In the next section of the presentation, C. Kent Kwoh, MD, professor of medicine and epidemiology and chief of the Division of Rheumatology at the University of Pittsburgh, summarized the ACR’s collaboration with the National Committee for Quality Assurance and the Physician Consortium for Performance Improvement to translate the recommendations into quality and performance measures. Their efforts yielded five standards: assessment of an RA patient’s disease activity (low/moderate/high) at least once a year; assessment of the patient’s functional status; assessment and classification of disease prognosis at least once a year; TB screening for patients receiving biologic agents; and glucocorticoid management.
Dr. Kwoh said that the guiding principles for developing the standards were that they be clinically relevant, evidence based, scientifically valid, and, most important, feasible. He then demonstrated the computation of quality scores for each of the performance standards. For instance, to rate one’s performance on the standard of TB screening for RA patients receiving biologic agents, the practice would divide the number of patients who were screened for TB by the total number of patients receiving biologics. If the practice performed TB screening on 90 of the 120 patients receiving biologics, this would yield a score of 75%.
Taking the Challenge
Why is it important to implement quality measures? Asking the questions outlined in the performance standards, and tracking the answers, will boost the quality of care rheumatologists render to patients with RA, noted Dr. Newman. “My task is to take the elegant work summarized by my colleagues Dr. Saag and Dr. Kwoh and kind of bring it out to the clinic. There are skills you need to learn, steps you need to take, and processes to put into place in the clinic so that you can begin to collect these types of measures.”
Dr. Newman remarked that most rheumatologists, when asked if they deliver quality care, would answer in the affirmative. However, he also noted that many may not be able to quantify their answers with solid data. It’s important for rheumatologists to create a “culture of change,” he said, and outlined a five-step process to implement the recommendations’ quality measures into clinical practice. Dr. Newman used examples from the experience at Geisinger Medical Center as well as training workshops he conducts with colleague J. Timothy Harrington, MD, delivered with a humorous and energetic approach.
The first step, said Dr. Newman, is to commit: “The person in charge has to make it clear that this is a very, very important part of what we do for our patients.” Then it is time to get buy-in from others in the group. Typically, Dr. Newman said, 10% of a group will view change as fun and positive, 80% will be willing to listen, and 10% may resist. “Spend time with the key players,” he advised, “and focus on those who are receptive so that you can overcome inertia to change.” Next, form a team to address quality measures. The team should include all members of your microsystem, not just physicians and nurses. “The best way to meet with success is to create a team that circles around the patient. For that to happen, everybody has to be a player.” This may entail some adjustment from physicians, who tend to view the medical practice in a hierarchical way. Often, associated staff members have the best ideas, he said.
