This article by Adam Weizman and colleagues is the first of a three-part series that will provide practical advice for practices that wish to develop a quality initiative. The first article, “Launching a quality improvement initiative” describes the infrastructure, personnel, and structure needed to approach an identified problem within a practice (variability in adenoma detection rates). This case-based approach helps us understand the step-by-step approach needed to reduce variability and improve quality. The authors present a plan (road map) in a straightforward and practical way that seems simple, but if followed carefully, leads to success. These articles are rich in resources and link to state-of-the-art advice.
John I. Allen, MD, MBA, AGAF, Special Section Editor
There has been increasing focus on measuring quality indicators in gastroenterology over the past few years. The adenoma detection rate (ADR) has emerged as one of the most important quality indicators because it is supported by robust clinical evidence.1-3 With every 1% increase in ADR, a 3% reduction in interval colorectal cancer has been noted.3 As such, an ADR of 25% has been designated as an important quality target for all endoscopists who perform colorectal cancer screening.1
You work at a community hospital in a large, metropolitan area. Your colleagues in a number of other departments across your hospital have been increasingly interested in quality improvement (QI) and have launched QI interventions, although none in your department. Moreover, there have been reforms in how hospital endoscopy units are funded in your jurisdiction, with a move toward volume-based funding with a quality overlay. In an effort to improve efficiency and better characterize performance, the hospital has been auditing the performance of all endoscopists at your institution over the past year. Among the eight endoscopists who work at your hospital, the overall ADR has been found to be 19%, decreasing to less than the generally accepted benchmark.1
In response to the results of the audit in your unit, you decide that you would like to develop an initiative to improve your group’s ADR.
Forming a quality improvement team
The first step in any QI project is to establish an improvement team. This working group consists of individuals with specific roles who perform interdependent tasks and share a common goal.4 Usually, frontline health care workers who are impacted most by the quality-of-care problem form the foundation of the team. A team lead is identified who will oversee the project. Content experts are also helpful members of the team who may have particular expertise in the clinical domain that will be the focus of the project. In addition, an improvement adviser, an individual with some expertise in QI, is needed on the team. This adviser may be from within your department or from outside. Although they may not possess expertise in the clinical problem you are trying to tackle, they should have skills in QI methodology and process to aid the team. An executive sponsor also needs to be identified. This should be an influential and well-respected individual who holds a senior administrative position at your institution who can help the team overcome barriers and secure resources. Physician engagement is a critical, often-overlooked step in any improvement effort. Regardless of the initiative, physicians continue to have tremendous influence over hospital-based outcomes.5 Identifying a physician champion, a prominent and respected physician at your organization to help spread the importance of your efforts and create a burning platform for change, is helpful. It also is valuable to have a patient on the improvement team to provide unique perspectives that only the end user of health care can convey and to ensure that the project is patient centered, as all improvement efforts should be.6
Improvement framework
Before starting any improvement effort, there are several important considerations that need to be addressed when choosing a quality improvement target.7 It is important to have a good understanding of the burden and severity of the problem. This often requires audit and measuring. For example, although we may think there is a problem with ADR in our endoscopy unit based on a general impression, it is critical to have data to support this suspicion. This is part of a current state analysis (discussed later). It also is important to select a quality-of-care problem that is under you or your group’s direct control. For example, it would be difficult to initiate a quality improvement project aimed at changing the practice of radiology reporting as a gastroenterologist. It is important to pick a problem that is focused and within a narrow scope that is feasible to address and then improve. Consideration of the unintended consequences of an improvement initiative often is overlooked, but needs to be considered because not all that comes out of quality improvement efforts is good. Finally, the likelihood of success of a quality initiative is increased significantly if it can generate momentum and lead to other interventions both within your department and beyond.
