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Neurologists at the Helm of the Quality Movement: What They're Doing to Change the Culture of Practice

Butcher, Lola

doi: 10.1097/01.NT.0000432286.54869.71
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Neurologists in different practice settings discuss efforts to develop and implement quality improvement initiatives.

As the health care quality movement gains steam, neurologists are jumping aboard with a wide range of improvement initiatives.

Some are starting new programs to reduce avoidable hospitalizations, and some are using transparency to motivate physicians to improve their performance. Many are training physicians in the mechanics of quality-improvement projects while others are creating ways to track compliance with care protocols.

Despite the diversity of approaches, the universal goal is to move toward evidence-based standards of care — and educate physicians about how uncommon that actually is.

Like other physicians, neurologists typically think they are doing exactly the right thing for their patients, not realizing that their training is outdated or that the standard of care has changed. This fact was reinforced for Steven P. Ringel, MD, vice president for clinical effectiveness and patient safety at the University of Colorado Hospital and editor-in-chief for Neurology Today, when his department sought to standardize treatment for status epilepticus.

“Everybody thinks they know how to do it, but when we did a chart audit, we found that no two doctors were doing it the same, and even though you're supposed to treat it immediately, there were lots of patients with long delays in getting treated,” he said. “So the first step was recognition that we're not as good as we think we are, and that we're not standardized.”

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The move to improve health care quality has been building for more than two decades, but the pace of change has varied considerably among medical specialties. Internal medicine, family practice, and surgery have been in the lead, Dr. Ringel said.

“Stroke is the first area in neurology that really got engaged with quality measures, and that's because we borrow from the cardiologists, and we generally run about 20 years behind them,” said Daniel L. Labovitz, MD, director of the Stern Stroke Center at Montefiore Medical Center in New York.

Even though most of the nation's largest hospitals have focused on the quality of stroke care for more than a decade, many smaller hospitals still do not meet the highest standards of stroke care, he said.

But changes in the health care landscape are prompting neurologists to work quickly to get up to speed. For one thing, consumers are being asked to become “smart shoppers” of health care services and a relatively new phenomenon — online public reporting of quality measures — will increasingly allow them to check up on physicians and hospitals before they make decisions.

For another, the Centers for Medicare & Medicaid Services (CMS), as well as state and private payers, are developing ways to tie health care payments to the quality of care provided. “Increasingly, there will be direct financial ramifications or rewards for adhering to quality benchmarks,” said S. Andrew Josephson, MD, director of the neurohospitalist program and medical director of inpatient neurology at the University of California, San Francisco.

Heretofore, quality-minded neurologists have been hampered because neurology-specific quality measures have been available only for stroke. In the last two years, the AAN and others have been developing measures for Parkinson's disease, epilepsy, and other neurologic conditions — and more measures are in the works. [To review all the AAN quality measures and related resources related to physician quality reporting systems, visit]

Meanwhile, CMS is already penalizing hospitals that have high rates of readmissions and other so-called quality failures — as well as publicizing those failures on publically available websites. That means neurologists will feel increasing pressure to improve their performance, including on non-neurologic measures, Dr. Josephson said.

“We as neurologists have typically not spent a great deal of time thinking about how good we are at giving pneumococcal vaccines or providing adequate deep venous thrombosis prophylaxis,” he said. “But our numbers will now count towards hospital-based metrics that affect the bottom line as well as public perceptions of our institutions.”

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At the University of Colorado Hospital, training staff in performance improvement techniques is a priority set by the hospital president and the dean of the medical school.

“Most universities train doctors how to do big randomized controlled trials, and the whole approach to performance improvement is very different than doing those kinds of research studies,” Dr. Ringel said. “To educate people how to do this takes time.”

Quality improvement typically involves making iterative small changes, collecting and analyzing data to see if they are effective, giving feedback to staff, creating protocols, and monitoring compliance.

In addition to training physicians and other staff on those skills, Dr. Ringel's hospital is incorporating performance improvement into many aspects of a physician's work. For example, its grand rounds schedule now includes quarterly sessions in which each department presents the results from its quality and safety improvement projects. Meanwhile, the journal club for residents and faculty, which previously focused exclusively on research articles, now discusses an article about health care quality, safety, or utilization at each monthly meeting.

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“We have created a comprehensive program to reinforce the importance of this in our culture,” he said. Each section — epilepsy, stroke, neuromuscular disorders, and others — at the University of Colorado Hospital neurology department undertakes a quality improvement project every year. The projects are not limited to the department members.

“They involve not just neurologists, but anybody else who needs to be involved,” Dr. Ringel said. “For example, in the case of stroke, a project involves the emergency room, nursing, and radiology.”

