Mount Sinai Beth Israel Endoscopy Clinical Integration Quality Improvement Program

Purpose/Introduction:

The mission of our endoscopy clinical integration program is to provide quality health care which recognizes theinherent human worth and dignity of all persons, and to make our programs and servicesavailable to all without restriction; to create a healing environment where physicians,allied health professionals and staff work together to provide personalized care; to be aleader in advocating high quality endoscopic programs and developing resources tosatisfy the digestive health care needs of the citizens of our service area; and to operate inan ethically and fiscally responsible manner without compromising the patient care needs.Consistent with this mission, our goal is to provide care that is:

Safe – avoiding injuries to patients from the care that is intended to help them:

Effective– providing services based on scientific knowledge to those who would benefit and refraining from providing services to those not likely to benefit;

Patient centered– providing care that is respectful of, and responsive to,individual patient preferences, needs, and values and ensuring that patient valuesguide all clinical decisions;

Timely– reducing waits and potentially harmful delays;

Efficient– avoiding waste, including waste of equipment, supplies, ideas andenergy;

Equitable– providing care that does not vary in quality because of personalcharacteristics such as gender, ethnicity, geographic location and/or socioeconomic status.

To achieve this goal, all employees of our integrated ambulatory centers and hospital based endoscopy units will participate in ongoing andsystematic quality improvement efforts. Our quality improvement efforts will focus ondirect patient care delivery processes and support processes that promote optimal patientoutcomes and effective business practices. This is accomplished through peer review,clinical outcomes review, variance analysis, performance appraisals, and otherappropriate quality improvement techniques.

Our Quality Improvement Plan demonstrates our program’s commitment to improve thequality of care we deliver. The QI Plan outlines the goals and strategies for ensuringpatient safety, delivering optimal care, and achieving high patient satisfaction. This program is integral to the overall mission of all integratedambulatory endoscopy centers and hospital based endoscopy units that are part of the Mount Sinai Beth Israel endoscopy clinical integration program.

The QI Process

All staff members must participate in the quality management and improvement process. Medical staff will be an integral part of the process and will have representation on the quality management and improvement committee. The facility’s quality management and improvement program will use appropriate analysis tools and statistical reporting to evaluate identified indicators. Reevaluation of quality improvement studies should occur consistently. The centers or hospitals may use a “FOCUS PDCA” strategy for improving organization performance:

  • Find a process to improve
  • Organize an effort to work on improvement
  • Clarify current knowledge of the process
  • Understand process variation and capability
  • Select a strategy for improvement.

The cycle that can be used in the ambulatory endoscopy unit is:

Plan

1. Determine data needed to monitor the improvement in the process

2. Determine measures or indicators for the improvement-monitoring plan

3. During the planning process several issues should be resolved:

  • Why is this idea being monitored?
  • Who will be involved in the process?
  • What do they need to know to participate in the process?
  • What are the timetables?
  • How will the process be implemented?
  • What are the success factors?
  • How will the process and the outcomes be measured and assessed?

Do

  • Collect and analyze data on improvement in the process
  • Make improvement changes/actions when indicated and appropriate

This step involves implementing the pilot test and collecting actual performance data

Check

  • Establish decision/review points to determine the effectiveness of changes
  • Assess the effects of improvements
  • Analyze the improvement results

This step involves analyzing collected data during the process to determine whether the improvement action was successful in achieving the desired outcome(s). Actual test performance is compared to desired performance targets and baseline results achieved using the established process.

Act

The team meets on a regular basis to determine what was learned. Tests or actions are repeated, if necessary, to ensure improvement. This step involves taking action:

  • If the pilot test is not successful, the cycle is repeated. Once the actions have been shown to be successful, they are made part of the standard operating procedure
  • The effectiveness of the action will continue to be measured and assessed to ensure that improvement is maintained
  • Report all activities to the governing body

Restudy

All actions implemented will be restudied within a specified period of time to evaluate effectiveness.

  • Study will be reopened as determined by committee
  • The quality management and improvement process will be a part of orientation and annual training of employees

Reporting

All quality management and improvement activities will be reported to the governing body.

  • The governing body will take appropriate action on the quality management and improvement activities as necessary

Annual evaluation of the quality management and improvement program should occur to determine the effectiveness of the program as part of the total surgery center appraisal. A written report of this evaluation is submitted to the governing body. This report includes:

  • Identified opportunities to improve care
  • Corrective actions taken to resolve issues identified and make improvements
  • Educational programs related to continuous quality management and improvement activities
  • Program changes planned as a result of the annual evaluation (changes in scope, organization, objectives, etc.)

Physician Quality Achievement and Improvement

As a part of a continued effort to monitor and modify physician behavior to achieve compliance with best practices, as well as enhance quality and value, physicians’ performance will be formally assessed as follows:

  1. All affiliated centers and hospital endoscopy units participate in GIQuIC, a national data repository and benchmarking program, that tabulates procedural data for colonoscopies.
  2. Data on 10 separate endorsed quality measures, including bowel prep quality, cecal intubation, ADR and adverse event tracking, related to the performance of colonoscopy is continuously aggregated by center and by individual physician.
  3. A quarterly quality achievement report (appendix A) will be generated for each physician performing procedures at any Mount Sinai Beth Israel clinically integrated facility. The reports measure each physician’s performance on measures derived from the GIQuIC database as well as satisfaction survey results and peer review compliance measures.
  4. Physicians will be scored individually and will also be compared to national benchmarks when available and internally by facility.
  5. Physician quality achievement reports will be posted on the Mount Sinai Beth Israel endoscopy clinical integration website where they will be available to multiple stakeholders including the general public, patients, and physicians.

Physician Quality Outlier Protocol

Based on results extracted from a member's quarterly quality performance achievement report, the following protocol should be followed for those physicians who are outliers in one or more measures:

1. The physiciansshould be informed by the medical directorthat the ongoing monitoring of quality is intrinsic to clinical integration and the goal is to educate all physicians so they can achieve compliance with all measures.

2. Non-compliant physicians must participate in one of the following three activities:

  1. 2 hours of targeted CME activity pertinent to the areas of deficiency. CME can be accessed on the clinical integration website under the “Physician Education” subheading. The medical director must receive successful documentation of completion of these activities within 30 days of the request being made.
  2. Proctoring - Physicians who are not in compliance with 6 minute withdrawal times and cecal intubation may request proctoring by the medical director of 2 procedures to document appropriate use of timed intervals, recognition and documentation of cecal landmarks. A record of the proctored exams should be placed in the physician's credentialing file.
  3. EHR Instruction- Some deficiencies in quality measure compliance may reflect incomplete knowledge of how to correctly input data using the EMR. Web based training by the vendor and/or instruction by senior nursing staff, unit "super users", or medical director should be offered and documented.
  4. A summary letter outlining the agreed upon plan should be signed by both the medical director and the physician and inserted into the physicians credentialing file. This letter should also include an agreement by the physician to complete the activities within 30 days of request and to meet in 60 days with the medical director to review progress.
  5. Failure to make progress 30 days after completion of the education plan will require an additional cycle of the above activities and reassessment by the medical director.