High value quality improvement

pillars PHASE I

HVPAA high value quality improvement initiatives for the 2017-2018 academic year address the 1st pillar of high value health care: diagnostic and therapeutic efficiency. Teams from experienced centers are co-authoring evidence-based guides to reduce unnecessary diagnostics and treatments. The papers include quality and safety outcomes data from value-based Q/I initiatives as well as an implementation blue print (content for educational campaigns and clinical decision support messages). A resident or fellow co-author is a requirement for every guide, in keeping with our mission to engage trainees in high value quality improvement.

Several of the efficiency improvement initiatives improve health care quality and safety, including adherence to American Association of Blood Banks’ Clinical Practice Guidelines and appropriate testing for C. difficile to avoid inappropriate treatment. In addition to publishing implementation guides, the team leaders for these initiatives will direct national campaigns to engage and guide medical centers through the quality improvement process.

For performance improvement in areas of practice without evidence based guidelines, collaborators are designing multicenter quality improvement initiatives. Examples include reducing inappropriate imaging and treatment for noninfectious pulmonary processes misdiagnosed as pneumonia.

A survey of alliance members identified evidence-based initiatives piloted by at least multiple member institutions, providing sufficient experience-based leadership for national expansion. Many of these initiatives are supported by one or more of the Choosing Wisely® recommendations. Links to clinical practice guides are included where available.

pillars Pillar I: Diagnostic & Therapeutic Efficiency

Reducing unnecessary laboratory tests

CK-MB in patients with suspected acute coronary syndrome

ACC/AHA Guidelines for management of patients with unstable angina and non-ST-elevation MI: Executive summary and recommendations
http://circ.ahajournals.org/content/102/10/1193
Implementation Guide Collaborators

Allan Jaffe, MD, Mayo Clinic
 Jeff Trost, MD, Roy Ziegelstein, MD & Matt Alvin, MD, MBA (resident), Johns Hopkins School of Medicine

JAMA Internal Medicine Special Communication: Eliminating Creatine Kinase–Myocardial Band Testing in Suspected Acute Coronary Syndrome A Value-Based Quality Improvement.
Repeat daily labs on inpatients
Implementation Guide Collaborators

Rodrigo Alban, MD, Cedars Sinai Medical Center
Harry Cho, MD, Icahn School of Medicine at Mt Sinai Medical Center
Amit Pahwa, MD & Kevin Eaton, MD (resident), Johns Hopkins Hospital
Chris Petrilli, MD & Kate Levy, MD (resident), Michigan Medicine
 Christine Soong, MD, University of Toronto
 Andrew S. Parsons, MD, MPH, University of Virginia

 

JAMA Internal Medicine Special Communication: Evidence-Based Guidelines to Eliminate Repetitive Laboratory Testing

 

Inappropriate C Difficile testing

Clinical Practice Guidelines for C Difficile Infection in Adults: 2010 Update by the Society of Healthcare Epidemiology in America and Infectious Diseases Society of America
https://www.cdc.gov/hai/pdfs/cdiff/cohen-idsa-shea-cdi-guidelines-2010.pdf
https://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/cdiff2010a.pdf

American College of Gastroenterology Guidelines for Diagnosis, Prevention and Treatment of Clostridium Difficile Infections
http://gi.org/guideline/diagnosis-and-management-of-c-difficile-associated-diarrhea-and-colitis/

Implementation Guide Collaborators

Karen Carroll, MD, Clare Rock, MD and Masako Mizusawa, MD (fellow), Johns Hopkins Hospital
Surbhi Leekha, MBBS, MPH, and Daniel Morgan, MD, University of Maryland
Nasia Safdar, MD, PhD, University of Wisconsin
Greg Seymann, MD, University of California San Diego

Preoperative labs on low risk patients

American Society of Anesthesiologists Practice Advisory for Presanesthesia Evaluation
http://www.asahq.org/~/media/Sites/ASAHQ/Files/Public/Resources/standards-guidelines/practice-advisory-for-preanesthesia-evaluation.pdf

Preoperative Testing Before Noncardiac Surgery: Guidelines and Recommendations from the AAFP
http://www.aafp.org/afp/2013/0315/p414.pdf

Implementation Guide Collaborators

Rodrigo Alban, MD, Cedars Sinai Medical Center
Lia Logio, MD, Grace Sun, MD & Natalia Ivascu, MD, Weill Cornell Medical Center
 Lee GoeddelMD & Jerry Stonemetz, MD, Johns Hopkins Hospital
Alan Curie, MD, University of Rochester
 Carol Peden, MD, University of Southern California, Keck
 Lori Ryder, MD and Jill Zafar, MD, Yale Medical Center

Reducing unnecessary telemetry

Practice Standards for Electrocardiographic Monitoring in Hospital Settings An American Heart Association Scientific Statement From the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young
http://circ.ahajournals.org/content/110/17/2721.full
Implementation Guide Collaborators

Lia Logio, MD & Jamuna Krishnan, MD (resident), Weill Cornell Medicine
Amit Pahwa, MD & Calvin Kagan, MD (resident), Johns Hopkins Hospital
Chris Petrilli, MD, & Garth Strohbehn, MD (resident), Michigan Medicine
Greg Seymann, MD & Meera Subash (resident), UCSD
Richard Wardrop, MD, PhD, UNC Chapel Hill
Karli Edholm, MD, University of Utah

