Design and measurement of quality improvement indicators in ambulatory pulmonary care: creating a "culture of quality" in an academic pulmonary division.
BACKGROUND
Quality improvement (QI) measures often are cited as goals for individual practices and medical centers and may someday form a component of reimbursement guidelines. Relatively few QI metrics relevant to ambulatory pulmonary medicine have been published. We describe the development and implementation of a QI program in an academic pulmonary division, including progress to date and lessons learned.


METHODS
Metrics for the pulmonary QI Dashboard were developed based on an extensive literature review. Patients were identified through International Classification of Diseases-based billing databases, and results data were obtained from a manual and automated review of the electronic medical record. The performance of the division was monitored and presented in regular faculty meetings. Quarterly, confidential, individual scorecards gave each clinician feedback about his or her performance and compared the feedback to that of the faculty of the entire division.


RESULTS
Significant improvements were found in many QI measures during a 2-year period. The number of patients with asthma who received appropriately prescribed inhaled corticosteroids increased from a baseline of 76 to 92% to 98%. Flu shot and pneumococcal vaccine administration documentation for patients with COPD increased from baseline values of 11 to 32% and 11 to 34%, respectively, to 90% and 93%, respectively. The COPD Global Initiative for Obstructive Lung Disease pharmacotherapy guidelines adherence increased substantially for patients with all disease stages. Chest CT scan results notification documentation improved from a baseline of 67 to 76% to 98%. Comparison between baseline and QI periods yielded statistically significant increases for these indicators.


CONCLUSIONS
QI measures for an ambulatory pulmonary practice can be designed, implemented, and monitored. Key components include a well-structured electronic medical record, measurable outcomes, strong QI leadership, and specific interventions, such as providing feedback through QI review meetings and individual "report cards."
Roberts
David H
DH
Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA. Electronic address: dhrobert@bidmc.harvard.edu.
Gilmartin
Geoffrey S
GS
Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
Neeman
Naama
N
Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
Schulze
Joanne E
JE
Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
Cannistraro
Sabrina
S
Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
Ngo
Long H
LH
Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
Aronson
Mark D
MD
Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
Weiss
J Woodrow
JW
Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
D000553:Ambulatory Care / Q000592:standards*; D003625:Data Collection; D006748:Hospital Departments / Q000592:standards; D006801:Humans; D008171:Lung Diseases / Q000628:therapy*; D008499:Medical Records; D015272:Pulmonary Medicine / Q000193:education / Q000592:standards*