Understand Health IT-enabled QI

Everyone participating in the QI work should have a shared understanding of key definitions (e.g., CDS), frameworks (e.g., CDS 5 Rights Framework), strategies (e.g., the QI process outlined in Section II.), tools (e.g., Essential CDS/QI Worksheet), and key QI project success factors.
 

• ‘Clinical Decision Support’ (CDS) is a key underpinning for the QI approach outlined in this Guide, but its meaning here might be different than what you have in mind (especially if ‘alert’ figures prominently in your definition). In this Guide, CDS is defined as a process for improving health-related decisions and actions with pertinent knowledge and patient information to enhance health and care delivery. Under this definition, CDS is about supporting care decisions and actions, ideally in a manner that makes the appropriate decisions and actions the easy ones to execute. That is, facilitating workflow not interrupting it – as alerts often do. There are many different ways to provide this support (e.g., CDS intervention types). See the CMS CDS tipsheet page for more details, including example CDS intervention types (e.g., order sets, focused patient data summaries, documentation templates).
   
• The CDS 5 Rights framework is a best practice QI approach (recommended by CMS in the tipsheet above) to support decisions and actions that drive performance targeted for improvement. It asserts that optimizing care processes and outcomes requires getting the right information to the right people in the right formats through the right channels at the right times (see figure below). The tools and approaches outlined in this Guide help organizations implement this framework and enhance the contributions, experience and results for those involved in care delivery.
   

• The Essential CDS/QI Worksheet is best used for initial efforts to map care processes and reveal potential enhancements. That is, to document and analyze target-focused information flows and workflows, and to brainstorm improvement opportunities (see figure with excerpts from this worksheet below). The tutorial that follows provides guidance and examples on how the worksheet can be used. to streamline and enhance care processes. (The Enhanced CDS/QI Worksheet, in the ‘Deeper Dive’ section below, is a more robust but more complicated tool for those already skilled in using the Essential CDS/QI Worksheet)
   
  • View the Tutorial on how to use the Essential CDS/QI Worksheet
     
  • See a completed Outpatient Essential CDS/QI Worksheet Example that uses this tool to illustrate the workflows and information flows that produced very high levels of blood pressure control in a small practice: Ellsworth Hypertension QI Case Study
     
• Attend to key QI project success factors:
   
  • Focus on People, Process, and Technology (in that order), recognizing that engaging everyone involved is critical for success.
     

• Focus on ‘the most important things’ when selecting improvement targets, opportunities to enhance care processes for the target, and activities to ensure successful implementation of those process changes.
   

• QI activities involve a chain of stakeholders including FQHC QI leads, clinicians and staff, and ultimately patients. As the QI project unfolds and each of these groups is touched by the effort, seek to escalate engagement, insights, and momentum toward goals.

• For a deeper dive into health IT/QI foundations, consider these resources:
   
  • Tasks and Key Lessons from each chapter in “Improving Outcomes with Clinical Decision Support, and Implementer’s Guide, 2nd Edition.” Detailed guidance on successful CDS-enabled QI programs and interventions.
     
  • Enhanced CDS/QI Worksheet: Similar in concept to Essential version, but with additional space to document/review optimal care activities for the target, and the individual CDS 5 Rights dimensions for the current state. Consider using only after you are comfortable with the Essential CDS/QI Worksheet version.
     
    • View the Tutorial: on how to use this worksheet.
       
    • See a completed Outpatient Example: CHC Inc. hypertension QI case study
       
  • White papers and guides on HIT-CDS/QI:
     
    • Qualis Health: Integrating Clinical Decision Support Tools into Ambulatory Care Workflows for Improved Outcomes and Patient Safety
       
    • AHRQ: Using Health Information Technology to Support Quality Improvement in Primary Care

Select Target(s); Initiate QI Project

Successful QI efforts typically require significant time, energy and resources, so it is important to choose targets where the return will warrant the investment. This requires a clear and accurate understanding of baseline performance on the target.
 

