Continuous Quality Improvement: The 'Unintended' Consequence of EHR Implementation

By Edgar D. Staren, MD
09:48 AM
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In a previous article ("Keys to EHR Team Success," Healthcare IT News; January 12, 2009) we detailed a number of governance structural components which are key to successful electronic health record (EHR) implementation.

In that article we emphasized that active involvement by both senior healthcare administrators and clinicians is essential to the successful planning, selection, and implementation of an EHR. We noted that it becomes rather tempting for both administrative and clinical leadership to view conversion from paper to electronic records as an information technology project. Conversely, we concluded that the ideal approach recognizes the essential role played by IT but acknowledges such activity is in fact best viewed as an operations effort supported by IT.

It is worth noting that the EHR implementation governance structure must be well delineated at the outset; however, at some point near the “go-live,” the organization must begin the process of conversion to an EHR management and maintenance structure. The entity that performs this role will go by varieties of names but often results from a morphing of the EHR Steering Committee. The timeline when this transition occurs is somewhat blurred and will be related to multiple factors including the autonomy and effectiveness of the project leadership; but for optimal functioning of the EHR, it must occur. Ideally, this entity will be quite active with adequate time prior to “go-live” to address issues such as risk identification and management with some level of facility.

When considering the precise role of this management/maintenance structure it is worth reviewing the rationale for implementing the EHR in the first place. With rare exception, this rationale will have at its core, the goal of optimizing the quality of care delivered by the healthcare organization. It is well recognized that increasingly clinicians and providers are challenged to monitor, and thereby manage, an apparently limitless array of measures while at the same time being expected by patients, payers, and regulatory bodies to spend more time documenting the care they deliver.

In an attempt to address these often conflicting expectations, substantial effort has supported health care organizations implementing an EHR. Moreover, in addition to the considerable governmental, payer, and regulatory pressure on EHR utilization, quality studies are beginning to demonstrate considerable justification for such support. A recent multi-hospital Texas study identified a 15 percent drop in mortality among hospitals going from paper-based to electronic health records (Amarasingham R et al, Arch Int Med, 2009). In addition, in this study, those hospitals with increased computer provider order entry (CPOE) adoption documented decreased overall complications.

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With this in mind our organizations EHR Steering Committee purposely morphed into an entity referred to as the Clinical Leadership and Improvement Council (CLIC); this evolution clearly came about as an opportunity from and in response to the EHR. Consistent with the goal of optimizing the use of EHR but particularly as a result of the group’s concerted effort to view the EHR as a tool to address the issues related to optimizing patient care, the CLIC Charter stated its purpose as:

  1. Develop and evaluate annual goals and objectives for the clinical, educational and other programs related to (cancer) care.
  2. Promote a coordinated multidisciplinary approach to patient management.
  3. Ensure quality management and improvement through completion of patient care evaluation that focuses on quality, access to care and outcomes and promotes clinical research.

Its responsibilities include:

  • EHR clinical design and adoption
  • Configuration development
  • Review and approval of changes in orders content
  • Practice guidelines/process and clinical protocol creation and/or adoption
  • Monitoring of safety/quality and outcome measures
  • Coordinate system wide quality improvement efforts
  • Identification/review of system technology needs
  • Identification/review of clinical staff education needs

Now 18 months since EHR “go-live”, this Council has been identified by senior leadership as an increasingly effective, high performance team. The components of such a team are well described by JR Katzenbach and DK Smith in The Wisdom of Teams and include a number of factors that have been critical to its success. A principle factor included ensuring that the Council was committed to its purpose. As with so many projects this necessitates careful consideration and selection of membership. We would also add that this purpose and the Council’s responsibilities were absolutely consistent with the organization’s vision, mission, and values. Consistent with The Wisdom of Teams, at its outset the Council established agreed upon goals and measurable objectives as well.

Such goals and objectives are likely to be quite dynamic; it is therefore important to regularly review and amend them as necessary. The success of the CLIC is also due to the truly diverse, multidisciplinary, and vested nature of its membership. The CLIC includes the organizational COO, CMO, CIO, hospital CEO’s, various hospital Senior Clinical Leadership, Sr. VP’s and VP’s, National Directors of Pharmacy, IT Applications, Clinical Informatics, Health Information Management, Compliance, Quality/Safety, Research, Finance, Patient Accounts, and Education, all with the shared purpose of evaluating and facilitating service enhancements, clinical processes, quality and safety initiatives, guidelines/protocols, clinical trials and other research activities.

