Reassessing Quality Assessment - The Flawed System for Fixing a Flawed System

The Rarest and Purest Form of Generosity: Simone Weil's Attention and Medical Practice

Attention is essential to the practice of medicine. It is required for expert and timely diagnoses and treatments, is implicated in the techniques and practices oriented toward healing, and enlivens the interpersonal dimensions of care. Attention enables witnessing, presence, compassion, and discernment. The French philosopher and activist Simone Weil (1909-1943) developed one of the most original and important descriptions of attention in the last century. For Weil, attention is not an attitude of strained focus but of perceptive waiting that leads to the acquisition and integration of knowledge. Contrary to activities often foregrounded in clinical medicine, it requires renunciation of the will, gentle directedness toward the origin of actions, and diminishment of the self. This paper critically examines Weil's concept of attention as it applies to health systems, technical/intellectual work, and interpersonal care, as well as its connection to theology, and considers whether attention might find a home within the contemporary clinic.

The risk of complaints against occupational physicians to the medical regulatory body in Ireland

Complaints against doctors to regulators are increasing in all jurisdictions. Occupational physicians (OPs) are at increased risk of complaint due to the unique doctor–patient relationship and the dual obligations of the role. OPs may become embroiled in third-party disputes and must be clear that their role is an advisor to the decision-maker, but not the decision-maker. OPs require training in how to reduce, cope with and defend against complaints to regulators.

Attention Among Health Care Professionals : A Scoping Review

BACKGROUND

The concept of attention can provide insight into the needs of clinicians and how health systems design can impact patient care quality and medical errors.

PURPOSE

To conduct a scoping review to 1) identify and characterize literature relevant to clinician attention; 2) compile metrics used to measure attention; and 3) create a framework of key concepts.

DATA SOURCES

Cumulated Index to Nursing and Allied Health Literature (CINAHL), Medline (PubMed), and Embase (Ovid) from 2001 to 26 February 2024.

STUDY SELECTION

English-language studies addressing health care worker attention in patient care. At least dual review and data abstraction.

DATA EXTRACTION

Article information, health care professional studied, practice environment, study design and intent, factor type related to attention, and metrics of attention used.

DATA SYNTHESIS

Of 6448 screened articles, 585 met inclusion criteria. Most studies were descriptive (n = 469) versus investigational (n = 116). More studies focused on barriers to attention (n = 387; 342 descriptive and 45 investigational) versus facilitators to improving attention (n = 198; 112 descriptive and 86 investigational). We developed a framework, grouping studies into 6 categories: 1) definitions of attention, 2) the clinical environment and its effect on attention, 3) personal factors affecting attention, 4) relationships between interventions or factors that affect attention and patient outcomes, 5) the effect of clinical alarms and alarm fatigue on attention, and 6) health information technology's effect on attention. Eighty-two metrics were used to measure attention.

LIMITATIONS

Does not synthesize answers to specific questions. Quality of studies was not assessed.

CONCLUSION

This overview may be a resource for researchers, quality improvement experts, and health system leaders to improve clinical environments. Future systematic reviews may synthesize evidence on metrics to measure attention and on the effectiveness of barriers or facilitators related to attention.

PRIMARY FUNDING SOURCE

None.

Seeking American Society of Clinical Oncology-Quality Oncology Practice Initiative (ASCO-QOPI) certification in a northern New England rural health system and cancer care network

In 2006 following several years of preliminary study, the American Society of Clinical Oncology (ASCO) launched the Quality Oncology Practice Initiative (QOPI). This cancer-focused quality initiative evolved considerably over the next decade-and-a-half and is expanding globally. QOPI is undoubtedly the leading standard-bearer for quality cancer care and contemporary medical oncology practice. The program garners attention and respect among federal programs, private insurers, and medical oncology practices across the nation. The MaineHealth Cancer Care Network (MHCCN) has undergone expansive growth since 2017. The network provides cancer care to more than 70% of the cases in Maine in a largely rural health system in Northern New England. In fall 2020, the MHCCN QOPI project leadership, following collaborative discussions with the ASCO-QOPI team, elected to proceed with a health system-cancer network-wide QOPI certification. Key themes emerged over the course of our two-year journey including: (1) Developing a highly interprofessional team committed to the project; (2) Capitalizing on a single electronic medical record for data transmission to CancerLinQ; (3) Prior experience, especially policy development, in other cancer-focused accreditation programs across the network; and (4) Building consensus through quarterly stakeholder meetings and awarding Continuing Medical Education (CME) and American Board of Medical Specialists (ABMS) Maintenance of Certification (MOC) credits to oncologists. All participants demonstrated a genuine spirit to work together to achieve certification. We report our successful journey seeking ASCO-QOPI certification across our network, which to our knowledge is the first-of-its-kind endeavor.

