The Challenge of Quality

The effort by the National Quality Forum to develop standardized quality measures for hospital care (see story on p. 1) is something I support 100%. Standardization around the NQF's recommendations—to be implemented by both Medicare and the Joint Commission—is useful because it drives better care, greater safety, and better quality. But implementing the recommendations can be quite a challenge.

One issue the forum assessed was prevention and treatment of deep vein thrombosis and pulmonary embolism (DVT/PE). Every year, 1 million patients develop one of these conditions, and 300,000 die from PE, so the NQF considered this an important issue to address.

To address DVT/PE, the National Patient Safety Goals standardize how blood thinners are used, requiring several steps:

▸ All patients may receive either regular unfractionated heparin or low-molecular-weight heparin via a defined dosing schedule.

▸ When using these agents, we need to measure the platelet count to make sure patients aren't developing an allergy, which happens in a small proportion.

▸ When using unfractionated heparin, we need to make sure that patients are anticoagulated within the first 24 hours of hospitalization, and then keep checking to ensure they stay anticoagulated.

▸ Warfarin is started in the first 24 hours concomitant with heparin. The two-drug regimen is maintained until the full effect of the warfarin is achieved.

If we do all of this in a standardized way, we reduce the risk of bleeding as well as the risk of thrombosis due to inadequate anticoagulation. In my role as a member of the board of trustees' quality committee at two hospitals, my job is to implement the procedure so it can be done automatically, and then to ensure that the results are measured. This allows me to report that, for instance, of 365 patients with blood clots, all got their medications in a timely manner, all were within the therapeutic range, all received warfarin and stayed on target until they achieved the appropriate INR, and all were discharged with instructions for administering warfarin at home.

One way to make this procedure easy for physicians to follow is to not have the physicians do it all themselves, but instead have most of this work done by the pharmacists. That is in fact what we're incrementally implementing—using a pharmacy-directed anticoagulation team.

It reminds me of when I was a house officer and we used gentamicin to treat certain infections; if too much was given, the patient had an increased risk of renal or ototoxicity, so you had to be very careful to measure the peaks and troughs of the drug to adjust the dose. As you might expect, the physicians were terrible at doing that. So we gave it to the pharmacists, and they did a phenomenal job. They are very good at working with this type of standardized process.

In addition to the NQF's standardization work, the Surgical Care Improvement Project—a group of organizations whose goal is to reduce the incidence of surgical complications nationally by 25% by the year 2010—has begun focusing on decreasing the incidence of postsurgical DVT/PE through the use of prophylactic anticoagulants in the perioperative period. That effort has resulted in more patients receiving this type of prophylaxis and a reduction in the number of DVT/PE cases.

Also, last September, acting Surgeon General Stephen Galson announced a national call to action to develop a team approach for preventing DVT/PE in hospitalized patients (HOSPITALIST NEWS, Oct. 1, 2008, p. 1). Coming from the Surgeon General, this is a major national endeavor.

But no matter how much official endorsement is behind programs like this, you still have to get physician buy-in to ensure success. Things are much different today than they were 10-15 years ago. Back then, doctors felt like they were the captains of their own ship. But physicians coming out of training today feel much more like part of a team.

An older physician may say, “I don't want a pharmacist managing the patient's coagulation. I'll go look at it myself.” What helps me change this attitude is my ability to show that I'm measuring results and giving feedback on performance. That helps me convince them that there are better ways to do this.

Handling variation is always an issue when you're trying to standardize a process, so your system must be set up to deal with outliers. But overall, standardization does result in better care.