Speaker 1: Doug, thank you to the organizers for inviting me to speak. Really thank you. And that was a terrific overview of the Affordable Care Act, really to distill for us what are those core issues. And Kim did mention quality, and quality means a lot of different things to a lot of different people. We'll talk about some quality initiatives as they may be relevant to IBD, and hopefully come away with something practical that we can think about taking back to our practices next week. So what is quality in healthcare? As I mentioned, the definition really can vary. The Institute of Medicine published this definition in 1990, the degree to which health services for individuals and populations increases the likelihood for positive health outcomes and is consistent with current professional knowledge. Now that's a mouthful. I like the way my colleague, Corey Siegel, has phrased it. In other words, quality of care is a mechanism to ensure that the best new research and ideas do not get left behind in journals, but get applied equally, and I emphasize equally, to all patients. And the CCFA takes this mission seriously. They actually have a quality of care mission, which is to improve the quality of care delivered to patients with IBD. And through that, created a series of steps under the leadership of David Rubin almost 10 years ago to define the standards of care for IBD, to develop an implementation program, to measure and deliver the care, to continuously evaluate and refine the process, and ultimately to demonstrate impact and improvement of patient outcomes. And I'll walk you through some of the progress that has been made to date. Taking a page from the book written by Brent James, really one of the fathers, the gurus, of the quality improvement movement, he's the CEO of Intermountain Health, where their paradigm really is quality improvement of their entire health system. Where are the opportunities today that tell us that we need to improve the quality of our care? Number one, there's significant variation in practice, and this is true all over medicine. This is certainly true in inflammatory bowel disease, and I'll show you just one example of that. Number two, inappropriate care, where risk exceeds the benefit. And I would argue that this, as well, is true oftentimes in the management of patients with inflammatory bowel disease. Number three, there are preventable complications, certainly an area where we have an opportunity to close the gap. And finally, as we've just heard, waste and high costs and efforts that are being done on a national level, but also that should be done on local and regional and practice levels to reduce that waste and high cost, which certainly exist as well for inflammatory bowel disease. So here's that example of variation in care in the United States. This is a map that basically lists for us and shows for us with a heat map of the use of biologics, really anti-TNF therapy, by zip code in the United States, presented last year at DDW. And what you can see is that it's all over the place. There is no consistency in care, and I can't imagine that this variation in the distribution of how biologics are used actually truly represents the severity of the patients. And finally, there's variation in practice, which is what this is intended to highlight. And in the world of quality improvement, variation usually means poor quality care. It means that somebody's overdoing it, underdoing it, or just doing it wrong. So what quality improvement initiatives are there that are available to help me or help us or help you in our care for patients on a day-to-day level? And I've listed them out for you. There are some formal quality improvement initiatives that's listed sort of at the top, these quality measures that have been – there are actually two sets of quality measures that are now available for inflammatory bowel disease. One by the AGA. And the AGA is supporting the Digestive Health Registry Program, where practices can enlist in the program. It's a registry to which they report actual patient data, and then that registry then reports these quality measures to CMS, to PQRS, can be used for maintenance of certification as well, and basically a way to enter patient data for the AGA quality measures and get some kind of incentive credit for participating in that. And actually in 2015, and I believe 2014 as well, there will be a penalty for those who don't report on PQRS measures, and this is one way to be able to get that credit. The CCFA, in parallel to the AGA, developed a set of quality measures, and I'll talk to you a little bit more about the work that we've done at the CCFA. Improved Care Now is a national, and actually extended now international, program where sites who care for pediatric patients with inflammatory bowel disease are networked together in a quality improvement collaborative, and they've done some incredible work over the last seven or eight years in order to raise the bar and improve care overall for children with IBD. There are maintenance of certification that touch upon IBD through the ABIM. And finally, I threw up here Care Pathways and Algorithms, which I think I'll show you an example of a recent algorithm that was published showing us that by standardizing our care, and we're actually now seeing some evidence showing that standardized care in inflammatory bowel disease actually improves outcomes. Another initiative for quality improvement that can be readily applied in practice is a checklist, and we'll talk a little bit about checklists. And then finally, I want to put down here that even though the title is What Quality Improvement Initiatives Are Out There for My Practice, we don't need a quality improvement initiative to actually start improving quality in our own individual practice. You don't need a program, you just need to start improving, and we'll talk about one way that we can perhaps start doing that next week. So with respect to the work that we've done at the CCFA, just