San Francisco, Calif.—Close on the heels of the evidence-based medicine movement comes increasing pressure for physicians and health care institutions to develop and implement quality improvement measures that will not only improve quality of care, but also reduce medical costs and provide a way to measure performance by physicians and institutions. Integral to this process is the development of appropriate metrics by which to measure outcomes and physician performance that accurately reflect otolaryngology and its subspecialties. Two sessions at the recent 2011 American Academy of Otolaryngology–Head and Neck Surgery Annual Meeting held here Sept. 13 highlighted issues that are important for otolaryngologists striving to meet the growing demand for quality improvement.
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October 2011
Bedrock of Quality Improvement
Among the external pressures on physicians and health care organizations to develop and implement metrics that can be used to evaluate outcomes are agencies such as the Joint Commission that require, through medical staffs, Ongoing Professional Practice Evaluations (OPPE) and Focused Professional Practice Evaluations (FPPE), according to Rahul K. Shah, MD, a pediatric otolaryngologist with Children’s National Medical Center at George Washington University Medical School in Washington, DC.
“Everyone in this room will have to help define our metrics and we’ll need to police ourselves,” he said, emphasizing that the onus is on otolaryngologists to develop appropriate metrics. These metrics, he said, must be consistent with the Joint Commission’s guidelines for developing OPPE and FPPE metrics. (For more information, see “Resources on the Joint Commission Standards for OPPE,”)
Brian Nussenbaum, MD, Christy J. and Richard S. Hawes III Professor and patient safety officer within the department of otolaryngology-head and neck surgery at Washington University School of Medicine in St. Louis, Mo., emphasized that the role of metrics is to identify areas of quality excellence and to identify areas for quality improvement. “These metrics should be indirect measures of quality of care,” he said. (See his “Characteristics of a Good Metric” on page 4.)
One major challenge for otolaryngology is to “choose metrics that are meaningful and applicable to otolaryngologists across a wide spectrum that might have very different subspecialty practices, especially in an academic department,” he said.
In 2009, Dr. Nussenbaum became the formal patient safety officer in his department and, in conjunction with Richard Chole, MD, PhD, Lindburg Professor and department chairman of otolaryngology-head and neck surgery at Washington University School of Medicine in St. Louis, Mo., initiated a comprehensive quality improvement process that includes OPPE and FPPE requirements. As part of that process, quality metrics are tracked using a computer program called Tableau, with the data provided quarterly by Barnes-Jewish Hospital in St. Louis, Mo. An OPPE is conducted every eight months on each attending physician, and the overall performance of the department is also tracked.
Scharukh Jalisi, MD, director of head and neck oncologic and skullbase surgery at Boston University School of Medicine in Boston, emphasized the importance of tracking physician performance. “The key for ongoing physician performance is to look for improvement,” he said. “It is not a witch hunt.”
The need for physicians and institutions to get on board to develop metrics appropriate to otolaryngology is critical, because these metrics will be increasingly used by patients to select care and by payors to determine reimbursement.
“We need to be prepared for increased transparency and the need for individual practitioners and hospitals to report performance metrics for their medical staff in the coming years,” Dr. Shah said. “Not only is this a Joint Commission requirement, it is being demanded by the public and, soon, the payors.”
How to Prepare
To help physicians and institutions prepare to implement quality improvement, Dr. Nussenbaum provided a list of recent research articles on quality improvement that are relevant to the everyday practice of otolaryngologists and head and neck surgeons (See “Key Studies on Quality Improvement,” page 4).
Of these, he described in detail a 2010 study on quality and performance indicators in an academic department of head and neck surgery in which the authors described a method for assessing physician performance and care outcomes adjusted for procedure acuity and patient comorbidity (Arch Otolaryngol Head Neck Surg. 2010;136:1212-1218). The study also identified best practices and developed a monitoring tool to identify trends that require intervention to improve quality of care.
The model proposed in the study, said Dr. Nussenbaum, allows surgeons to assess individual outcomes in relation to their peers, identify best practices and positively affect patient outcomes through self-improvement. He said that the risk adjustment included in the model, which took into consideration both acuity of surgery and patient comorbidities, had a significant impact and was an important consideration for analyzing the data.
“The model appears to be a useful tool, and this model could potentially be applicable to other specialty practices,” he said.
Randal S. Weber, MD, the lead author of the study who was attending the session, commented that he and his colleagues are continuing to look at trends in the data and hope to see surgeons tend toward the mean but will track outliers to modify practice. Dr. Weber, professor of head and neck surgery at the University of Texas MD Anderson Cancer Center in Houston, also said that other risk factors, such as disease stage and prior treatment, may need to be incorporated into the model.
Patient Involvement
Matthew A. Kienstra, MD, section head of ENT and oral surgery and director of the Facial Trauma Services at St. John’s Mercy Medical Center and Clinics in Springfield, Mo., focused attention on an issue raised in a study (Medical Care Res Rev. 2010;67:119-148) that looked at what he thinks will be a growing trend: the involvement of patients in their own safety. An example of this, he said, is “Speak Up,” a program sponsored by the Joint Commission that has focused on hand washing to decrease infections. Other examples are exercise and safe sex programs and breast self-exams.
Dr. Kienstra noted several risks that come with basing quality improvement on involving patients in their own care, including the patients’ perception that they bear the burden of their illness, a misconception that may lead to an erosion of trust between physician and patient and potential punitive consequences in terms of reimbursement for perceived insufficient involvement.
Overall, he said that engaging patients in their own safety has not been shown to be effective and has been poorly studied. The key for patient involvement is staff involvement, he added. The idea of including patients in their own safety is not perfect, he said, “but can be successful over time and needs to be done down the road.” ENT Today