INTEGRATING PEER REVIEW AND QUALITY IMPROVEMENT TO ENHANCE THE HEALTH OF OUR STUDENTS

1. INTEGRATING PEER REVIEW AND QUALITY IMPROVEMENT TO ENHANCE THE HEALTH OF OUR STUDENTS Ron Bradshaw, MD, CPA Sharon Stern, MD Baylor University Health Services

2. LEARNING OBJECTIVES After this session attendees should be able to: • Describe challenges to implementing the Peer Review process in the college health setting. • Explain an innovative method of linking the Peer Review process to the overall Quality Improvement program. • Identify specific steps to implement a model for linking Peer Review and Quality Improvement.

3. OVERVIEW FOR TODAY • Describe the Problem – Rationale/Background • Accreditation Requirements • Challenges in Meeting Requirements • Limited Resources • Clinician resistance • Lack of well-defined performance indicators • Describe the Solution – Method/Process • Participative process – all clinicians involved • Evidence-Based • Educational (not punitive) • KISS • Examples • Apply the Method - Implementation at your institution

4. DISCLAIMERS • We do not represent an accreditation organization nor is our method “approved” by any accreditation organization. • Baylor University Health Center is AAAHC accredited. • We do not have a financial interest in the methodology that will be presented today.

5. Part One: Describe the Problem Describe challenges to implementing the peer review process in the college health setting. Sharon Stern, MD Baylor University Health Services – Medical Director

6. RATIONALE/BACKGROUNDAAAHC Accreditation Requirements Maintain an active, integrated, ongoing… • Quality Improvement Program • Focus indicators on patient outcomes as well as clinical, administrative, and cost-of-care issues • Peer Review Program • Include all licensed health care professionals in the process • Development and application of the criteria • Results included in credentialing, privileging, and performance evaluation process • Each professional should receive individual results and aggregate results

7. CHALLENGES • Resource Limitations • Time • Funding • Dedicated Staff • Clinician Resistance • Previous experience: Peer Review viewed in a negative way • Emphasis on “outliers”; perceived as punitive • Old habits die hard: “We’ve always done it this way!” • Problem with n = 1 : “My last case…” or “In my experience…” • Lack of well-defined “Performance Indicators” in college health

8. PERFORMANCE INDICATORS: Do they apply to college health? AHRQ NCQA/HEDIS Applies mostly to: Health Plans Managed Care Organizations Medicare/Medicaid HCAHPS Scores Hospitals Patients’ perceptions of hospital care • Prevention Quality Indicators • Perforated Appendix • Diabetes Complications • COPD Admission Rates • Inpatient Quality Indicators • Safety Quality Indicators • Anesthesia Complications • Pressure Ulcers • Retained Surgical Items • Post-op Wound Dehiscence Rate • Pediatric Quality Indicators • Neonatal Pneumothorax (iatrogenic) • Transfusion reactions

9. OUR APPROACH TO PEER REVIEW GOAL: To integrate peer review with the overall quality improvement program and meet accreditation requirements through development of an efficient process to achieve the following objectives: • Address clinical problems relevant to the college health setting • Apply current evidence-based guidelines to the assessment of these problems (include clinical, administrative, and cost-of-care issues) • Emphasize quality improvement through education in best practices instead of focusing on outliers

10. Part Two: Describe the Solution Explain an innovative method of linking the Peer Review process to the overall Quality Improvement program. Ronald W. Bradshaw, MD, CPA Baylor University Health Services

11. EVIDENCE-BASED MEDICINE The integration of: • Best Current Evidence • Clinical Expertise • Patient Values • Sackett DL, Richardson WS, Glasziou P, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM 3rd Ed., New York: Churchill Livingstone.

12. ELEMENTS OF A QI STUDY • Purpose of the Study • Significance of the Problem • Performance Goals • Current Performance • Data Collection – Plan • Data Collection – Results • Data Analysis • Current Performance vs. Performance Goals • Corrective Action Plan • Re-Measurement • Additional Corrective Actions • Communication of Findings “Closing the QI Loop”

13. EBM and QI/Peer Review: KISS Choosing a Topic: • Current Evidence Is: • Reliable • Consistent AND • Minimal Variation Due To: • Clinical Expertise • Patient Values • Keep It Simple!

14. PEER REVIEW TOPICS • Acne Management • ADHD Documentation • Ankle Sprains • Asthma Diagnosis and Treatment • Cervical Cancer Screening • Corneal Abrasions • Incidental Elevated Blood Pressure • Infectious Mononucleosis • Influenza (2009 H1N1) • Low Back Pain • Mild Traumatic Brain Injuries/Concussions • Mental Health Management • Skin Abscesses • Thyroid Disorders • Warts

15. Example #1:CORNEAL ABRASIONS 2008

16. EXAMPLE #1:CORNEAL ABRASIONS • Why did we choose to study Corneal Abrasions first? • Common condition in student health center • Current evidence was changing: • Use of eye patches • Choice of antibiotics – especially in contact lens wearers • We did not anticipate a lot of variation among providers • We believed this would be a “non-threatening” first attempt • Objectives: • Improve Patient Outcomes – guided by best current evidence • Reduce Cost of Care – choice of antibiotics; reducing referrals

