3 Tips for Successful Clinic Quality Improvement
Let’s say you work in a healthcare clinic. It might be at a community health center, a small rural clinic, or even part of a large health system. Wherever you are, it’s likely that quality improvement (QI) is what everyone seems to be talking about.
Quality improvement in healthcare refers to systematic changes that improve the delivery of care and patient outcomes. These could be things like adding provider reminder systems into your electronic health record (EHR) or optimizing workflows. W. Edwards Deming was a pioneer in QI. He encouraged improvement to follow these key principles: processes, not people, need to be changed, improvement is constant, and transformation is everyone's job.
It can be overwhelming to identify where to start, but you can follow these three tips to get started with your next QI project: 1) don't go it alone, 2) make a plan, and 3) start small.
1. Don’t go it alone
Quality improvement requires input from everyone who will be impacted by a change. This includes front desk staff, medical assistants, nurses, providers and administrators. The Institute for Healthcare Improvement recommends including these people on your team: Clinical Leader, Technical Expert, day to day leadership, and project sponsor. While not dissimilar, based on my experience, here is my recommendation:
It is important to identify a project lead or champion who will continue to drive the work forward.
Changes will need to be approved by a decision maker, so include them early in your process.
Include the people who can best inform the changes that will most likely result in improvement - clinical staff and others who interact with patients.
Invite an EHR expert because everyone knows how painful extracting data from the EHR scan be, but an IT expert knows how to work magic. This person will be important for helping your team to measure your changes - see more below in tip #2.
Consider this example -
Quite a few of your patients are tobacco users. You know that healthcare providers can play an influential role in connecting patients to cessation resources. Patients fill out their tobacco use status on intake forms, but the information never seems to be entered into the EMR nor discussed with the patient. This is the perfect opportunity to plan an intervention that may help your patients quit tobacco. Before you plan the intervention, you need to identify your team. Having a well-rounded team like the one described below will help you learn what’s happening throughout the current process, and where it can be improved.
Front Desk/Receptionist - What happens to the form once the patient has completed it?
Medical Assistant - Do they ever see the form? Can they enter the information into the EHR? Can they take the lead on identifying a better process and be the champion for this QI initiative?
Provider - Are they alerted that their patient is a tobacco user? Do they know what cessation resources are available to discuss with the patient?
IT Manager - Is there a certain field within the EHR that this information should be documented so that it ends up in the tobacco metric report?
Clinic Manager - What are the implications if the current workflow is changed? Who is best equipped to complete each task in the workflow? Will a new process be approved and disseminated to all staff?
2. Make a Plan
Your team has been identified. You and others on your team may be aware of what is not working or what could be improved. However, take some time to look at your data and make an informed decision about where you want to start. In what areas are you already doing well? In what areas are you lagging? In most cases, your clinic already has metrics it tracks. If you want to become more familiar with nationally recognized quality metrics, then search the National Quality Forum measures.
Once you’ve selected an area of opportunity, your next step is to set clear goals to make sure everyone stays focused on the same end vision. Remember that you can't fix everything overnight. Instead, narrow your focus where your patients really need you and make small changes from there - see more below on starting small. Use the acronym SMART to write your goal(s).
Example -
Let's continue with the example of patients who use tobacco. Only 80% of your patients have a documented tobacco use status. Among those who are tobacco users, only 10% are provided counseling or a referral to cessation services. In the next year, you think you can increase documentation and refer more tobacco users to cessation. Now, write a SMART goal (or two!).
By June 30, 2020, outline standardized documentation process to increase EHR documentation of tobacco use status among active patients from 80% to 95%.
By December 31, 2020, develop an EHR alert to notify providers if patients are tobacco users to increase percentage of tobacco users referred to cessation services from 10% to 20%.
3. Start Small
You don't have to fix everything all at once or make large sweeping paradigm shifts to be successful. Find something small that you can implement and test. With a goal set, you can be very intentional about the changes you test. Did that small change make an improvement? If so, figure out how to make it sustainable. If the change wasn't an improvement, abandon it and try something else.
Source: Associates in Process Improvement http://www.apiweb.org/
Use the Model for Improvement and Plan-Do-Study-Act (PDSA) cycles to test your changes. Download a PDSA Cycle Template Here.
Example -
You decide to have Medical Assistants enter tobacco use status into a patient's chart when they room the patient. They can confirm the patient's current intake form response and update information that may already be entered into the EHR. You try this for one month to see if there is an improvement in tobacco use status documentation as well as determine if there are any other unforeseen impacts in the overall workflow. The data and anecdotal feedback from MAs demonstrate that it is working, so you update your documented workflow and make sure the updated version is discussed at the next all staff meeting.
Hopefully this gives you a place to start. Quality improvement can seem overwhelming, but it doesn’t have to be if you follow the simple tips outlined here: Don't go it alone, make a plan, and start small.