Free help is available for outcome measures

Peer review organizations are QI firms

Free of charge to medical groups: nurses to abstract outcomes data from patient charts; outcomes experts to analyze data and provide comparisons; feedback sessions to discuss interventions, education, and consensus-building.

Would you jump at that offer? Peer review organizations around the country hope you will.

Armed with contracts from the Health Care Financing Administration to improve care for Medicare patients, these organizations are developing collaborative projects with medical groups and other providers. If you have the desire for quality improvement, they will provide the means.

"We do the project design, data collection, analysis, feedback sessions. We assist them with quality improvement plans and provide them with tools to use in their interventions," says Linda Gaskell, RN, CPHQ, project manager of the Ohio Diabetes Project for Peer Review Systems in Columbus, OH. "We offer them a lot. Most physician offices have scant resources when it comes to quality improvement."

Collecting and using data

The Ohio Diabetes Project provides an example of such a collaborative. So far, 12 medical groups have signed on to measure and seek to improve on 12 indicators, which include patient education, HbA1c and cholesterol testing, foot exams, and ophthalmology referrals.

As the first groups completed their remeasurement after a year-long period of intervention, initial results show improvement. While their data remain confidential, other medical groups will learn of their successes, says Stephani J. Wilmer, community relations manager for Peer Review Systems.

"We’re able to identify the collaborators who have the best practice and highlight [it]," she says.

Collaboratives such as the Ohio Diabetes Project represent a fundamental shift from retrospective review of Medicare care that occurred several years ago to a proactive approach. "We’ve always been concerned with the quality of health care provided to Medicare beneficiaries," says Wilmer. "The method we use to assess that care has changed."

The Ohio Diabetes Project actually began when a medical group approached Peer Review Systems with a proposal. PRS officials also had been considering a focus on outpatient diabetes care.

"We formed a study group of diabetes experts from Ohio," says Gaskell. "We developed the study design and methodology, the data collection tool, the definitions."

Collaborative efforts

The indicators were based on practice guidelines from the American Diabetes Association (ADA), and are updated to reflect any changes. Medical groups receive free forms that may help them improve their care: Checkpoints, a flowchart that is attached to the patient record, and Checkmate, an educational tool that allows patients to track needed care.

Once the first medical group successfully completed the one-year program, PRS began soliciting new collaborators. There is no limit on the number of Ohio medical groups that can participate, and no time limit on the life of the project.

"Every time a collaborator comes on board, we consider that a separate project with them," Gaskell says. "We look at one year period of care because a lot of [diabetes] indicators are based on annual events."

Themes for improvement

As PRS gathered baseline data, one consistent problem area arose: On average, only 24% of diabetic patients received a foot exam every visit. Gaskell recommends medical groups to include that indicator in their intervention programs.

"I think sometimes clinics are surprised at their results because the physicians think they’re doing better than what our report may show for a particular indicator," says Gaskell. "To stimulate change you need to give physicians comparative data, not just education. You have to show them how they’re doing and how they compare to others."

Medical groups in the Ohio Diabetes Project design their own interventions, so they all may make different changes in their processes based on their individual needs. But Gaskell has noticed some basic themes as the first groups show improvement:

1. Ensure physician buy-in before launching your quality improvement project.

One medical group used the small group consensus process to promote physician buy-in, which involves meetings in which physicians first reach agreement on the standards of care. In the case of the Ohio Diabetes Project, many of those standards are set by the American Diabetes Association guidelines.

Then, they identify the opportunities where they want to improve based on their baseline data. They brainstorm with a focus on barriers and possible solutions. In this case, the group even used a pre- and post-test on ADA standards and attitudes toward practicing using the standards of care, says Gaskell.

2. Involve patients in their own clinical improvement.

Physicians have a better chance of improving both clinical outcomes and quality indicators with the support and interest of patients. The Checkmates form helps patients monitor their own care, including cholesterol screening, foot and eye exam, and blood glucose.

"It encourages patients to become more aware of the kind of care they should be receiving and to get them more involved," says Gaskell. "We suggest that [physicians] ask patients to bring it to every visit. There’s even a place where patients can list their goals, such as blood sugar level," she says. "They can use this to talk to their doctor."

3. Use a team approach to guide improvement.

The Ohio Diabetes Project requires participating medical groups to appoint an interdisciplinary team to work on improvements. In addition to physicians, that team may include nurses, diabetes educators, and the office manager.

Even simple changes can make a difference, Gaskell noted. For example, the staff person who guides a patient into a room can make sure that patient removes his or her socks. The doctor then will find it easier to conduct a foot exam — and harder to forget.