Administration of such a large group requires absolute attention to active participation of membership, well planned agendas, prompt distribution of thorough minutes, and monitoring/timely completion of action items. In fact, the success of this entity has led to the establishment of local hospital CLIC’s which have either merged with or replaced the standard Medical Executive Committees.

Dr. Edward Deming is considered by most to be the Father of Quality. In “Out of the Crisis”, 1986, he suggests that optimizing the odds of successful quality implementation requires a “committed leader”. He further defines commitment to mean that the leader is involved, supportive (in words, actions, and resources), active, and participatory (in quality care). We believe that this same “leader” can be a group of individuals leading together; such is the case with the CLIC. Deming described the Plan-Do-Study-Act (PDSA) cycle and stressed the importance of “continuous” improvement. This background on Deming is presented to note how an optimal EHR implementation and governance can, and we believe should, form the structural background for a comprehensive, continuous clinical quality improvement program. This occurs as a result of the enhanced communication, camaraderie, process improvement, and support associated with the EHR selection, design/build, testing, training, “go-live”, stabilization, optimization, and ongoing governance.

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To provide optimal point-of-care process modeling, measure and monitoring, assessment and evaluation, education and communication, the CLIC established and administers seven system-wide User (working) Groups. These groups are the hands-on functional entities for CLIC and include diverse representation of individuals from across the organization with interest and expertise in the relevant areas;

  • Computerized Provider Order Entry
  • Clinical Documentation (Clin Doc)
  • Peri-operative/Lab/Radiology
  • Patient Accounts and Record Management (PARM)
  • Quality/Safety
  • Education/Communication
  • (Research - development)

These groups are the “action” components of a well considered PDSA cycle. Each of these groups has well-defined Charters with purpose, responsibilities, membership, etc. Working together the CLIC and its User Groups provide a highly organized effort to evaluate/develop clinical processes, study (measure)/analyze that delivery of care, communicate/educate that level of care or needed “new” care process, and so on. Continuous quality improvement is grounded in all aspects of the organizational CLIC, the hospital CLIC’s, and the User Groups. For example, the purpose of the Quality/Safety User Group is to provide operational interface services that facilitate and drive the quality cycles of the organization.  These quality cycles are reflected by and expressed in prioritized organization-wide dashboard initiatives. The responsibilities of the Quality/Safety User Group are:

1. CLIC dashboard maintenance for established initiatives...
2. CLIC dashboard item development for new/proposed initiatives, including new core measures...
3. Facilitate the flow and coordination of initiatives from CLIC to individual hospital CLICs by...
4. Provide a triage mechanism and/or facilitate the flow of proposed initiatives from hospital-CLICs to CLIC utilizing prioritization tools...
5. Monitor compliance and investigate variance concerning dashboard initiative objectives.

Evidently this entire process of continuous improvement is an example of continuous (positive) change. In The Heart of Change, Dan S. Cohen, suggests that leaders must make change “the way we do our business”. In that regard, Harvard business school professor, Rosabeth Mosa Kantor, 1999, proposes that “successful companies develop a culture that just keeps moving all the time...”

Consistent with these principles, essential aspects which ensure continued success of the CLIC include its attending to its purpose statement. This includes annual review and modification of its goals and objectives. Also key is regular assessment of its effectiveness through analysis of measurable objectives and appropriate adjustment when/if required. This assessment can be performed by varieties of methods including further drilldown via performance of affinity diagrams and summits with associated brainstorming or related sessions to address deficits.

In this manner over its course, the CLIC identified the need for additional User Groups. In our single specialty organization, certain User Groups were identified at the outset to be integral to the process and shortly thereafter changed based upon the organizational priorities. In most cases however, it is likely that multispecialty hospitals and organizations will have an increased number of additional User Groups in order to address the various clinical interests and needs. Some of this will become self evident through a process of natural evolution of demonstrated need and availability of interested individuals with appropriate expertise.

Another recommendation from this regular review was ensuring that the User Groups and its members were optimally enabled and held accountable to deliverables with specific timelines. Such a recommendation demonstrates the essential need for CLIC representation by the same diverse, administrative, clinical, and IT senior leadership described at the outset of this article and which are necessary to empower this important governance structure. Continuous quality improvement is exactly as the name implies, continuous. It is in that vein that the EHR becomes the tool of “unintended” consequences. Specifically, the CLIC, User Groups, hospital CLICs, and all such efforts are consistent with the principal of utilization of the EHR implementation and function as a tool for both global and specific continuous clinical quality improvement.