCPMG has come in the form of an organization-wide investment in healthcare information technology. Kaiser Permanente HealthConnect (KP HealthConnect) is a $4 billion information systems investment, and is a critical foundation for improving the patient experience and effectiveness of care.

KP HealthConnect helps ensure that caregivers, in both the ambulatory and inpatient setting, have the information they need to provide the right care at the right time. Evidence-based medical knowledge and best practices that address many of the key effectiveness of care measures are built in to provide clinicians with point-of-care decision support. The system makes it easy and convenient to connect patients to the people and services that they need to keep themselves and their families healthy.

The system provides innovative tools that enable SCPMG physicians to deliver high-quality, safe, and efficient care in new and unique ways by integrating care across the continuum. With 24/7 access to information at every point of contact — in the appointment call center, exam room, pharmacy, hospital and even online — KP HealthConnect increases healthcare access, fosters more patient-centered care, and enhances staff and physician satisfaction.

Alongside KP HealthConnect, SCPMG uses a robust disease management registry called POINT (Permanente Online Interactive Network Tools), which is a stand-alone system unique to KP Southern California. POINT is used in population-based medicine to assist physicians in providing evidence-based treatment. Within Kaiser Permanente’s integrated healthcare delivery system, POINT is a robust tool with access to information from the labs, pharmacy, and visit data. By mining POINT data, SCPMG is able to identify care gaps and conduct multi-tiered patient outreach to significantly improve outcomes.

Challenging Systems

Technology is just a portion, albeit a critical component, of SCPMG’s overall quality improvement program. In addition, SCPMG maintains a system focus through the use of multidisciplinary team involvement within the inpatient setting. SCPMG’s multidisciplinary teams include hospital-based physicians, ED physicians, nurses, and pharmacy and quality improvement personnel. Quality reviews and interventions are performed prior to patient discharge, allowing physicians to identify issues and apply best practices in a timely manner.

Additionally, SCPMG utilizes a rapid cycle improvement process in order to fast track quality improvement efforts. This is the practice of breaking down complex systems and issues into smaller, more manageable pieces, and then focusing on the individual components. This approach offers an important tool for healthcare teams frustrated by the slow pace of other improvement methods.

Using rapid cycle improvement, the team sets a global outcome measure based on the system’s goals. Improvement occurs through small, rapid PDSA (Plan, Do, Study, Act) cycles of change. At the completion of each PDSA cycle, a decision is made to adopt and implement the change, to adapt the change (as a result of conducting PDSA cycles under a variety of conditions), or to abandon the change. By emphasizing the testing of improvements on a small scale — identifying and focusing on one component of performance at a time — rapid cycle improvement enables a more expeditious completion of the overall strategy.

Clinical Strategic Goals: 2007, A Year of Great Strides

Each year, SCPMG selects clinical quality goals to help improve care. The physician group designates a handful of the clinical strategic goals (CSG) as “imperatives,” the highest-priority goals for clinical improvement.

In identifying specific clinical measures as imperatives, SCPMG is focusing on improving care in measurable ways that make a real difference to patients. Raising performance on quality measures like chronic disease management and cancer screenings, the physician group is improving health and saving lives.

Through August 2007 (the most current data available), SCPMG has made improvements on almost all of its 2007 CSG imperatives, including cancer screening rates, blood pressure control, lipid control, community-acquired pneumonia, smoking cessation, and hospital care for members with acute myocardial infarctions.

Since the beginning of the year, SCPMG has shown strong improvements in the following areas:

• Preventive cancer screenings. Colorectal cancer screening rates continue to improve significantly, rising 8.7 percent year to date.
• Controlling blood pressure in members with hypertension.
• Counseling members who smoke. Results from the SCPMG’s Ambulatory Satisfaction Questionnaire (ASQ) indicate improvements in patient perceptions that the physician group is advising them to quit (up 8 percent year to date) and offering strategies and/or medications to support them (up 7 percent year to date).
• Hospital care for patients admitted with:
• Pneumonia
• Heart Failure
• Heart Attack

Among SCPMG’s successes during this past year, controlling blood pressure in members with hypertension proved to be a stand-out. The physician group has made considerable progress in this area over the last few years, helping patients with hypertension live healthier, longer lives.

A recent study by Kaiser Permanente’s Care Management Institute (CMI) forecasts the number of strokes and heart attacks that can be prevented when patients and physicians maintain hypertension control. Based on this forecast, by improving the hypertension control rate to 80 percent from its current rate of 74.9 percent, and maintaining that improvement for five years, SCPMG could potentially prevent 650 strokes and 470 myocardial infarctions.

One area that remains a challenge is helping patients with diabetes control their glycemic levels. Control rates have declined slightly since the beginning of 2007.

In a recent SCPMG study, patients who attended one of the group’s “Living Well with Diabetes” health education courses improved their HBA1c levels by one or two percentage points within three months. Thus, indicating that health education may be an important part of the solution to improving outcomes and performance on this measure.

Partnerships for Better Health

Engaging patients to actively participate in their own healthcare is key to long-lasting, overall quality improvements. SCPMG clinicians identify and engage high-risk patients and those with chronic illnesses in comprehensive disease management programs with strong outreach and health education. By emphasizing prevention and wellness, and by providing easy access to health improvement programs, education, incentives, and decision support tools, SCPMG creates the foundation necessary for physician/patient partnerships focused on achieving the best possible health.

Looking Forward

As the enormous pressure to rapidly improve healthcare systems continues to rise, SCPMG will push forward in its challenge of the status quo, in an effort to improve access and the effectiveness of care, and enhance physician and staff satisfaction.

It is important to remember that successful quality improvement is dependent upon the ability to challenge one’s own thinking about organizational processes, and challenge all parts of the current system. Quality takes time and an ongoing, sustained commitment.