540512
research-article2014
AJMXXX10.1177/1062860614540512American Journal of Medical QualityMarshall et al
Article
Continuous Quality Improvement Program for Hip and Knee Replacement
American Journal of Medical Quality 1–7 © 2014 by the American College of Medical Quality Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614540512 ajmq.sagepub.com
Deborah A. Marshall, PhD1,2, Tanya Christiansen2, Christopher Smith, BCom, MBA2, Jane Squire Howden, RN, BScN3, Jason Werle, MD, FRCSC1,3, Peter Faris, PhD2, and Cy Frank, MD, FRCSC1
Abstract Improving quality of care and maximizing efficiency are priorities in hip and knee replacement, where surgical demand and costs increase as the population ages. The authors describe the integrated structure and processes from the Continuous Quality Improvement (CQI) Program for Hip and Knee Replacement Surgical Care and summarize lessons learned from implementation. The Triple Aim framework and 6 dimensions of quality care are overarching constructs of the CQI program. A validated, evidence-based clinical pathway that measures quality across the continuum of care was adopted. Working collaboratively, multidisciplinary experts embedded the CQI program into everyday practices in clinics across Alberta. Currently, 83% of surgeons participate in the CQI program, representing 95% of the total volume of hip and knee surgeries. Biannual reports provide feedback to improve care processes, infrastructure planning, and patient outcomes. CQI programs evaluating health care services inform choices to optimize care and improve efficiencies through continuous knowledge translation. Keywords quality improvement, continuous quality improvement, health care quality improvement, performance measures To ensure improvements in the quality of health care, many regions have been developing quality improvement (QI) programs with conceptual frameworks designed to monitor, measure, and manage the performance of health care systems.1,2 With the demand for health care and costs increasing as the population ages, QI programs are critical to continuously monitor opportunities for improvements, reduce duplication of services, and eliminate the unnecessary complexity of health system processes.2,3 The conceptual framework should be the critical starting point in the design of any QI program.1 From the conceptual framework, key performance indicators (KPIs) are identified to monitor, evaluate, and improve services and outcomes using a range of QI tools and methods.1 These tools and methods build the needed infrastructure and processes of a QI program.2,4-6 However, despite the abundance of information available regarding the basic methods and processes of QI programs, they have not been widely implemented.2 Reasons for the limited implementation include the extensive and integrated resources needed, the lack of step-by-step implementation instructions for organizations, and the changes required by organizations to realize the potential benefits.2 As such,
selecting the most relevant QI elements is important to more accurately and directly address the specific needs of the targeted patient population and the associated quality care issues that need improvement. In addition, to optimize effectiveness, QI elements must be implemented across the full continuum of care and must be determined and agreed to by stakeholders in advance of QI program implementation.7 Improving the quality of care and maximizing efficiency are top priorities in the area of hip and knee replacement, where surgical demand and costs continue to increase as the population ages.5,8,9 However, most provinces across Canada lack a provincial system to 1
University of Calgary, Calgary, Alberta, Canada Alberta Bone and Joint Health Institute, Calgary, Alberta, Canada 3 Hip & Knee Working Group, Bone & Joint Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada 2
Corresponding Author: Deborah A. Marshall, PhD, Room 3C56, Health Research Innovation Centre, 3280 Hospital Drive NW, Calgary, Alberta, Canada T2N 4Z6. Email: [email protected]
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monitor the quality of care across the full spectrum of health service delivery. The primary purpose of this article is to present the rationale for the selection of QI structural elements and processes from the Continuous Quality Improvement (CQI) Program for Hip and Knee Replacement Surgical Care in the province of Alberta. The goal is to provide an overview of the highly integrated structures and processes and to summarize the lessons learned from the implementation of this CQI program.
The Overarching Construct of the CQI Program To build a comprehensive CQI program, careful consideration was needed to select from a range of QI elements in the literature with the intention of integrating the most appropriate QI elements for the hip and knee replacement population. This CQI initiative is managed by the Alberta Bone and Joint Health Institute (ABJHI) as part of its service agreement with the Bone and Joint Health Strategic Clinical Network (BJHSCN). The ABJHI is a not-forprofit organization focused on channeling research and knowledge into better bone and joint health care services and engaging stakeholders in adopting best practices within the province of Alberta. The BJHSCN is a provincial initiative launched by Alberta Health Services (AHS) to address the bone and joint health needs of the population. An overarching construct from Donabedian was used as the foundation of the CQI program. The Donabedian construct specifically distinguishes among 3 aspects of quality in health care: (a) the structure of the health care system, (b) the processes of care, and (c) the outcomes of medical care.4 The Triple Aim framework and 6 dimensions of quality care were incorporated (as defined in the Alberta Quality Matrix for Health [AQMH]) (Figure 1). The 6 dimensions of quality care expand on the Triple Aim framework by providing specific aspects of quality of care to measure.
Six Dimensions of Quality The 6 dimensions of quality care were defined in the AQMH13 and were derived from the Institute of Medicine’s health care quality outcomes from a patient and a health system perspective.14,15 The 6 AQMH dimensions are acceptability, accessibility, appropriateness, effectiveness, efficiency, and safety (Figure 1). The AQMH provides a common language, understanding, and approach to the measurement of health care quality.13 Within each dimension are explicitly defined KPIs that are used to measure and monitor health services to better understand opportunities to improve the quality of health care delivery.16,17 The measures used to evaluate criteria within quality dimensions are reliable and valid measures of health service delivery, as determined by a standing provincial clinical committee.2,9 The CQI program focuses on the 6 dimensions of quality for hip and knee replacement surgical care. AHS, the publicly funded organization responsible for the planning and delivery of health care for the entire province of 3.7 million Albertans, measures patient and system quality of care specific to total hip and total knee replacement surgery using 6 dimensions of quality. Together, the Triple Aim Framework and the 6 dimensions of quality address similar ideas. For example, to achieve Goal 1 (ie, to improve care), hip and knee replacement surgical care must be accessible, efficient, appropriate, and effective. Similarly, to improve the patient experience (ie, Goal 2), the surgical care received also must be accessible, appropriate, and effective. Last, to achieve Goal 3 (ie, lowering per capita costs), surgical care must be efficient and effective. The advantage of overlaying the 6 dimensions of quality care with the Triple Aim Framework is the opportunity to break down and accurately define the specific areas for quality improvement. By assigning a quality dimension to each area identified for improvement one could then operationalize this element by developing a KPI that had a related quantifiable measure (ie, the operational metric), and a set benchmark of what is considered “good quality.”
Triple Aim Framework
Structure of the CQI Program
The Triple Aim framework addresses how improvements in the quality of health care can be applied across the full continuum of care.6,10-12 The Triple Aim framework simultaneously integrates 3 goals: (a) improving the individual health care experience of the patient, (b) improving the health of populations, and (c) lowering per capita health care costs for populations. These 3 goals outlined in Figure 1 encompass the 6 dimensions of quality care that are used to define KPIs to measure performance.
The CQI Program was first initiated by ABJHI in 2011 as part of a 5-year plan to improve patient access to hip and knee replacement surgery. The primary goal of the 5-year plan was to reduce waiting time for surgery to less than 14 weeks.18 Within the CQI Program, the BJHSCN works together with ABJHI as integrators.6 Integrators are responsible for the linking of health organizations across the continuum of care for the hip and knee population6 and ensure that patients are receiving timely access to care, with minimal duplication in services, and maximum
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Figure 1. The Continuous Quality Improvement Program for hip and knee replacement in context with the Triple Aim Framework and the 6 Dimensions of Quality Care.
Abbreviations: ABJHI, Alberta Bone and Joint Health Institute; AHS, Alberta Health Services; BJHSCN, Bone and Joint Health Strategic Clinical Network; EQ-5D, EuroQol 5 Dimensions; LOS, length of stay; THA, total hip arthroplasty; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.
efficiencies. They also hold a key role in focusing and coordinating services toward the achievement of all 3 goals of the Triple Aim Framework.6
Infrastructure Part of the foundation of the CQI program is based on a solid infrastructure provided by an independent organization that acquires data via a standardized data collection mechanism under the terms of formal agreements with data custodians and a robust Privacy Impact Assessment (PIA). There are 3 critical enablers for this infrastructure. First, ABJHI is a trusted third-party organization that provides unbiased analysis. Their project team includes analysts, information technology specialists, and project managers well versed in QI methodology. Use of a third party helps ensure the privacy of these confidential data.
Clinicians remain the custodians of the data and voluntarily choose to share it with ABJHI. Moreover, the project management team is embedded with local quality review teams to facilitate QI initiatives at a grassroots level. Second, the PIA process assesses and mitigates risks to patient and provider privacy. All custodians participating in the CQI Program must assess and document the risks that exist to patient privacy as a result of their participation in the program and the steps taken (technical, procedural, and legal) to protect the privacy of patients and providers. Third, there is the contractual affiliation agreement between ABJHI and the custodians of health information (surgeons and AHS) that ensures confidentiality of the data presented in the CQI reports. AHS and ABJHI signed a data sharing agreement and individual surgeons signed an affiliation agreement endorsed by the Alberta
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Event Date 1 Referral Date
Event Date 2 Referral Received Date
Event Date 3 MSK Consult Date (if applicable)
Event Date 4 Actual Surgeon Consult Date
Event Date 5 Surgical Decision Date
Event Date 6 Pa ent Ready for Surgery Date
Event Date 7 Surgery Date
Figure 2. Standardized event dates from referral date to specialist to surgical date according to the Alberta Wait Times Rules. Abbreviation: MSK, musculoskeletal.
Orthopaedic Society. Currently, 83% of surgeons participate, representing 95% of the total volume of hip and knee surgeries in Alberta. It is important to note that there are no other “incentives” to staff or participants in the CQI Program other than receiving the CQI reports with confidential feedback on performance against the Measurement Framework, which will be discussed.
Clinical Pathway Prior to the initiation of the CQI Program, variations in preoperative and postoperative care for patients undergoing total hip and knee replacement presented an opportunity to optimize system performance in Alberta.19 As a result, in collaboration with the Alberta Orthopaedic Society, Alberta Health and Wellness, and AHS, an evidence-based clinical pathway was developed using standardized objective outcome measures according to the 6 dimensions of the AQMH.19,20 The new clinical pathway was evaluated in a pragmatic clinical trial called The Alberta Hip and Knee Replacement Project, which randomly assigned patients to compare the clinical pathway to the standard of care at the time.20 The results revealed numerous benefits to using the clinical pathway over the standard of care, and across multiple dimensions.19,20 Of particular significance, standardized objective outcome measurement was considered critical in the evaluation of strategies aimed to improve access to and quality of health care services. Recognizing the benefits of the clinical pathway over the standard of care, AHS considered the implementation of the clinical pathway pivotal to achieving better quality outcomes. To this end, the CQI Program was developed based on 3 guiding principles that incorporated the clinical pathway:
1. The development of an organizational commitment to quality, which included the implementation of the clinical pathway for hip and knee replacement surgery 2. Ensuring a client-centered focus throughout the delivery of care 3. Data gathered through CQI Program processes were used as feedback to further improve care processes and outcomes
The Measurement Framework This standardized Measurement Framework identifies core elements in the delivery of health care, costs, and outcomes using common metrics across the continuum of care, including wait times rules, patient characteristics, and demographics (Figure 1). The Measurement Framework incorporates both patient- and system-specific measures associated with hip and knee replacement surgery. The hip and knee replacement Measurement Framework established standardized definitions across the organization. As an example, the standardized Wait Times Rules define 7 key event dates (Figure 2).21 In addition to collecting these event dates, data including patient characteristics and demographics are collected to identify the number of patients waiting, where they are waiting, and for how long they are waiting on a real-time basis in each service zone.21 Acquisition of waiting list data directly informs the 5-year plan model, which is recalibrated semiannually to incorporate changes in demand.
Key Performance Indicators Table 1 outlines selected KPIs included in the CQI report and how they relate to each of the 6 dimensions of the
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Marshall et al Table 1. Key Performance Indicators for Each of the 6 Dimensions of Quality Care for the Continuous Quality Improvement Program. Six Quality Dimensions Accessibility Efficiency Appropriateness
Quality Dimension Defined13 Health services are obtained in the most suitable setting in a reasonable time (days) and distance. Resources are optimally used in achieving desired outcomes. Health services are relevant to user needs and are based on accepted or evidencebased practice.
Effectiveness Safety Acceptability
Health services are provided based on scientific knowledge to achieve desired outcomes. Evaluation of complications/risk factors for patients. Health services are respectful and responsive to user needs, preferences, and experiences.
Examples of Key Performance Indicators Within CQI Program Time (number of days) to receive total joint replacement surgery Length of stay (days) in acute care after surgery Length of stay in transfer facility following surgery Ensure only appropriate postoperative transfer to subacute or alternative level of care Routine adoption of a provincial protocol to manage PONV and pain control following surgery Promotion of early mobilization on Day 0 post joint replacement Capture of pre- and postsurgical outcomes such as pain, quality of life, and physical function (WOMAC and EQ-5D) Rate of inpatient safety events Overall patient satisfaction scores
Abbreviations: CQI, continuous quality improvement; EQ-5D, EuroQol 5 Dimensions; PONV, postoperative nausea and vomiting; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.
CQI Program. These KPIs were established based on international evidence and findings from The Alberta Hip and Knee Replacement Project pilot study.19,22,23 Each KPI has 2 elements: (a) a standardized objective outcome measure—an operational metric that identifies the parameter(s) and includes clear and specific goals that can be tracked to measure outcomes, and (b) an evidencebased threshold considered to be “good” quality of care (Figure 1). Operational metrics were derived from a hip and knee replacement clinical pathway providing quantitative measurement of key outcomes including length of hospital stay, level of functioning, and adverse events, among others. The rationale for setting specific thresholds of “good” quality was 2-fold. First, set thresholds established a common organizational standard across the province, and second, they allowed quantifiable measurement of each performance indicator. The benchmark of “good quality” was determined by an expert panel of clinicians specializing in the care of patients with hip and knee replacements.
Processes of the CQI Program One of the key challenges of QI programs in general is duplicative reporting.1 As such, a comprehensive, centralized reporting system was planned in advance to minimize reporting inefficiencies in the CQI program for hip and knee replacement surgery.
The CQI report From the highly integrated structural elements of the CQI program, several processes emerge. The key processes are the CQI reports published semiannually (spring and fall) with individual feedback and continuous assessment of the reports to meet user requirements. These reports are generated for a range of users including individual physicians (physician performance remains strictly confidential to each physician), hospitals administrators and quality review teams where hip and knee replacement surgeries are performed, zone leads across the 5 service zones in Alberta, and policy and health service decision makers at the provincial level within the BJHSCN. The CQI report compares performance in the 5 zones to established benchmarks/performance targets for Alberta. CQI reports aggregate information received from 12 hip and knee clinics, AHS administrative databases, and clinical records. This information is compiled and organized by ABJHI and released through a secure Web site. CQI reports provide feedback through measurement outcomes, as well as offer opportunities for knowledge translation that can be embedded within clinical systems in a measurable manner. The outcomes collected serve as a data repository aligned with the values of the Triple Aim, which helps ensure any improvements in outcomes are monitored and maintained over the long term. Moving toward the adoption of the clinical pathway province-wide,
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the authors will be better able to measure variability and analyze differences in outcomes in order to enhance the delivery of health services to this specific patient population. CQI reports formed the foundation for engaging frontline staff in continuous measurement and quality improvements and led to the development of various new initiatives aimed at improving the delivery of health care across the Alberta hip and knee replacement population.24,25 For example, CQI reports were the precursor for the Balanced Scorecard used within the Transformational Improvement Program,25 which was an initiative that evolved from the CQI Program to improve waiting times for surgery through better efficiencies in health service delivery.25 The other processes that are key to the CQI program are the measurement of outcomes across the continuum of care. These are typically part of the clinical pathway and are collected manually on paper by each clinic site.
framework across the full continuum of care, has been embedded into the day-to-day business practices in clinics and hospitals in both rural and urban settings across Alberta. The vision of the CQI Program for the hip and knee joint replacement population included sustainable monitoring over the long term. The implementation of standardized objective outcome measures that are collected and analyzed by an independent third party also should be an integral step of CQI Programs. In this way, health care organizations focused on improving the quality of service delivery can ensure that changes are being measured accurately, monitored, and maintained over the long term. CQI reports are an integral part of this process and serve as a basis from which to “measure variability” and from this to stimulate further improvements in health care quality, efficiency, and delivery.
Conclusions
Lessons Learned Most provinces across Canada lack a provincial system to monitor the quality of care across the full spectrum of health service delivery. The CQI Program, through highly coordinated and collaborative processes, has enabled a provincial tracking system throughout the continuum of care for patients undergoing hip and knee replacement. The CQI Program has changed practice to adopt a standardized integrated care pathway province-wide that is evidence based, reliable, valid, and measured over the long term. An established infrastructure through an independent organization under a PIA agreement; a high level of participation by surgeons, clinicians, and other key stakeholders; and the application of a defined Measurement Framework to provide ongoing feedback through CQI reports are integral to the success of the CQI Program to improve quality of care. Currently, the program is focused on implementing the clinical care pathway for total hip and knee replacement surgeries. In the future, the authors can see this CQI program also being extended to the ongoing evaluation of health service delivery. The evaluation of data from health care services can lead to informed choices regarding process and structure to optimize care and resolve inefficiencies through continuous knowledge translation. To summarize the CQI Program, the intent has been to change practice to adopt a standardized integrated care pathway province-wide that is evidence based, reliable, valid, and measured over the long term. This change in practice was initiated by measuring variability within a defined health care process among patients undergoing total hip and knee replacement surgery using a standardized approach and a defined Measurement Framework. The CQI philosophy, which integrates the Triple Aim
To date, CQI programs have been challenging to implement because of the extent of collaboration needed, the integration of the infrastructure required across health care facilities, and the long-term sustainability of such an infrastructure. This article presents how it is possible to integrate a range of appropriately selected QI processes and structural elements as a part of an ongoing CQI Program. As a next step, the authors will analyze the outcomes of the program using the CQI reports to highlight the quantitative improvements in patient and service delivery outcomes throughout the continuum of care. Acknowledgment We would like to acknowledge the editorial support and assistance of Zoe Agnidis, MSc, in the preparation of this article.
Declaration of Conflicting Interests The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Marshall is a Canada Research Chair in Health Systems and Services Research, and Arthur J. E. Child Chair in Rheumatology. All other authors declared no conflicts of interest.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr Marshall is supported through a Canada Research Chair in Health Systems and Services Research, and the Arthur J. E. Child Chair in Rheumatology Outcomes Research.
References 1. Arah O, Klazinga N, Delnoij D, Ten Asbroek H, Custers T. Conceptual frameworks for health systems performance:
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Marshall et al a quest for effectiveness, quality, and improvement. Int J Qual Health Care. 2003;15:377-398. 2. Counte MA, Meurer S. Issues in the assessment of continuous quality improvement implementation in health care organizations. Int J Qual Health Care. 2001;13: 197-207. 3. Harrigan ML. Quest for quality in Canadian health care: continuous quality improvement (Report No. 2). http:// publications.gc.ca/pub?id=424086&sl=0. Published 2000. Accessed February 1, 2013. 4. Donabedian A. Evaluating the quality of medical care. Milbank Q. 2005;83:691-729. 5. Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med. 1989;320:53-56. 6. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27: 759-769. 7. Health Quality Ontario. Quality Improvement Guide. http:// www.hqontario.ca/portals/0/Documents/qi/qi-qualityimprove-guide-2012-en.pdf. Published 2012. Accessed April 4, 2014. 8. Campbell SM, Roland MO, Buetow SA. Defining quality of care. Soc Sci Med. 2000;51:1611-1625. 9. Chambers L. Quality and value in orthopedic surgery. Health Aff (Millwood). 2010;29:566. 10. Dentzer S. The “triple aim” goes global, and not a minute too soon. Health Aff (Millwood). 2013;32:638. 11. Hinshaw PM. Understanding the triple aim. Nurs Manage. 2011;42(2):18-19. 12. Levine JF, Herbert B, Mathews J, Serra A, Rutledge V. Use of the triple aim to improve population health. N C Med J. 2011;72:201-204. 13. Health Quality Council of Alberta. Alberta Quality Matrix for Health user guide. https://d10k7k7mywg42z. cloudfront.net/assets/5328869d4f720a651500030b/User_ Guide_R290506.pdf. Published June 1, 2005. Accessed May 30, 2014. 14. Institute of Medicine. Envisioning the National Health Care Quality Report. Washington, DC: National Academies Press; 2001. 15. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.
