166304_spring_07.qxp

Benchmarking To Excellence: Using Quality Indicators To Improve Performance begin to distinguish appropriate, high- detail and a predict- quality endoscopy from inappropriate, able improvement in To err is Human: Building a Safer Health System" is the title of areport released by the Institute of poorly performed procedures. This will performance. Bench- Medicine (IOM) in 1999. The report improve patient care, provide comparative marking invariably raised awareness of medical compli- information for consumers, and prepare "moves the perfor- cations. The claim of the report is that as us for the future reporting requirements mance curve to the many as 98,000 people die each year that will surely come." right." The author due to medical errors.1 A later report, had the opportunity, "Crossing the Quality Chasm: A New Following the publication of Barclay, while being employed Health System for the 21st Century," Vicari, et al's article linking colonoscopic as a Vice President Irving M. Pike, MD, FACG
issued by the IOM advocated a full withdrawal time and adenoma detection of Medical Affairs revamping of health care to improve rate during screening colonoscopy in the par t-time for a number of years, quality.2 These reports have stimulated New England Journal of Medicine (NEJM),4 to participate in a health system-wide, the development of local and national and its subsequent coverage in numerous efforts by hospitals, health care systems, media articles, the author has project. The seven-hospital system and medical-specialty organizations and, experienced several patients who have measured more than twenty clinical to a lesser extent, group practices to inquired about his withdrawal time when performance measures in each hospital produce measurement tools for reporting performing screening colonoscopy.
and benchmarked with each other. Each performance. The public in general and Happily, he has been able to answer, with year per formance in all facilities individual patients are looking and asking evidence based on measurements in his improved. Whereas an incidence of 4.5 for evidence that their physician is a good practice's endoscopy suite, that his ventilator associated pneumonias per physician. It is quickly becoming evident withdrawal times are greater than those 1000 ventilator days may have been a that as gastroenterologists, we should be recommended as minimum times in the good score when the program started, prepared to answer their questions.
NEJM article they had read. This is likely having 1.5 ventilator associated Beyond assuring our patients, is the beginning of additional requests for pneumonias per 1000 ventilator days there additional benefit derived from more information. It would be a wise three years later would have been a very gastroenterologists measuring our own thing to begin measuring now and poor performance among the seven- finding out how your practice per forms hospital benchmarking group. In the with respect to some of the currently interim, each hospital's medical staff and In 2006, David J. Bjorkman, MD, MSPH, published quality indicators. It is a well- critical care unit staff spent time and ASGE President 2004-2005, and John W.
accepted adage that "one improves effort understanding what steps needed Popp, Jr., MD, FACG, ACG President only what one measures." Knowing how to be taken to reduce the incidence. The 2004-2005, in an introductory message you currently score with respect to top score continuously moved to the right.
to five endoscopy quality indicator indicators, will allow you to look into the No doubt, Gastroenterology practices articles, cautioned that if we do not reason for any apparent areas that measuring adenoma find rates on develop evidence-based quality measures, need improvement before the call for colonoscopy and comparing themselves an administrative or government agency transparency in medical practice comes to other practices will increase the find without experience or insight into the to be. You'll have time to improve your rate and presumably decrease the colon practice of endoscopy will define these per formance before you decide to cancer rate over time. Of course, only by measures for us. They urged gastro- provide this information about your measuring will we know this.
enterologists to use measurement tools practice to the public, or a request for to distinguish appropriate, high-quality this information comes from CMS or Beyond improving scores, and likely, endoscopy from inappropriate, poorly private insurance companies.
quality, how can clinical benchmarking performed procedures.3 In referring to the benefit Gastroenterology practices? It is articles concerning gastrointestinal endo- As physicians, we have an inherent not difficult to envision being able to scopic quality indicators that followed in tendency to compete. Knowing we are present a practice's performance record the same journal, they conclude, "By being compared to others in our practice to insurance companies at time of adopting these recommendations, we can or individuals in practices in our region or contract negotiation for leverage in these across the country, invokes attention to discussions. As pay-for-per formance Volume Twelve • Spring 2007 programs (P4P) are developed by corporate support, to pilot a tool that will Medical University of South Carolina insurance companies across the country, allow gastroenterologists nationally to Rockford Gastroenterology Associates, Ltd. it is becoming evident that many of these submit data. This can be done either Asheville Gastroenterology Associates programs are more about rewarding cost manually or directly from their electronic Riverdale Gastroenterology and Liver containment than about improving quality.
endowriters, via a protected web-based Physicians Endoscopy Having a benchmarking tool with site, in order to regularly produce reports to NYU Gastroenterology Department standardized quality indicators will enable the physicians about their quality Digestive Health Specialists, Tacoma gastroenterologists to argue effectively performance compared to other part- Cincinnati Gastroenterology for P4P programs based on recognized icipants in the program. The tool is based Carolina Digestive Health Associates, Charlotte, N. C.
indicators, rather than the cost contain- on the articles pertaining to quality in GI Associates, Knoxville ment project of the year for each and endoscopy published simultaneously in the Oregon Health Science University every insurance company. Should we not American Journal of Gastroenterology and Gastroenterology Associates of North Texas, receive a bonus for high percentage of screening colonoscopies with successful 2006.5,6,7,8,9 If successful, this tool should Gastrointestinal and Liver Specialists of Tidewater, cecal intubations and a high adenoma provide participants with the information PLLC, Southeast Virginia find rates rather than for writing needed to improve the care of their prescriptions for generic omeprazole patients, participate in quality focused P4P instead of a brand name PPI, as at least programs, and manage risk within their Olympus of America one insurance company has decided? practice. A sample of quality measure- ProVation Medical The author envisions Gastroenterology ments can be seen in the table below.
