No "I" in Small Teams

June 24, 2011
The dust is only just beginning to settle on healthcare quality improvement (QI). The Institute of Medicine's "Preventing Medication Errors: Quality

The report was a result of the Centers of Medicare and Medicaid Services' request for medication error examination. The IOM checked into what was happening in hospitals. What it found was nothing less than egregious: medication errors are one of the leading causes of injury to hospitalized patients. According to "Preventing Medication Errors," they occur most frequently during the prescribing and administering stages. "A hospital patient can expect on average to be subjected to more than one medication error each day," the report states.

"I still have physicians in my community who say, 'Everything I need to know is right here,’” Hale says, motioning to her head. "It's a scary thought, but that's they way we were trained. We were trained that we are supposed to be able to do everything on our own."

Not surprisingly, in the six months since the bomb fell, the push for better quality, patient safety and reduced medication errors is in full swing. From pre-admission medication lists (PAML), which rely on physicians, nurses and pharmacists to see that nothing is missed — be it over-the-counter, herbal or prescription — to evidence-based screen reminders that assess patients' pain levels, healthcare IT executives are trying to come up with ways to increase quality and patient safety at the point of care. And while they are certainly helping, the real fix looks to be an organizational push towards teamwork.

In another push for QI, more and more organizations are using performance measures, but there is still much debate over exclusions. As the industry moves more into pay for performance, many providers, especially smaller ones, worry about how they will measure up.

For small providers, the business of quality improvement may feel a little like climbing a mountain. Patricia Hale, M.D., chief medical information officer at Glens Falls Hospital in the Adirondacks in New York state, is enthusiastic about QI, but worries about how small family physicians will fit in. "This is a really steep path ahead of us to get small physicians on board," she says. "How do we come up with the organization's commitment to quality? How can we really change this whole system that we have where physicians are reimbursed for providing services rather than quality?"

Some are turning to each other and sharing the responsibility of entering data. Still others have yet to cross that bridge. "I still have physicians in my community who say, 'Everything I need to know is right here,’” Hale says, motioning to her head. "It's a scary thought, but that's the way we were trained. We were trained that we are supposed to be able to do everything on our own."

Another QI hot topic is public reporting. Many clinicians worry that they will be forced to keep up with the Joneses, when the Joneses may be of a different size practice and may see different types of patients. "The best is when you are measuring against your own improvement, rather than absolute numbers," Hale says.

With the move for nationally accepted measures of data collection, there is much debate over what's in and what's not, over which patients will end up being included or excluded.

Of course, while registries may work as tools for large practices to help coordinate patient education, track allergies and coordinate medication management, they are a challenge in smaller ones. More and more small practices are getting together to pool information and resources, Hale says. So, what's the new office paradigm for quality improvement? For Patricia Hale, it's a challenging one. "It's not enough to have a real good EMR," She says. "Cross redesign is what makes these things successful."

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