16. Dixon E, Armstrong C, Maddern G, et al. Development of quality indicators of care for patients undergoing hepatic resection for metastatic colorectal cancer using a Delphi process. J Surg Res. 2009;156:32-38. 17. Walter LC, Davidowitz NP, Heineken PA, Covinsky KE. Pitfalls of converting practice guidelines into quality measures: lessons learned from a VA performance measure. JAMA. 2004;291:2466-2470. 18. Alberta Health Services. Alberta Health Services Q4 performance report 2011/12. http://www.albertahealthservices. ca/Publications/ahs-pub-pr-2012-06-performance-report. pdf. Published June 7, 2012. Accessed August 25, 2012. 19. Gooch KL, Smith D, Wasylak T, et al. The Alberta Hip and Knee Replacement Project: a model for health technology assessment based on comparative effectiveness of clinical pathways. Int J Technol Assess Health Care. 2009;25:113-123. 20. Alberta Health and Wellness. Alberta Hip & Knee Joint Replacement Project: evaluation report. http://www.health. alberta.ca/documents/Hip-Knee-Evaluation-2006.pdf. Published 2006. Accessed August 25, 2012. 21. Marshall D, Christiansen T, Smith C, et al. Voluntary versus involuntary waiting for joint replacements: new Alberta wait times rules for hip and knee arthroplasties, with provincial consensus. Healthc Q. 2012;15(3):37-42. 22. Frank C, Marshall DA, Faris P, Smith C. Essay for the CIHR/CMAJ award: improving access to hip and knee replacement and its quality by adopting a new model of care in Alberta. CMAJ. 2011;183:E347-E350. 23. Gooch K, Marshall DA, Faris PD, et al. Comparative effectiveness of alternative clinical pathways for primary hip and knee joint replacement patients: a pragmatic randomized, controlled trial. Osteoarthritis Cartilage. 2012;20:10861094. 24. Werle J, Dobbelsteyn L, Feasel AL, et al. A study of the effectiveness of performance-focused methodology for improved outcomes in Alberta public healthcare. Healthc Manage Forum. 2010;23(4):169-174. 25. Alberta Health Services. Alberta’s Transformational Improvement Program: increasing surgery capacity and improving quality of care for hip and knee replacement patients. http://www.albertaboneandjoint.com/media/TIP%20 Report%20for%20BJ%20Canada%20June%202011.pdf. Published June 2, 2011. Accessed October 30, 2012.
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research-article2014
AJMXXX10.1177/1062860614540512American Journal of Medical QualityMarshall et al
Article
Continuous Quality Improvement Program for Hip and Knee Replacement
American Journal of Medical Quality 1–7 © 2014 by the American College of Medical Quality Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614540512 ajmq.sagepub.com
Deborah A. Marshall, PhD1,2, Tanya Christiansen2, Christopher Smith, BCom, MBA2, Jane Squire Howden, RN, BScN3, Jason Werle, MD, FRCSC1,3, Peter Faris, PhD2, and Cy Frank, MD, FRCSC1
Abstract Improving quality of care and maximizing efficiency are priorities in hip and knee replacement, where surgical demand and costs increase as the population ages. The authors describe the integrated structure and processes from the Continuous Quality Improvement (CQI) Program for Hip and Knee Replacement Surgical Care and summarize lessons learned from implementation. The Triple Aim framework and 6 dimensions of quality care are overarching constructs of the CQI program. A validated, evidence-based clinical pathway that measures quality across the continuum of care was adopted. Working collaboratively, multidisciplinary experts embedded the CQI program into everyday practices in clinics across Alberta. Currently, 83% of surgeons participate in the CQI program, representing 95% of the total volume of hip and knee surgeries. Biannual reports provide feedback to improve care processes, infrastructure planning, and patient outcomes. CQI programs evaluating health care services inform choices to optimize care and improve efficiencies through continuous knowledge translation. Keywords quality improvement, continuous quality improvement, health care quality improvement, performance measures To ensure improvements in the quality of health care, many regions have been developing quality improvement (QI) programs with conceptual frameworks designed to monitor, measure, and manage the performance of health care systems.1,2 With the demand for health care and costs increasing as the population ages, QI programs are critical to continuously monitor opportunities for improvements, reduce duplication of services, and eliminate the unnecessary complexity of health system processes.2,3 The conceptual framework should be the critical starting point in the design of any QI program.1 From the conceptual framework, key performance indicators (KPIs) are identified to monitor, evaluate, and improve services and outcomes using a range of QI tools and methods.1 These tools and methods build the needed infrastructure and processes of a QI program.2,4-6 However, despite the abundance of information available regarding the basic methods and processes of QI programs, they have not been widely implemented.2 Reasons for the limited implementation include the extensive and integrated resources needed, the lack of step-by-step implementation instructions for organizations, and the changes required by organizations to realize the potential benefits.2 As such,
selecting the most relevant QI elements is important to more accurately and directly address the specific needs of the targeted patient population and the associated quality care issues that need improvement. In addition, to optimize effectiveness, QI elements must be implemented across the full continuum of care and must be determined and agreed to by stakeholders in advance of QI program implementation.7 Improving the quality of care and maximizing efficiency are top priorities in the area of hip and knee replacement, where surgical demand and costs continue to increase as the population ages.5,8,9 However, most provinces across Canada lack a provincial system to 1
University of Calgary, Calgary, Alberta, Canada Alberta Bone and Joint Health Institute, Calgary, Alberta, Canada 3 Hip & Knee Working Group, Bone & Joint Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada 2
Corresponding Author: Deborah A. Marshall, PhD, Room 3C56, Health Research Innovation Centre, 3280 Hospital Drive NW, Calgary, Alberta, Canada T2N 4Z6. Email: [email protected]
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monitor the quality of care across the full spectrum of health service delivery. The primary purpose of this article is to present the rationale for the selection of QI structural elements and processes from the Continuous Quality Improvement (CQI) Program for Hip and Knee Replacement Surgical Care in the province of Alberta. The goal is to provide an overview of the highly integrated structures and processes and to summarize the lessons learned from the implementation of this CQI program.
The Overarching Construct of the CQI Program To build a comprehensive CQI program, careful consideration was needed to select from a range of QI elements in the literature with the intention of integrating the most appropriate QI elements for the hip and knee replacement population. This CQI initiative is managed by the Alberta Bone and Joint Health Institute (ABJHI) as part of its service agreement with the Bone and Joint Health Strategic Clinical Network (BJHSCN). The ABJHI is a not-forprofit organization focused on channeling research and knowledge into better bone and joint health care services and engaging stakeholders in adopting best practices within the province of Alberta. The BJHSCN is a provincial initiative launched by Alberta Health Services (AHS) to address the bone and joint health needs of the population. An overarching construct from Donabedian was used as the foundation of the CQI program. The Donabedian construct specifically distinguishes among 3 aspects of quality in health care: (a) the structure of the health care system, (b) the processes of care, and (c) the outcomes of medical care.4 The Triple Aim framework and 6 dimensions of quality care were incorporated (as defined in the Alberta Quality Matrix for Health [AQMH]) (Figure 1). The 6 dimensions of quality care expand on the Triple Aim framework by providing specific aspects of quality of care to measure.
Six Dimensions of Quality The 6 dimensions of quality care were defined in the AQMH13 and were derived from the Institute of Medicine’s health care quality outcomes from a patient and a health system perspective.14,15 The 6 AQMH dimensions are acceptability, accessibility, appropriateness, effectiveness, efficiency, and safety (Figure 1). The AQMH provides a common language, understanding, and approach to the measurement of health care quality.13 Within each dimension are explicitly defined KPIs that are used to measure and monitor health services to better understand opportunities to improve the quality of health care delivery.16,17 The measures used to evaluate criteria within quality dimensions are reliable and valid measures of health service delivery, as determined by a standing provincial clinical committee.2,9 The CQI program focuses on the 6 dimensions of quality for hip and knee replacement surgical care. AHS, the publicly funded organization responsible for the planning and delivery of health care for the entire province of 3.7 million Albertans, measures patient and system quality of care specific to total hip and total knee replacement surgery using 6 dimensions of quality. Together, the Triple Aim Framework and the 6 dimensions of quality address similar ideas. For example, to achieve Goal 1 (ie, to improve care), hip and knee replacement surgical care must be accessible, efficient, appropriate, and effective. Similarly, to improve the patient experience (ie, Goal 2), the surgical care received also must be accessible, appropriate, and effective. Last, to achieve Goal 3 (ie, lowering per capita costs), surgical care must be efficient and effective. The advantage of overlaying the 6 dimensions of quality care with the Triple Aim Framework is the opportunity to break down and accurately define the specific areas for quality improvement. By assigning a quality dimension to each area identified for improvement one could then operationalize this element by developing a KPI that had a related quantifiable measure (ie, the operational metric), and a set benchmark of what is considered “good quality.”
Triple Aim Framework
Structure of the CQI Program
The Triple Aim framework addresses how improvements in the quality of health care can be applied across the full continuum of care.6,10-12 The Triple Aim framework simultaneously integrates 3 goals: (a) improving the individual health care experience of the patient, (b) improving the health of populations, and (c) lowering per capita health care costs for populations. These 3 goals outlined in Figure 1 encompass the 6 dimensions of quality care that are used to define KPIs to measure performance.
The CQI Program was first initiated by ABJHI in 2011 as part of a 5-year plan to improve patient access to hip and knee replacement surgery. The primary goal of the 5-year plan was to reduce waiting time for surgery to less than 14 weeks.18 Within the CQI Program, the BJHSCN works together with ABJHI as integrators.6 Integrators are responsible for the linking of health organizations across the continuum of care for the hip and knee population6 and ensure that patients are receiving timely access to care, with minimal duplication in services, and maximum
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Figure 1. The Continuous Quality Improvement Program for hip and knee replacement in context with the Triple Aim Framework and the 6 Dimensions of Quality Care.
Abbreviations: ABJHI, Alberta Bone and Joint Health Institute; AHS, Alberta Health Services; BJHSCN, Bone and Joint Health Strategic Clinical Network; EQ-5D, EuroQol 5 Dimensions; LOS, length of stay; THA, total hip arthroplasty; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.
efficiencies. They also hold a key role in focusing and coordinating services toward the achievement of all 3 goals of the Triple Aim Framework.6
Infrastructure Part of the foundation of the CQI program is based on a solid infrastructure provided by an independent organization that acquires data via a standardized data collection mechanism under the terms of formal agreements with data custodians and a robust Privacy Impact Assessment (PIA). There are 3 critical enablers for this infrastructure. First, ABJHI is a trusted third-party organization that provides unbiased analysis. Their project team includes analysts, information technology specialists, and project managers well versed in QI methodology. Use of a third party helps ensure the privacy of these confidential data.
