Guidance to Select Healthcare Quality Improvement Project
Posted on: November 1, 2008
Three precedents bear consideration as effective systems to select improvement projects. Although two were successful quality improvement systems, they failed to persist and become today’s North American gold standard models. Williamson’s Achievable Benefits Not Achieved (ABNA) system to identify and prioritize potential projects has a remarkable track record among alternatives. Similarly, the so-called Denver Connection of the same era is a story of successful amalgamation and reorganization of two hospitals in a way that put quality improvement supported by real-time performance data analysis as the centerpiece of medical staff departmental meetings and continuing medical education (encouraged by board-level involvement while the usual array of advisory committees was eliminated). Finally, the Institute of Medicine’s (IOM’s) Model Process for semiquantitatively ranking alternative projects is instructive for its mathematical approach.
Dr. John W. Williamson developed systems for health accounting and ABNA during an impressive body of work that spans decades on the faculty of the Department of Health Services Administration at the Johns Hopkins University School of Hygiene and Public Health, Medicine and Medical Informatics at the University of Utah School of Medicine, Regional Medical Education Center of the Salt Lake Veterans Affairs Medical Center, and service on government commissions. Health accounting, conceptualized in the early 1960s, is “a management model to integrate continuing education and patient care research into an ongoing cyclic function to systematically improve the quality of medical areâ. It is an evidence-based outcome-focused approach that selects project priorities through ABNA, a formal, efficient process refined in the 1970s. Although proven effective and cost effective in a wide range of applied research and demonstration projects at the American National Institutes of Health, Veterans Administration, and elsewhere, Williamson acknowledges that the most successful application of his system to enhance national quality is in the Netherlands. The fact that Williamson’s name and work are unfamiliar to many members of the healthcare quality special interest group of the Society for Healthcare Epidemiology of America and the American Society for Quality’s (ASQ’s) Health Care Division reflects lack of recognition throughout North American hospitals. This is hauntingly reminiscent of the history of W. Edwards Deming’s influence taking decades to return to North America, heeded by American manufacturers only after Japan capitalized on Deming’s leadership to outperform its American counterparts (and heeded by health service organizations decades after that!). Williamson stresses the following:
• The importance of applying principles of epidemiology, sampling, and simple statistical testing to QA-focused reviews
• The necessity of a multidisciplinary team approach to QA, in which the consumer was the most important member of the team
• The need to use structured group judgment methods for establishing priorities, criteria, and standards as well as QA action decisions under the usual conditions of factual uncertainty
• The need for a unique set of statistical methods for QA that allowed comparison of measured results against consensus standards that reflected reasonably achievable projected outcomes
Consistent with concurrent surveillance methods that have become a mainstay of contemporary infection surveillance programs, Williamson recognized long ago that chart-based audits as a basis for quality assurance may be misleading and severely limit the potential impact of programs to improve quality. His ABNA process consists of selecting a team (ideally 7 to 11 persons, including at least four knowledgeable and respected staff physicians and representatives of other functional areas and the lay public), then supporting that team through two 2-hour meetings 3 to 4 weeks apart. The first meeting is a training session simulating the later priority-setting session. A master list of potential topics developed during the training session, together with team recommendations on additional data, literature, or consultationâl required, provides an indication of support materials that will be needed at the second session. Ideally, these are gathered during the 3 to 4 week hiatus. There are seven tasks in the priority-setting meeting:
• Introductory remarks by the moderator clarify meeting purpose, tasks, and timing of the 2-hour session and review the ABNA framework (5 to 10 minutes).
• A simple four-column form is distributed so that individual team members can each list as many topics as they wish, listing along one row for each topic:
o exactly who (what group) will benefit
o for what health problem
o from what action(s)
o by which provider(s)
A cue sheet is provided to give examples of various patient characteristics, health problem characteristics, provider characteristics, and (inter)action types that might be considered. Time is given to work individually (10 minutes).
