- Volume 10 | Fall 2012
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GIP in Focus
Quality Improvement: The Importance of Feedback
What helps physicians put asthma guidelines into practice? Real–time feedback on how well they deliver guidelines–based asthma care.
That’s one of the valuable lessons learned by four quality improvement projects funded by the National Asthma Education and Prevention Program’s (NAEPP) National Asthma Control Initiative (NACI). The projects—led by the American Academy of Allergy, Asthma & Immunology; American Board of Family Medicine; Medical Society of Virginia Foundation; and University of Washington—used customized feedback to accelerate physicians’ use of the six key actions for improving asthma care and control according to the NAEPP’s clinical practice guidelines.
The support that the NACI provided to investigators afforded them the time to engage participating physicians and their staff in planning and testing ways to improve guidelines–based asthma care within their everyday practice, review feedback on their progress, and act on the feedback—making changes until they reached or exceeded their performance goals.
Project staff teamed with clinical and quality improvement experts to give individual and/or group feedback to physicians, nurses, and other health care providers about their progress toward pre–established goals, such as routinely assessing patients’ asthma control and providing written asthma action plans. The feedback came digitally, in person, and by phone.
For example, the Web–based “Asthma Specialist Tool to Help Manage Asthma and Improve Quality” (ASTHMA IQ), developed by the American Academy of Allergy, Asthma & Immunology (AAAAI), a NACI Strategic Partner, is used to educate and help physicians to assess and manage a patient’s asthma based on the NAEPP’s clinical practice guidelines. It also enables physicians to review, graph, and report performance and quality improvement measures and identify areas for improvement—all with the click of a mouse.
AAAAI first created ASTHMA IQ for allergists, immunologists, and other asthma specialists. Then, through the NACI, AAAAI teamed with the American Academy of Family Physicians National Research Network to adapt, test, and disseminate the tool for primary care use. The adapted tool took into account the clinical, practice improvement, and administrative needs of primary care providers.
“Asthma IQ [for Primary Care] has received positive reviews from many primary care physicians, including pediatricians, family medicine physicians, and internists, and [it] promotes the guidelines while integrating physician training and buy–in,” said Thomas Casale, M.D., AAAAI executive vice president and co–developer of Asthma IQ.
Similarly, the American Board of Family Medicine (ABFM), another NACI Strategic Partner, designed its asthma Self–Assessment Modules (SAMs) to help physicians improve asthma–care knowledge and demonstrate their understanding through simulated clinical encounters. In addition to its online asthma SAM, ABFM initiated a group asthma SAM process that gave participants the chance to get face–to–face feedback from trained ABFM faculty members.
How did physicians respond to the feedback?
“SAM participants were energized by the feedback experience,” said Michael Hagen, M.D., senior vice–president, ABFM, “and they shared many of their challenges and questions about the guidelines, as well as specific clinical scenarios that pertained to the guidelines.”
The University of Washington’s (UW) NACI Strategic Partnership project, Spirometry 360, also found that participants were energized by the customized feedback they received from clinical experts on the quality of spirometry—a measurement of lung function—they performed. To give more providers this opportunity, UW’s NACI Clinical Champions train–the–trainer project then recruited and mentored four additional Spirometry 360 training sites across the country.
“A lot of people buy the spirometer with good intentions, but it's easy to use improperly without some training and feedback,” said James W. Stout, M.D., M.P.H., F.A.A.P., Department of Pediatrics professor at UW. “Think of learning to play a sport or musical instrument. You first have to see it done properly, then you need to practice, and then you need someone to tell you whether you’re doing it correctly.”
Finally, the Medical Society of Virginia Foundation’s (MSVF) NACI Demonstration Project engaged five pediatric practice teams in Virginia in clinical training and practice redesign through its Improving Asthma Care and Treatment (IMPACT™) program.
After selecting quality improvement aims, each team tested practice changes using Plan–Do–Study–Act cycles. Participants created a small–scale plan for change (Plan), tried out the change (Do), analyzed the results (Study), and refined the change (Act). After each cycle, MSVF and its network of asthma and quality improvement experts reviewed reports from a sample of patient charts and provided feedback to each team.
As a group, the teams achieved their aims with strong gains in measures of quality asthma care. Building on these accomplishments, MSVF’s NACI Clinical Champions project enlisted additional pediatric and primary practices in the IMPACT™ program, and achieved similarly positive results, which will be reported elsewhere.
Beyond their use of feedback, AAAAI, ABFM, MSVF, and UW had something else in common: the challenge of getting and sustaining the participation of busy physicians. So, how did they manage to get their foot in the door? The answer is the projects provided a non–monetary incentive. Physicians that agreed to participate were eligible for Maintenance of Certification (MOC) credit to help them meet the requirements for continued board certification in their specialty. The projects found not only that MOC credit was an excellent recruitment tool, but also that it kept physicians engaged in the quality improvement process.
“Having the opportunity to expand our program through the NACI was a crucial component of our success in engaging pediatric practice teams in quality improvement activities,” noted Helen Ragazzi, M.D., Pediatric Medical Director, MSVF.
Given the end of the NACI funding, AAAAI, ABFM, MSVF, and UW sought new resources to continue the valuable work started by the NAEPP. Activities may include, but not be limited to more in–depth analysis of project findings and fostering new relationships and collaborations to sustain and expand their asthma control efforts.
“We were very encouraged by the success of Spirometry 360, especially the positive response to the program from physicians, and are continuing the project by seeking additional funding,” added Dr. Stout.
Changing clinical practice by integrating and receiving feedback on performance is not always easy. But the enthusiastic response by physicians and their practice teams who participated in these NACI–supported quality improvement projects—and applied the use of the NAEPP’s guidelines and the six key actions in their own practices—demonstrates that it is possible to accomplish.