Reducing inappropriate imaging

Radiology consensus recommendations for incidental findings

Quality Improvement Collaborators

Alexandre Frigini, MD, Baylor Medical Center
Michael Atalay, MD, Brown University
Marco Molina, MD, University of Connecticut
Eddie Hersovitz, MD, PhD, University of Maryland
Mary Scanlon, MD & Hannah Zafar, MD, University of Pennsylvania
Ryan Lee, MD, MBA, Thomas Jefferson University/Einstein Health Network
Pamela Johnson, MD and Jeff Trost, MD Johns Hopkins Medicine
Danny Kim, MD, NYU Langone Health
Christopher Fung, University of Alberta, Canada
David Fetzer, MD & Cecilia Brewington, MD, University of Texas Southwestern
Yoshimi Anzai, MD, MPH, University of Utah

Lumbar spine MRI for uncomplicated low back pain in patients with < 6 weeks of conservative treatment

ACR Appropriateness Criteria® : Low back pain
https://acsearch.acr.org/docs/69483/Narrative/

Routine ICU chest radiographs

ACR Appropriateness Criteria® : Intensive Care Unit Patients
https://acsearch.acr.org/docs/69452/Narrative/

Inappropriate Chest CTA for pulmonary embolism

ACR Appropriateness Criteria®: Acute Chest Pain- Suspected Pulmonary Embolism
https://acsearch.acr.org/docs/69404/Narrative/

Brain Imaging (CT, MRI) for chronic headache

ACR Appropriateness Criteria®: Headache
https://acsearch.acr.org/docs/69482/Narrative/

Reducing inappropriate treatments

Transfusions and Blood Management

AABB Clinical Practice Guidelines
http://www.aabb.org/programs/clinical/Pages/default.aspx
Implementation Guide Collaborators

 Moises Auron, MD & Divyajot Sadana, MD (resident), Cleveland Clinic
Steve Frank, MD & Lauren Scher, MD (resident), Johns Hopkins Hospital
Nicole Adler, MD, Frank Volpicelli, MD, Arielle Pratzer, MD (resident) & Harry Saag, MD, New York University Langone Health System

Antibiotics for Asymptomatic Bacteriuria

Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults
https://academic.oup.com/cid/article-lookup/doi/10.1086/427507
Implementation Guide Collaborators

Shafinaz Akhtar, MD, Crozer Chester Medical Center
Amit Pahwa, MD, Sara Keller, MD, Michael Daniel, MD (intern), Johns Hopkins Hospital
 Christine Soong, MD, University of Toronto

Proton Pump Inhibitor Administration
Implementation Guide Collaborators

Society of Hospital Medicine
  Harry Cho, MD, Icahn School of Medicine at Mt Sinai Medical Center
Johns Hopkins Hospital
Nicole Adler, MD, Frank Volpicelli, MD, Arielle Pratzer, MD (resident) & Harry Saag, MD, New York University Langone Health System
Deepak Agrawal, MD, and Arjun Gupta, MD, University of Texas Southwestern

Reducing inappropriate imaging and treatment for noninfectious pulmonary processes misdiagnosed as pneumonia. 
Quality Improvement Collaborators

Michael Rothberg, MD, Cleveland Clinic
Brandyn Lau, Ken Lee, PhD, Lenny Feldman, MD, John Eng, MD, Paul O’Rourke, MD, Pam Johnson, MD, Tony Lin, MD, Jenny Townsend, MD, Sara Keller, MD & Sara Cosgrove, MD, representing Infectious Disease, Internal Medicine & Radiology from Johns Hopkins Medicine
Christopher Petrilli, MD, Christopher Grondin, MD & Valerie Vaugh, MD, Michigan Medicine
George Hoke, MD, University of Virginia

Optimizing Procedures

Venous Access: Midlines vs PICC lines
Quality Improvement Collaborators

Kelvin Hong, MD, Johns Hopkins Hospital
Chris Petrilli, MD & Dave Bozaan, MD, Michigan Medicine
Nicole Adler, MD & Frank Volpicelli, MD, New York University Langone Health System
Deepak Agrawal MD, and Bhavan, MD, University of Texas Southwestern

 

pillars PERFORMANCE IMPROVEMENT

Annual recognition will be made for high performing HVPAA members as follows:

Bronze Medalist: Successfully implement 1 value-based Q/I initiative

 

Silver Medalist: Successfully implement 2-4 value-based Q/I initiatives

 

Gold Medalist: Successfully implement 5+ value-based Q/I initiatives

 

pillars PHASE II

The 2nd phase of implementation will address data from a recent Kaiser Foundation/NYT survey, demonstrating that the 2 biggest contributors to health care debt are hospitalizations and emergency department visits. Accordingly, value-based health care quality improvement efforts will focus on the 4 pillars of high value care designed to reduce preventable admissions, inpatient length of stay and emergency department visits.

pillars Pillar II: Quality Driven Medical & Surgical Pathways

Pathway Design Team

Rodrigo Alban, MD, Cedars Sinai Medical Center
Lisa Ishii , MD and Amit Pahwa, MD, Johns Hopkins Hospital
Nicole Adler, MD, Paresh Shah, MD, Frank Volpicelli, MD, Prashant Sinha, MD, New York University Langone Health System

pillars Pillar III: IMPROVING Discharge Transitions

 

pillars Pillar IV: Optimizing Patient Care Setting

 

pillars Pillar V: Preventative Medicine