Improving Clinical Quality Measures in the Osteopathic Family Practice: A Practical Approach

In today’s reimbursement environment, it is more important than ever to be proactive and continuously work on quality improvement plans to be a competitive osteopathic healthcare provider and to provide the best possible care for our patients. It is also important that everyone has an understanding of the importance of value-based care and how it affects our patients' health and our practice viability.

Individuals should focus on quality measures that they personally feel represents and demonstrates quality performance that will truly enhance a patient's health. Other factors to consider may include practice payor mix, potential bonus payments and utilization of reports from payers on current quality measures. (You may need to request these, but they will be available for review.) I suggest contacting your largest insurers for a list of the quality measures they are utilizing and picking easier measures initially.

Step 1: Start small.

When implementing a quality improvement plan, it is best to start out with something easy to track so you can build confidence and enhance the positive reinforcement that comes with success. Once you have chosen a quality measure, a baseline report should be created, and a staff member should be assigned to take the lead and provide continued updated reports at set intervals, usually quarterly or semi-annually, so progress can be demonstrated. It is suggested if staffing permits to utilize a team to work on the given measures. The progress—whether good or bad—should be shared with all affected staff to determine if further improvement is needed or to commend a job well done. This is also a good time to request feedback from all staff and suggestions for further improvement but especially share the impact of the successes, such as early detection of breast or colon cancer. It is important to remember that improvement may be slow during the initial implementation process, but can be life-saving and rewarding.

Some easy-to-implement tools we use to improve our quality measures include:

1. Creating chart and practice alerts or tickle files if you are on paper charts
2. Using a clinical decision support system
3. Pre-visit planning
4. Implementing in-house, rapid, prior-authorization procedures
5. Determining and implementing protocols for testing and vaccine administration
6. Setting up templates and macros in the electronic health record (EHR) to capture data and generate orders quickly. Paper charters will need to develop mechanisms to track, order and report that will fit their particular workflow.
7. Following up on progress at fixed intervals
8. Scheduling in advance or creating actions for future needed measures

Step 2: Identify barriers.

The next step is to determine barriers to obtaining the desired measurement goals. For example, while implementing various quality improvements, our practice found that the number one barrier—for many of our measures—was out-of-pocket expenses for patients. To combat this, we have implemented the following solutions:

• Utilizing TransactRx and Availity to know the actual out-of-pocket patient cost in advance of providing the recommended services, and providing the information to the patient prior to their appointment.
• Providing community resources for free or reduced cost services when possible;
• Incorporating credit services for patients to obtain credit for more costly services; and
• Offering payment plans.

Our second largest barrier was getting clinicians to take the necessary time to identify and recommend the quality measure needed and to educate patients on the importance of the given measure. Recommendations should be made from multiple ancillary staff (utilizing set protocols) and then the clinician for more resistant patients. When a clinician strongly recommends a vaccine, a cancer screening test or other important test or lifestyle modification, it is more likely to be successful.¹

Another barrier was obtaining records. We utilize Florida Shots, which is helpful for vaccine information, and our EHR system can also obtain prescription history from pharmacy databases. Our office does referral tracking, but it is still a constant effort to obtain reports from specialists. We ask for record releases when patients are in the office and educate them to ask for their records to be sent to our office at every visit with another healthcare provider so we can be their medical home and keeper of all their important data. Our office also uses a statewide health information system, registries, insurance company portals and some local hospital systems to obtain information.

Probably the most difficult barrier to overcome is supply—including vaccines, specialists, testing/treatment facility access and in-network facilities and providers. We keep lists of in-network providers for various insurance companies to help with referrals. A referral to an out-of-network provider may be cost-prohibitive and should be avoided.

Step 3: Monitor success.

Watching the improvement over time using quality reports at preset intervals is not only extremely rewarding, but also allows you to compare your outcomes with the national standards, so you can see where you stand against yourself and others. If you are below national standards, you have some real work to do. If you are significantly above the national standards, it may be time to pick a different quality measure.

Review the reports and discuss strategies to improve—which implementation processes were most successful? Which ones were not?

People enjoy a little competition, especially when it is for something positive like healthcare outcomes, so set up team competitions and incentives for those with the best results. A lagging team will become very motivated if their outcomes are inferior to others’. For example, the provider or team with the highest percentage of patients up-to-date on colon cancer screenings or mammograms gets a gift card, or if the office improves the percentage of eligible patients receiving a particular vaccine by X% by the end of the year, everyone gets a gift card or pizza party.

I encourage family medicine practices to start small, set realistic goals and monitor their success before implementing too many things simultaneously. Choose an enthusiastic team leader and incorporate the entire team in strategies for efficiency and improvement. Implementing these tactics benefits patients’ health, staff satisfaction and your practice’s finances.

1. Hausman A. Modeling the patient-physician service encounter: Improving patient outcomes. JAMS. 2004;32:403. doi:10.1177/0092070304265627