Clinicians remain the custodians of the data and voluntarily choose to share it with ABJHI. Moreover, the project management team is embedded with local quality review teams to facilitate QI initiatives at a grassroots level. Second, the PIA process assesses and mitigates risks to patient and provider privacy. All custodians participating in the CQI Program must assess and document the risks that exist to patient privacy as a result of their participation in the program and the steps taken (technical, procedural, and legal) to protect the privacy of patients and providers. Third, there is the contractual affiliation agreement between ABJHI and the custodians of health information (surgeons and AHS) that ensures confidentiality of the data presented in the CQI reports. AHS and ABJHI signed a data sharing agreement and individual surgeons signed an affiliation agreement endorsed by the Alberta
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Event Date 1 Referral Date
Event Date 2 Referral Received Date
Event Date 3 MSK Consult Date (if applicable)
Event Date 4 Actual Surgeon Consult Date
Event Date 5 Surgical Decision Date
Event Date 6 Pa ent Ready for Surgery Date
Event Date 7 Surgery Date
Figure 2. Standardized event dates from referral date to specialist to surgical date according to the Alberta Wait Times Rules. Abbreviation: MSK, musculoskeletal.
Orthopaedic Society. Currently, 83% of surgeons participate, representing 95% of the total volume of hip and knee surgeries in Alberta. It is important to note that there are no other “incentives” to staff or participants in the CQI Program other than receiving the CQI reports with confidential feedback on performance against the Measurement Framework, which will be discussed.
Clinical Pathway Prior to the initiation of the CQI Program, variations in preoperative and postoperative care for patients undergoing total hip and knee replacement presented an opportunity to optimize system performance in Alberta.19 As a result, in collaboration with the Alberta Orthopaedic Society, Alberta Health and Wellness, and AHS, an evidence-based clinical pathway was developed using standardized objective outcome measures according to the 6 dimensions of the AQMH.19,20 The new clinical pathway was evaluated in a pragmatic clinical trial called The Alberta Hip and Knee Replacement Project, which randomly assigned patients to compare the clinical pathway to the standard of care at the time.20 The results revealed numerous benefits to using the clinical pathway over the standard of care, and across multiple dimensions.19,20 Of particular significance, standardized objective outcome measurement was considered critical in the evaluation of strategies aimed to improve access to and quality of health care services. Recognizing the benefits of the clinical pathway over the standard of care, AHS considered the implementation of the clinical pathway pivotal to achieving better quality outcomes. To this end, the CQI Program was developed based on 3 guiding principles that incorporated the clinical pathway:
1. The development of an organizational commitment to quality, which included the implementation of the clinical pathway for hip and knee replacement surgery 2. Ensuring a client-centered focus throughout the delivery of care 3. Data gathered through CQI Program processes were used as feedback to further improve care processes and outcomes
The Measurement Framework This standardized Measurement Framework identifies core elements in the delivery of health care, costs, and outcomes using common metrics across the continuum of care, including wait times rules, patient characteristics, and demographics (Figure 1). The Measurement Framework incorporates both patient- and system-specific measures associated with hip and knee replacement surgery. The hip and knee replacement Measurement Framework established standardized definitions across the organization. As an example, the standardized Wait Times Rules define 7 key event dates (Figure 2).21 In addition to collecting these event dates, data including patient characteristics and demographics are collected to identify the number of patients waiting, where they are waiting, and for how long they are waiting on a real-time basis in each service zone.21 Acquisition of waiting list data directly informs the 5-year plan model, which is recalibrated semiannually to incorporate changes in demand.
Key Performance Indicators Table 1 outlines selected KPIs included in the CQI report and how they relate to each of the 6 dimensions of the
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Marshall et al Table 1. Key Performance Indicators for Each of the 6 Dimensions of Quality Care for the Continuous Quality Improvement Program. Six Quality Dimensions Accessibility Efficiency Appropriateness
Quality Dimension Defined13 Health services are obtained in the most suitable setting in a reasonable time (days) and distance. Resources are optimally used in achieving desired outcomes. Health services are relevant to user needs and are based on accepted or evidencebased practice.
Effectiveness Safety Acceptability
Health services are provided based on scientific knowledge to achieve desired outcomes. Evaluation of complications/risk factors for patients. Health services are respectful and responsive to user needs, preferences, and experiences.
Examples of Key Performance Indicators Within CQI Program Time (number of days) to receive total joint replacement surgery Length of stay (days) in acute care after surgery Length of stay in transfer facility following surgery Ensure only appropriate postoperative transfer to subacute or alternative level of care Routine adoption of a provincial protocol to manage PONV and pain control following surgery Promotion of early mobilization on Day 0 post joint replacement Capture of pre- and postsurgical outcomes such as pain, quality of life, and physical function (WOMAC and EQ-5D) Rate of inpatient safety events Overall patient satisfaction scores
Abbreviations: CQI, continuous quality improvement; EQ-5D, EuroQol 5 Dimensions; PONV, postoperative nausea and vomiting; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.
