Changes in health care have made quality improvement (QI) program participation more than a good idea. Today, QI activities are part of the alphabet soup of regulations impacting provider pay.
Changes in health care have made quality improvement (QI) program participation more than a good idea. Today, QI activities are part of the alphabet soup of regulations impacting provider pay. For example, a practice’s participation in QI activities, known as Improvement Activities (IAs), accounts for 15% of its Merit-based Incentive Payment System (MIPS) score for CMS. Practices that choose not to send any 2017 QI data may be subject to up to a negative 4% payment adjustment, while those that do participate are eligible to receive a positive payment adjustment, according to CMS (qpp.cms.gov/).
QI programs are popping up locally and nationally to help urologists and others meet the requirement. The problem for many practices, however, is how best to get started, according to J. Stuart Wolf, Jr., MD, professor of surgery and perioperative care at Dell Medical School, The University of Texas at Austin.
Also see: A snapshot of recent urology QI programs
Dr. ChrouserQuality improvement is a formal analysis of performance, and it includes a systematic effort to improve it, according to Kristin L. Chrouser, MD, MPH, assistant professor of urology, University of Minnesota and Minneapolis VA, in Minneapolis, who presented the take-home messages on QI and patient safety at the AUA annual meeting in Boston.
“Some people think, isn’t all research quality improvement?” said Dr. Chrouser, who for the last 6 years has served on the AUA’s Quality Improvement and Patient Safety Committee. “Globally, it is. But when people talk about ‘QI,’ they’re talking about a specific look at some aspect of performance or outcome, how we got there, and what we’re going to do to fix it.
“It tends to be on a relatively small scale, so the vast majority of QI projects are local. It’s only recently where you’ve seen some collaboratives that are doing some more innovative QI interventions on a larger scale.”
“There are lots of potential quality improvement projects going on all over the country,” said Dr. Wolf, who chairs the AUA Science and Quality Council.
In the bucket of current national and regional programs for urologists to consider: programs offered under the Medicare Access and CHIP Reauthorization Act (MACRA). Urologists can visit the CMS.gov website to to find a list of improvement activities that have been proposed (qpp.cms.gov/mips/improvement-activities). (Also see, “Urology-specific quality measures are coming.")
Dr. Wolf“Practices’ participation in these contribute to that 15% of MIPS, which could give them a financial benefit,” Dr. Wolf said. “That’s an easy way to get started.”
Another option for urologists is to get involved in a national quality registry. The AUA Quality (AQUA) Registry, which is designated a qualified clinical data registry (QCDR) by CMS, is an excellent one, according to Dr. Wolf. The AQUA Registry reports data back to member practitioners, so they can do quality improvement, he says.
“We are developing a quality improvement structure built into the AQUA Registry,” he said.
The AUA also will offer customized QI services tailored to individual practice needs, training webinars to educate members on principles of QI, an online community to foster information sharing among practices, urology-specific quality resources, as well as report assessments and action plans to improve quality of care.
There are regional robust QI programs for urologists and other specialties, including Pennsylvania Urology Regional Collaborative, or PURC, and Michigan Urological Surgery Improvement Collaborative (MUSIC). MUSIC, a 5-year-old quality improvement collaborative, is sponsored by Blue Cross Blue Shield of Michigan. Ninety percent of the state’s practicing urologists are MUSIC members, according to Khurshid R. Ghani, MD, MS, assistant professor of urology, University of Michigan, Ann Arbor, and MUSIC’s co-program director.
On a more local level, urologists can turn to ongoing QI programs at hospitals and health systems or start one on their own.
“Oftentimes, as physicians we react negatively to quality improvement initiatives that are kind of forced onto us because they don’t feel very organic. They don’t feel like they’re really speaking to how we want to take care of our patients,” Dr. Wolf said. “The advantage of a home-grown quality improvement initiative is that you can design it the way you want.”
Before starting a QI program, urologists should get basic QI training, according to Dr. Chrouser. There are different QI approaches from which to choose, including Continuous Quality Improvement Cycles, Six Sigma, and lean methodologies.
“The research training most of us received as residents is not quite QI specific enough to get you started,” she said.
The second step is to define the problem, which requires looking at a process from various perspectives. If it’s a process in a hospital, for example, the urologist would talk to administrators, secretaries, and nurses and determine why something happens the way it does-what the rationale is, according to Dr. Chrouser.
“Particularly if you’re doing hospital-based QI, there are a lot of people in the hospital who can help you. There might be a QI department or a patient safety officer or an infection control person, and those individuals can really help with data,” she said. “You need a measurable outcome of some sort; then you make a change and re-measure it. That’s the QI cycle.”
Dr. GhaniUrologists looking to start collaboratives need to get a source of funding and develop a leadership structure and team, according to Dr. Ghani.
“It really is a team effort, and it requires urologists to work together across the spectrum and come together around a simple and positive mission,” he said.
Dr. Ghani says that QI initiatives require effort, including data entry.
“This can be manual data entry, which is what we do in MUSIC,” Dr. Ghani said. “We train data extractors in each practice to put in high-quality data, which we regularly audit to assess for quality and accuracy. Or they could be involved in something like the AQUA Registry, where the registry links in with the practice EHR and extracts certain data elements using natural language processing techniques.”
QI also takes an organizational commitment.
“Each practice has to identify one urologist who is known as the clinical champion and provides the local leadership for QI projects,” Dr. Ghani said.
The first goal of participating in QI initiatives is to improve quality. But the key for urologists is to participate in those programs that will most benefit their practice and patients.
Dr. StorkUrologist Brian Stork, MD, says his Muskegon, MI-based West Shore Urology practice has been involved in a number of different quality incentive programs over the years.
“I’ve previously questioned the value of many of these programs. Aside from additional income, the data we’ve received back from these programs hasn’t resulted in any meaningful changes in the day-to-day care of our patients or the management of our practice,” Dr. Stork said.
“Participation in MUSIC, however, has been markedly different. By participating in the collaborative, we receive actionable outcomes data-both individually and as a group. Individual surgeons also receive feedback directly from their patients.”
In general, Dr. Chrouser says urologists should focus on addressing issues that frustrate them most “because if a particular problem matters to you, that will motivate you,” she said.
Other considerations include starting with a program that fits into the practice’s work flow and attacking problems that will present a win-win for physicians and patients, according to Dr. Wolf.
For example, he says, a QI initiative that focuses on reducing the no-show rate in the outpatient clinic has a clear benefit to patients (by improving access) and also is a win for practices. On the other hand, a QI program aimed at increasing active surveillance for prostate cancer could have negative financial consequences for some practices when viewed in a narrow context, and this might be a barrier to such a QI program, Dr. Wolf says.
“Some barriers to QI exist only because of our perverse reimbursement system that rewards volume over value. We’re heading into a time in the future when that’s going to change. For now, though, urologists should look for projects that align everyone’s interests,” Dr. Wolf said.
QI does expose imperfections, inconsistencies, and sub-par care. The transparency leaves some wanting to avoid the process.
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“I think, in general, surgeons have to admit that we’re not perfect. You only have to look at the data to realize nobody is,” Dr. Chrouser said. “The best thing you can do for your patients and yourself is to learn from others, learn from mistakes, and improve over the course of your career. QI projects provide the opportunity to improve not only our personal performance but that of the systems in which we practice.”
QI initiatives can revive urology practices, according to Dr. Wolf.
“As anybody in their job does, urologists can get in ruts, doing what they do because they do it well. You don’t really see the forest for the trees. Quality improvement is kind of looking at the forest and trying to figure out, how can I make this better? How can I stop accepting the status quo?” Dr. Wolf said.
Dr. Chrouser says that doing QI projects requires urologists to talk to people outside the specialty, such as administrators, nurses, patients, or other physician specialists.
“You really get a perspective you didn’t have before on what all has to happen to get somebody to the operating room and through their surgery and post-op,” Dr. Chrouser said. “As surgeons, we’re used to asking for something during a case, and it just appears. I think it’s very easy to get into the mindset that, well, it’s somebody else’s job to get me what I need, and they’ll figure it out. But if you want to improve the whole process, you have to understand other people’s roles and the constraints of the system.”
The Michigan Urological Surgery Improvement Collaborative is an example of a successful, long-running QI collaborative.
Khurshid R. Ghani, MD, MS, says MUSIC uses four key principles. First, the collaborative collects high-quality data, using a standardized method. It features a custom-designed clinical registry into which practices feed their data.
Second, MUSIC collects that data and analyzes it on a systematic and regular basis, then uses the information to provide feedback to individual urologists.
Third, the program has a collaborative atmosphere.
“We have meetings three times a year, where all of the state urologists will come together, including their practice managers, nurses, and data abstractors. We go through the information and identify areas for improvement, then we implement processes of care,” Dr. Ghani said.
The last element, which is the primary aim of the whole collaborative, is that MUSIC focuses on improving patient care.
“We’re not a research enterprise. Everything we do is centered around the patient experience, the patient outcome. We have patient advocates who are our moral compass and guide us on what matters and maybe things that we could be doing better,” Dr. Ghani said.
The AUA is hosting its third Quality Improvement Summit Oct. 21, 2017, focused on “Challenges and Opportunities for Stewardship of Urological Imaging.”
“The agenda will include didactic presentations and panel discussions focusing on the evolving landscape of practical opportunities to pursue QI in this important area,” according to Matthew Nielsen, MD, a member of the AUA Quality Improvement and Patient Safety Committee, who is chairing the upcoming summit. “The concept of stewardship-the careful and responsible management of a valuable resource-has been well-established in the QI arena by the decades-long efforts toward stewardship of antimicrobial medications. Similar principles are emerging in physician-led efforts to address concerns of overuse and potentially avoidable harms from advanced imaging services.”
The urology community, according to Dr. Nielsen, has been visibly engaged in this space, with several of the AUA’s Choosing Wisely recommendations addressing imaging-related questions, as well as successful efforts from MUSIC and other groups to reduce potentially avoidable imaging in prostate cancer.
“Recent related activities led by colleagues in the emergency medicine and radiology communities provide additional opportunities for urologists to collaborate and improve the quality and safety of imaging for the large population of patients with stone disease,” he said. “It’s important for urologists to learn about what our colleagues are doing and learn about ways that we can work together. That will be a big focus of the meeting.
“Another critical part of the meeting is going to be providing urologists with practical tools that they can bring home to their practices and institutions to engage in specific quality improvement projects around enhancing value and reducing harms from CT scan.”
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