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Design and Measurement of Quality Improvement Indicators in Ambulatory Pulmonary Care: Creating a “Culture of Quality” in an Academic Pulmonary Division

David H. Roberts, MD, FCCP; Geoffrey S. Gilmartin, MD; Naama Neeman, MSc; Joanne E. Schulze, BA; Sabrina Cannistraro, MSc; Long H. Ngo, PhD; Mark D. Aronson, MD; J. Woodrow Weiss, MD
Author and Funding Information

Affiliations: From the Division of Pulmonary, Critical Care, and Sleep Medicine (Drs. Roberts, Gilmartin, and Weiss, Ms. Schulze, and Ms. Cannistraro), and the Department of Medicine (Drs. Ngo and Aaronson, and Ms. Neeman), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.

Correspondence to: David H. Roberts, MD, FCCP, Pulmonary & Critical Care Division, Beth Israel Deaconess Medical Center, KSB 23, 330 Brookline Ave, Boston, MA 02215; e-mail: dhrobert@bidmc.harvard.edu


All work was completed at Beth Israel Deaconess Medical Center, Boston, MA.

Stoneman Center for Quality Improvement and Patient Safety, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(4):1134-1140. doi:10.1378/chest.09-0619
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Background:  Quality improvement (QI) measures often are cited as goals for individual practices and medical centers and may someday form a component of reimbursement guidelines. Relatively few QI metrics relevant to ambulatory pulmonary medicine have been published. We describe the development and implementation of a QI program in an academic pulmonary division, including progress to date and lessons learned.

Methods:  Metrics for the pulmonary QI Dashboard were developed based on an extensive literature review. Patients were identified through International Classification of Diseases-based billing databases, and results data were obtained from a manual and automated review of the electronic medical record. The performance of the division was monitored and presented in regular faculty meetings. Quarterly, confidential, individual scorecards gave each clinician feedback about his or her performance and compared the feedback to that of the faculty of the entire division.

Results:  Significant improvements were found in many QI measures during a 2-year period. The number of patients with asthma who received appropriately prescribed inhaled corticosteroids increased from a baseline of 76 to 92% to 98%. Flu shot and pneumococcal vaccine administration documentation for patients with COPD increased from baseline values of 11 to 32% and 11 to 34%, respectively, to 90% and 93%, respectively. The COPD Global Initiative for Obstructive Lung Disease pharmacotherapy guidelines adherence increased substantially for patients with all disease stages. Chest CT scan results notification documentation improved from a baseline of 67 to 76% to 98%. Comparison between baseline and QI periods yielded statistically significant increases for these indicators.

Conclusions:  QI measures for an ambulatory pulmonary practice can be designed, implemented, and monitored. Key components include a well-structured electronic medical record, measurable outcomes, strong QI leadership, and specific interventions, such as providing feedback through QI review meetings and individual “report cards.”

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