The Wild Wild West of Improving Quality


“Managing quality of care shouldn’t be “one MORE thing” our care teams have to do. With Avhana, I say, there’s “one LESS thing” you have to do.”

- Dr. Shelly Nash, CMIO of AdventHealth’s Physician Enterprise

Amongst the craziness of HIMSS (the country’s largest health technology conference, with over 50,000 attendees), Dr. Shelly Nash and Avhana Health held an intimate breakfast with senior leaders of leading healthcare organizations in the country. It was a riveting conversation about improving quality care in the disparate ambulatory care setting - or what the group deemed the “Wild Wild West of Healthcare Quality”.

Here are three key findings from the conversation:

  1. It is not enough to have a handful of individuals focused on quality and a “quality module” in the EHR. Quality improvement should flow through EHR workflows for all members of the care team.

  2. A top-down or centralized approach hasn’t worked. A local focus works best but is tough to execute and manage. Large organizations with clinicians in a wide array of locations must drive focus on quality initiatives at the local level and support care teams with resources from the national or central office.

  3. The greatest impact on quality results from coordinated initiatives before, during, and after patient encounters. Tools that streamline EHR workflows in support of these initiatives don’t just improve quality, they can reduce a clinical team’s time to manage care quality and understand where they  have opportunity to improve.

At Avhana Health we get a lot of fascinating insight into ongoing healthcare trends that are not well understood. To outsiders, a healthcare team’s focus on providing “quality care” is the most fundamental aspect of the job. However, healthcare teams and organizations who care for large populations know it is a big challenge to make sure that everyone who should get screened for colorectal cancer, breast cancer, or hundreds of other forms of “quality care”, gets them.

Coordinating the highest quality of care, especially in the ambulatory setting, is still very much the Wild Wild West. Avhana’s mission is to support the thousands of frontiersmen and frontierswomen across the country, like Dr. Shelly Nash, to bring order and prosperity to a rapidly evolving healthcare landscape.

Quality should be baked-in throughout clinical workflow

Many breakfast attendees agreed that the ways current technology focuses on quality are ineffective.  Quality improvement should not be a separate module inside of the electronic health record used by a select group of users.

Quality improvement should be baked-in throughout the entire clinical workflow for all members of the care team. Examples include:

  • Before the patient encounter, suggestions to help the care team plan efficiently and fill any outstanding gaps in care.

  • During the encounter, patient-specific advisories and order sets that help providers follow evidence-based protocols and feedback if they stray from best practice.

  • After the encounter, feedback for the care team on how they are doing amongst their peers and feedback for improvement to help understand breakdowns in the workflow.

How quality is measured should also evolve to incentivize the correct changes.  Currently, much of care quality is measured based on process (e.g. did I order a HbA1c screening for my diabetic patients?). In the future, quality will be measured on outcomes (e.g. what percentage of my diabetic patients have HbA1c < 9?).

Keep quality local but support and resource nationally

The most successful quality initiatives result from taking a local approach. However, it is critical that the national organization support local practices. The best indicator for a successful quality initiative is buy-in from a respected and local clinical leader (e.g. Chief Medical Officer) that serves as a conduit for the national or centralized organization. This critical champion emphasizes the goals of the national organization to their local clinical teams and funnels feedback on local challenges experienced by front-line care teams back to the national organization.

In the breakfast attendees’ experience, the organizations who developed local practice performance teams to help implement a quality strategy were most successful. Local organizations can be extremely competitive and competition has been a powerful driver in promoting quality. One health system discussed that not only did the competitions improve engagement, but it also led to open dialogue on specific ways to improve quality. The winning groups get bragging rights, however, the real winners are the patient.

Digital tools enable feedback

The most popular tools used for improving quality are still paper checklists, weekly promotions written on whiteboards, and ad hoc reporting to individuals and managers.  Many companies are developing products to help care teams improve quality with varying degrees of success.

Attendees agreed that coordinating these tools to support quality improvement before, during, and after patient encounters is the best way to implement a technology-enabled process. When done well, health systems are finding that they can actually reduce the time care teams are spending on managing care quality. Additionally, the data generated in a digitally-enabled system provide invaluable feedback that further enables quality improvement.

About Avhana Health

Our mission is to offer impactful, patient-specific support for healthcare teams. At the core of what we do is the Avhana Quality Improvement Software Suite which we embed into leading electronic health records (e.g. Allscripts, athenahealth, Cerner & Epic). Our team is located in Baltimore, Los Angeles, and Boston. Avhana Health was awarded “Best Provider Facing Company” during Health 2.0 in 2018.