High Value Quality Improvement

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 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.

[icon name=”university” class=”” unprefixed_class=””] PILLAR I: DIAGNOSTIC & THERAPEUTIC EFFICIENCY

[icon name=”arrow-circle-right” class=”” unprefixed_class=””] REDUCING UNNECESSARY LABORATORY TESTS

CK-MB in patients with suspected acute coronary syndrome

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), 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

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

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

[icon name=”arrow-circle-right” class=”” unprefixed_class=””] 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

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

[icon name=”arrow-circle-right” class=”” unprefixed_class=””] REDUCING INAPPROPRIATE IMAGING

The HVPAA Radiology Collaborative includes faculty from > 25 academic radiology departments collaborating on the following initiatives:

  1. Consensus standardized management recommendations based on ACR AC®ACR incidental finding white papers and society evidence-based guidelines.
    • Phase I: lung nodule, thyroid nodule, AAA
    • Phase II: adrenal nodule, ovarian cyst, small renal mass
    • Phase III: pancreatic cyst, renal cyst
  2. Harmonizing abdominal CT protocols to reduce unnecessary multiphase imaging as detailed in the new ACR Choosing Wisely® recommendations
  3. Pooling data to establish benchmarks for emergency department imaging positive exam rates
  4. Evidence-based diagnostic pathways for the CMS Priority Clinical Areas(CAD/ACS, pulmonary embolism, headache, neck pain, low back pain, shoulder pain, hip pain and lung cancer).

Imaging tests being targeted in multiple academic centers:

[icon name=”arrow-circle-right” class=”” unprefixed_class=””] REDUCING INAPPROPRIATE TREATMENTS

Transfusions and Blood Management

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

JAMA Internal Medicine Special Communication:  Promoting High-Value Practice by Reducing Unnecessary Transfusions With a Patient Blood Management Program

Antibiotics for Asymptomatic Bacteriuria

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

JAMA Internal Medicine Special Communication: An Implementation Guide to Reducing Overtreatment of Asymptomatic Bacteriuria

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

[icon name=”arrow-circle-right” class=”” unprefixed_class=””] OPTIMIZING PROCEDURES

Venous Access: Midlines and 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

[icon name=”university” class=”” unprefixed_class=””] 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

[icon name=”university” class=”” unprefixed_class=””] 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 hospitalizations,  inpatient length of stay, preventable admissions and emergency department visits.

[icon name=”university” class=”” unprefixed_class=””] PILLAR II: QUALITY DRIVEN MEDICAL & SURGICAL PATHWAYS

Pathway Collaboators

 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

[icon name=”university” class=”” unprefixed_class=””] PILLAR III: IMPROVING DISCHARGE TRANSITIONS

[icon name=”university” class=”” unprefixed_class=””] PILLAR IV: OPTIMIZING PATIENT CARE SETTING 

[icon name=”university” class=”” unprefixed_class=””] PILLAR V: PREVENTATIVE MEDICINE

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog