Approaches to Quality Improvement

Quality improvement is a “systematic, formal approach to the analysis of practice performance and efforts to improve performance.”1 In practice, this term means improving the program’s operations in a way that provides the best care possible while causing the least strain on staff due to errors, slowdowns, and confusion. To successfully implement new programs, initiatives, or processes, providers need to build a practice culture that supports quality improvement and integrate these efforts into the practice’s standard processes and procedures.1

Programs can use or adapt a number of different models or approaches to quality improvement based on their individual needs and capacity. For example:

Each of these models is based on a similar set of principles, and any of them could help guide a program’s quality improvement efforts as they implement medication-assisted treatment (MAT). This Playbook does not endorse one model over another, but rather highlights some of the core principles of quality improvement that are common among different approaches.

The areas for improvement that practices identify, quality measures tracked, and methods of change may vary based on the practice’s priorities, capacities, patients served, and resources. Not all MAT programs will be able to implement rigorous quality improvement programs or initiatives. However, at a minimum, staff should try to identify realistic and feasible improvements given their programs’ context.

North Star

The practice continually identifies opportunities to improve their performance, quality of patient care, and confidence of clinicians and staff in their own operations and teamwork. The practice uses the data generated by patient care to monitor and improve performance.

How Do You Do It?

Select Measures and Determine How Data Will Be Collected and Analyzed

Systematically tracking quality measures (also known as “performance measures”) will help identify areas in need of improvement; set measurable goals for change; and evaluate the effectiveness of a new policy, process, or procedure.1 Measures can be used for quality improvement initiatives, benchmarking against other providers or organizations, and accountability.2 Performance measures can also be similar, if not the same, as those used for Tracking Patient Progress and simply used for different purposes.

Practices should consider the program’s strengths and weaknesses and identify areas with room for improvement, such as issues related to access, implementation, and outcomes:

Access—Patients may experience gaps in service coverage or other barriers to care, as evidenced by high no-show rates or loss to followup. Programs could consider tracking measures related to the number of patients on a waiting list, time elapsed between first contact and patient’s first treatment services, time elapsed between followup visits, and similar measures.

Implementation—Programs may need to improve their processes to identify patients with opioid use disorder, attitudes toward those with substance use disorders or MAT, capacity to serve MAT patients, or confidence in team function and shared workflows. Related performance measures include:

  • Percentage of patients screened for opioid use disorders,
  • Percentage of patients being prescribed medication among those with an opioid use disorder,
  • Number of patients served by the MAT program,
  • Proportion of eligible providers with a buprenorphine waiver,
  • Proportion of waivered providers actively prescribing,
  • Proportion of waivered providers prescribing at capacity, and
  • Average caseload per prescriber.

Outcomes—Additional areas for improvement related to the impact of the MAT program on patient outcomes include reduction in opioid use, retention in treatment, patient functioning, followup and engagement with external referrals, overdose rates, utilization of hospital services, impact of co-occurring conditions, and other health outcomes among high-risk patients. To measure progress in these areas, providers may consider monitoring:

  • Results of urine drug screens,
  • Retention rates (30 day, 60 day, 90 day, 6 month, 1 year),
  • Health-related quality of life scores,
  • Functional outcomes,
  • Patient satisfaction,
  • Patient Health Questionnaire (PHQ-9) scores,
  • Clinical Opiate Withdrawal Scale (COWS)/Subjective Opiate Withdrawal Scale (SOWS) side effect scores,
  • Pain, Enjoyment, and General Activity (PEG) scores (among patients with chronic pain),
  • Participation in psychosocial supports,
  • Rate of opioid-related emergency department visits,
  • Rate of opioid-related hospital admissions, and
  • Mortality rates.

The measures used will vary based on the program’s goals, model, and capacity for analysis. When selecting measures, programs should consider the time and resources needed to collect and analyze these data. It is best to start by selecting one or more measures that are both important to the program or patient population and reasonable to measure with existing resources.3

How will data be collected? Practices need to determine the intervals at which data will be collected for each measure they focus on at any given time. When choosing quality measures, practices should consider the burden on providers and other staff to collect the data as well as how data will be stored (e.g., electronic health record system, care registry, separate database, or spreadsheet). Data from existing sources should be used whenever possible. Practices may want to adapt this table of data to consider tracking(This link will open in new window) (Word—57.4 KB) to help think about whether these measures exist in a form that can be easily pulled for analysis.

How will data be analyzed and reported? Practices need to decide how frequently they will conduct data analysis and summarize the results. They should consider whether performance indicators will be reported on the practice as a whole, by program or care team, or specifically by provider.

Address Barriers to Change

When undertaking quality improvement initiatives, practices should consider any barriers to change in the program, such as internal resistance due to negative attitudes, a lack of understanding, or competing priorities. NIATx recommends picking a powerful change leader with the respect, authority, and time to help with these quality improvement activities.4 Also, involving stakeholders from across the practice in the planning and implementation of any changes will provide unique insight from members with different roles and will encourage staff buy-in.

