Chest
Volume 136, Issue 4, October 2009, Pages 1134-1140
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Transparency in Health Care
Design and Measurement of Quality Improvement Indicators in Ambulatory Pulmonary Care: Creating a “Culture of Quality” in an Academic Pulmonary Division

https://doi.org/10.1378/chest.09-0619Get rights and content

Background

Quality improvement (QI) measures often are cited as goals for individual practices and medical centers and may someday form a component of reimbursement guidelines. Relatively few QI metrics relevant to ambulatory pulmonary medicine have been published. We describe the development and implementation of a QI program in an academic pulmonary division, including progress to date and lessons learned.

Methods

Metrics for the pulmonary QI Dashboard were developed based on an extensive literature review. Patients were identified through International Classification of Diseases-based billing databases, and results data were obtained from a manual and automated review of the electronic medical record. The performance of the division was monitored and presented in regular faculty meetings. Quarterly, confidential, individual scorecards gave each clinician feedback about his or her performance and compared the feedback to that of the faculty of the entire division.

Results

Significant improvements were found in many QI measures during a 2-year period. The number of patients with asthma who received appropriately prescribed inhaled corticosteroids increased from a baseline of 76 to 92% to 98%. Flu shot and pneumococcal vaccine administration documentation for patients with COPD increased from baseline values of 11 to 32% and 11 to 34%, respectively, to 90% and 93%, respectively. The COPD Global Initiative for Obstructive Lung Disease pharmacotherapy guidelines adherence increased substantially for patients with all disease stages. Chest CT scan results notification documentation improved from a baseline of 67 to 76% to 98%. Comparison between baseline and QI periods yielded statistically significant increases for these indicators.

Conclusions

QI measures for an ambulatory pulmonary practice can be designed, implemented, and monitored. Key components include a well-structured electronic medical record, measurable outcomes, strong QI leadership, and specific interventions, such as providing feedback through QI review meetings and individual “report cards.”

Section snippets

Materials and Methods

Beth Israel Deaconess Medical Center (BIDMC) is a 600-bed, full-service, adult teaching hospital with nearly 750,000 patient visits annually from persons in and around Boston, MA. The Division of Pulmonary, Critical Care, and Sleep Medicine at BIDMC delivers subspecialty services for patients with critical illnesses, thoracic diseases, and sleep-related disorders. The ambulatory services of the division account for > 5,000 pulmonary visits annually, with patients seen by attending physicians

Results

Since the implementation of the BIDMC pulmonary QI program in quarter 4 of 2006, performance has improved in many of the areas being tracked. Two main disease areas, asthma and COPD, were evaluated. Additionally, various measures for all patients were evaluated (Table 1).

For patients with asthma, a sample of 50 visits of approximately 250 visits were reviewed quarterly for the percentage of patients who had been appropriately prescribed inhaled corticosteroids. Treatment compliance prior to the

Discussion

Global guidelines and standards for the management and prevention of lung diseases have been developed and can lead to improved morbidity and mortality if implemented consistently and appropriately. By implementing programs that monitor adherence to evidence-based guidelines, we sought to improve quality of care, promote patient safety, and reduce medical errors through improved documentation of prior care and timely results notification.

Effectively implementing QI programs aimed at adherence

Acknowledgments

Author contributions: Dr. Roberts was responsible for designing and implementing the QI/PS within the Division of Pulmonary, Critical Care, and Sleep Medicine at BIDMC. He contributed to the development of QI measures, the program design, data collection, data analysis, and manuscript writing and editing. Dr. Gilmartin contributed to the program design, data analysis, and manuscript writing and editing. Ms. Neeman contributed to the design and implementation of the QI/PS, including working with

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Funding/Support: Stoneman Center for Quality Improvement and Patient Safety, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.

All work was completed at Beth Israel Deaconess Medical Center, Boston, MA

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).

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