17. EXAMPLE #1:CORNEAL ABRASIONS • Performance Indicators – agreed on by providers • Documentation of symptoms in “History” • Documentation of eye exam – visual acuity; fluorescein exam • Treatment plan – choice of antibiotics; patching; referral • Follow-up plan • Chart Review • Charts were identified by ICD-9 Code #918.1 • Reviewed by two physicians

18. EXAMPLE #1:CORNEAL ABRASIONS • Results: • Symptoms were documented appropriately • Majority of corneal abrasions were in contact lens wearers – 70% • Visual Acuity was documented in <10% of patients • This was an unanticipated finding • Antibiotic choice was consistent with current guidelines – 100% • Eye patches were limited to unusual situations • Appropriate follow-up or referral was documented in >90%

19. EXAMPLE #1:CORNEAL ABRASIONS • Action Plan: • Provider meeting was scheduled (one-hour meeting w/ bagels) • Each provider received a report comparing their individual results to the aggregate results • Aggregate results were reviewed as a group and recommendations for improvement discussed • Most Important– “Visual Acuity” measurement was added to eye problem template • Pharmacy provided list of ophthalmic antibiotic preparations and cost • Follow-up chart review: 100% Visual Acuity documented

20. EXAMPLE #1:CORNEAL ABRASIONS • Conclusions from our first attempt: • Providers had positive response – included in defining the measurements; appreciated educational approach (not punitive) • Confirmed that we were providing appropriate care • Important Quality Improvement result from unanticipated finding – Documentation of Visual Acuity • Process was not resource or time-intensive • Areas for improving the process: • Define “Performance Standards” in advance – 80%? 90%? 100%? • Include all providers in reviewing charts

21. Example #2:CONCUSSIONS 2012

22. EXAMPLE #2:CONCUSSIONS/MTBI • Rationale: • Mild Traumatic Brain Injury/Concussion receiving increased scrutiny (especially in athletes) due to concerns about long-term consequences • Common problem in college health population • Clinical Guidelines evolving and sometimes conflicting • Performance Indicators – patient outcomes; cost of care: • Documentation of certain elements of History & Physical – 90% • Utilization of Imaging Studies – CT vs. MRI? • Appropriate Referrals – ER? Neurologist? Other?

23. EXAMPLE #2:CONCUSSIONS/MTBI • Data Collection: • Developed a chart review form (see next slide) • Identified 5-6 charts for each provider • Each provider reviewed one chart for every other provider • Data Analysis: • Results presented in individual and aggregate form for each provider (see next slide after the next slide) • Meeting scheduled to review results

26. EXAMPLE #2:CONCUSSIONS • Performance Assessment: • Documentation of Circumstances and LOC – Goal met • Documentation of Amnesia – Goal not met • Eye Exam, Neuro Exam, Mental Status Exam – Goal met • Ear Exam – Goal not met • Descriptive Only – CT – 16%; MRI – None; ER – 23% • Patient Education – 23 of 24 not sent to ER (>95%) • Corrective Action: • Encouraged use of “Head Injury” template in EMR • Distributed algorithms and guidelines for provider education

27. Part Three: Implementation Apply to Your InstitutionCustomize to the Unique Needs of Your Student Health Center Identify specific steps to implement a model for linking Peer Review and Quality Improvement at your health center. Ronald W. Bradshaw, MD, CPA Baylor University Health Services

28. ELEMENTS OF A QI STUDYReview • Purpose of the Study • Significance of the Problem • Performance Goals • Current Performance • Data Collection – Plan • Data Collection – Results • Data Analysis • Current Performance vs. Performance Goals • Corrective Action Plan • Re-Measurement • Additional Corrective Actions • Communication of Findings “Closing the QI Loop”

29. Steps to Implementation • Select your TOPIC to study • Common problem • Current Best Evidence; Provider and Patient Variability limited • Provider education would be beneficial – “good reminder” • Buy-in from your providers • Set your PERFORMANCE GOALS • Choose your PERFORMANCE INDICATORS • Resist the temptation to overdo it – choose 4-5 main points

30. PEER REVIEW TOPICS • Acne Management • ADHD Documentation • Ankle Sprains • Asthma Diagnosis and Treatment • Cervical Cancer Screening • Corneal Abrasions • Incidental Elevated Blood Pressure • Infectious Mononucleosis • Influenza (2009 H1N1) • Low Back Pain • Mild Traumatic Brain Injuries/Concussions • Mental Health Management • Skin Abscesses • Thyroid Disorders • Warts

31. Steps to Implementation • TOPIC • PERFORMANCE GOALS • PERFORMANCE INDICATORS • Collect and Analyze your DATA • Each provider reviews 1-2 charts for each other provider • We do this BEFORE we meet – that way we can collate and analyze the data prior to meeting to discuss the results • COMPARE – Actual Results vs. Performance Goals

32. Steps to Implementation • TOPIC • PERFORMANCE GOALS • PERFORMANCE INDICATORS • COLLECT AND ANALYZE DATA • COMPARE ACTUAL VS. PERFORMANCE GOALS • Develop and Implement an ACTION PLAN • Plan for RE-MEASURMENT • Additional CORRECTIVE ACTIONS • COMMUNICATE FINDINGS • CLOSE THE LOOP – Include “Acknowledgement”

34. Group Discussion Opportunity “What are some ways that you might consider to implement this methodology for integrating Peer Review with Quality Improvement at your health center?”

35. Final Observations Sharon Stern, MD Medical Director Baylor University Health Services

36. QUESTIONS?