The testing process in primary care: Safety and quality implications for improving health care

1. The testing process in primary care: Safety and quality implications for improving health care Nancy C. Elder, MD, MSPH University of Cincinnati Department of Family Medicine Funded by AHRQ K-08HS013914-04, 2005-2010

2. 2001: Me, new to town, week 1 in new medical practice • 21 year old woman, no period for 3 months, scared she may be pregnant!! (she is not) • Review of medical chart (paper) • 6 months ago TSH = 29. (hypothyroidism) • Dr.’s note to MA: call patient and have her rtc. • MA’s note: tried to call patient, no answer. • 3 visits in intervening 6 months for colposcopy and F/U of abnormal pap smear. None mention TSH • Me: “We screwed up” • Reality: Lots of mistakes like this occur, but how many, causes, outcomes, interventions to improve are unknown How I got interested in the testing process

3. If you can't describe what you are doing as a process, you don't know what you're doing.” W. Edward Demings The testing process in primary care

4. Frequent? • Error reports, interviews and observations, chart reviews • Adverse events and consequences? • Error reports, chart reviews • Hinder progress toward patient centered medical home and similar reforms? • Look at testing process steps relationship to PCMH characteristics Are testing process errors really that important to quality?

5. Error reports from family physicians and staff • AAFP National Research Network (NRN) reporting studies (Dovey, 2002, Phillips, 2006, Hickner 2008) • 14 – 25% of ALL physician and staff reported errors were related to testing • Testing process errors break down: • ordering tests (12.9%), • implementing tests (17.9%), • reporting results to clinicians (24.6%), • clinicians responding to results (6.6%), • notifying patient of results (6.8%), • general administration (17.6%), • communication (5.7%), • charting or filing (14.5%) • other categories (7.8%) “Frequency” and types of testing process errors

6. Observations and interviews with family physicians and staff (Elder, 2006, Elder, 2008, Elder 2009) • 18 focus groups of family physicians and staff identified problems with all steps in the testing process. Underlying contributing factors included • not following procedures, • inadequate systems, • lack of standardization • communication problems. • 4 family medicine offices in SW Ohio overwhelming depend on individuals to work around testing process problems “Frequency” and types of testing process errors

7. Chart reviews (ongoing) • In 261 test results in 8 offices in SW Ohio: • 74% had a clinician’s interpretation, • 70% of patients were notified • 53% of abnormal results had follow up plans • In 11 urban CHC offices in Chicago, only 61% of abnormal results for pap smears, mammograms, INRs and PSAs had appropriate follow up documented. • Interviews with patients (ongoing) • Most patients have experienced results not received, not timely and/or not understandable. “Frequency” and types of testing process errors

8. Error reports from family physicians and staff (Hickner, 2006) • Adverse consequences included • time lost and financial consequences (22%), • delays in care (24%), • pain/suffering (11%) and • adverse clinical consequence (2%). • 18% of events resulted in some patient harm • Chart review (Ongoing) • In 11 urban CHC offices, more abnormal mammograms and INRs (70%)had documented follow up than did abnormal pap smears and PSAs (55%). Adverse events and consequences from testing process errors

9. PCMH evaluations consistently indicate that redesigning the delivery of care around a primary care PCMH yields an excellent return on investment: • Quality of care, patient experiences, care coordination, and access are demonstrably better. • Reductions in emergency department visits and inpatient hospitalizations that produce savings in total costs. • PCMH White House briefing document, 2009 • Patient Centered Medical Home characteristics include: • Better Quality of Care • Early ID and management of health problems • Fewer unnecessary tests and procedures • Higher patient satisfaction • http://www.familydoctor.org PCMH hindered by testing process errors

10. Most common breakdowns in diagnostic process in closed malpractice claims (Phillips, 2004) • 55% failure to order appropriate test • 45% failure to create a proper follow up plan • 37% incorrect interpretation of a test result • Testing process steps: • ordering • interpretation • follow up PCMH: Quality of Care

11. Process of care failures in breast cancer diagnosis (Weingart, 2009) • Failure of patients to complete ordered tests a common factor in breast cancer diagnostic delays • Testing process step • Tracking PCMH: Early identification of health problems

12. Missing clinical information during primary care visits (Smith, 2005) • Clinicians reported missing laboratory results in 6.1% of all visits and radiology results in 3.8%. • 59.5% felt these missing results resulted in delayed care or additional services, including repeating tests. • Testing process steps: • Tracking • Documentation • Patient notification PCMH: Fewer unnecessary tests

13. Patient preferences for notification of normal laboratory test results: a report from the ASIPS Collaborative (Baldwin, 2005) • Privacy, responsive and interactive feedback, convenience, and timeliness with detailed information are critical for patient satisfaction • Effect of providing information about normal test results on patients' reassurance: randomised controlled trial (Petrie, 2007) • Providing patients with information about normal test results before testing can improve rates of reassurance and reduce the likelihood of future reports of chest pain. • Testing Process steps • Ordering • Implementing • Patient notification PCMH: Higher patient satisfaction

14. Quality performance measures reliant on testing outcomes • HEDIS measures • Ambulatory Care Quality Clinical Performance Measures for Ambulatory Care • Pay for Performance • So why study the testing PROCESS? BUT…test result OUTCOMES are what really matter, right?

15. Use of process measures to monitor the quality of clinical practice (Lilford, 2007) • most suitable management tool for judging and rewarding quality • Clinical outcomes are likely to be affected by factors other than the quality of care • Outcome measures provide insufficient information about how to improve • Assessment of process encourages universal improvement rather than focusing on outliers Importance of improving testing PROCESS

16. Testing process errors are frequent and occur across all process steps • Adverse events and harm have been associated with testing process errors • Poorly functioning testing processes hinder practices from achieving PCMH standards • Studying processes is appropriate to monitor and reward health care quality Summary: Testing process implications for improving health care

17. What is necessary to improve testing process safety and quality? • Adoption of technology AND a culture of safety! • Improving which steps give the most “bang for the buck?” • Identified errors of implementation and patient notification associated with harm and/or adverse events! • Follow up of abnormal results most often missing, but rarely identified by staff and clinicians! • What interventions at what step will bring the most improvement to the testing process? • ?????????? The Future…

18. “We should work on our process, not the outcome of our processes.” • W. Edward Demings Nancy C. Elder, MD, MSPH eldernc@fammed.uc.edu Thanks!