Robert A. Klugman

Physician Quality Officer: A New Model for Engaging Physicians in Quality Improvement

The slow progress in health care quality improvement and patient safety in America can be attributed, in part, to the challenge of physician engagement. As multidisciplinary patient-centered care becomes the standard, it is essential to integrate physicians into this process. To this end, the UMass Memorial Medical Center redesigned its Physician Quality Officer (PQO) program in 2007. The PQOs of the UMass Memorial Medical Center, who are all practicing clinicians, are fully compensated for their time and effort, trained in safety science, and teamed with other members of the department of quality and patient safety. Over the first year of the new program, the PQOs have successfully led major hospital initiatives in areas such as surgical care improvement, critical values reporting, and medication reconciliation. In this article, the authors describe the challenges and insights in the development and implementation of this new program. (Am J Med Qual 2009;24:295-301)

Mortality rates as a measure of quality and safety, "caveat emptor".

The objective of this study was to demonstrate the impact of a single ICD-9 (International Statistical Classification of Diseases and Related Health Problems, Version 9) code on the observed-to-expected mortality ratios for acute care hospitals, calculated using administrative data. The study was a retrospective analysis of mortality data and prospective measurement of the impact of a change in coding on expected mortality rates. Measurement included overall mortality observed-to-expected mortality index for 2 hospitals and rate of use of the palliative care ICD-9 code. The main result was that both retrospective and prospective applications of this single ICD-9 code significantly reduced observed-to-expected mortality ratios. Both regulators and hospitals need to be aware of the impact of the quality of coding on publicly reported quality and patient safety data.

Home Medication Support for Childhood Cancer: Family-Centered Design and Testing

PURPOSE Errors in the use of medications at home by children with cancer are common, and interventions to support correct use are needed. We sought to (1) engage stakeholders in the design and development of an intervention to prevent errors in home medication use, and (2) evaluate the acceptability and usefulness of the intervention. METHODS We convened a multidisciplinary team of parents, clinicians, technology experts, and researchers to develop an intervention using a two-step user-centered design process. First, parents and oncologists provided input on the design. Second, a parent panel and two oncology nurses refined draft materials. In a feasibility study, we used questionnaires to assess usefulness and acceptability. Medication error rates were assessed via monthly telephone interviews with parents. RESULTS We successfully partnered with parents, clinicians, and IT experts to develop Home Medication Support (HoMeS), a family-centered Web-based intervention. HoMeS includes a medication calendar with decision support, a communication tool, adverse effect information, a metric conversion chart, and other information. The 15 families in the feasibility study gave HoMeS high ratings for acceptability and usefulness. Half recorded information on the calendar to indicate to other caregivers that doses were given; 34% brought it to the clinic to communicate with their clinician about home medication use. There was no change in the rate of medication errors in this feasibility study. CONCLUSION We created and tested a stakeholder-designed, Web-based intervention to support home chemotherapy use, which parents rated highly. This tool may prevent serious medication errors in a larger study.

The Physician Quality Officer Model 5-Year Follow-up

Physician engagement is a key element of health care quality improvement. Challenges include competing demands, inconsistent compensation, knowledge deficits, and lack of mentorship and role modeling. To help address these obstacles, UMass Memorial Medical Center developed a physician quality officer (PQO) program in 2007. Since its inception, several elements of the program have changed, including PQO roles in projects, approaches to training, logistics of group communication, the role of PQOs in medical staff education, and the PQO compensation model.

Measuring Harm in Health Care: Optimizing Adverse Event Review

Objective: The objective of this study was to identify modifiable factors that improve the reliability of ratings of severity of health care–associated harm in clinical practice improvement and research. Methods: A diverse group of clinicians rated 8 types of adverse events: blood product, device or medical/surgical supply, fall, health care–associated infection, medication, perinatal, pressure ulcer, surgery. We used a generalizability theory framework to estimate the impact of number of raters, rater experience, and rater provider type on reliability. Results: Pharmacists were slightly more precise and consistent in their ratings than either physicians or nurses. For example, to achieve high reliability of 0.83, 3 physicians could be replaced by 2 pharmacists without loss in precision of measurement. If only 1 rater was available for rating, ∼5% of the reviews for severe harm would have been incorrectly categorized. Reliability was greatly improved with 2 reviewers. Conclusions: We identified factors that influence the reliability of clinician reviews of health care–associated harm. Our novel use of generalizability analyses improved our understanding of how differences affect reliability. This approach was useful in optimizing resource utilization when selecting raters to assess harm and may have similar applications in other settings in health care.

