Quality Improvement Initiatives

Physicians in all divisions in the Department of Medicine (DOM) now participate in the Medicare Physician Quality Reporting System (PQRS) and report the clinical quality measures that allow them to meet the standards for “meaningful use” of the electronic health record set by CMS. In addition, every division has adopted clinical quality indicators to measure the quality of care provided, determine quality-based incentive payments to physicians, suggest new opportunities for quality projects, and inform existing quality improvement projects. The divisions have launched or continued quality improvement interventions, some of which are detailed below.

This year, a DOM Quality Council was formed, consisting of physician quality leaders in each of the divisions. The council, which meets approximately once a month, provides participants with a forum for sharing QI projects, learning QI methodology from each other, and brainstorming solutions to shared challenges. This year, the council learned about operational changes made by Geriatrics to become a Patient Centered Medical Home (PCMH), explored the issues surrounding ensuring appropriate pneumococcal vaccination in patients who are on immunosuppressive drugs, heard about how care plans decrease utilization in patients with frequent admissions, and considered how to monitor appropriateness of TPN in the hospital, among other topics.

The Quality Council spawned a project involving the Gastroenterology, Pulmonary, and Rheumatology divisions that commonly prescribe immunosuppressive drugs. These divisions are working together on a project to develop a common set of standards for monitoring toxicity from these drugs; design electronic tools, such as order sets to facilitate compliance with good practice standards; and deploy operational changes to ensure appropriate monitoring.

In addition, the Hospital Medicine Leadership Group has been formed, consisting of nursing and physician leadership on the various medicine nursing units at UPMC Presbyterian. This group, which will regularly review quality data for the units, provides an opportunity for nurses and physicians to work collaboratively on QI projects on the internal medicine service.

Members of the DOM collaborate with UPMC in hospital quality-improvement initiatives, including initiatives in the medical intensive care unit and projects to improve diabetes care. In addition, the DOM continues to provide medical leadership to assist UPMC in successfully adhering to CMS CORE measures most relevant to the medical service—namely, hospital treatment of community acquired pneumonia, acute myocardial infarction and heart failure.

The DOM has helped UPMC achieve high performance in the measures for acute myocardial infarction (AMI). In particular, within the DOM, compliance with these measures has been 100 percent for the past year (Figure 1).

Likewise, despite a very high-risk cardiac population of patients, the department has once again helped UPMC achieve high compliance with heart failure quality measures, with rates within the DOM of 100 percent for three out of four measures, with similar or improved compliance in every measure compared to last year (Figure 2). 

QUALITY IMPROVEMENT: DIVISION ACTIVITIES

Each division has launched or continued quality-improvement projects. New projects are highlighted.

Cardiology:

• Collaborated with the hospital and the UPMC Health Plan to reduce the CHF readmission rate
• Investigated outcomes for acute myocardial infarction and PCI
• Developed and is testing care pathways for Acute Coronary Syndrome

Endocrinology:

• Evaluated two intensive IV insulin protocols in use at UPMC showing that they were equally safe and effective for patients who had previously been diagnosed with diabetes and those who had not
• Collaborated with anesthesia to develop a protocol for the management of patients who come to same-day surgery with an insulin pump. Evaluation showed that the protocol was safe and decreased variability in the treatment of these patients.
• Began a feasibility study to address readmissions in patients admitted with diabetes
• Worked with the hospital to improve the quality of inpatient diabetes management and provided medical leadership for the Diabetes Inpatient Safety committee
• Measured intermediate outcomes (such as A1c, LDL, and blood pressure levels) in diabetes care as well as usage of DEXA and vitamin D monitoring in patients with osteoporosis

Gastroenterology and Hepatology:

• Audited peripheral nutrition (PN) utilization in the hospital, characterizing the reasons for ‘avoidable PN days’ with the ultimate goal of decreasing “avoidable PN days”
• Collected data on reasons that pharmacists have to call the ordering team for PN orders to develop new processes that decrease the need for pharmacy ‘call backs’ (by insuring complete, unambiguous, and correct orders at the time of order entry)
• Collaborated with the Starzl Transplant Institute and the Department of Surgery to realign goals/objectives/operating procedures related to the Liver Transplant team

General Internal Medicine:

• Was awarded recognition by the National Committee for Quality Assurance, Patient-Centered Medical Home (PCMH) 2011 Program
• Medication adherence project resulted in change in the number of patients who scored as low adherers on the MMAS-8 instrument from 35 percent to 25 percent with the percentage of patients reporting financial barriers to adherence falling from 7 percent to 3 percent. In addition, Press-Ganey score for “the Information the Care Provider gave you about your medications” improved from baseline of 85.2 percent to 94.1 percent
• Project to improve LDL measurement in patients with CAD resulted in LDL measurement increase from 83 percent at baseline to 90 percent in first quarter 2012
• Achieved UPP Pacesetters Recognition in first quarter 2012 for sustained high scores in the “Care Provider” section of Press Ganey survey
• Piloted for system redesign in primary care to allow for more protocol-based team-based care, including utilization of protocols so that nurses can ensure patients are up to date with preventative care and chronic disease care at every phone contact, when feasible
• Implemented care plans on the inpatient service for patients with high admission rates, resulting in a 19 percent decrease in admissions and a 34 percent decrease in hospital days among the 20 patients in the pilot
• Measured quality indicators for diabetes, HTN, CAD, CHF, and preventative care in the outpatient setting and performed continuous quality improvement methods to improve performance

Geriatrics:

• Participated in the Governor’s Model project involving continuous quality improvement in the care of identified conditions at the Senior Care site
• Achieved Patient Centered Medical Home (PCMH) recognition from NCQA for Senior Care and Benedum Geriatrics Center
• Achieved Pacesetters Recognition by UPP for Press Ganey patient satisfaction scores
• Decreased readmissions by regularly reviewing readmissions
• Increased outreach to high risk patients, post discharge phone calls, and protocols for:
  • reviewing our readmissions at our regularly scheduled physician meetings
  • increasing intensity of high-risk patient review and outreach utilizing CRNP’s
  • ongoing post hospital and post nursing home discharge phone calls
  • follow-ups in the office after discharge from hospital or emergency department

Hematology/Oncology:

• Implemented a nocturnist program on attending service
• Achieved certification by Quality Oncology Practice Initiative (QOPI)

Infectious Diseases:

• Continued to provide leadership for the Antibiotic Management Program (AMP)
• Designed an Outpatient Intravenous Antibiotic Program to ensure the follow-up of all patients discharged on IV antibiotics
• Ensured completion of Hepatitis B Vaccine Series in HIV-Infected Patients resulting in improved compliance from baseline of 14 percent to 43 percent (won third place for quality in UPMC Presbyterian Campus Quality & Safety Fair)
• Awarded first prize at Quality Fair for Sustained Improvement for Opioid Management Project, which included chart review showing that opiates were prescribed appropriately 80 percent of the time, leading to plans for improved use of urine drug screens
• Based on data from a molecular epidemiologic study of environmental contamination of outpatient clinics with toxigenic Clostridium difficile (C diff), clinic eliminated fabric- covered furnishings, installed plastic keyboard covers, and trained housecleaning staff on cleaning methods to eliminate C diff from the environment
• Evaluated the incidence of colectomy after lung transplantation, leading to identification of high-dose of mycophenalate as a risk factor and recommended lower dose along with higher-dose steroids, leading to return to baseline of complication rates and decreased organ rejection
• Achieved PCMH recognition by NCQA in the HIV/AIDS PACT clinic

Pulmonary:

• MICU mobility project achieved early mobilization of ventilated patients by focusing on active ROM, out of bed to chair, and ambulation for all mechanically ventilated patients. This project resulted in a decreased percentage of patients with delirium, and increased numbers of patients with sedation interruption, weaning trials during sedation interruption, and time out of bed while on mechanical ventilation. This project won a first prize at the 2011-2012 Quality & Safety Fair
• Improved passive range of motion of sedated ventilated patients using MotaMed, funded by Beckwith Institute for Innovation in Patient Care at UPMC
• Worked to develop a clinic for the long-term follow-up of survivors of prolonged mechanical ventilation
• Collaborated with Vascular Surgery and Cardiothoracic surgery to develop protocols and a 24/7 consultation service for treatment of complex patients with pulmonary embolism

Renal:

• Collaborated with the Starzl Transplant Institute and the Department of Surgery to realign goals/objectives/operating procedures related to the Liver Transplant team
• Collaboration with FMC and DCI in their Dialysis Quality Initiatives

Rheumatology:

• Reduced toxicity of DMARDS by monitoring adherence to lab test guidelines
• Launched project to improve rates of pneumococcal vaccination in immunosuppressed patients from baseline of 15 percent to 52 percent. When patients who were offered pneumococcal vaccination but deferred are included, the rate increased from 15.2 percent to 68 percent