Dr. Holly was invited by the National Quality Forum to attend the NQF National Priorities partnership Care Coordination Convening Workshop as an invited content expert in this field and to participate in the round table discussions.

National Quality Forum
National Priorities Partnership
Care Coordination Convening Workshop
Washington, D.C.
September 1-2, 2010

Introduction to SETMA's Notebook

There are numerous "transition" points in healthcare, at each of which points it is possible to seriously diminish the quality of care if the transition is not made effectively.  One metaphor which illustrates these points of transition is that of seeing the responsibility of a patient's care as a "baton."   As in a relay race at the highest levels of competition, if the "baton" is dropped, the team is disqualified, no matter how excellent they are.  So it is with healthcare, if the "baton" of responsibility of care is dropped during a transition of care, no matter how excellent the care was in the previous setting, the transition failure will result in  the quality of care being diminished. 

The other reality which makes this metaphor apt is that there are 8,760 hours in a year.  If a person is receiving extensive healthcare, they are still "carrying the baton of responsibility for their own healthcare" for over 8,700 hours in the year.  If through education, understanding, empowerment and acceptance of that responsibility, the patient is not prepared or quipped to exercise that responsibility, their care will be seriously diminished.

Perhaps, the most serious potential for the "dropping of the baton of care" is as the patient transitions from inpatient to outpatient  care.  The opportunities for the dropping of the baton are many:

1. Failure to receive proper medication instructions
2. Failure to be given medication prescriptions
3. Failure to obtain new medications
4. Failure to stop previous medications which should not be continued
5. Giving of duplicate medications
6. Giving of medications which conflict with other medications or conditions
7. Failure to receive appropriate follow-up instructions
8. Failure to receive appropriate follow-up appointments
9. Failure to receive the results of incomplete or unreported evaluations or tests started in the inpatient setting
10. Failure to understand why the patient was admitted to the hospital and what they can do to avoid readmission or complications
11. Failure for principle caregivers to understand how to care for their loved one.
12. Failure to communicate effectively with other care-giving organizations with complete and proper orders, i.e., long-term care facilities, hospice, home health, primary care providers, DME, etc.
13. Failure for patient to have follow-up contact prior to their next visit to assess whether their transition has been safe and effective, maintaining their care advantages gained in the in-patient setting.
14. Failure to be seen quickly enough to reinforce the instructions, education or plan of care or treatment plan which was established in the in-patient setting.

These and many more issues complicate the transition from in-patient  to out-patient care. 

It is for these reasons that Southeast Texas Medical Associates (SETMA) began completing the Hospital Discharge Summary in our electronic health record (EHR) almost ten years ago.  By completing the Admission History and Physical Examination, and then the Daily In-Patient Progress Note in the EHR, it became possible to complete the Discharge Summary completely and efficiently so as to:

1. Compete Medication Reconciliations in a way that can be monitored.
2. Complete follow-up instructions in a way that can be communicated to the patient and care givers in writing
3. Complete follow-up appointments with primary care and specialty care providers BEFORE the patient leaves the hospital
4. Give the patient the date, time, place and person with whom their follow-up care is already scheduled.
5. Compete the scheduling of any addition referrals or testing to be done before patient leaves the hospital and give them that information in a written form which is also documented in the patients personal health records.

Thus, SETMA has given the patient, family and other care givers a written set of follow-up instructions which are identical to the instructions which are in the EHR, which include:

1. A complete and accurate medication list
2. Follow-up instructions and appointments with time, place and person with whom that care will take place.
3. Self-care instructions including why they were admitted and what they can do to avoid re-admission.

To effectively complete this transition, SETMA began calling all patients discharged from the hospital the day after they left the hospital to inquire:

1. Did they get their medications
2. Do they understand the medications they are to take.
3. Have they had any reaction to new medications
4. Have they improved, stayed the same or gotten worse for the condition or conditions which resulted in their hospitalization
5. Do they have and understand and can they keep their follow-up visits with primary and/or specialty care givers.
6. Have they developed any new symptoms.

The result of that call is then  reported to the patient's principle healthcare provider.  If any adverse event has taken place, the patient is given an appointment that day.

Care Transitions and Quality Metrics

In June, 2009, the Physician Consortium for Performance Improvement (PCPI) published a quality metric set entitled  "Care transitions."   When SETMA saw that set, we realized that with one exception, we had been performing the 14 data points and 4 actions with the discharge of our approximately 3,000 inpatient admissions a year.  And, with our electronic record capacity, it was relatively easy for us to document our performing of these 18 quality measures.

In addition, as is indicated in this notebook in my response to a "perspective piece" in the New England Journal of Medicine in which a physician objected to quality metrics and expressed no intention of improving her performance, SETMA believes that this "Care Transitions" "cluster" of metrics about one area of health concern would, if met, improve the quality of care which our patients are receiving. Therefore, we deployed this measurement set and began publishing our results.

SETMA believes that a single quality metric has little impact upon quality of care, but a "cluster" - seven or more - of metrics on a single condition, or a "galaxy" --  a group of quality metric "clusters," such as a cluster on diabetes, hypertension, dyslipidemia, CHF, etc --  of quality metrics on a single patient will effectively change the outcomes of care, if met.  Additionally, the only metrics which are of value are ones which are evidence-based and which require intentional actions by a healthcare provider.  And, these intentional actions must distinguish one provider's care from another's.  An illustration of this is the taking of blood pressure.  A quality metric which gives credit for a provider taking the blood pressure is of relative little importance, but metrics which reflect any or all of the following would impact the quality of care of high blood pressure:

1. Was the blood pressure taken with a blood pressure cuff after the bicep was measured and with an algorithm the proper size of cuff was used and documented?
2. Was the blood pressure taken with the patient sitting in a chair, with both feet on the floor and documented?
3. Was the blood pressure repeated after ten minutes of sitting quietly if initially elevated and documented?.

These intentional acts will improve the outcomes of blood pressure treatment and management if routinely followed, documented and audited.

Content

The  contents of this notebook are listed. They reflect SETMA's Model of Care in which:

1. Each SETMA provider tracks  one patient at a time at each encounter over 200 quality metrics.
2. SETMA audits panels of patients and or populations of patients for provider compliance with "clusters" and "galaxies" of quality metrics.
3. SETMA statistically analyzes the data we audit in order to discover points of leverage for improving outcomes.
4. SETMA public reports by provider names on our website at www.jameslhollymd.com our performance on PCPI, NQF, NCQA HEDIS, NCQA diabetes, AQA, Bridges to Excellence and PQRI quality metrics.
5. SETMA then designs quality improvement initiatives on the basis of these steps in our Model of Care.

The note book also contains the published audits of SETMA's performance on numerous NQF-endorsed quality measures.

We look forward to the NQF workshop.  We expect to learn more about the process of designing quality metrics.   We expect to get a better idea of how our program is working to meet the needs of our patients and how others evaluate our efforts.  And, it is our hope that our input to this process will in a small way advance the process of patient safety and of excellence in care for all of our patients.

James L. Holly, MD
CEO, SETMA, LLP
www.jameslhollymd.com