The "physician-led chart audit: " engaging providers in fortifying a culture of safety.

Objectives Engaging physicians in quality and patient safety initiatives is a well-described challenge. Barriers include time constraints, lack of defined common purpose and leadership support, poorly communicated goals, and scarcity of supporting data (references 1, 2, 3). With reference to strengthening a culture of safety while meeting regulatory and performance standards, health-care systems face a difficult twin objective: educate the medical staff and its trainees and maintain high levels of compliance across inpatient, ambulatory clinic, and procedural areas. In 2010, our institution identified opportunities for improvement in physician performance related to several important patient safety standards. These issues had not been previously corrected by didactic sessions, written communication, and the chain of command. Methods To help address these general and site-specific problems, we developed and deployed a set of medical record audit tools entitled “physician-led audits” (PLAs). We trained providers in leadership positions to use the tools and to teach their use to others. We designed a system to capture data on frequency of use and results. The PLA process is distinctive in that it holds physicians accountable for the auditing and for follow-up afterward. Results With support from department chairs, division chiefs, residency program directors, and other leaders, close to 2000 PLAs were performed over a 10-month study period. Conclusions The audits engaged physician leaders and the at-large medical staff, making them key participants in a system-wide improvement campaign. The tool was customized for use in a broad range of clinical settings and was widely and rapidly adopted, leading to important dialogue and a substantive contribution to our safety culture.

Letter to the editor: the UMass Memorial Quality Scholars program at year three: a response to the editorial by Drs Myers and Jaeger.

To the Editor, As the current leaders of UMass Memorial Healthcare’s (UMMHC) Quality Scholars program, we are pleased to respond to some of the questions posed by Drs Myers and Jaeger in their editorial (March/April 2012). Since the initial group completed the program, we have recruited and trained 2 more classes and are currently organizing the fourth. Support now comes primarily from the Department of Quality and Patient Safety at UMMHC. We have enjoyed robust demand for positions and strong support from senior administration including our department chairs, many of whom provide funding to allow Quality Scholars to carve time from their clinical responsibilities. Although the program has maintained most of its original format (combining reading and online study, didactic sessions, and an independent, mentored quality improvement project), we have progressively aligned curriculum with major institutional initiatives including Lean and Patient-Centered Care. Quality Scholars have created a variety of improvement projects (Table 1), spanning inpatient and ambulatory settings. In each case, the Quality Scholar leads a team, collects and analyzes data, and prepares a poster and didactic presentation for an end-of-year event. Feedback from past participants reinforces our institution’s ongoing commitment to the program. In a recent survey of 19 of 21 current Quality Scholar graduates, asking them to reflect on the program and their current professional lives (Table 2), all but one said learning from Quality Scholars is being incorporated and built on in their clinical work, and a large majority said the same about their teaching. Almost three quarters of the group have participated in additional quality improvement initiatives since their time as Quality Scholars, and most expressed interest in opportunities to develop new skills in quality improvement. The survey also yielded other important information about the graduates. About a third are leveraging their quality improvement knowledge in initiatives related to the patient-centered medical home, with one involved at the state level here in Massachusetts. Several are connected to an institutional diabetes care improvement collaborative. Two have become directors of quality for their practices, and one has become a system-wide quality officer who helps coordinate a quality improvement elective for fourth-year medical students. Many others are involved in more focused, local efforts to improve quality and patient safety in their various practice settings. In summary, the Quality Scholars program continues to evolve and remains vital to our mission: high-quality, safe, patient-centered, and efficiseent care. We have successfully transitioned from a grant-supported pilot to an institutionally-supported program that dovetails with an ever-widening web of quality improvement activity encompassing clinical, administrative, and academic settings.