• Each team member, sequentially, is then asked by the coordinator to nominate one problem from their list. The coordinator develops a summary chart; in addition to the four columns identified in step 2, when acting as coordinator I found it helpful to list in two additional columns an indication of whether the intervention is known to work (nature of evidence for efficacy or effectiveness) and whether it is feasible (information on cost, cost-effectiveness, case study, etc.). Discussion is limited to clarification at this stage, and the process repeats until all the most promising ideas from each member’s list are presented (30 minutes).
• Individuals then vote in an “initial weights column on their form to assign a priority rank (high to low on a 5-point scale) for each project nominated (5 minutes).
• The coordinator then collects the votes, anonymously recording both initial individual weights and their sum for each nominated project. This information, superimposed on the summary chart, is projected back to the group (10 minutes).
• Discussion of results, one topic at a time, then examines whether priority ranking is tightly or widely dispersed, the strength of evidence, and other detailed considerations. On completion of comprehensive discussion, members are then asked to vote again on every topic, in a revised weights column on their form. The coordinator again collects and records votes anonymously (50 minutes).
• The highest-ranked ABNA topics are then forwarded as recommendations from the team, along with any further recommendations for additional data or evidence required for any of the topics. The meeting is adjourned, the team thanked for completing its work, and special teams of qualified individuals then take responsibility for moving approved projects forward.
Meanwhile, also in the 1970s, radical changes under the amalgamation of the medical staffs at Denver’s Swedish Medical Center and Porter Memorial Hospital occurred. Radical change was needed because as Dr. William Robinson, Director of Medical Education, noted, In spite of the hundreds of physician hours devoted to medical staff activities, little actually was accomplished. It was almost impossible to demonstrate that quality of care was in any way influenced by the physicians’ repetitive, duplicative, unrewarding medical staff activities. The usual litany of committees was reduced to just three (Executive, Professional Activities, and Credentials). A reduced number of subcommittees composed of small numbers of individuals, the bulk of whom were not physicians, served these committees, and much of the quality-related work was shifted from committees to medical staff departments supported by the work of subcommittees or research and education department employees. Medical staff members were strongly encouraged to ask questions at their departmental meetings about quality issues, then make policy decisions based on evidence delivered soon thereafter (answers supplied through real-time research capacity in their own institution).
Although successful into the 1980s, by the turn of the twenty-first century the Denver Connection was so far dismantled that it no longer even existed in the institutional memory of Porter Hospital’s present administration! Porter and Swedish, partners of the so-called Denver Connection formed in 1972, went their separate ways in 1992. These two hospitals serving health needs of southeast Denver had remained separate corporate entities, yet collaborated successfully for many years following formal merger of their medical staff organizations. That merger was initiated by the doctors, not the administrators, for the purpose of improving quality of care. Administrative support grew following demonstrated successes, and the hospitals cooperated in division of complementary health services instead of duplication of what the other offered solely to compete. That was before big business entered sickness. Ultimately, poor quality of management in emerging, large, managed-care corporations led to unexpected deficits in profitability of operations, and corporate vision shifted to preoccupation with that debt. A grass-roots anticompetitive way of serving the community’s health needs could not sustain itself in the face of powerful market forces and growing business empires awash in corporate debt. Personal ideologies in administrative leadership compounded the difficulty of making effective alliances, and mistrust grew where open communication once thrived. Key participants later interviewed conveyed a sense of loss and regret, a realization they participated in something very unique and beneficial that was lost for illogical reasons (nobody had any appreciation what we were doing was special or unique)only in retrospect we came to appreciate the specialness of what we were doing.). The influence of accreditation programs in this saga was noteworthy only for its lack of influence. It is tempting to speculate that this visionary effort thrived because it followed characteristic principles that seem to distinguish great companies from others and that the Denver Connection ultimately fell when it strayed from core values and these fundamental principles.
Reference : Birnbaum D. How to Select Improvement Projects. In Hospital Epidemiology and Infection Control, 3rd Edition. Editors: Mayhall, C. Glen. Copyright ©2004 Lippincott Williams & Wilkins.
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