Lessons Learned From 15-Plus Years of Clinical Quality Improvement

Am J Accountable Care. 2022;10(4):38-40. https://doi.org/10.37765/ajac.2022.89287

I have spent more than 15 years working with physicians on clinical quality improvement. My roles have included leading quality improvement as a faculty member of a family medicine residency program, starting 2 successful physician-led accountable care organizations (ACOs), and convening regional quality improvement collaboratives using accredited continuing medical education (CME) and Part IV Maintenance of Board Certification curriculums. These past 15 years, I have worked with more than 50 primary care clinics, ranging from independent primary care clinics to health system–employed clinics to federally qualified health centers. Despite these varied settings, I have seen several common factors that lead to either success or failure. My hope is that by sharing these observations, I can help others achieve their quality goals more quickly and efficiently.

Lesson 1: Clinician Leadership and Starting With “Why” Are Essential

One of the most common mistakes is the lack of a physician champion and not taking the time to explain the why. A common scenario for clinics that have struggled to improve is that the office manager tries to lead quality improvement because the physicians are “too busy” to get involved. Because the physicians aren’t involved, there is little buy-in or support, and the clinic struggles to make needed changes in clinic workflow. I have learned that often the biggest barrier is getting in front of the physicians to explain why the change is needed and identifying a clinical champion. If you can identify a motivated physician champion and take time to explain the why, you are already halfway to success.

Clinicians are intelligent and competitive professionals, so if they think this is a priority, it will get done. On the other hand, if the project is perceived as one more thing being added to their already overloaded plate or mere “bureaucratic box checking,” then it is doomed to fail. I try to start each quality improvement project in a clinic by addressing the “5 whys” of the project:

• It’s good patient care.
• If we do it as a group, we improve the health of our whole population.
• If you are the best, you get style points, and who doesn’t like that?
• If you are in an ACO, you get paid better.
• If you complete the project, you get both CME credit and your Part IV Maintenance of Board Certification completed.

If none of those 5 whys speak to you, you are in the wrong profession and need to change careers.

Lesson 2: Clinician Leadership Is Essential, but the Trifecta Is Even Better

Although physician leadership is key, it must be followed with the “doers.” Physicians are important to the process, but most of the implementation is done by the office manager, nursing staff, and care coordinators. The clinics that do the best have a quality team, including a physician champion, a care coordinator who has time to follow up with patients outside of the clinic visits or work the gaps in care lists, and an office manager who supports the staffing changes needed. When all 3 roles are filled and engaged—physician champion, care coordinator, and office manager—you have the trifecta and quality improves rapidly.

Lesson 3: Clinics Need Adequate Staffing

I have frequently found that understaffing—either intentional or unintentional—is rampant in primary care. Staffing for quality improvement requires designated staff roles with the time to work on workflow redesign, follow up with patients, and communicate with the rest of the team. Quality improvement takes time and can’t be just one more thing added to the workload of rooming patients, giving vaccinations, pharmacy refills, and the like.

A common understaffing scenario is when a clinic creates a care coordinator role only to have that person repeatedly pulled into direct patient care responsibilities such as rooming patients or helping with vaccinations. I was recently at a national ACO meeting, where chief medical officers were complaining about their centrally managed care coordinators “going native.” They were frustrated with their care coordinators not getting their assigned work done because they were too often helping the primary clinic’s staff take care of the day-to-day patient needs. My response was that they were misdiagnosing the clinic’s ailment. The problem wasn’t the care coordinators going native, it was that their primary care clinics were woefully understaffed. How can a caring care coordinator (redundancy intended) not step in to help if the clinic is short staffed when patients are in need of care?

Lesson 4: Share Comparable Data in a Psychologically Safe Way—Don’t “Rank and Spank”

One of my favorite quality improvement quotes is from health care transformation expert Thom Walsh, PhD: “If you want to build an organization that is fearful, angry, cynical, and full of resistance to change, dump in data without explanation and start ranking and spanking.”

Start by sharing summary clinical data results at the clinician or clinic level in a blinded fashion and acknowledge that the first round of data is likely inaccurate (eg, bad reports from mapping errors or misattributed patients) or skewed due to factors outside of a clinician’s control (eg, a high number of uninsured patients). Have an open discussion about why some are doing better than others. Often you will find “bright spot” clinicians who have figured it out or rapidly improve. Call out their great performance and ask them to explain how they did it. They are usually happy to share what is working for them. Highlighting your bright spots will improve quality faster than ranking and spanking the lower performers.

