It's Time to Take Action on Quality Measures

Michael K. Keng, MD

Quality improvement is a method for ensuring that all the activities necessary to design, develop, and implement a product or service are effective and efficient with respect to the system and its performance.

That basic definition was developed decades ago by W. Edwards Deming, the father of quality improvement. Deming is best known for his work in Japan after World War II, particularly his efforts to help the leaders of the Japanese automotive industry.

He discovered deficiencies in the process of car manufacturing and improved the efficiency and quality of the vehicles that we now know as the brand Toyota. Many in Japan credit Deming as the inspiration for how Japan rose from the ashes of war to become one of the largest economies in the world.

Yet Deming’s principles were not unique to the auto industry, and many professions have adopted his ideas to improve their disciplines. The field of medicine, where human lives are at stake, is even more in need of measures that can eliminate deficiencies and fine-tune efficiencies.

As physicians, we have not only a responsibility to care for our patients, but also a duty to improve patient care. Quality improvement is often known as a mechanism to reduce cost, but it is much more than that. It is an opportunity to improve the full patient experience. And, whether we want to admit it or not, quality control is becoming a significant part of our oncology world. Our licensing boards, governing bodies, and insurance companies are basing our competency and reimbursements on our ability to standardize care.

Better Training Needed

Programs such as the American Board of Internal Medicine’s Maintenance of Certification, the Centers for Medicare & Medicaid Services’ programs (Hospital Value-Based Purchasing, the Physician Quality Reporting System, and the Merit-Based Incentive Payment System), and the ASCO Quality Oncology Practice Initiative are changing the ways we practice. Although measures of quality have not invaded all cancer subspecialities, it is only a matter of time until we will all have to prove that we are delivering quality.Most of our colleagues would agree on the importance of focusing on quality improvement. But they may be quick to give the responsibility to the administration or the nursing staff because, when it boils down to the process of assessing quality as a whole, we are not adequately trained.

When do we ever receive education on how to measure the quality of our patient care? Our medical students, residents, and fellows are focused on learning standard-of-care and clinical guidelines. Aside from receiving subjective evaluations about attending to patients, they do not learn how to assess the care they give patients as individuals and as part of the team. Evaluations provide feedback on individual performance but do not address the system and context in which the trainee is working.

Thus, learning how to evaluate and change the medium in which patient care is delivered is not a standard part of the medical training curriculum. But if we were to train our students on the basic principles of quality improvement as delineated by Deming—identifying a problem, planning a solution, executing the solution, and evaluating its progress—indeed, we would be training our students for the real world.

Recognizing Value of Quality Care

The real world cares greatly about quality because poor care leads to medical errors. We tend to learn about system errors only after they occur, instead of being proactive about finding ways to improve deficiencies. But if we taught our trainees how to approach these deficiencies before errors occur, they would be much more prepared for the less glamorous aspects of medicine.Despite having practical applications on the macroscopic level, the field of quality improvement is not seen as a hard science. Involvement in quality improvement is not as sexy on the curriculum vitae as multiple research projects and published articles.

The hardest challenge to overcome is helping everyone understand the value of this kind of training. We say we understand the importance of quality care, but we do not think it is worth our time to obtain formal training in a “softer” side of oncology to find out how to deliver this care.

I only started to appreciate the value of quality improvement several years ago during a fellowship at the Cleveland Clinic, when I participated in a project and realized that my previous training did not provide me with the skills to tackle the problem at hand: timely antibiotic administration for patients with febrile neutropenia.

Through my mentor and coaches, I learned how to deliver a better system that not only met national guidelines but also decreased length of stay for patients with febrile neutropenia and improved their outcomes. We implemented a system that allowed patients to receive the correct antibiotics promptly and consistently.

The project was both presented and published but, most important, the project solved a problem that greatly impacted patient care. When I saw my research changing the outcomes of patient care, decreasing medical errors, and solving system inefficiencies, I knew that I had found the underdog of academic medicine. My journey in quality improvement had begun.

UVA’s Be Safe Program

This journey led me to become an assistant professor of medicine and a quality director in the Division of Hematology and Oncology at the University of Virginia (UVA). We are committed to continuously improving the quality of patient care, research, and training through a comprehensive review and evaluation process.At UVA, delivering the highest-quality and most advanced healthcare to our patients is our top priority. Our goal is to be the safest place in America to receive care and to work, as we believe that team member safety is essential to providing the best healthcare to our patients.

