Quality assured

By Ruth Carol, Contributing Writer, November 1, 2021

Quality improvement (QI) efforts can boost reimbursement but engaging in QI activities can have an even more positive impact on a dermatology practice’s overall performance. 

It’s true that QI is increasingly tied to reimbursement. Reporting measures in the quality category of the Merit-based Incentive Payment System (MIPS) comprises 40% of the total MIPS score. Additionally, engaging in improvement activities (IA) comprises 15% of the MIPS composite score. That means more than half of the MIPS score focuses on quality efforts. More importantly, participating in QI activities can improve patient outcomes and operational efficiencies as well as patient and physician satisfaction.

“When you participate in QI, you not only have an opportunity to help your patients, but you have an opportunity to improve the efficiencies of your practice,” noted Margo J. Reeder, MD, FAAD, associate professor and medical director of QI at University of Wisconsin Madison, and chair of the Academy’s Performance Measurement Committee. “Any time you can create or implement a process that better serves your patients, it makes your work more efficient and leads to greater job satisfaction,” she said.

Developing dermatology-specific measures

Quality measures can be divided into three categories, explained Laura Vera, MSW, LSW, LSSGB, associate director of quality innovation at the AAD. The MIPS measures, which are publicly available, comprise one category. The qualified clinical data registry (QCDR) measures, which are only available in DataDerm™ — the Academy’s Centers for Medicare & Medicaid Services (CMS)-certified registry — comprise a second category and include additional measures for pruritis, quality of life, and surgical margins, among other dermatology-specific measures. The third category of measures housed in DataDerm are dermatology-specific as well and can be used for reporting purposes for the IA category for MIPS or driving improvement activities, she said. 

The Academy plays a significant role in measure development, noted Stephanie C. Braxton, MPH, the Academy’s manager for performance measures and analysis. The process for developing dermatology-specific measures begins with a group of dermatologists conducting a needs assessment to identify topics that would be appropriate for measures. It includes reviewing the literature and clinical guidelines. Once the needs assessment is complete, a measurement development workgroup composed of physicians and patient representatives is convened. Once drafted, the proposed measures undergo a review and approval process by the workgroup, the Academy’s Performance Measurement Committee, and the Council on Science and Research. Measures are then tested for validity, reliability, and feasibility. After testing, the measures are sent to the AAD’s Board of Directors for approval for measures to be included in MIPS. This rigorous process can take a total of 18 months, Braxton noted. Once approved, the measures are submitted to CMS for approval for use in MIPS. The AAD continues efforts to expand the number and type of dermatology-specific measures.

Based on 2020 data, the most used dermatology-specific quality measures in DataDerm are:

• MIPS 137, which addresses continuity of care for melanoma patients

• MIPS 265, which addresses biopsy follow-up

• MIPS 138, which addresses coordination of care for melanoma patients within a month of diagnosis

• MIPS 410, which addresses psoriasis vulgaris patients’ response to systemic medications

• MIPS 337, which calls for active tuberculosis prevention for patients with psoriasis, psoriatic arthritis, and rheumatoid arthritis who are taking a biologic

• AAD 6, which calls for biopsy results to be reported to the clinician/patient within 14 days

Finding the right measures 

In addition to developing measures, the AAD has developed myriad resources to navigate the world of measurement. “The biggest challenge we hear from dermatologists is about finding the time and resources to engage in QI,” Vera said. The AAD maintains that dermatologists are already committed to and engaging in quality efforts, they just don’t think of it in those terms. “If you are reading guidelines, implementing changes in your practice, or collecting data from your electronic health record to report measures, you’re already engaged in the major steps to improve clinical care,” she added.

For its part, the AAD continues to create innovative resources and opportunities to assist dermatologists in fulfilling their reporting requirements, whether they come from CMS, insurance companies, or specialty boards. The Academy strives to create resources and content to meet multiple requirements, Vera noted. The AAD recently launched on-demand courses on how to implement guidelines into practice. The first set of courses, which focus on the psoriasis guidelines, links to appropriate measures and IAs as well as an example of a quality improvement initiative, Vera said. There is also a new learning module on how to implement a QI project based on a patient safety event, a phototherapy burn, and one on the fundamentals of patient safety. An online lecture series on QI curriculum for residents is designed to help faculty teach dermatology-specific QI. It meets the Accreditation Council for Graduate Medical Education’s requirements for QI training and can also be used to help educate office staff on QI methodologies and tools, she added. The Academy also provides Resident QI Award recipients presentations on the quality webpage for members to explore dermatology-specific quality improvements initiatives that improve care processes, patient outcomes, and workflow efficiency. Still have questions? Email quality@aad.org to get individual support. 

