Quality assurance impacts urologists on multiple levels

Urology Times Editorial Consultant Philip M. Hanno, MD, MPH, interviews Roger Dmochowski, MD, about his institution’s Patient Advocacy Reporting System as well as quality improvement and creating algorithms for appropriate care.

Please describe your quality assurance-related work at Vanderbilt.

I am active in quality assurance and patient safety on several fronts. I’m vice chair of the section of surgical sciences for professionalism, patient quality, and safety. In that role, I interface with my surgical colleagues across all disciplines related to system- and behavior-based quality issues. I’m also the executive medical director for safety and quality for Vanderbilt University Hospital; that’s more of a hospital systems and operations position. Finally, I’m medical director for risk management solutions, which entails litigation awareness and prevention.

What are the current hot-button issues in quality?

We’re seeing the evolution of rapidly expanding and massively available data to the general public. The hot-button issues are reportable data and patient safety indicators. By virtue of Centers for Medicare & Medicaid Services regulations, Joint Commission recommendations, and even state boards, we’re being required to share our experience with a variety of patient care issues with the general public, which is a very good outcome.

Examples of reported patient safety indicators include ventilator-associated pneumonia and central line infection. Catheter-associated urinary tract infection is a recently published patient safety indicator that is especially pertinent to urology, which used to be only reported from intensive care units and now is reported for all hospitalized patients.

At Vanderbilt, we have learned from prior experiences with central line and ventilator infections that care bundles are very helpful for reducing untoward experiences. For example, by having a central line replacement bundle that included a daily assessment of need for line replacement, we were able to decrease our central line infections dramatically. We’ve used that experience to develop a bundle for management of Foley catheters that offers guidance on when they should be placed and when they should be removed.

Urologists have a very high level of comfort with the use of the Foley catheter; however, our general medical peers are not as aware of some of the risks associated with Foley catheters. With the evolution of these bundles, we’ve given physicians a framework to govern their use of catheters.  A care bundle uses evidence-based data to formulate a standardized approach to a clinical situation. Care bundles incorporate a series of care steps in a systematized grouping for purposes of optimizing outcomes. These bundles have been shown to improve care by removing variability from care delivery, a lesson learned from the Toyota method.

Aside from catheter-associated infections, what aspects of value-based purchasing are likely to have the greatest impact on urologists?

Interestingly enough, there is already a substantial component of value-based purchasing related to readmissions for cardiac diseases and pneumonia. One of the things that we will see in the surgical subspecialties in the not-too-distant future will be negative consequences for reimbursement for institutions with high readmission rates.

At Vanderbilt, we’re looking at the specific transitions of care from outpatient to inpatient and then back to outpatient and how to facilitate those transitions, not only from the standpoint of making sure that aspects of care are done in a timely manner and/or discontinued in appropriate time and that adequate preparations are made for discharge and outpatient care. We’re evolving from the concept of episodic care and are now looking at the “continuum of care” concept. The ability to correctly predict and control the continuum of care is going to have broad ramifications for the future of health care in the United States and for practitioners.

What specific metrics are you looking for in the future with regard to Medicare reimbursement?

CMS has been very aggressive about using candidate measures and looking at measures of care delivery (inclusive of process and outcome measures). When I say “measures,” I mean the threshold of good care as determined by quantifiable criteria of care-such as appropriate antibiotic choice and timely administration of same.

As noted, catheter-associated urinary tract infection is one measure that most urologists are familiar with. A measure that we tend not to think about is surgical site infection. This may not currently be a major issue for urology, but it’s going to be an area of great focus and an area where CMS is already starting to establish a broad architecture for review. As we move forward, that architecture will be migrated from current experience (such as the American College of Surgeons’ National Surgical Quality Improvement Program) and start reaching smaller specialties such as urology.

Many departmental chairs are trying to implement specific protocols to maximize quality outcomes. Have you seen urology chairs trying to standardize procedures, practices, and protocols, and how receptive are physicians to that effort?

That’s a great question, because so much of quality of care is the direct result of physician behavior. By “behavior,” I don’t just mean social interactions; I mean the willingness of physicians to use evidence-based medicine to create algorithms for appropriate care.

Much of this effort is coming from outside strict departmental structures and is actually originating at the institutional level. At Vanderbilt, one of our recent experiences involved standardization of administration of antibiotics for prostate biopsy, which meant getting physicians to agree on what is evidence-based regarding the use of antibiotics and appropriate preparation of the rectum. For instance, there is a disagreement about whether a routine enema should be done before prostate biopsy.

These sorts of care standardizations have been very difficult to implement because much of what drives physician practice is experiential behavior; it’s like training old dogs new tricks. Persuading providers to acquire and utilize new algorithms can be problematic at the local level. However, some institutions are already creating reimbursement structures that are reflective of adoption and facilitation of protocols or the lack thereof.

Are you doing peri-anal swabs at Vanderbilt prior to prostate biopsy?

We are not. What we have struggled with most at Vanderbilt is whether routine cleansing of the lower bowel should be done prior to biopsy. I feel, based upon my colorectal experience and that specialty’s challenges with surgical site infection, that bowel preparations are a critical part of prevention of urinary tract infections and septicemia associated with prostate biopsy.

What therapeutic areas are most important to you from a quality perspective, and how do you see this changing in the next 3 to 5 years?

My focus is the interaction of the surgical specialties, including urology, with the larger organism of the hospital. This is driven by the demands and needs of CMS, the Joint Commission, and other entities inclusive of third party payers. A lot of what I do is reactive in terms of responding to requirements. However, we are becoming more proactive at developing algorithms of care. We’ve also become very proactive in medical risk management by addressing physician behavioral issues. Those areas of focus within surgery are going to become very important for us, mainly as components of being good citizens in the larger hospital environment.

Has the push to decrease length of stay impacted quality?

There’s a lot of argument about that. Vanderbilt has always done very well with length of stay. The issue with length of stay is preparation for outpatient care and management. That transition back to the outpatient environment is critical. We’re all being forced to assiduously evaluate our length of stays and decrease them as much as possible as part of the cost modification/cost reduction strategies that are being utilized.

The corollary to length of stay is appropriate transition to the outpatient environment such that you have an informed patient who is capable of self care with or without family members who are also capable of caring for the patient; who has realistic expectations; and who has an understanding of what is within the realm of normal for postoperative convalescence.

We’re always trying to balance cost savings with quality improvement, and it can be extremely difficult. Is anyone looking at the amount of time per office visit and how physicians are being pushed to see more and more patients in more contracted periods of time?

Yes. This is a fascinating area where the drive to increase volume has very negative effects. If you look at complaint cycles across physicians, one complaint that has become much more prominent than before is, “He was rushed,” or, “She didn’t take enough time to listen to me,” which comes from the pressure of trying to push through volume in order to maintain stability of revenue. We have attempted to deal with this through greater involvement of nurse practitioners or physician assistants. Patients are made aware that they may or may not see the physician at their appointment. They are also made aware that for continuation of care, a nurse practitioner or physician assistant may make significant decisions with the approval of the consulting physician.

The other thing that we’re trying to do is create standardized educational materials regarding common procedures and common treatment cycles that can be given to the patient in print or online.

Are you teaming up with any external consultants or vendors to complement your quality assurance efforts?

Yes. That’s very important because those entities can give unique input on care cycles and care quality. We do a fair amount of work on the patient satisfaction side with unique consultants who are very focused on the patient experience with health care.

Is quality led mostly by physicians and nurses or by non-clinicians trained in process improvement?

At our institution, the process is largely led by the dyadic relationship between physician and nurse. Our quality consultants are experienced nurses who receive extra training in quality roles. We also have a very interesting group of process engineers in our Center for Surgical Safety who help us with some of the systems-based analysis. But the actual directing and strategic formation comes from the dyadic relationship between the physician and nurse, with the nurse representing the operations side of the hospital.

Do you use Press Ganey?

Yes. We also have several homegrown tools that we have migrated to because of the lack of specificity from HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems). Internally developed, these tools look at specific items to create a condensed symptom score of sorts that assesses patient experience not only in the hospital but also with the physician to give us better direction on what the areas of improvement are. We use these findings not in a negative way but in a process improvement way. We look at those scores not only for systems-based improvement but also in a caregiver-specific manner, examining areas where physicians and nurses could potentially improve teamwork. The most common area for improvement is communication skills.

One potential problem I see with patient satisfaction surveys is a non-response bias, since dissatisfied patients seem more likely to respond to surveys. Additionally, surveys done prior to discharge might suffer from the fact that no one wants to offend their caregiver. How do you deal with these problems?

We do not do in-hospital surveys because of exactly that concern. We do conduct post-op and post-discharge surveys, and there is occasionally selection bias where a person who is extremely dissatisfied will want to make sure that everyone knows it. But there are also patients who are extremely satisfied who want to provide feedback.

My take-home message for physicians is that not only are our institutions requiring these metrics to be kept and tracked, but third-party payers are keeping track of these data as well. Third party payers are increasingly using these scores as part of their metrics in contracting with institutions and practice groups. Will that happen with CMS? CMS has tremendous data through HCAHPS, but HCAHPS is episode specific, not caregiver specific. That data is going to be much more difficult to extrapolate because the physician-specific questions on the HCAHPS are very limited and are not specific to either the primary physician or any of the consultants.

So we have to learn to live with these; they’re not going away?

No, they’re not going away. As a matter of fact, I think they’ll become a bigger part of what we deal with.