Sentara Healthcare practices and our national societies Physician A
Physician B
Physician C
Physician D
urging, if not insisting, that insurance companies choose to develop their P4P Indication (AUGE) programs around accepted quality indi-cators rather than economic indicators.
Screening Cecal Intubation Rate with Photographic As health savings accounts become the Evidence of Landmarks vehicle for more and more individuals topay for their health care, it is predicted Withdrawal Time During Screening Colonoscopy (avg) that health care shoppers are going to bemore selective about what services they Adenoma Find Ratein Screening receive and where they receive them.
Incidence of Perforation Those able to demonstrate quality careare more likely to attract these patients.
Incidence of Post Polypectomy Bleed The inability to demonstrate that the careyou are providing is of high quality may be As gastroenterologists, we maintain that Dr. Irving Pike joined Gastroenterology Consultants in no better to the consumer than providing we receive the training and acquire and Virginia Beach, Virginia in 1983, which is now a divisionof Gastrointestinal and Liver Specialists of Tidewater, a maintain the skills to provide the highest 28-physician group where he served as President and quality of cognitive digestive system as a member of its Board of Managers. Dr. Pike recently Having a benchmarking tool to help medicine and gastrointestinal endoscopic retired from a part-time executive position with Sentara improve the quality of care provided by Healthcare, an integrated deliver y system in care available from physicians today. The Southeastern Virginia. He had served in various gastroenterologists will also serve to help time has arrived for us to be able to positions from 1994-2006. While at Sentara he manage risk. True risk management is demonstrate what we maintain to be true.
developed a two year curriculum for business education about limiting the likelihood of injury or for practicing physicians. His last position with Sentara Benchmarking will be a powerful tool to before returning to full-time gastroenterology practice poor outcome to a patient and, was as Vice President of Medical Affairs at Sentara incidentally, the risk of legal claims against Bayside Hospital. He currently serves as the Chairman the physician. Following quality guidelines, of the American College of Gastroenterology's PracticeManagement Committee and improving one's performance and having The author acknowledges the accomp- American Society for Gastrointestinal Endoscopy's documentation of that per formance, lishment of the joint task force for Ambulatory Endoscopy Center Special Interest Group.
overall, is a proactive method of risk endoscopic quality, created by the 1 Institute of Medicine. (1999). To err is human: Building a safer health system.
management. Too often medical liability American College of Gastroenterology Washington D. C. National Academy Press.
companies consider risk management to and American Society for Gastrointestinal Institute of Medicine (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington D. C. National Academy Press.
be negotiating as low a settlement as Endoscopy, in creating the ar ticles 3 Bjorkman, David J., Popp, John W. Jr., Measuring the Quality of Endoscopy. AmericanJournal of Gastroenterology 101(4): 864-865, 2006.
possible and passing on the cost of referenced. The ar ticles provide the 4 Barclay Robert L., Vicari Joseph J., Colonoscopic Withdrawal Times and AdenomaDetection during Screening Colonoscopy. New England Journal of Medicine 355(24): settlements in the form of higher framework for the benchmarking of 2533-2541, 2006.
premiums to their insured physicians.
quality indicators in gastroenterology.
Faigel Douglas O., Pike Irving M., et. al., Quality Indicators for Gastrointestinal Endoscopic Procedures: An Introduction. Gastrointestinal Endoscopy 63(4):S3-S9, Current participants and sponsors are 2006. Cohen Jonathan, Safdi Michael A., et. al., Quality Indicators for Esophagogastro-duodenoscopy. Gastrointestinal Endoscopy 63(4):S10-S15, 2006.
A benchmarking group of gastroent- listed as follows. Other physicians and Rex Douglas K., Petrini John I., et. al., Quality Indicators for Colonoscopy. The American Journal of Gastroenterology 101(4):873-885, 2006.
erologists composed of 12 groups from corporate sponsors are in the process of Baron, Todd H., Petersen Bret T., et. al., Quality Indicators for Endoscopic Retrograde Cholangiopancreatography. The American Journal of Gastroenterology 101(4):892-897, many different areas of the country have joining this effort.
Jacobson B.C., Chak A., Quality Indicators for Endoscopic Ultrasound, come together, with the assistance of The American Journal of Gastroenterology 101(4): 898-901.

Source: http://www.mygastro.md/pdf/benchmark.pdf