CQI Program. These KPIs were established based on international evidence and findings from The Alberta Hip and Knee Replacement Project pilot study.19,22,23 Each KPI has 2 elements: (a) a standardized objective outcome measure—an operational metric that identifies the parameter(s) and includes clear and specific goals that can be tracked to measure outcomes, and (b) an evidencebased threshold considered to be “good” quality of care (Figure 1). Operational metrics were derived from a hip and knee replacement clinical pathway providing quantitative measurement of key outcomes including length of hospital stay, level of functioning, and adverse events, among others. The rationale for setting specific thresholds of “good” quality was 2-fold. First, set thresholds established a common organizational standard across the province, and second, they allowed quantifiable measurement of each performance indicator. The benchmark of “good quality” was determined by an expert panel of clinicians specializing in the care of patients with hip and knee replacements.
Processes of the CQI Program One of the key challenges of QI programs in general is duplicative reporting.1 As such, a comprehensive, centralized reporting system was planned in advance to minimize reporting inefficiencies in the CQI program for hip and knee replacement surgery.
The CQI report From the highly integrated structural elements of the CQI program, several processes emerge. The key processes are the CQI reports published semiannually (spring and fall) with individual feedback and continuous assessment of the reports to meet user requirements. These reports are generated for a range of users including individual physicians (physician performance remains strictly confidential to each physician), hospitals administrators and quality review teams where hip and knee replacement surgeries are performed, zone leads across the 5 service zones in Alberta, and policy and health service decision makers at the provincial level within the BJHSCN. The CQI report compares performance in the 5 zones to established benchmarks/performance targets for Alberta. CQI reports aggregate information received from 12 hip and knee clinics, AHS administrative databases, and clinical records. This information is compiled and organized by ABJHI and released through a secure Web site. CQI reports provide feedback through measurement outcomes, as well as offer opportunities for knowledge translation that can be embedded within clinical systems in a measurable manner. The outcomes collected serve as a data repository aligned with the values of the Triple Aim, which helps ensure any improvements in outcomes are monitored and maintained over the long term. Moving toward the adoption of the clinical pathway province-wide,
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the authors will be better able to measure variability and analyze differences in outcomes in order to enhance the delivery of health services to this specific patient population. CQI reports formed the foundation for engaging frontline staff in continuous measurement and quality improvements and led to the development of various new initiatives aimed at improving the delivery of health care across the Alberta hip and knee replacement population.24,25 For example, CQI reports were the precursor for the Balanced Scorecard used within the Transformational Improvement Program,25 which was an initiative that evolved from the CQI Program to improve waiting times for surgery through better efficiencies in health service delivery.25 The other processes that are key to the CQI program are the measurement of outcomes across the continuum of care. These are typically part of the clinical pathway and are collected manually on paper by each clinic site.
framework across the full continuum of care, has been embedded into the day-to-day business practices in clinics and hospitals in both rural and urban settings across Alberta. The vision of the CQI Program for the hip and knee joint replacement population included sustainable monitoring over the long term. The implementation of standardized objective outcome measures that are collected and analyzed by an independent third party also should be an integral step of CQI Programs. In this way, health care organizations focused on improving the quality of service delivery can ensure that changes are being measured accurately, monitored, and maintained over the long term. CQI reports are an integral part of this process and serve as a basis from which to “measure variability” and from this to stimulate further improvements in health care quality, efficiency, and delivery.
Conclusions
Lessons Learned Most provinces across Canada lack a provincial system to monitor the quality of care across the full spectrum of health service delivery. The CQI Program, through highly coordinated and collaborative processes, has enabled a provincial tracking system throughout the continuum of care for patients undergoing hip and knee replacement. The CQI Program has changed practice to adopt a standardized integrated care pathway province-wide that is evidence based, reliable, valid, and measured over the long term. An established infrastructure through an independent organization under a PIA agreement; a high level of participation by surgeons, clinicians, and other key stakeholders; and the application of a defined Measurement Framework to provide ongoing feedback through CQI reports are integral to the success of the CQI Program to improve quality of care. Currently, the program is focused on implementing the clinical care pathway for total hip and knee replacement surgeries. In the future, the authors can see this CQI program also being extended to the ongoing evaluation of health service delivery. The evaluation of data from health care services can lead to informed choices regarding process and structure to optimize care and resolve inefficiencies through continuous knowledge translation. To summarize the CQI Program, the intent has been to change practice to adopt a standardized integrated care pathway province-wide that is evidence based, reliable, valid, and measured over the long term. This change in practice was initiated by measuring variability within a defined health care process among patients undergoing total hip and knee replacement surgery using a standardized approach and a defined Measurement Framework. The CQI philosophy, which integrates the Triple Aim
To date, CQI programs have been challenging to implement because of the extent of collaboration needed, the integration of the infrastructure required across health care facilities, and the long-term sustainability of such an infrastructure. This article presents how it is possible to integrate a range of appropriately selected QI processes and structural elements as a part of an ongoing CQI Program. As a next step, the authors will analyze the outcomes of the program using the CQI reports to highlight the quantitative improvements in patient and service delivery outcomes throughout the continuum of care. Acknowledgment We would like to acknowledge the editorial support and assistance of Zoe Agnidis, MSc, in the preparation of this article.
Declaration of Conflicting Interests The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Marshall is a Canada Research Chair in Health Systems and Services Research, and Arthur J. E. Child Chair in Rheumatology. All other authors declared no conflicts of interest.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr Marshall is supported through a Canada Research Chair in Health Systems and Services Research, and the Arthur J. E. Child Chair in Rheumatology Outcomes Research.
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