High Value Quality Improvement Guides

pillars PHASE I

Numerous organizations have succeeded in educating providers about how to improve the value of care they deliver, including more than 70 medical societies who contributed recommendations to the ABIM Foundation Choosing Wisely® campaign, the American College of Radiology Appropriateness Criteria®, the American Association of Blood Banks’ Clinical Practice Guidelines and JAMA’s Clinical Guidelines. The mission of HVPAA is to serve as the bridge between knowledge and high value practice and facilitate advancement of these best practice recommendations by creating mentoring relationships between a group of experienced medical centers and institutions interested in launching new value-based quality improvement.

HVPAA has selected a slate of high value quality improvement initiatives for the 2017-2018 academic year. This program represents the 1st phase of implementation for the alliance. Teams from experienced centers are co-authoring evidence-based guides to assist implementation across multiple centers. 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. The first guide on biomarker testing in suspected acute coronary syndrome has been completed and is under review for publication.

Several of these initiatives can 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. More information on how your hospital can participate will be provided soon.

A survey of alliance members determined that the following 12 evidence-based initiatives have been piloted by at least 20% of member institutions, providing sufficient experience-based leadership for national expansion. Each of these initiatives is supported by one or more of the Choosing Wisely® recommendations. Links to clinical practice guides are included where available.


 Transfusions 

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 and Lauren Scher, MD (resident), Johns Hopkins Hospital
Nicole Adler, MD, Frank Volpicelli, MD & Steve Chatfield, MBA, Arielle Pratzer (resident) and Harry Saag, New York University Langone Medical Center


 Reducing unnecessary laboratory tests

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

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

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), University of Michigan
Jennifer Myers, MD & Justin Ziemba, MD, University of Pennsylvania
 Christine Soong, MD, University of Toronto
 Andrew S. Parsons, MD, MPH, University of Virginia

Urinalysis and urine culture on all admissions

Choosing Wisely in Healthcare Epidemiology and Antimicrobial Stewardship.Infect Control Hosp Epidemiol. 2016 Jul;37(7):755-60.
https://www.ncbi.nlm.nih.gov/pubmed/27019058

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


 Reducing inappropriate treatments

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


 Reducing inappropriate 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), University of Michigan
Greg Seymann, MD & Meera Subash (resident), UCSD
Richard Wardrop, MD, PhD, UNC Chapel Hill
Karli Edholm, MD, University of Utah


 Reducing inappropriate imaging

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/

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, quality improvement efforts will focus on preventative care, reducing readmissions and decreasing length of stay.

Large scale efforts using quality metrics to reduce length of stay and variability of costs during hospital admission will also be undertaken. The value-driven outcomes model established by Vivian Lee, MD, PhD, MBA and others at the University of Utah serves as exemplary work in this regard: Implementation of a Value-Driven Outcomes Program to Identify High Variability in Clinical Costs and Outcomes and Association With Reduced Cost and Improved Quality