In 2014, under the leadership of UVA Executive Vice President Richard P. Shannon, MD, the Be Safe initiative was developed. The Be Safe program emphasizes three main areas.

First, a root cause analysis will be performed promptly after an identified deficiency. The expectation is that any team member is encouraged to identify any safety concerns. Then, the quality officers investigate the root cause of the problem as a healthcare system.

Second, we implement “standard work” to all units and specialties. Once we have found the best way to complete a task, we automatically apply this method to all units in the same way to improve consistency.

Third, we have a rapid escalation of safety issues within a tiered leadership chain. There is an open communication between the bottom and top of the chain of command that allows for quick responses and results.

The initiative focuses on six priorities of improvement in patient care: mortality, central line—associated bloodstream infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers, patient falls with injury, and team member injuries.

Every UVA inpatient and outpatient setting runs its own daily Be Safe rounds with its unitbased leadership. All of the top six priorities are always discussed, but each unit has its own secondary objectives and priorities. UVA highly recommends that all unit leaders obtain formal training in quality improvement, which the health system provides.

At UVA, a significant focus of quality improvement is in fellowship education. Fellows receive lectures on quality improvement and patient safety, participate in morbidity and mortality conferences, and regularly perform chart reviews. With faculty support, every fellow is required to execute a quality improvement project during the course of fellowship and apply knowledge to real-world clinical practice.

Many times, the trainees are able to understand the value of quality improvement training only after going through the process themselves. Designing and implementing their own projects helps them grasp the reasons behind quality improvement, the importance of these efforts, and how to use these tools in their clinical practice going forward.

Faculty are engaged and actively participate in the formation of a multi-disciplinary team to evaluate the design, implementation, data collection, and analysis of the fellow quality improvement project. Presentations and publications of the quality improvement projects are highly encouraged. We learn from all projects, building upon positive and negative aspects to continuously provide self-evaluation and improvement.

The current UVA fellow projects include: early palliative care referral for patients with metastatic non—small cell lung cancer; implementation of prophylactic beta blocker use and standardization of cardiac imaging for patients with breast cancer; use of antifactor Xa versus partial thromboplastin time in heparin dosing nomogram; improving the rates of fungal infections in patients with acute leukemia; direct admission process for patients scheduled for chemotherapy; and systemwide approaches to febrile neutropenia.

Patients’ Experiences Count

The latter three projects have been selected for participation in ASCO’s Quality Training Program. Other quality improvement projects initiated in our inpatient oncology unit are: improving oral mucositis care in our patients with hematologic malignancies: pharmacy-led discharge medication rounds; and utilization of early warning system for acutely ill patients. The scope of these projects means that all have the potential to be broadened to improve care at other cancer centers.In addition to providing training and implementing quality care, the goal of UVA’s program is to ensure that we focus on our patients and families first. UVA measures the quality of care not only through our clinical outcomes, but also through our patients’ measure of their experience. We value our patients’ feedback and invite them to be an active part of their care.

UVA aims to provide quality by respecting the patients’ culture, personal preferences, and quality-of-life goals as part of their treatment plan. UVA values patient-centered care models through multidisciplinary care and interdisciplinary collaborations. We strive to treat the whole patient through the journey of diagnosis to treatment to recovery.

As we focus on improving our system deficiencies daily and training our future physicians to see the benefit of fixing inefficiencies that directly impact their patients, we believe we are giving a unique experience to every UVA patient who has a choice for their healthcare.

When the patients see the extent to which their hospital system delivers quality care on every level, even those with a discouraging diagnosis are given hope that they are in a place that will help them. Their confidence in their high-quality care is the reason we continue to strive for better care and hope to inspire other institutions to do the same.

Surely Deming did not know how the principles he applied to car manufacturing would someday save lives when applied to medicine. Because he was not satisfied with complacency and aimed for perfection, a whole economy was reborn.

We still have much to learn in medicine, and improving quality care has become an expectation. Only when we are trained in how to handle the deficiencies in healthcare and strive to make our systems better are we able to look our patient in the eye and tell him, “We have done our best.”