Are You Ready for Kaizen in Your Clinical Practice?
Article ID: CJ-20-0087
Details
Article ID: CJ-20-0087
Quality indicators (QIs), a tool for kaizen (“change for better”) for clinical practice in medical care, allow quantitative assessment of daily practice and functions to bridge the evidence-practice gap. A conceptual model proposed by Avedis Donabedian1 has been widely used to develop QIs in various speciality areas. The Donabedian model explains the quality of medical practice based on 3 domains (structure, process, and outcome; Figure), and numerous disease-specific QIs have been proposed, including for cancer, acute myocardial infarction, and chronic obstructive pulmonary disease, as well as for specific areas, such as the intensive care unit (ICU) in cardiovascular practice.2 In general, a QI is initially developed and proposed by clinicians who are focused on the need to improve the quality of practice in a specific area; QI items in an area with no consensus of indicators are sometimes examined by systematic review for generalization. Using QI, clinicians are expected to improve quality of care by reviewing daily practice. In some English-speaking countries, QIs may serve as measures for “pay for performance (P4P)”, in which the QI score acts as a financial incentive.3 QIs can also be used to complement existing clinical guidelines to achieve specific outcomes in complex clinical situations. Indeed, in cardiovascular practice, the European Society of Cardiology, American Heart Association (AHA), and other medical speciality societies have proposed QIs for specific diseases or in particular areas, including acute myocardial infarction (AMI),4–7 adults with heart failure (HF),8 and cardiac rehabilitation.9
The Donabedian model of measuring healthcare system performance. Adapted from Brien SE et al.1
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Because most cardiologists seem to be inexperienced with regard to the methodology used to develop QIs, knowing the development process may be of value in assessing the different publications on QI. The Delphi survey, an established methodology used to develop QIs, is used to answer many questions of interest in medical and social sciences by developing consensus around a particular issue. For example, a QI-development process using a modified four-step Delphi approach was proposed by the European Society of Gynaecological Oncology.10 The first step in this process is to list potential QIs from guidelines and the literature, with expert panel members then independently rating the relevance, validity, and feasibility of each QI item with no interaction. The second step involves a moderated expert panel discussion of each potential QI item. In this step, each panel member independently provides a second rating for each item after discussion (first panel meeting). In the third step, the external panel of expert reviewers rates the relevance, validity, and feasibility of each QI item with no interaction. The fourth and final step consists of a moderated expert panel discussion that integrates reviewer comments. In this step, the expert panel members independently provide a final rating for each QI item after the discussion (second panel meeting). After finishing the process, the proposed QI is examined for generalizability.
Recently, systematic reviews of specific area-focused QI sets in cardiovascular practice have been reported. For example, Goldfarb et al reported a systematic review of QIs in the cardiac ICU.2 In that review, 108 QIs (70 process, 18 structural, 18 outcome, 1 patient engagement, 1 covering multiple domains) were identified in 30 articles, representing 23 agencies, organizations, and societies. Goldfarb et al then surveyed the results with 14 expert cardiac intensivist-administrators (7 Americans, 7 Europeans), with the final QI set including 7 structure, 2 process, and 6 outcome measures. Interestingly, during the survey process, differences in choosing some items as important and relevant became evident between American and European expert cardiac intensivist-administrators, suggesting that the rating of a particular QI is likely to be affected by region-specific medical issues. With this in mind, QIs for focused area of practice should be developed in view of the evidence and region-specific medical issues, including the healthcare insurance system.
In this issue of the Journal, Hamatani et al11 report on the development of QIs for palliative care in HF patients, for whom care is less advanced than for cancer patients. Developing QIs in palliative care is deemed essential because the goal of care is to achieve quality of life (and death) for patients, which requires multidisciplinary intervention. Hamatani et al identified 44 potential QIs for further consideration and proposed a final set of 35 QI items for palliative care in HF patients (74% process, 26% structure, 0% outcome in the Donabedian model).11 The final set of QIs included 4 domains: (1) structure and process in disease care; (2) HF treatment and care; (3) total pain management; and (4) decision support and ethical issue management. In a practical preliminary test, Hamatani et al found that intervention by a multidisciplinary team, opioid therapy for patients with refractory dyspnea, and screening for psychological symptoms (process indicators), as well as preparation of a screening sheet for total pain and a medical manual about advanced care planning (structure domain) remained as appropriate targets to improve quality in practice with maximum potential for improvement.11 The next step is to examine the generalizability of the proposed QIs; after this has been done, the QI set of Hamatani et al may serve as a reference for QIs in palliative care in Japan.
Thus, QIs allow us to clarify issues to improve quality of care in specific cardiovascular practice, and QI rating is the first step to refine our practice. Most of us recognize the benefit of guiding indicators, particularly in areas of care involving multidisciplinary teams, which are now becoming mainstream in highly developed medical care. As Hamatani et al note in their article, the next step in establishing their proposed QIs will be to generalize their proposed QIs by collaborating with medical speciality societies.11 It is understandable that the most difficult issue would be to disseminate QIs into general practice. To this end, most medical speciality societies globally take a leading role in authorizing QIs for focused areas of clinical practice that implement their existing clinical guidelines. Establishing medical speciality society-guided QIs will meet the need of clinicians as well as other medical staff who are making an effort to implement evidenced-based principles into daily practice with a great deal of enthusiasm. In addition, standardized and well-selected QIs based on guideline-recommended management will allow us not only to refine daily practice, but also to expand necessary knowledge and practice rapidly in focused areas with urgent need.
Kaizen is not a speciality only of Japanese automobile companies: we already have a tool to refine our daily practice.
The author has received lecture fees from Otsuka, Mitsubishi-Tanabe, Abbott Japan, and Daiichi-Sankyo, and consultant fees from Novartis Pharma.