Some practices may also need additional external support from other individuals or organizations to help with quality improvement efforts, such as5:

  • Data feedback and benchmarking: Offers feedback on key quality indicators and allows practices to compare performance with other practices and providers. It can identify areas for improvement and provide motivation to change.
  • Practice facilitation or practice coaching: Helps build the practice’s skills and internal capacity for quality improvement through sharing of tools, resources, and expertise.
  • Expert consultation: Encourages adoption of best practices by sharing knowledge and experience.
  • Learning collaboratives: Creates a community to collaborate among peers, share lessons learned, and promote a culture of quality improvement.

These external supports may come from a variety of sources such as quality improvement organizations, practice-based research networks, professional organizations, and public or private insurers.5 Practices should check for local organizations, State programs, or federally funded initiatives that may be available.

Plan and Test Changes

“While all changes do not lead to improvement, all improvement requires change. The ability to develop, test, and implement changes is essential for any individual, group, or organization that wants to continuously improve.”6

Whenever possible, practices should make changes to their program based on observations in the data that are collected and analyzed. After selecting an area for improvement, the practice needs to create goals or objectives for the desired changes. These goals should be SMART (S-Specific, M-Measurable, A-Achievable, R-Realistic/Relevant, T-Timely).

Plan-Do-Study-Act (PDSA) Cycles. Changes can be implemented and tested with a process such as the PDSA cycle. PDSA is a series of short, rapid cycles in which changes are tested first on a small scale, adjusted if needed, and then fully implemented when the results indicate significant improvement. This incremental method of implementing and testing changes helps minimize resources invested until a change has demonstrated significant impact. Starting on a small scale also allows practices to make changes in a manner that is less disruptive to clients and staff and less likely to encounter staff resistance.7

The stages of a PDSA Cycle are7, 8:

  • Plan—Identify the purpose and goal of the change. Develop a plan to test the change, including who should be involved and how data will be collected and analyzed.
  • Do—Implement the change on a small scale. Collect data and document any problems or unexpected observations.
  • Study—Analyze the data and compare the results with your predicted outcome. Summarize and reflect what you have learned so far.
  • Act— Make a plan for the next steps you will take based on the results of the test. Consider whether the change should be adopted (implement and test on a larger scale), adapted (modify the change and begin a new PDSA cycle), or abandoned (stop testing this change idea).

Lean Management Principles. This approach has been used effectively in manufacturing companies for decades, particularly in Japan. So what is meant by “lean thinking”? Simply put, lean means using less to do more. While lean thinking is not typically associated with health care, the principles of lean management can, in fact, work in health care in much the same way they do in other industries. Lean thinking is not a manufacturing tactic or a cost-reduction program, but a management strategy to improve processes.

All organizations—including health care organizations—use a series of processes or sets of actions intended to create value for those who use or depend on them (e.g., patients). The core idea of lean involves determining the value of any given process by distinguishing value-added steps from nonvalue-added steps, and eliminating waste so that ultimately every step adds value to the process.

Learn more about lean management principles in the Institute for Healthcare Improvement’s white paper Going Lean in Health Care.

Communicating the Results. Practices should share successes of quality improvement efforts with all providers and staff. It can create a positive feedback loop in which seeing discernible changes and improvements will help gain staff buy-in for future quality improvement initiatives.

What Not To Do

  • Don’t forget that quality improvement is an ongoing process, not a singular initiative.
  • Don’t jump right in and make a change. Collect baseline data first so you can see if the change has a measurable effect.

Resources

References

  1. American Academy of Family Physicians. Basics of Quality Improvement. Leawood, KS: American Academy of Family Physicians; n.d. https://www.aafp.org/practice-management/improvement/basics.html. Accessed June 12, 2019.
  2. American Academy of Family Physicians. Quality Measures. Leawood, KS: American Academy of Family Physicians; n.d. https://www.aafp.org/practice-management/improvement/measures.html. Accessed June 12, 2019.
  3. Six Building Blocks. Measuring Success Metrics; 2018. https://depts.washington.edu/fammed/improvingopioidcare/wp-content/uploads/sites/12/2018/05/Measuring-success-metrics_2018-05-16.pdf. Accessed June 12, 2019.
  4. NIATx. The Five Principles; n.d. https://niatx.net/Content/ContentPage.aspx?NID=131. Accessed June 12, 2019.
  5. Agency for Healthcare Research and Quality. Quality Improvement in Primary Care. Rockville, MD: Agency for Healthcare Research and Quality; 2018. https://www.ahrq.gov/research/findings/factsheets/quality/qipc/index.html. Accessed June 12, 2019.
  6. Institute for Healthcare Improvement. Changes for Improvement; n.d. Boston, MA: Institute for Healthcare Improvement. www.ihi.org/resources/Pages/Changes/default.aspx. Accessed June 12, 2019.
  7. NIATx. Conducting a Change Exercise. Madison, WI: University of Wisconsin—Madison; 2008. Available from: https://niatx.net/PDF/PIToolbox/PDSA_Cycle.pdf. Accessed June 12, 2019.
  8. Institute for Healthcare Improvement. Quality Improvement Essentials Toolkit; n.d. Boston, MA: Institute for Healthcare Improvement. http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx. Accessed June 12, 2019.