Development and Description of a National Cohort of Patients With Chronic Limb-Threatening Ischemia

Background

Chronic limb-threatening ischemia (CLTI) is a common condition with high rates of morbidity and mortality. Despite extensive literature documenting poor outcomes in patients with CLTI, as well as racial, ethnic, socioeconomic, and geographic disparities in these outcomes, process measures for high-quality CLTI care have not been developed. We developed the Chronic Limb threatening Ischemia Process PERformace (CLIPPER) cohort to develop and test the validity of CLTI care quality measures.

Methods

Using inpatient and outpatient claims data from patients with fee-for-service Medicare from 2010 to 2019, we created a coding algorithm to identify patients with CLTI. To qualify for a CLTI diagnosis, patients had to have either diagnostic codes for peripheral artery disease and for ulceration, infection, or gangrene on the same inpatient or outpatient claim or a CLTI-specific diagnostic code. Patients were also required to have a procedural code indicating arterial vascular testing within 6 months before or after the earliest qualifying CLTI diagnostic code(s). We describe baseline characteristics and long-term outcomes of this cohort.

Results

The final cohort comprised 1,130,065 patients diagnosed with CLTI between 2010 and 2019. Mean (±SD) age of the cohort was 75 ± 5.8 years; 48.4% were women, and 14.6% were Black. Within 30 days of CLTI diagnosis, 20.4% of patients underwent either percutaneous or surgical revascularization. Within 6 months, 3.3% of patients underwent major amputation; 16.7% of patients died within 1 year and 50.3% within 5 years.

Conclusions

We described the development of a cohort of fee-for-service Medicare patients with CLTI using inpatient and outpatient Medicare claims data. CLIPPER will be a resource for developing a set of process measures that can be captured from administrative claims data, with plans to describe their association with limb outcomes and corresponding racial, ethnic, socioeconomic, sex-based, and geographic variability.

The Volume and Cost of Quality Metric Reporting

Importance

US hospitals report data on many health care quality metrics to government and independent health care rating organizations, but the annual cost to acute care hospitals of measuring and reporting quality metric data, independent of resources spent on quality interventions, is not well known.

Objective

To evaluate externally reported inpatient quality metrics for adult patients and estimate the cost of data collection and reporting, independent of quality-improvement efforts.

Design, Setting, and Participants

Retrospective time-driven activity-based costing study at the Johns Hopkins Hospital (Baltimore, Maryland) with hospital personnel involved in quality metric reporting processes interviewed between January 1, 2019, and June 30, 2019, about quality reporting activities in the 2018 calendar year.

Main Outcomes and Measures

Outcomes included the number of metrics, annual person-hours per metric type, and annual personnel cost per metric type.

Results

A total of 162 unique metrics were identified, of which 96 (59.3%) were claims-based, 107 (66.0%) were outcome metrics, and 101 (62.3%) were related to patient safety. Preparing and reporting data for these metrics required an estimated 108 478 person-hours, with an estimated personnel cost of $5 038 218.28 (2022 USD) plus an additional $602 730.66 in vendor fees. Claims-based (96 metrics; $37 553.58 per metric per year) and chart-abstracted (26 metrics; $33 871.30 per metric per year) metrics used the most resources per metric, while electronic metrics consumed far less (4 metrics; $1901.58 per metric per year).

Conclusions and Relevance

Significant resources are expended exclusively for quality reporting, and some methods of quality assessment are far more expensive than others. Claims-based metrics were unexpectedly found to be the most resource intensive of all metric types. Policy makers should consider reducing the number of metrics and shifting to electronic metrics, when possible, to optimize resources spent in the overall pursuit of higher quality.

How Design Thinking and Quality Improvement Can Be Integrated into a "Human-Centered Quality Improvement" Approach to Solve Problems in Perinatology

Both quality improvement (QI) and design thinking (DT) methodologies have their unique strengths and weaknesses. Although QI sees problems through a process-centered lens, DT leverages a human-centered approach to understand how people think, behave, and act when encountering a problem. By integrating these 2 frameworks, clinicians have a unique opportunity to rethink how to solve problems in health care by elevating the human experience and putting empathy back at the center of medicine.

Performance on Patient Experience Measures of Former Chief Medical Residents as Physician Exemplars Chosen by the Profession

Importance

Physicians' knowledge about each other's quality is central to clinical decision-making, but such information is not well understood and is rarely harnessed to identify exemplars for disseminating best practices or quality improvement. One exception is chief medical resident selection, which is typically based on interpersonal, teaching, and clinical skills.

Objective

To compare care for patients of primary care physicians (PCPs) who were former chiefs with care for patients of nonchief PCPs.

Design, Setting, and Participants

Using 2010 to 2018 Medicare Fee-For-Service Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data (response rate, 47.6%), Medicare claims for random 20% samples of fee-for-service beneficiaries, and medical board data from 4 large US states, we compared care for patients of former chief PCPs with care for patients of nonchief PCPs in the same practice using linear regression. Data were analyzed from August 2020 to January 2023.

Exposures

Receiving the plurality of primary care office visits from a former chief PCP.

Main Outcomes and Measures

Composite of 12 patient experience items as primary outcome and 4 spending and utilization measures as secondary outcomes.

Results

The CAHPS samples included 4493 patients with former chief PCPs and 41 278 patients with nonchief PCPs. The 2 groups were similar in age (mean [SD], 73.1 [10.3] years vs 73.2 [10.3] years), sex (56.8% vs 56.8% female), race and ethnicity (1.2% vs 1.0% American Indian or Alaska Native, 1.3% vs 1.9% Asian or Pacific Islander, 4.8% vs. 5.6% Hispanic, 7.3% vs 6.6% non-Hispanic Black, and 81.5% vs. 80.0% non-Hispanic White), and other characteristics. The Medicare claims for random 20% samples included 289 728 patients with former chief PCPs and 2 954 120 patients with nonchief PCPs. Patients of former chief PCPs rated their care experiences significantly better than patients of nonchief PCPs (adjusted difference in composite, 1.6 percentage points; 95% CI, 0.4-2.8; effect size of 0.30 standard deviations (SD) of the physician-level distribution of performance; P = .01), including markedly higher ratings of physician-specific communication and interpersonal skills typically emphasized in chief selection. Differences were large for patients of racial and ethnic minority groups (1.16 SD), dual-eligible patients (0.81 SD), and those with less education (0.44 SD) but did not vary significantly across groups. Differences in spending and utilization were minimal overall.

Conclusions and Relevance

In this study, patients of PCPs who were former chief medical residents reported better care experiences than patients of other PCPs in the same practice, especially for physician-specific items. The study results suggest that the profession possesses information about physician quality, motivating the development and study of strategies for harnessing such information to select and repurpose exemplars for quality improvement.

Association Between Surgical Quality Metric Adherence and Overall Survival Among US Veterans With Early-Stage Non-Small Cell Lung Cancer

Importance

Surgical resection remains the preferred treatment for functionally fit patients diagnosed with early-stage non-small cell lung cancer (NSCLC). Process-based intraoperative quality metrics (QMs) are important for optimizing long-term outcomes following curative-intent resection.

Objective

To develop a practical surgical quality score for patients diagnosed with clinical stage I NSCLC who received definitive surgical treatment.

Design, Setting, and Participants

This retrospective cohort study used a uniquely compiled data set of US veterans diagnosed with clinical stage I NSCLC who received definitive surgical treatment from October 2006 through September 2016. The data were analyzed from April 1 to September 1, 2022. Based on contemporary treatment guidelines, 5 surgical QMs were defined: timely surgery, minimally invasive approach, anatomic resection, adequate lymph node sampling, and negative surgical margin. The study developed a surgical quality score reflecting the association between these QMs and overall survival (OS), which was further validated in a cohort of patients using data from the National Cancer Database (NCDB). The study also examined the association between the surgical quality score and recurrence-free survival (RFS).

