Out of the (check) box

By Allison Evans, Assistant Managing Editor, December 1, 2022

Quality improvement (QI) efforts are increasingly tied to reimbursement. Reporting measures in the quality category of the Merit-based Incentive Payment System (MIPS) comprises 30% of the total MIPS score while attesting to improvement activities (IA) comprises 15% of the total score for the 2022 reporting year. This means that nearly half of the MIPS score is directed at quality efforts.

Aside from the fiscal incentive to implement improvement activities and track quality metrics, engaging in meaningful QI efforts can improve patient outcomes and operational efficiencies as well as patient and physician satisfaction. However, many dermatologists have a limited capacity to pour time, energy, and resources into checking these boxes, particularly if they don’t feel that the activity will truly add value to their practice.

But what if these activities didn’t have to overwhelm dermatologists and their teams? Dermatologists discuss their experiences making quality improvement activities manageable and share what they’ve learned along the way.

Starting small

“One of the biggest misconceptions about quality and improvement activities is that it has to be a large undertaking,” said Martina Porter, MD, FAAD, member of the Academy’s Patient Safety and Quality Committee (PSQC) and assistant professor of dermatology at Beth Israel Deaconess Medical Center.

“It can be very intimidating and overwhelming to the average practicing dermatologist to try and undergo an improvement or quality project,” agreed Lindsay Strowd, MD, FAAD, member of the Academy’s QI Education Workgroup and associate professor of dermatology at Wake Forest Baptist Health in North Carolina. “Starting out small is often the best way to go because then you learn what works and what doesn’t. The smallest projects can have the most impact on day-to-day practice operations.”

Straightforward examples

Dr. Strowd identified a problem with the pathology lab in which tissues that required immunofluorescence were not being properly processed. “The lab used to have a specific container for the immunofluorescence biopsies that looked completely different from the regular skin biopsies. The lab changed the containers so that both looked the same, resulting in erroneous processing errors. We had about three errors within a month.”

She wanted to determine whether the pathology lab was getting confused because the two containers looked so similar (although one was smaller than the other). “We bought little yellow stickers and wrote ‘DIF’ [direct Immunofluorescence] on the top and stuck those on the smaller bottles. Then we told the path lab that immunofluorescence containers will have a yellow sticker on them.” This simple act of using stickers stopped the reoccurring processing errors.

More recently, Dr. Strowd focused her efforts on laser safety. “We have multiple different providers that use our lasers, including medical students and residents. There had been a couple of instances where people didn’t have the right protective eyewear, or we found an uncovered mirror in the laser room. We realized that we didn’t have a standard sign-off checklist for each laser before it was used.”

Dr. Strowd and her team developed a laser safety checklist that the nurse would set by the laser so that providers could check and make sure everything was safe before turning on the laser. “There were a couple of days where the checklist didn’t make it into the laser room, so we had to go back and reassess the process. We laminated the checklist and used a dry erase marker and then placed the list physically on the laser over the switch.”

MIPS improvement activities

While the current MIPS program can be burdensome to physicians, there are IAs that span a wide range of topics and interests, with some more relevant to dermatology practices than others. Most dermatologists will need to complete between one and four IAs, depending on activity weighting and practice size. Get more information.

“Each year, the Patient Safety and Quality Committee reviews new and modified IAs in the Medicare Physician Fee Schedule final rule to provide guidance to members on which IAs are most applicable to dermatologists,” said Laura Vera, AAD associate director of quality innovation. “We have a spreadsheet on the website that includes IAs that are recommended by the committee with examples in practice as well as which quality measures align with or are linked to the IAs. The goal is to help members understand which CMS improvement activities can be met by reporting or utilizing certain measures with examples of how the IAs can work within dermatology.”

“In my practice, we meet the high-weighted improvement activity requirement by incorporating third- and fourth-year medical students and residents from a local medical school that rotate with us,” said South Carolina dermatologist Sylvia L. Parra, MD, FAAD.

Measurement

“There are likely many dermatologists already doing the types of projects that qualify as improvement activities and may not even realize that they are improvement activities or that the outcomes could be measured,” Dr. Porter said. “Anything you’re doing to try and make things more efficient or to make care more equitable is truly quality improvement. It’s just a matter of figuring out if you can measure before and after.”

“Incorporate measurement into daily work,” said Rita Khodosh, MD, PhD, FAAD, deputy chair of the Academy’s Patient Safety and Quality Committee, in a bonus May issue of Dialogues in Dermatology. “A little bit of data can go a long way. We’re not trying to be comprehensive. We’re not trying to collect data on everything we do. You can do it over one day. You can do it over one week. It requires just enough data to know where to focus.”

“You have to be able to measure the impact of what you’re doing, and that metric has to change meaningfully,” agreed Gideon Smith, MD, PhD, MPH, FAAD, member of the Academy’s Performance Measurement Committee, in the same episode of Dialogues in Dermatology. “There are lots of things that we do that generate data. There are lots of things captured in electronic health records.”

“It can be tricky to come up with the metric and to make it as seamless as possible and integrate it into clinical flow,” Dr. Smith said. “One way to ease the burden of data collection is to use electronic medical records or the Academy’s DataDerm™ to extract data after the events,” he added.

“Personally, I have found some of the psoriasis measures — tracking tuberculosis pre-biologic screening, tracking body surface area, and monitoring for disease improvement — have been helpful to my practice,” Dr. Parra said. “The challenge for some of these activities is getting buy-in from your practice that they add value, and finding ways to implement them in a way that minimizes impact on work flow. Sometimes, the tracking that you need requires the EHR vendor to make a modification for you, which can be difficult depending on the system being used,” she added.

Increasing importance of equity

“The pandemic has clearly demonstrated disparities in care and health outcomes in the U.S. We cannot improve health without improving equity,” Dr. Khodosh said. “More and more, quality improvement efforts encompass equity-related issues,” Dr. Porter added. “Since a lot of younger dermatologists and residents are focused on equity right now, there are a lot of these projects coming through.”

In fact, for 2022 reporting, CMS added seven improvement activities related to promoting health equity, six of which are on the Academy’s list of dermatology-related improvement activities. