QI talk: How do you improve the performance of medicine?

by Jolene Singh

At our last didactic, Dr. Mark Zeidel talked to us about Quality Improvement (QI) initiatives in the inpatient setting.

First he tried to disabuse us of the notion that good medicine involves individual "physicians [who] can craft a unique diagnostic and treatment regimen customized for [every] patient."

This ideal is not good for patients because it leads to operational inefficiencies--i.e. when orthopedic surgeons in the same service each order different knee implants, patients do not benefit from the cost-savings that bulk orders yield--and poor continuity of care--i.e. ventilator settings that are changed at each new shift unnecessarily increase nursing workload and do not benefit patients.

To solve the problems created by "craft-based practice" models in which individual physicians come up with unique regimens with varied "quality" outcomes, "profession-based practice" models in which groups of peers treating similar patients in a shared setting develop a standard approach (i.e. agree to use the same knee implant or standardize orders for ventilator settings) have been very successful at decreasing morbidity and mortality. Several successful pilot programs were cited including: Global Risk Assessment and Careplan for Elders (GRACE), the Triggers program, and the MUST protocol.

To implement QI in the outpatient setting, it might be worth considering how ambulatory access might be improved. In our clinic, QI projects might also include the development of peer-review processes to detect areas for improvement and/or opportunities to standardize the delivery of chronic disease care.

Importantly, having coordinated/standardized care delivery plans does not mean there's no room to adapt to patient-specific needs. An appropriate reason to vary from a validated standard practice would include working with "idiosyncratic patients" who do not fit the profile of the other patients who have been shown to have successful outcomes with the protocol. Instead QI initiatives provide an opportunity for evidence-based practices to be systematically implemented, assessed and adopted--ultimately this minimizes variations in care based on what individual physicians can 'craft' and thus far the evidence has shown that standardized practices produce significant benefits to patients.

For more on ...
GRACE, visit: http://www.bidmc.org/QualityandSafety/EffortstoImproveQualityofCare/QualityandSafetyatWork/~/media/Files/QualityandSafety/2011%20Silverman%20Symposium/Effectiveness/Global%20Risk%20Assessment%20and%20Careplan%20for%20Elders%20%20GRACE%20%20Revised%20%202.ashx

The Triggers Program, visit: http://www.bidmc.org/QualityandSafety/EffortstoImproveQualityofCare/QualityandSafetyatWork/~/media/Files/QualityandSafety/2012%20Silverman%20Symposium/Sustaining/The%20Triggers%20Program%20Sustaining%20Gains.ashx

The MUST Protocol, read: http://www.madisonemergencyphysicians.com/userfiles/clinical/2012-01article2.pdf

To contact Dr. Mark Zeidel, e-mail: mzeidel_AT_bidmc.harvard.edu