Achieving Better Outcomes Through Quality Improvement

Quality improvement (QI) in medicine is a constant work in progress and remains a priority in the busy dermatologic practice today. There are many different aspects that factor in to achieving QI, and dermatologists must strive to develop and implement QI programs and measures to improve office standards, as well as the quality of care and outcomes in their patients.

In 2001, an Institute of Medicine committee published a landmark report “Crossing the Quality Chasm: Health Care in the 21st Century,” identifying the 6 aims of health care quality (safety, timeliness, effectiveness, efficiency, equitable, patient-centered), and these 6 dimensions of quality continue to be the foundation of QI initiatives today.¹

“While professional satisfaction is not a target of QI, the reduction of medical errors and increase in patient satisfaction has a positive effect. It can seem overwhelming at times and a systematic improvement approach is needed. Physicians should familiarize themselves with basic QI frameworks, and the AAD is developing training modules to assist its members,” said Amanda F. Marsch, MD, assistant clinical professor, Department of Dermatology, University of California, San Diego, California, who recently spoke at the 2021 American Academy of Dermatology Virtual Meeting Experience (AAD VMX 2021).

Amanda F. Marsch, MD

According to Marsch, the first step in QI is to identify what one is trying to accomplish or improve. The next step is selecting process and outcome measures that are needed to identify when a change to a system actually leads to an improvement.

Once the aim and measures have been chosen, one can begin testing the change with PDSA cycles (Plan, Do, Study, Act). This process involves multiple small sequential tests, as opposed to one large test, with a goal of collecting just enough data to learn from it and then move on to the next cycle. After multiple large-scale PDSA cycles have been conducted under a wide scope of conditions, the final stage to consider is the implementation stage to “hard-wire” the change into the system.

Dermatologists realize the need for QI in their practice Marsch said, and as such are active in developing and implementing QI programs to improve patient outcomes.

The AAD recently conducted a survey collecting data from dermatologists in solo, group or multi-specialty practices. Of the 237 dermatologists who completed the survey, only 12 percent indicated that no one in their practice is involved in QI activities, while most dermatologists claimed to spend about 1-2 hours per week on QI activities.²

“I think with the increasing QI culture and regulatory requirements, the number of dermatologists involved in QI will increase and new aspects of patient care to improve will surface,” Marsch said.

Physicians are also required to maintain and improve quality standards through QI in their practice. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established the Medicare Quality Payment Program which rewards physicians who report cost and quality data.

The Quality Payment Program consists of 2 major tracks: The Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs); most providers participate through MIPS. MIPS involves 4 components, Marsch said, including Quality, Cost, Promoting Interoperability, and Improvement Activities.

Under MIPS, eligible physicians are evaluated on their performance relative to other clinicians in the country and receive a positive, neutral, or negative payment adjustment to their Medicare Part B payments. According to Marsch, MIPS Value Pathways (MVPs) will launch in 2022 and involves condition or procedure-based grouping of measures and improvement activities.

In addition to governmental regulatory requirements, the American Board of Dermatology has also implemented QI in their certification program (ABD patient safety course, practice improvement activities). The Accreditation Council for Graduate Medical Education has now also included patient safety into the residency program curriculum (referred to as the Clinical Learning Environment Review program), which requires residents to participate in QI projects during residency.

“The most urgent practice areas requiring QI include teledermatology and patient experience," Marsch said. "Other areas that remain important are surgical complications, medication errors, patient compliance and pathology specimen tracking. As evidence of how QI can promote better patient outcomes emerges, more physicians will be motivated to participate in QI activities.”

Quality improvement in teledermatology will have the biggest impact on patient outcomes and the development of practice guidelines here is crucial. According to Marsch, patients love telemedicine appointments mostly because of their convenience. This is also a way to improve access to healthcare for rural populations, but it is up to the physicians to investigate and address care gaps such as access to high-speed internet and devices.

“There is a misconception that quality improvement is solely a regulatory requirement," Marsch said. "If we can focus on the benefits of QI such as improving patient outcomes, streamlining our workflow, and learning best practices for specific dermatologic conditions, we can replace this negative perception with motivation. Quality improvement is the basis of ultimate success in any industry or service. In the words of W. Edwards Deming, ‘It is not enough to do your best; you must know what to do, and then do your best'."

References:

1. Committee on Quality of Health Care in America, I. of M. Crossing the Quality Chasm: A New Health System for the 21st Century. (National Academies Press, 2001).

2. AAD Patient Safety and Quality Committee.