to talk a little bit about quality indicators, these are quality measures. You can't improve something unless you're measuring it, so what are we actually going to be measuring? This is what the work that the CCFA set out to identify the specific measurable elements of care for which there might be some evidence that shows that this is a good thing for delivery of care for patients, and that offers a uniform, minimally acceptable level of care. And with quality improvement, we're really trying to raise the floor, we're not trying to set the ceiling. We really want to try to improve the floor and raise the basic level of care for all patients. And this was a rigorous process that basically went through all potential 500-plus potential candidates of quality measures and ended up with a final set of top process measures and outcome measures. These are the process measures, things that are done on an individual practitioner-provider practice level for inflammatory bowel disease that are published out there for the CCFA. And the picture in the corner is basically picking the low-hanging fruit, and this was part of the initial first step of creating quality measures. Where are the low-hanging fruit? What are the easier things to measure? It's not so easy to measure and report upon the right time to start an anti-TNF therapy, for example, although arguably that may have a much greater impact on actual patient outcomes and overall care for IBD than some of the measures that were listed in these top 10. So therefore, the process was extended from not just process measures but also outcome measures, and listed here are 10 outcome measures through this process that were identified that are important to tell us that we are improving the quality of care of our patients. So now that we've got a set of some defined measures, and again, these are iterative and change progressively and should be updated over time, but for what we have, what do we do with them? Well, we can do nothing with them. We can just simply measure, and that's what, in the United Kingdom, they underwent a series of audits in 2006, 2008, 2010, and what they found was without instituting any actual new improvement changes, they simply, the act of measuring demonstrated improvements in several of their measures over the years. And so even though we create measures because we want to try to do something to change them, simply having them and measuring may actually produce what we call the Hawthorne effect or actually show some kind of improvement, and that's what this data is intended to show. But what we've done through the CCFA's efforts is really try to take it a step further, not just have measures for purpose of measures but actually use the measures to help us understand where the issues are that need improvement. And so we undertook a 12-month pilot program where we involved six sites around the country where we did collect information about some of these measures with monthly reports, and I'll show you an example of a report card that we received with coached webinars where we actually went through our reports with a quality improvement coach and learned and thought about how we might improve them. This is just a snapshot of some data over time. We were able to recruit about 1,000 patients in a six-month period, and each site would get on a monthly report, each provider really could get a report card of how he or she were doing. So, for example, shown here is my report card, and on the top line are the percent of my patients that were in remission. And you can see my report card shows I got a 23 percent, whereas the rest of the group scored higher than that. And that basically told me something about my patients and doesn't tell us what the issues are but forced me to actually look a little bit deeper and understand where some of the issues were that could be improved upon. But the first step really for me in participating in this kind of program was to understand what my denominator is. How can you know 23 percent of what really is the question? And that I would challenge everyone in the audience who cares for patients with inflammatory bowel disease to think about what your denominator actually is. Well, how many patients do you care for with inflammatory bowel disease as a first step in beginning to think about improvement? So we have checklists, templates, and tools. On the left is a book by Atul Gawande, which is a quick read thinking about how checklists have in some ways been demonstrated to actually improve outcomes in medicine. This is a study that he was involved with, published in the New England Journal of Medicine. Basically showing that a surgical checklist, without going through all the details, actually significantly improved surgical mortality. And so simply going through a 19-point checklist at the time of every operation was able to significantly impact patient outcomes. And IBD checklists are available. This is an example of a snapshot of the cornerstones checklist for IBD patients. It's a one-page, easily downloadable PDF that anyone can go onto online. It's free and download and print out, which is a simple checklist for assessment of patients' health maintenance issues, vaccinations, bone health, and cancer screenings. This is an example of a care pathway. This was published in Gastroenterology just last month with a very nice editorial written by Bill Sanborn talking about how we can think about using care pathways and algorithms. This is one for Crohn's disease, one for ulcerative colitis is forthcoming, and really taking it to the next step of really helping us standardize how we think about the decision making of when is the appropriate time to start a therapy, when is the appropriate time to monitor, when is the appropriate time to do a diagnostic test. And through the use of these care pathways or clinical decision support tools, we can somehow implement that as well as part of quality, overall quality improvement initiatives. And that