Lesson 5: Don’t Overdefine the Workflow—Clinicians Are Smart and Will Figure It Out Themselves

Ten years ago, when I was first involved in starting an ACO, I thought I could create an ideal workflow for all our clinics. I thought that once I had that ideal workflow developed, I could then have all 15 clinics adopt it, resulting in outcomes of similar high quality in every clinic. What I found instead is that our best clinics were developing their own workflows based on their unique cultures, structures, and strengths. Physicians and nurses are very intelligent and creative individuals, and they know their clinic better than anyone else. As long as they are motivated (they know the “why” from lesson 1) and have adequate time and staffing (lessons 2 and 3), they will develop their own workflows and improve. For example, I found that the 2 best clinics in our ACO for improving Medicare Annual Wellness Visits (both > 80%) chose very different approaches, and neither was the way I thought would work best for them. They knew their clinic structures, strengths, and staff better than I and came up with a better plan, and they had the data to prove it!

Lesson 6: Well-Designed Clinical Quality Improvement Should Improve Efficiency
and Take Less Time, Not More

For the past 3 years, our ACO has had the best human papillomavirus (HPV) vaccination rates in the state. The 3 common approaches that worked were the following:

• Start with the first vaccine in the series at the 9- or 10-year well-child check.
• Have the right pitch when rooming the patient, then give the vaccine before the physician enters the room.
• Have a recall system to follow up on the second vaccine if patients miss the follow-up appointment.

The rooming pitch was a major factor. We found that some rooming staff were saying, “The school requires Tdap [tetanus, diphtheria, pertussis] and meningitis vaccines, and we can also give you the HPV vaccine if you want it.” Although this was accurate, it was a bad pitch. We switched to: “We recommend the Tdap, meningitis, and HPV vaccines; is it OK if I go ahead and give them?” That was an honest and much more successful pitch for several reasons. First, it really is the current recommendation. We focus on the best medical practices, not government requirements, to set the standard of care. Second, if the answer was yes, it was taken care of before the physician even entered the room and was one less thing for the physician to discuss. Third, because the anxiety of getting a vaccine was past, it allowed for a better patient/clinician discussion during the visit. Fourth, it freed up the room for another patient faster, because the vaccine administration was done in the middle of the visit rather than tacked on to the end.

Lesson 7: Sometimes Clinicians Need to Learn to Give Up Control

Medicine is a highly complex and high-liability occupation, which leads some clinicians to be overly controlling. Sometimes physicians think they have to approve every single decision, but quite a few things are actually pretty easy to automate. It doesn’t take a medical degree to know when a flu shot is due, and many refills can be turned into standing orders. For example, a patient with hypothyroidism with a normal thyroid-stimulating hormone level and a scheduled follow-up visit within a year can be given a refill via standing orders until their next thyroid follow-up. Why bother the clinician with a decision that should be automatic and easily turned into a protocol?

Final Lesson: High-Quality Care Is Good for Patients, Physicians, and the Community

Good quality improvement is both good medicine and good management if done correctly. Over time, clinics can improve the health of their patients, their office efficiency, and profitability. At OneHealth Nebraska ACO, our quality and costs have continued to improve year after year, and the difference between our expected and actual costs continues

to diverge. For our Medicare Shared Savings Program ACO contract in 2021, we received a 100% on our quality score while lowering overall costs by 6%. For 2022, our third quarter estimates show us at 8% under budget. The combined result over the past 6 years is better care for our patients, a better practice environment for our physicians, and lower health care costs for our community!

Author Affiliation: OneHealth Nebraska ACO, Lincoln, NE.

Source of Funding: None.

Author Disclosures: Dr Rauner is the chief medical officer of an accountable care organization.

Authorship Information: Concept and design; drafting of the manuscript; and critical revision of the manuscript for important intellectual content.

Send Correspondence to: Bob Rauner, MD, MPH, OneHealth Nebraska ACO, 4600 Valley Rd, Ste 400, Lincoln, NE 68510. Email: brauner@onehealthne.com.