Exposures

Surgical treatment of early-stage NSCLC.

Main Outcomes and Measures

Overall survival and RFS.

Results

The study included 9628 veterans who underwent surgical treatment between 2006 and 2016. The cohort consisted of 1446 patients who had a mean (SD) age of 67.6 (7.9) years and included 9278 males (96.4%) and 350 females (3.6%). Among the cohort, 5627 individuals (58.4%) identified as being smokers at the time of surgical treatment. The QMs were met as follows: timely surgery (6633 [68.9%]), minimally invasive approach (3986 [41.4%]), lobectomy (6843 [71.1%]) or segmentectomy (532 [5.5%]), adequate lymph node sampling (3278 [34.0%]), and negative surgical margin (9312 [96.7%]). The median (IQR) follow-up time was 6.2 (2.5-11.4) years. An integer-based score (termed the Veterans Affairs Lung Cancer Operative quality [VALCAN-O] score) from 0 (no QMs met) to 13 (all QMs met) was constructed, with higher scores reflecting progressively better risk-adjusted OS. The median (IQR) OS differed substantially between the score categories (score of 0-5 points, 2.6 [1.0-5.7] years of OS; 6-8 points, 4.3 [1.7-8.6] years; 9-11 points, 6.3 [2.6-11.4] years; and 12-13 points, 7.0 [3.0-12.5] years; P < .001). In addition, risk-adjusted RFS improved in a stepwise manner between the score categories (6-8 vs 0-5 points, multivariable-adjusted hazard ratio [aHR], 0.62; 95% CI, 0.48-0.79; P < .001; 12-13 vs 0-5 points, aHR, 0.39; 95% CI, 0.31-0.49; P < .001). In the validation cohort, which included 107 674 nonveteran patients, the score remained associated with OS.

Conclusions and Relevance

The findings of this study suggest that adherence to intraoperative QMs may be associated with improved OS and RFS. Efforts to improve adherence to surgical QMs may improve patient outcomes following curative-intent resection of early-stage lung cancer.

Society for Maternal-Fetal Medicine Special Statement: Curriculum outline on patient safety and quality for maternal-fetal medicine fellows

To help fellows in maternal-fetal medicine gain a well-rounded education in patient safety and quality, we present a curriculum outline that addresses the requirements of the Accreditation Council for Graduate Medical Education and the American Board of Obstetrics and Gynecology. For each month of fellowship, the outline suggests brief video clips, readings, and activities. Emphasis is placed on helping fellows develop and complete a quality improvement project. If desired, the curriculum can be modified to fit program-specific needs and can be adapted for use with residents in obstetrics and gynecology.

"Learn from each other": A qualitative exploration of collaborative quality improvement

BACKGROUND

Collaborative quality improvement is an established method to conduct quality improvement in surgical care. Despite the success of this method, little is known about the experiences, perceptions, and attitudes of those who participate in collaborative quality improvement. The following study elicited common themes associated with the experiences and perceptions of surgeons participating in collaborative quality improvement.

METHODS

We conducted an interpretive description qualitative study of surgeons participating in the Michigan Surgical Quality Collaborative, which is a statewide collaborative quality improvement consortium in Michigan. Semi-structured interviews were conducted using an interview guide.

RESULTS

A sample of 24 participants completed interviews with a mean (SD) age of 48.7 (11.5) years and 16 (80%) male participants. Two major themes were identified. First, the contextualization of individual performance was seen as key to identifying opportunities for improvement and creating motivation to improve. Contextualization of individual performance relative to peer performance was collaborative rather than punitive. Second, peer learning emerged as the primary way to inform practice change and overcome hesitancy to change. Rather than draw upon external evidence, practice change within the collaborative was informed by the practices of peer institutions. Both themes were strongly exemplified in one of the Michigan Surgical Quality Collaborative's largest initiatives-reducing excessive postoperative opioid prescribing.

CONCLUSION

In this qualitative study of surgeons participating in statewide collaborative quality improvement, contextualization of individual outcomes and peer learning were the most salient themes. Collaborative quality improvement relied upon comparing one's own performance to peer performance, motivating improvement using this comparison, deriving evidence from peers to inform improvement initiatives, and overcoming hesitancy to change by highlighting peer success.