editorial really talks about the merging of care pathways, standardized algorithms, and quality measures. So when it comes to quality improvement, there are some tenets, some basic principles in the QI world. Every system is perfectly designed to get the results that it gets. So therefore, if you want to get different results, you actually have to redesign the system. You have to change something. You can't just try harder doing what you normally do. You've got to do something differently about what you normally do in order to achieve better results. And there's another one which you could think about and argue with me, but it's better to do the same, it's better to do it the same than to do it right. And I would just illustrate that with this picture here. Which one of these would you prefer to have as your archery score? And which one could more readily be adapted with change in order to achieve better results? So where are we going in our CCFA program? Well, we've learned a lot from our pilot program with the help of the Improved Care Now folks who helped us design that pilot study. And now we're thinking about widespread implementation to help us think about ways that we can spread the network, a quality improvement network throughout the country. And we're doing this in partnership with the Dartmouth Institute to develop a program where we as clinicians will be involved in entering our own patient data on a limited set of quality measures that relate specifically to patient outcomes on the right there, but putting that together on the left with patients and involving patients in co-production of care, involving patients really at the center because they're at the center of their own disease in a partnership for co-production of care and utilizing patient reported outcomes together with information that we can put in in a shared registry that we have access to, that patients have access to in order to demonstrate improvement in outcomes. So what can we start doing in our own practices next week? So again, I challenge you, do you know your denominator? How many patients were at the end of 2014? How many patients did you take care of or were you involved in the management of with inflammatory bowel disease in 2014? And only if you know that number can you then know what proportion of them are in remission, what proportion of them are on steroids or narcotics or have anemia or went to the emergency room in the past year. You really need to know that denominator. How many patients do you take care of who have inflammatory bowel disease? And it's not that hard to figure out what your denominator is. You can go through billing records, you can look at an EMR with ICD-9 codes and run a quick query to understand who are those patients that I am responsible for. And then to start with one area for improvement. Improvement is really a slow process that's step by step, iterative over time. And there's any number of areas that one can think about improving. Patient outcomes. We have a nice list of patient outcomes that we can pick from. Pick any one of them. Steroid free remission, anemia, visits to the emergency department. What one thing can we think about just measuring and once we start measuring we can start to improve. Patient management. There's any number of things that we can think about in our own individual practices and I'm sure many of us engage in quality improvement initiatives without really thinking that they're quality improvement initiatives. Phone calls. Making sure that they're all done by the end of the day. Timeliness of appointments. Doing what we can to shorten the time a patient needs to get a visit. Thinking about multidisciplinary programs. Psychosocial interventions. Psychosocial measurement in the practice. Multidisciplinary programs. Involvement of surgery. Other ways that we can think about somehow improving the management experience of patients. And then we have the process measures and I've left these for last because as we think about what the actual federal initiatives are for quality improvement, how many of them actually really, these process measures actually really cause us to think about changing and improving the care of inflammatory bowel disease. We do them. We fill them out. They do provide incentives but I think that increasingly on a federal level there's also recognition that the existing programs really need to be updated in order to demonstrate true and real improvement on patients. And finally, to think about the future. To start small in your own practice, your own patients, and think big, linking together with others, ideally with measures that we can all relate to, that we can all measure together because they're relevant to everyone. To minimize that variation in care. To think about the future where we can link registries with patient metrics and outcomes as part of regional and global learning health systems to improve quality metrics for patient care. And I just want to finish with this picture. I had the opportunity to attend a course at the Institute for Healthcare Improvement together with Corey Siegel and our QI teams representing the CCFA and they've got quotes all over the building. And this is one quote which actually I took for two reasons. One is the quote itself by Anne Frank, how wonderful it is that nobody need wait a single moment before starting to improve the world. But the other is the funny angle of the picture is intended to capture what's written on the side there. I don't know if you can read it from the back, but on every doorway it says over there, patient centered. Just as a reminder that whatever we do for quality improvement in healthcare has the patient at the center and that's something that really should be at the forefront of any initiative that we undertake, whether it's checklists, whether it's pathways, whether it's checking off federal incentive bonus claims, it's really to keep the patient at the forefront and in the center. Thank you very much. Thank you.