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CMS and other payers have identified avoidable inpatient readmissions as a quality failure. Last October, CMS began financially penalizing hospitals that have high 30-day readmission rates.

“Currently, the rates for hospitals are defined by patients who have specific non-neurologic conditions, including myocardial infarction and heart failure, but it is extraordinarily likely that in the near future these metrics will include patients with stroke, epilepsy, and other neurological conditions,” Dr. Josephson said. “So, locally, we have spent a great deal of time trying to analyze our readmission rates and beginning a number of initiatives to decrease unplanned readmissions.” [For more on strategies to reduce hospital readmission rates and other initiatives, see the sidebar, “In Progress: Quality Improvement Projects.”]

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Aneesh B. Singhal, MD, director of neurology quality and safety at Massachusetts General Hospital, continually monitors progress on the department's quality and safety measures. “We have a dashboard with 75-odd measures that we keep track of,” he said. “We track things like the average length-of-stay, the number of readmissions to the hospital and hand-off failures. We have defined goals and thresholds for each measure, and we review them on a regular basis every month.”

Patient satisfaction, an important quality measure to CMS and an element of its value-based purchasing formula for hospitals, is also monitored. “We put a lot of weight on that and we pay attention to the feedback received from patients,” Dr. Singhal said.

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When the American Heart Association's Target Stroke initiative set a benchmark that 50 percent of stroke patients would have tissue plasminogen activator (tPA) delivered within 60 minutes of arrival in the emergency department, Montefiore Medical Center found that its average door-to-needle time ranged from about 60 minutes for the fastest neurologist to more than 100 minutes for the slowest.

Dr. Labovitz, director of the Stern Stroke Center at Montefiore, said sharing the information with the seven vascular neurologists prompted self-analysis and behavior change.

“The slowest doctors got the message,” he said. “They realized, ‘I thought I was doing a good job, but clearly I'm not’ and they stepped up. Our (hospital-wide average) door-to-needle time has dropped.”

At Massachusetts General, the performance dashboard that Dr. Singhal uses to keep tabs on quality measures does not provide physician-specific information. That is why the neurology department is developing an internal dashboard that will allow individual physicians to see how their own performance compares with that of their colleagues. For example, physicians can check to see their compliance with a department guideline that requires an outpatient visit note to be completed and signed within five days.

“We measure rates of compliance, so if you have seen 50 patients and you were non-compliant in two, the drill-down option gives you the ability with one click to get to a patient's record and complete the note right then,” he said.

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Because patient hand-offs are a well-documented source of safety failures, Massachusetts General has developed protocols to make sure that information is properly relayed from one caregiver to the next.

“If there is a failure in the hand-off, whether or not there is patient harm, we have encouraged a culture where the receiving individual — or even the hand-off person if he or she has made an error — has authority to file a safety report,” Dr. Singhal said. “I receive about 2,000 such safety event reports every year and we go through them every week — really, every day — and then at our monthly quality assurance meeting, we discuss the hand-off failures.”

At Massachusetts General, Dr. Singhal works with the quality assurance chairs from other departments in the hospital's Center for Quality and Safety so they can learn from one another. For example, the templates that the neurology department created to help with patient hand-offs are being adapted for use in other departments. “There's a Center for Quality and Safety hand-off team that is looking into common themes across various departments,” he said. “They will take best practices from each.”

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Like other quality-minded institutions, University of Colorado Hospital is taking a multi-pronged approach to communicate the importance of quality improvement. The hospital conducts an annual survey to find out how physicians, nurses, and other staff feel about quality and safety.

“We actually gauge the culture, and we have demonstrated the increasing recognition of and endorsement of quality improvement at the hospital level,” Dr. Ringel said. “We feed that data back to people to encourage them.”

Further, the hospital is changing its incentive compensation formula for physicians to include their performance on quality performance measures, in addition to the traditional productivity measures.

“We have leadership showing their commitment, we have financial incentives, and we have measurement — not only of individual projects, but of the attitude, the culture as it relates to quality and safety,” he said. “That's a big part of our program.”

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Although awareness of quality improvement is building, most neurologists are not familiar with the processes and concepts involved. Anup Patel, MD, director of the complex epilepsy clinic at Nationwide Children's Hospital in Columbus, OH, said learning the language of quality improvement — terms such as “small test of change” or “run chart” — is the first hurdle. [See the sidebar, “Quality Improvement Glossary” for a list of commonly-used phrases.] He is involved in a team effort to reduce the use of hospital services by patients with epilepsy.

