By Gregory Liptak, President, Intelligent Medical Decisions
A key factor in closing the quality gap between best practice and common practice is the ability of healthcare providers and their organizations to rapidly and constantly identify, test and adopt changes that work for their systems. The American Diabetes Association (ADA) and Intelligent Medical Decisions, Inc. (iMD) have designed a 24-month Quality Improvement (QI) initiative called Diabetes INSIDE that, since 2012, has improved diabetes care processes and patient outcomes at four large, diverse health systems across America. Diabetes INSIDE combines QI science, tools and techniques with data-driven education in a 24-month curriculum that gives healthcare providers the necessary resources to design, implement and measure sustainable change within their clinical systems.
The overall goal of Diabetes INSIDE is to improve glycemic control in populations of patients with Type 2 diabetes through a series of structured interventions targeting the entire health system. We engage providers, staff and patients at each enrolled health system through QI training, coaching and facilitation, data analysis, data-driven professional education, guideline support, and ADA’s Living with Type 2 Diabetes patient education campaign.
The Knowing-Doing Gap
In recent years, the CE industry has greatly enhanced its ability to improve—and measure—the knowledge and competence of healthcare providers. However, there exists a persistent “knowing-doing” gap in the application of this knowledge to clinical practice. Despite continuous advances in therapeutic options, increased application of technology (e.g., electronic health record, decision support), improved educational design and better scientific evidence for care standards, poor clinical outcomes too often remain the status quo. These tools — though useful — are not “magic bullets” toward improvement.
Education often targets individual providers, yet we consistently see that performance measured across groups of providers at their respective health systems shows no statistically significant difference in patient outcomes from one provider to another. The largest quality differences are revealed only when comparing one system to another. Blanketing the U.S. healthcare system with this type of traditional education — focused on individuals and knowledge acquisition — is not an effective or efficient strategy to improve population health.
The central tenet of improvement science is that processes, not people, are the primary determinant of outcomes. To improve patient outcomes, systems must make changes to their clinical processes. Diabetes INSIDE bridges the knowing-doing gap by shifting the focus of intervention from individuals to systems and from knowledge acquisition to process change. Diabetes INSIDE trains entire healthcare systems on how to implement and measure changes using proven improvement science methods. These methods — well established and practiced in manufacturing and service industries — are new to most healthcare providers. Diabetes INSIDE disrupts the status quo by providing ongoing QI facilitation to health systems and guiding them in the application of these QI principles over time to achieve local quality objectives.
The Intelligent Use of Data
True quality improvement efforts are predicated on the collection and analysis of diverse types of data and using these data to inform change. A critical question all QI practitioners ask themselves is: “How will we know if a change is an improvement?” The first step to answer this question is to establish a rigorous local baseline; this both identifies actionable areas for improvement and provides the necessary data from which to quantify the impact of clinical process changes. The Diabetes INSIDE model then uses this local baseline to determine appropriate content and interventions for each enrolled health system. This local approach is much more effective than tailoring interventions based on broad literature reviews, thought leader interviews and big data aggregators, as clinical sites vary vastly in their resources, staffing, record keeping and patient demographics. Published research is often not reflective of real-world practice due to stringent selection criteria and controls, and big data can lack granularity and applicability to local care processes.
Quality measures (also known as accountability metrics) are evolving standards that aim to report and rank the quality of care provided to patients and even determine reimbursement for health services based on these rankings. While these may serve as a good starting point for setting QI objectives, educators and clinicians alike often confuse quality reporting with quality improvement. Knowing the proportion of patients with a hemoglobin A1c >9 percent, for example, provides little insight into why this quality gap exists and how to improve it. Educational programs that purport large shifts in quality by simply imparting new knowledge on healthcare providers and measuring change in accountability metrics are destined to underwhelm. Successful QI programs must strive to understand the processes, root causes and systemic issues that lead to quality gaps and then iteratively design and implement specific changes to overcome them. The many tools of improvement science are well suited to this task, and Diabetes INSIDE provides a comprehensive suite of QI tools and techniques and guided facilitation in their application.
Education is foundational in reinforcing the evidence base and creating awareness around new research, technology and therapies, but to bridge the knowing-doing gap and improve quality, we must do a better job implementing what is already known, rather than solely relying on new or previously untested ways of doing things. Organizational change is difficult and challenges many psychosocial norms such as institutional precedent, risk aversion and fear of making changes due to potential failure or adverse consequences. By embracing improvement science methods, Diabetes INSIDE creates a culture of change and provides a safe and measured environment for healthcare systems to overcome these barriers to improve the health of their patients.
We’d like to thank Eli Lilly, Novo Nordisk and Sanofi Aventis for their continued support of the Diabetes INSIDE initiative.