Cover Story-Field Guide
Quality and Patient Safety Basics
As a new doctor, you will encounter quality-improvement initiatives that were unheard of 10 years ago. They may include the use of guidelines to provide care, computerizing medical records and prescription ordering, and participation in pay-for-performance programs.
National Resources on Providing Quality Care
National Guideline Clearinghouse
(www.guideline.gov),
a database of evidence-based guidelines
National Quality Measures Clearinghouse
(www.qualitymeasures.ahrq.gov), a searchable database of quality measures |
This recent emphasis on improving quality and patient safety started in 1999 with the release of the Institute of Medicine’s report To Err is Human: Building a Safer Health System. The report got the nation’s attention with the startling estimate that 98,000 patients died each year because of medical errors.
In 2001, the IOM followed up with Crossing the Quality Chasm: A New Health System for the 21st Century. This report suggested there was not a gap but a chasm between ideal medical practice and what actually occurs in the United States.
Quality Improvement Players in Minnesota
The following are a few of the organizations in Minnesota that are leading the quality improvement and patient safety movement.
MN Community Measurement
MN Community Measurement is an independent nonprofit organization supported by the MMA and various health plans. It rates clinics on care delivered for diabetes, vascular disease, asthma, and upper respiratory infections and sore throats; blood pressure control; and rates for immunizations, Chlamydia screening, and breast and cervical cancer screening.
The Institute for Clinical Systems Improvement (ICSI)
ICSI is an independent collaborative composed of 57 medical groups and sponsored by six Minnesota health plans that’s focused on helping members deliver patient-centered care. ICSI work groups create evidence-based treatment guidelines that are used by providers around the country.
The organization also helps clinics create protocols designed to improve care. In one local initiative, known as DIAMOND, ICSI has been working with physician groups, health plans, and state health officials to change the way primary care providers screen and care for patients with depression and reimburse them for those services. For more information about ICSI go to www.icsi.org.
The Minnesota Alliance for Patient Safety (MAPS)
Created in 2000, MAPS is a joint initiative of the Minnesota Hospital Association, the MMA, the Minnesota Department of Health, and nearly 50 health care organizations dedicated to improving patient safety.
MAPS has produced a standardized, informed consent form for patients that is written at a fourth-grade reading level; the My Medicine List, a form patients can use to keep track of their medications; and Patients as Partners materials that teach physicians to empower patients so they can make sure they receive safe care. MAPS also tries to promote a “just culture” in health care that differentiates between individual behaviors and system failures.
Stratis Health
The Centers for Medicare and Medicaid Services (CMS) contracts with Stratis to serve as Minnesota’s Medicare Quality Improvement Organization (QIO). More than 50 QIOs across the nation do case reviews and work with providers to try to ensure that Medicare patients get the right care at the right time. Among other things, Stratis helps providers discover and implement evidence-based practices.
Minnesota Medical Association
The MMA has a standing quality committee and has assembled an extensive list of links to quality tools and resources on its website (www.mmaonline.net, click on Key Issues, then click on Quality and Safety). It also launched a publication in 2006 highlighting Minnesota’s quality efforts called the MMA Quality Review. |
Even today, only about half of patients receive recommended preventive care. Seventy percent receive recommended care for acute needs, 60 percent get such care for chronic conditions, and almost a third of patients receive contraindicated acute care, according to the National Quality Forum, a not-for-profit organization charged with creating a national strategy for developing and implementing quality measurement and reporting in health care.
In Crossing the Quality Chasm, the IOM identified six aims for quality (that it is safe, effective, patient-centered, timely, efficient, and equitable) and said the way to achieve them was to radically reform health care by analyzing processes and measuring, reporting, and rewarding outcomes. Instead of placing blame on individual providers, it faulted the entire system: “Health care has safety and quality problems because it relies on outmoded systems of work. Poor designs set the workforce up to fail, regardless of how hard they try. If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes.”
Congress, state governments, regulators, health care provider organizations, and insurers have spent the last several years pursuing the report’s recommendations. Efforts to improve quality and safety started in hospitals and have moved into clinics. It’s likely that the practice you join has in some way been touched by this movement.
What's happening in Minnesota?
Minnesota has been a leader in the health care quality arena with firsts in reporting errors, measuring outcomes, and passing laws promoting electronic health systems.
In 2003, Minnesota became the first state to require hospitals to report the occurrence of 27 preventable errors such as wrong-site surgeries, falls, and medication errors. In 2007, the state added three more “never events” to that list, one of which was artificial insemination with the wrong sperm or donor egg. When an error does occur, Minnesota hospitals are required by law to conduct a root-cause analysis during which they examine the factors that contributed to it and modify systems to make sure the error doesn’t happen again. The Minnesota Health Department releases a report on preventable errors that occurred in hospitals in January of each year (www.health.state.mn.us/patientsafety/).
Minnesota is one of the few states that rates and publicly reports the performance of its clinics. It does this through MN Community Measurement, an independent organization that rates clinics on care delivered. You can find any clinic’s score as well as a list of the best and worst performers at www.mnhealthcare.org.
Will my work be graded?
Your clinic’s work might be graded through MN Community Measurement, and your work might be tracked as part of a pay-for-performance initiative.
Currently, nine pay-for-performance programs are operating in Minnesota, eight of which provide bonus opportunities for participating clinics. The programs are offered by Blue Cross and Blue Shield of Minnesota, Bridges to Excellence (implemented through the Buyers Health Care Action Group, a coalition of large employers), HealthPartners, Medica, PreferredOne, UCare, and the Centers for Medicare and Medicaid Services. One HealthPartners program includes a potential withhold. In 2007, the MMA released the first report evaluating pay-for-performance programs operating in the state. It is available at www.mmaonline.net.
Most pay-for-performance programs in Minnesota are voluntary. The terms of participation are generally spelled out in the contracts between health plans and medical groups. They most frequently base their awards on diabetes care, Chlamydia screening, cervical cancer screening, breast cancer screening, childhood immunizations, and generic drug use.
Are all clinics and hospitals going electronic?
In 2007, 62 percent of Minnesota’s clinics that treat adult patients had partially or fully implemented an EMR; 24 percent planned to do so within two years, according to Stratis Health. The state has mandated that all clinics have EMRs that are part of an interoperable, statewide network for sharing patient information among providers by 2015.
Electronic medical records have a number of features that can help you deliver high-quality care. For example, many have prompts to remind you to ask patients about their smoking status or to tell a woman that it’s time to schedule a mammogram. Currently, however, there is wide variability among the functionality of systems in terms of computerized physician order entry, patient tracking, and integration of lab results and other diagnostic tests.
If you work for a clinic that is moving to the electronic age, Stratis Health offers free advice for implementing an EMR. Go to http://stratishealth.org, click on Tools and Resources, and download the DOQ-IT toolkit.
In addition to having EMRs, Minnesota clinics will be required to electronically transmit prescriptions to pharmacies by 2011. In 2007, only about 1.2 percent of prescriptions in Minnesota were transmitted electronically, according to a report from the Center for Improving Medication Management.