“There are certain terms and usage of those terms that are important to understand before we can successfully even interpret what a quality improvement project is about and how to be successful within that project,” he said.

Many institutions have a supportive infrastructure that includes training on quality improvement techniques and experts to help devise projects, collect data, and interpret results. However, that external support is not essential to quality improvement initiatives.

“There is enough information out there to allow one to be successful, even without the infrastructure in place,” Dr. Patel said. “One of the things we want to see within neurology is for everybody to be involved with quality improvement projects. They are very much in line with what is happening in health care, and specifically within neurology, and how we as neurologists are going to be reimbursed and how we as neurologists are going to be viewed.”

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Measure: An indicator of change. Key measures should be focused, clarify the aim, and be reportable. A measure is used to track the delivery of proven interventions to patients and to monitor progress over time.

Run chart: A graphic representation of data over time, also known as a time series graph or line graph. This type of data display is particularly effective for process improvement activities.

Test: A small-scale trial of a new approach or a new process. A test is designed to learn if the change results in improvement, and to fine-tune the change to fit the organization and patients. Tests are carried out using one or more PDSA cycles.

Source: Institute for Healthcare Improvement

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This article launches a new series that will profile innovative neurology initiatives around quality improvements and performance measures.

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TUNE IN: Anup Patel, MD, director of the complex epilepsy clinic at Nationwide Children's Hospital in Columbus, OH, and his colleagues are working to reduce hospital use by their patients with epilepsy. In a podcast, he describes how he applies the “Plan, Do, Study, Act” technique suggested by the Institute for Healthcare Improvement to assess how a small change in process can ensure a larger improvement in quality of care:

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Following are highlights of quality improvement projects under way:

  • REDUCING HOSPITAL USE: Anup Patel, MD, director of the complex epilepsy clinic at Nationwide Children's Hospital in Columbus, OH, and his colleagues are working to reduce hospital use by their patients with epilepsy in three ways: decreasing unnecessary emergency department visits, which often lead to hospital admissions; reducing readmissions after a hospital discharge; and standardizing inpatient procedures to shorten the average length of stay.

To learn how to meet their goals in each area, the neurologists are using the Plan-Do-Study-Act technique developed by the Institute for Healthcare Improvement to implement quality improvement projects. That technique is an iterative four-step process that includes a “small test of change” to see if an intervention works as expected. [For more on the technique, see “Quality Improvement Glossary.”]

Dr. Patel's own project sought to decrease emergency department (ED) and/or inpatient visits in four high-risk patients with epilepsy by 50 percent during 2012 and sustain this for six months. The project started with a single patient who had four ED visits and hospitalizations for seizures in 2010. Because of several interventions — including case management services for the family — that patient had no ED visits or hospitalizations in 2011, and was weaned off an anti-epileptic medication.

In 2011, the project was expanded to four patients, who accounted for 46 ED or hospital visits for seizure and/or epilepsy during the year, racking up costs of more than $380,000. After a year of using a case management checklist to support the patients and their families, those patients had 15 visits — and less than half the health care costs — in 2012.The project is now being expanded to a larger group of patients to further identify what works best in reducing ED and hospital use.

  • REDUCING HOSPITAL ADMISSIONS: In response to the CMS mandate that hospitals reduce their 30-day readmission rate, S. Andrew Josephson, MD, director of the neurohospitalist program and medical director of inpatient neurology at the University of California, San Francisco, said the hospital had adopted a relatively simple intervention. A nurse calls every patient within 72 hours of discharge to check on their well-being, answer questions, and make sure prescriptions are being taken correctly. Problems are routed to the inpatient physician who cared for the patient.

As part of a larger initiative, the hospital has created a discharge clinic in which high-risk patients are scheduled to see their inpatient neurologist within about a week of their hospital discharge. This was started in recognition of the fact that even though patients can typically see their primary physician shortly after leaving the hospital, it can take at least a few weeks to get an appointment with their regular outpatient neurologist.

“This situation can lead to patients being vulnerable for neurologic deterioration that can lead to readmission to the hospital and substantial morbidity,” Dr. Josephson said. “Seeing their inpatient neurologist in the outpatient setting one time serves as a bridge between discharge and the first visit with their outpatient neurologist.”

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•. Institute for Healthcare Improvement:
    •. Centers for Medicare & Medicaid Services Innovation program, — a $1 billion initiative to fund projects aimed at improving health care systems by delivering better care and quality, and lowering costs for patients:
      •. AAN Resources on Quality Measures and Reporting:
        •. Neurology Today's coverage of practice improvement measures for neurology:,,
          © 2013 American Academy of Neurology