• Consider targets associated with business imperatives, such as UDS reporting (especially for conditions where the FQHC is under-performing), and value-based payment initiatives from the private sector and CMS (e.g., the Quality Payment Program which is radically overhauling Medicare payments to clinicians, and related value/risk-based payment models for Medicaid). Seek QI synergies with pertinent FQHC initiatives such as PCMH recognition and HRSA Health Center Quality Improvement Grant Awards.
   
• Examine local performance gaps and improvement opportunities when reviewing payment drivers noted above and selecting targets.
  • See the figure below from the HIMSS guidebook on improving outcomes for examples of local factors to consider in selecting targets for quality improvement intervention.

Image Reference: Osheroff JA, Teich JM, Levick D, et. al. Improving Outcomes with Clinical Decision Support: An Implementer’s Guide, 2nd ed. Chicago: HIMSS. 2012.
 

• Measure and understand your baseline performance on your target(s).
  • The CMS/ONC eCQI Resource Center has information about quality measure specifications for providers. The Checklist for Analyzing Performance Measure Data has detailed information about validating and interpreting these data.

Document/Analyze Flows; Identify Improvements

A helpful QI adage is that “systems are perfectly designed to produce the results they deliver.” This truism highlights the importance of understanding current care processes that are driving suboptimal performance on the targeted measure (e.g., diabetes control, preventive care, use of expensive tests) so they can be refined to deliver better results. The CDS/QI worksheet supports this analysis through a structured, broadly applicable framework for documenting, analyzing, sharing and improving target-focused care activities.

• Use the CDS/QI worksheet to help examine patient-specific and population management information flows and workflows, as well as foundational activities such as EHR configuration, policies, staff training, etc., that are producing sub-optimal performance on the target. For example, if the QI target is hypertension control, consider the current status of staff competency and training on measuring blood pressure appropriately (foundational activities); registry use to identify and recall patients with poorly controlled blood pressure (population management activities); and optimizing pre-visit huddles, order set use, and patient engagement/care plan adherence tools (patient-specific supports).
   
  • Walk through the care process (with special attention to the patient experience) and document results in the Essential CDS/QI Worksheet.
     
  • Engage all care team members in the workflow/information flow and improvement analysis– including the patient, if possible.
     
  • If you are comfortable with the Essential CDS/QI Worksheet, consider using the Enhanced CDS/QI Worksheet instead of, or in addition to, the Essential Worksheet for a deeper dive into the ‘optimal state’ and the details of each CDS 5 Rights dimension
     
• Analyze this current state (“what is?”) to identify opportunities to improve target-focused information flow, workflow and results; i.e., to better address the CDS 5 Rights for the target. Document these potential enhancements in the CDS/QI Worksheet. (Review the tutorial for the worksheet you are using (i.e., essential vs. enhanced) for guidance.) For example, consider enhancements such as:
   
  • documentation templates, and related workflows for completing them, that make it easier to identify patient barriers to adherence with the care plan (foundational activity);
     
  • text messages and/or personal calls to patients to decrease no-show rates (patient-specific support), and
     
  • performance dashboards (and related conversations) to share target measure results with teams and clinicians as a springboard for brainstorming strategies to accelerate improvement (population management activities).
     
• Review evidence-based best care practices for the target (“what should be”)
   
• Consider available best practice ‘change packages’ for the target:
   
  • For hypertension management, the CDC Hypertension Control Change Package presents change concepts, change ideas, and proven tools that outline ‘what should be’ best practices in categories that correspond to the categories on the CDS/QI Worksheets (i.e., Foundation Activities, Population Management, and Patient-specific Supports (and its subcomponents)).
     
  • For detecting hypertension that may be ‘Hiding in Plain Sight’ in FQHCs and diagnosing hypertension so it can be managed appropriately to reduce heart attacks and strokes, see this similarly-structured “HIPS” change package.
     
  • Similarly-structured change packages for other targets are planned – check back to this page for updates.
     
• Examine other case examples and best practices for successful target-focused care strategies (e.g., QI case studies published by ONC, and other resources):
   
  • Case examples on hypertension control
     
    • Ellsworth Medical Clinic ; (Summary information in the Essential CDS/QI Worksheet: Ellsworth hypertension QI case study)
       
    • CHC, Inc.2; (Summary information in the Enhanced CDS/QI Worksheet: CHC Inc. hypertension QI case study)
       
    • EHR Innovations for HTN Challenge results
       
  • Colorectal cancer screening recommendations for community health centers from the Oregon Primary Care Association and the National Colorectal Cancer Screening Roundtable 
     
  • Case example on tobacco use screening and smoking cessation support at Miramont Family Medicine
     
• Define potential workflow and information flow enhancements for the target (“what could be here?”) by combining ‘top down’ approaches (i.e., starting from ‘what should be?’ best practices) and ‘bottom up’ approaches (i.e., improvement opportunities that emerge from the “what is?” analysis with stakeholders).
   
• Prioritize identified enhancements to implement:
  • Identify several enhancements that are most likely to deliver the greatest benefit in the shortest time with the least effort for initial implementation (that is, use the “low hanging fruit” approach – see prioritization tools such as this Priortization Matrix). Give special attention to changes that could yield strong benefits across multiple targets, or that appear especially promising for strengthening critical workflows and information flows (e.g., related to patient engagement, registry use to identify and close care gaps, pre-visit planning, and efficiently executing evidence-based care plans).

Implement & Evaluate Changes

Implementing enhanced care processes requires that people (e.g., FQHC clinicians, other staff, and patients) do things differently. Formal change management approaches can help ensure that these changes are successful and that they produce desired results.
 

• Use a QI methodology (e.g., PDSA cycles) to engage frontline staff and other key stakeholders in care processes and results to design, implement and evaluate the prioritized changes. Be sure to do this work with all the stakeholders and not to them (i.e., seek and act on team members’ (and patients’) input and feedback throughout the process).

• Be ready to modify patient care and quality improvement activities, CDS intervention details (across any of the CDS 5 Rights dimensions), and other parameters if needed as improvement cycles unfold.

• Monitor implementation activities with structured tools that help you document and manage who’s doing what when, as well as the results.

• Sample monitoring tools:
   
  • Worksheets from Chapter 8: Putting Interventions into Action and Chapter 9: Measuring Results and Continuously Refining the Program in “Improving Outcomes with Clinical Decision Support: An Implementer’s Guide. Second Edition” from HIMSS
     
  • IHI PDSA http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx
     
• Validate and analyze performance measure data to make sure that the results are accurate, and that the team understands what they mean and what to do about them.

Harvest/Spread Results

Ongoing attention to performance on key targets beyond ‘focused QI projects’ is generally warranted (because performance may backslide for various reasons). In addition, there is a growing list of targets on which improvement is imperative. It is therefore important to ‘harvest’ learning, strategies and tools from each project that can be applied in an ongoing way to the target, and spread to other targets. The CDS/QI Worksheet’s structure can facilitate such cross fertilization among QI targets.
 

• As the scheduled initiative concludes, review the QI project with stakeholders to better understand what worked well, what could have been done better, and what useful tools were created.
   
• Apply this learning and these results to strengthen ongoing ‘maintenance’ efforts on the current target and other target-focused QI initiatives.
   
  • Transition target-related QI efforts from ‘project-focused’ to ‘this is how we do business.’ Build in ability to detect the need for, and implement, tweaks to target-related processes when required because of changes to people/processes/technology.
     
  • Incorporate proactively the insights and results from each QI project into subsequent QI initiatives. Although a particular target-focused QI project may be time-limited, the QI and clinical teams should remain alert for ways to continually improve care across all targets. For example, learning from a QI project might indicate opportunities to more broadly modify clinical and quality work and roles, as well as health IT configurations (with this latter triggering feedback to developers about broadly needed enhancements).
     
• Contact the HITEQ Center if you are interested in sharing results further with your peers, and opportunities for health IT/QI peer learning.