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4 Breakout Groups W orkshop attendees were asked to split into three breakout groups, each discussing one of the following: defining the value proposition, effective intraorganizational spread of quality improvement gains, and effective industrywide quality improvement gains. Value proposition The value proposition is a plan that will enhance value for patients by improving outcomes, lowering costs, or both, said Laura Leviton of the Robert Wood Johnson Foundation, reporting for the value proposition group. Discussion of this working definition led to the realization that there were actually two different value propo- sitions in question: one for quality improvement itself and one for research on quality improvement. The value proposition for quality improvement must take into account three different perspectives, Leviton said. First, the patient must be the focus of all interventions, at a reasonable cost. Second, while alignment of all interests is praiseworthy, it must be acknowl- edged that quality improvement will most likely not be a winâwin situation for everyone. In the end, the value proposition must focus on what is best for society and individual patients. Recognizing the second perspective, the group identified a third perspective: There should be research to study the value proposition. While the goal is 40
BREAKOUT GROUPS 41 to promote having informed patients, the challenge remains doing so effectively, which requires efforts to promote transparency both in terms of costs and quality outcomes. Creating a value proposition for research on quality improve- ment is somewhat different than for quality improvement itself and involves a number of issues. Recognition that data give weight to health care leadersâ desire to champion and implement quality improvement was an important point in the discussion. Becoming better at translating the research available for uptake is urgently needed because research is done for a purpose, not merely for its own sake. Priorities for quality improvement research must be set, Leviton said, because they allow society to effectively allocate resources. Having priorities would also help to articulate the poten- tial value of quality improvement, as has occurred successfully with cancer research (number of lives saved) and smoking cessa- tion research (the societal effect of quit rates). Finally, data currently being gathered are not tracking outcomes that matter. Data should be collected over time, which could be facilitated by electronic health records and could have beneficial effects on improving patient edu- cation and producing health care reform. Intraorganizational quality improvement gains Effective intraorganizational quality improvement gains must be created within an environment where quality is a top priority and not just a short-term project, OâNeill said, reporting for the breakout group that explored that topic. Organizations successfully improv- ing quality do not have an attitude of âweâre great at everything we do,â but instead think of ways to continuously improve. Quality improvement and safety should be automatic within an organiza- tion to promote change. A number of common themes arose from this breakout group. First, there is an essential need for transparency, as found in the value proposition group. Management and top leadership must accept responsibility for everything that goes wrong within an organization because doing so gives those people actually making mistakes permission to identify their mistakes. People must not be punished, blamed, or criticized for their mistakes so that lessons can be learned to prevent the same mistakes from recurring. Second, having clear objectives is critical to make progress both within and across organizations. Clarity of objectives allows people
42 CREATING A BUSINESS CASE FOR QIR to relate and understand how they need to function in relation to agreed-on goals. Third, the group identified a need to deal with things gone wrong. People must deal with intraorganizational transfer in a man- ner as close to real time as possible, allowing for connections to be made between observations and the change and success of new experiments. Everyone within an organization must believe in the ability to improve and the methods for doing so. Those not willing to attempt to improve actually destroy the ability to change for those who want to get it right, OâNeill said. Deviation from producing the right outcomes and perfect care cannot be tolerated. Improvement can only be fostered in a blame-free culture. Industrywide quality improvement Richard Kahn of the American Diabetes Association (ADA) recapped the industrywide quality improvement groupâs discus- sion, which focused on four examples of widespread interventions and some commonalities. The first example was administration of beta blockers after an acute myocardial infarction (MI). The first study that showed some benefit of this therapy was published in 1982, but the use of beta blockers did not really gain traction until the mid-1990s, when the American College of Cardiology/American Heart Association developed guidelines recommending the use of the drug after an MI. Around the same time, the National Committee for Quality Assur- ance and the Joint Commission developed a performance measure for beta blockers, which led to the development of incentives and tools to encourage the use of beta blockers by health plans and oth- ers. At the onset of reporting, data showed that approximately 60 percent of people with MIs received beta blockers soon after the event. Recently, this number has grown to more than 90 percent, and because of its success, the measure has been retired. Smoking cessation counseling was the second example of an industrywide quality improvement intervention. After the first sur- geon generalâs report on smoking cessation, states and the federal government became involved, and the publicâs concern grew. It was later found that physicians had an influence on smoking cessation rates. A performance measure was then developed for physicians to initiate discussions about counseling. Smoking cessation counsel- ing now occurs nearly 100 percent of the time, and the health care industry along with other forces can take credit for reducing the prevalence of smoking, Kahn stated.
BREAKOUT GROUPS 43 Testing hemoglobin A1c (HbA1c) levels can determine glycemic control in people with diabetes. This is an essential test for guiding treatment and establishing treatment goals. In the early 1980s the first report appeared, indicating that the amount of glucose bound to hemoglobin was a good surrogate measure of the circulating glu- cose concentrations over the preceding 3 to 4 months. In 1993 the first well-controlled study was published showing that HbA1c was an excellent predictor of diabetes complications, and any reduction in HbA1c would reduce the likelihood of complications. In 1995 a performance measure for HbA1c was developed (patients with diabetes should receive at least one HbA1c measurement annually). A variety of tools were developed by the ADA and the National Diabetes Education Program to help promote the use of the HbA1c test and to use the HbA1c level as a treatment target. Performance improved (i.e., number of patients receiving at least one test annu- ally) from around 60 percent in the mid-1990s to a current level of about 97 percent. The final example provided was childhood vaccinations. Changes in law and public policy played a large role in vaccination rates when schools required all children to be vaccinated. State and county governments provided financial support for vaccines to be distributed to physicians or schools. These four examples shared three common themes, Kahn said. First, they were all discrete and focused interventions. Second, the intervention and the desired outcome were closely linked. Third, guidelines and performance measures were developed by credible organizations. Nonetheless, how individual institutions actually implemented these interventions remains unclear because no lit- erature has documented the exact steps or determined the most effective and efficient methods of implementation. Much like teach- ing a child to ride a bike, there is no exact science or literature that describes the best, most efficient learning process, but widespread success is eventually achieved.