I’d also like to note that the Joint Commission has established goals for hospital credentialing groups around the concept of professional evaluations; they have ongoing professional evaluation and focused professional evaluation and metrics that they require. We are using these scores as part of that evaluation schema in direct response to what the Joint Commission is asking for now. The Joint Commission hasn’t specifically said they want this patient satisfaction in these ongoing annual assessments, but we feel that it is coming, so we are already building those into the 360 assessment (comprehensive annual evaluation) that every physician has to undergo every year now.

Let’s turn to an effort developed at Vanderbilt by Dr. Gerald Hickson: the Patient Advocacy Reporting System, or PARS. Can you explain what this program, which has been rolled out nationally, entails?

PARS essentially takes spontaneous patient complaints that are voiced to the hospital or to the institution’s ombudsman and sorts them into five different categories (such as communication or access to care). These data are utilized to generate a score for the physician that can be compared to his or her peers internally, to the institution, and to a national database that encompasses more than 40,000 physicians, 5,000 of whom are surgeons.

The scores have a very interesting parabolic schema. The majority of physicians have minimal or no complaints. Then there’s a middle group, and then there are “far outliers” who have very high scores, and that correlates directly to risk of malpractice as well as risk of adverse surgical events; specifically, wound infection.

PARS is, if you will, the canary in the coal mine for concerns that may arise regarding care groups, even among individual physicians. We have curves that are general for all physicians, and we have specific subspecialty curves. There’s a urology curve, which is right in the middle of the surgical subspecialties in terms of the degree of complaints. In general, the interventionalists, which comprise surgeons and proceduralists, have a displaced curve in that they tend to have more complaints than their non-proceduralist peers. But even with the proceduralists, there are differences in experience.

Most of the complaints relate to communication or access. There’s the old saw that physicians need to be available, affable, and affordable. Availability is critical, and another negative consequence of the push to see more patients in shorter amounts of time is that physicians are less available. Patients notice this, and in some cases it really impacts the patient’s perception of their caregiver.

Has PARS improved quality at Vanderbilt?

Yes, we feel it has improved quality, because we’re able to help physicians document behavioral issues and work in a stepwise process to refocus physicians on areas of concern. What we’ve found is that no one is specifically malicious, but things happen in people’s lives, people react to them, and that can cause issues related to physician performance and interaction with patients. Common events such as divorce, personal or child illness, and other issues that can impact the physician at work are reflected in these scores, and they’re very helpful in identifying people who may benefit from graded intervention.

These scores can also reveal more serious concerns. On a national level, several physicians were noted to have a significant climb in their scores, and significant concerns were voiced about them by other team members. These physicians actually had cognitive decline associated with early dementia that hadn’t been picked up previously.

PARS is controversial. Physicians say that patient complaints about poor food in the hospital, wait times, and other factors that the physician doesn’t really have control over get scored against him or her. As I understand it, it’s designed to limit the number of lawsuits by stopping behavior that’s been associated with a higher risk of medicolegal problems. But the face validity of it seems low. Apparently the data are useful, or I’d assume we wouldn’t be using it. What are your thoughts?

I’ve had my share of complaints regarding poor food and other systems-based issues, but the system does factor those out. There are attributable complaints and systems-based complaints. But sometimes, when you talk about waiting time and lack of communication, the problem lies not with individuals but with groups-microenvironments within the hospital that are dysfunctional for whatever reason. PARS allows us to help those areas revert to a more standard level of practicing and functioning.

The other argument I have is that we’ve shown marked improvement in patient satisfaction scores for those individuals who have adopted the program. Seventy percent of physicians respond to the simple fact of self-awareness. They didn’t perceive how their behavior was affecting people around them. Self-awareness is a critical aspect of the success of this, and I want to be clear that there’s nothing pejorative about the system. It’s meant to be a positive way of helping physicians change aspects of their practice that have been shown to be detrimental based upon feedback from their primary consumer, the patient.

Do you enjoy this work, and what would be the career path that this could take you on ultimately?

Yes, I enjoy it. As a surgeon, I enjoy being part of a process that is much more uniform in terms of its outcomes. One of the reasons I’ve become a big believer in bundling and creating algorithms is that it takes variability out of care, which decreases variability in outcome.

This has been a real career awakening. In the not-too-distant future, this will probably become a full-time endeavor for me. I’m still very active in urologic care, I still run a fellowship, and those things are very important to me, but you get to a time in your life when those things need to be passed on. My work in quality represents a logical extension of what I like doing, which is interacting with my peers.

Is this an avenue worth pursuing to enhance a career for the young urologist, and how should they get into it?

Absolutely. As a matter of fact, we’ve been asked by the AUA to have a course about this at next year’s annual meeting, and it’s already been submitted. I’m very excited about that, and I’m in the process of trying to mentor not only young surgeons but specifically young urologists in this area because this is going to be a part of our physician experience for the foreseeable future.UT

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