“Even if you’re totally new to QI, the AAD’s website can guide you through the process,” stated Steven Daveluy MD, FAAD, deputy chair of the Academy’s Performance Measurement Committee. The Academy’s practice management section on quality reporting is the best source for dermatology-specific measures, he added. It lists all the measures with a quick summary of the steps involved in meeting them, plus validated tools. As an example, the MIPS measure selection tool helps dermatologists select the most appropriate MIPS measures for their practice, Braxton said. In addition to frequently asked questions, documentation tip sheets, and videos, the Academy records webinars that can provide information on new measures and updates for members to use to report. 

Identifying QI measures from clinic

Some of the most rewarding QI initiatives are plucked from everyday practice. When Dr. Reeder identifies a process that she thinks could be improved upon, she turns it into a QI project. Decreasing missed follow-up appointments, standardizing lab orders, and decreasing burns resulting from phototherapy treatment are just some of the processes she has improved through QI efforts. 

Similarly, when Martina J. Porter, MD, FAAD, a member of the AAD’s Patient Safety and Quality Committee, notes an inefficient process or a recurring problem, she does a root cause analysis with staff to identify the root causes of the problem and propose appropriate solutions. As an example, biopsy mix-ups are not an uncommon occurrence in high-volume dermatology practices. If two biopsies from a single patient, one from the right arm and one from the right leg, get mixed up, staff could brainstorm about what steps could be taken to improve the process or prevent the problem from recurring. Potential changes to the process could be labeling the specimen jars differently, specifying how to order specimen collection so that specimens from the arm are always collected before those on a leg, and/or verifying the biopsy site verbally with the patient. Physicians intuitively do this type of problem solving all the time, she said, adding that QI just formalizes the process.

For a QI project targeting prior authorizations, Dr. Porter and her colleagues implemented a centralized pharmacy intervention that reduced the time to submit and receive a decision while increasing approval rates. Additionally, they demonstrated that patients whose prior authorizations were approved had a higher likelihood of disease improvement compared with those who were denied. 

“Having worked at different institutions as part of my training, I have seen a lot of the same issues come up regardless of whether it was in private practice or academic practice,” Dr. Porter said. One benefit of being in an academic institution is there are more people, including trainees, who can work on QI initiatives. When she worked with the pharmacy department on prior authorizations, the pharmacy technicians collected the data to establish a baseline. 

Another difference is that academic institutions have systems for capturing errors that physicians in private practice don’t have, said Sara Samimi, MD, FAAD, chair of the AAD’s Patient Safety and Quality Committee. But that doesn’t mean that dermatologists in private practice can’t target near misses and/or errors. For example, the inability to identify the correct biopsy site could lead to wrong-site surgery, which is considered a sentinel event by the Joint Commission. Locating a healed biopsy site is particularly difficult on patients with actinic damage. Dermatologists can collect data on their processes for capturing a biopsy site, evaluate them, implement changes to improve the processes, and measure for improvement. The change could be developing and implementing a protocol that calls for sending high-resolution photographs with at least one anatomical landmark to the dermatologic surgeon, uploading photos to the patient’s chart in real time if using an electronic health record (EHR), and/or providing a detailed description of the biopsy site in the patient’s notes. It’s important to embed the improvements into the workflow so that they don’t take additional time, she said. The Academy currently has a measure in the registry titled: Skin Cancer: Use of Biopsy Site Photos or Directional Diagrams Sent Prior to Surgery. It can currently be used to report improvement activity MIPS IA_PSPA_8: Use of Patient Safety Tools.

Dr. Daveluy concurs. “You need to be practical. It can’t be something that will require spending an extra 10 minutes with each patient,” he said. Implementing the Numerical Rating Scale (NRS) to record itch not only fit into the workflow; it made it more efficient, he said. Before using the NRS, Dr. Daveluy and his colleagues thought they were doing a good job asking about and documenting itch for patients with psoriasis and eczema. Then they made it the focus of a QI project. Baseline data revealed that they were only capturing itch in about 30% of patients. After implementing the NRS, documentation soared to more than 95%. Using a tool to measure itch helped the dermatologists quantify it and consequently tweak treatment, if necessary. Patients had an easier time describing their itch, freeing up time during the appointment to address other issues. 

Making small changes 

Today’s QI efforts are all about making small changes that have a big impact. QI projects don’t have to be groundbreaking, Vera said. They could be as simple as implementing a checklist for follow-up calls, changing how patients are queried when checking in, or moving patients more efficiently from an exam room to a surgical suite. They can come from a conversation with staff or patients complaining about a problem with the telephone lines. 

Physicians are used to traditional research, enrolling a large sample size of patients over a long period of time and showing proof of effectiveness, noted Amanda Marsch, MD, FAAD, who led the recent AAD VMX Quality Improvement Symposium. In contrast, QI projects typically focus on a small number of patients over a short period of time and require gathering just enough data to show improvement. 

In rapid-cycle QI projects, the Plan-Do-Study-Act cycle can be used to test an intervention on one patient, Dr. Marsch said. If it works, it can be tested on a few patients. If it doesn’t work, the improvement can be tweaked and re-tested. “Using these small successive tests is a very efficient way to determine if a change leads to an improvement,” she added. “As physicians understand that QI work is a lot less time-intensive than traditional research, they will likely be more willing to engage in it.”

Dr. Reeder cautioned against making large-scale changes, which could be confusing to the staff and patients alike. She also stressed the importance of collecting the data and measuring the improvement to know, with certainty, that it is effective and by how much. “QI projects can be eye opening,” she said. “Very often, you think that you’re checking labs 100% of the time for patients with certain diseases. But you may find out that you’re only doing it 75% of the time or less. And that’s how you identify an opportunity for improvement.” 

Changes should result in an improvement for everyone, Dr. Reeder emphasized. Sometimes, a change is better for the physician but not the nurses. That’s why it helps to engage the whole team — nurses, medical assistants, and office staff — in QI efforts. “Many times, the little projects that improve workflow efficiency can be the most satisfying because they help everyone in the practice,” she noted.

When designing new processes, Dr. Daveluy stressed the importance of thinking how they could fail and implementing strategies to mitigate that from happening. For example, medical assistants are asked to record the NRS, but then the physicians check to make sure that it was recorded. That way, if the medical assistant was distracted or forgot to administer the tool, the physician could do it. Other options are building an alert about the NRS in the EHR or having the patient fill it out in the exam room while waiting to see the doctor. Dr. Daveluy is looking at the feasibility of using a QR code that more tech-savvy patients could scan to fill out the NRS over a secure server. 

Using the QI tools to drill down to the problem(s) and not just assuming the cause(s) is essential, Dr. Daveluy added. When patients were being double booked for surgeries at a clinic, the assumption was that human error was at fault. After doing a root cause analysis, he and his colleagues found that the online scheduling system was causing the problem, which was eliminated by tweaking the software. “If we didn’t use QI tools, we would have kept coming up with solutions that weren’t addressing the problem,” he said.

Promoting dermatology

Working across specialties on a QI project helps promote the value of dermatology, which doesn’t always get the respect it deserves in the house of medicine, Dr. Daveluy noted. But when a dermatologist contacts a cardiologist about developing a screening tool for psoriasis patients because of their increased risk of heart disease, it starts conversations and helps build relationships, he said. 

Dr. Porter is working with infectious disease specialists on a QI patient safety project to establish vaccination guidelines before prescribing immunosuppressive drugs for patients with psoriasis and eczema. For example, patients with psoriasis need a pneumococcal vaccine and must be tested for hepatitis before being prescribed a biologic. Dermatology refers an average of 10 patients a week to infectious disease for this purpose, she said. The guidelines are currently being pilot tested, and if successful, they will be used as a template for working with the gastroenterology, rheumatology, and neurology departments. Thus far, preliminary data show that the rate of patients receiving a pneumococcal vaccine has increased significantly since implementing the guidelines, Dr. Porter said.  

“When dermatologists look to improve systems to schedule patient appointments or create template notes in their EHR, they’re participating in quality efforts to run their practice,” Dr. Reeder said. QI simply serves as a framework for measuring the improvement around the efforts.

At the end of the day, physicians are scientists, Dr. Daveluy concluded. “We look at science and evidence. QI is just a scientific approach to practice improvement.”

Additional DermWorld Resources