The evolution of quality improvement in health care

How Alberta’s physicians are enhancing peer-to-peer review

The concept of quality improvement is nothing new. Think about when your cell phone was the size of a brick, or the time you backed into a pole because a back-up camera was still an idea not yet on paper. In health care, quality improvement has always been part of the expectation that physicians are sustaining and enhancing their competence throughout their careers. This could be large-scale improvements that are implemented system-wide or something as simple as enhancing your prescription writing so a pharmacist can properly identify the correct medication and dosage recommendations.

The latter was the outcome for one Edmonton Zone emergency physician who participated in the Periodic Review and Feedback Process-an initiative started in 2015 by Dr. Kirstie McLelland, Associate Zone Medical Director – Emergency & Suburban Hospitals, and Dr. Warren Ma, Emergency Zone Clinical Department Head, to enhance the Alberta Health Services peer-review requirement.

Personalizing the process

“When we started getting involved in the zone emergency medicine program and looking at the peer-review process, we recognized there was a gap in the information being provided to the physician leaders, along with the physicians themselves,” said Dr. Ma.

After consulting with physician leaders to get a better understanding of the data they felt would be useful, Dr. Ma and Dr. McLelland began developing packages to provide physicians with a more robust and personalized peer-review process.

“We included operational metrics in terms of how many patients they see per hour, their time to disposition, utilization metrics such as how many ultrasound scans they order, and then we actually incorporated a 360 feedback tool that is randomized and anonymized as part of each physicians’ review package,” said Dr. Ma.

In addition, the packages include self-audits that physicians are required to complete when a patient is re-admitted to any Edmonton Zone emergency department within 72 hours of their initial visit.

“We were looking for data that would be meaningful to this group of physicians and for tools that would help physician leads have really good development conversations with physicians, so each of them has the opportunity to get the most out of their careers,” added Dr. McLelland.

Opening the feedback loop

While the metrics provide a good baseline for self-reflection and education, Dr. McLelland noted that a highlight of the program has been the opportunity for physicians to receive anonymized feedback from 10 of their physician and nursing colleagues.

“In general, I don’t think we’re always very good at giving positive feedback, but this has given us a good way to tell each other that we’re doing a good job. It’s nice to know, from your nursing colleagues specifically, that they find you approachable and they’re comfortable coming to you with any concerns. It’s also nice to know that your colleagues think you do a really compassionate job when handling difficult patients.

“We hadn’t had a great way of capturing those comments before, and now our physicians are able to see that feedback in writing and I think that has helped engage them in the process.”

The Edmonton Zone Periodic Review and Feedback initiative is just one of many positive examples that showcase the shift that’s happening across health care in Canada from Physician Revalidation (FMRAC) to Physician Practice Improvement (FMRAC – PPI).

“The evolution of our profession is such that, at one point, we were practising medicine based on clinical experience and what the experience provider has seen,” said Dr. Ma. “At some point we decided we should have a more broad incorporation of evidence-based medicine. Quality improvement is just the next iteration of how do you apply that evidence-based medicine going forward; it’s the act of actually continuing to learn and get better, which is our professional obligation.”

So where does one start?

For those looking to implement system-wide quality improvement initiatives, Dr. McLelland draws from her personal experience with the Edmonton Zone Periodic Review and Feedback Process.

“It’s really important for the front-line physicians to be involved in how the metrics are chosen and deciding on what things are important to them. Nobody can understand the clinical context for the physicians the way front-line physicians do.

“If you’re going to decide on measurements, and somebody’s going to decide where you fit in comparison to your peers, those things should be developed by the people who have intimate knowledge of the context in which you work. Then using those metrics for education and self-reflection is the most important of the objectives.”

In the coming months, CPSA will share more about quality improvement initiatives across Alberta as we prepare for the roll out of the Quality Improvement Mandate over the next several years.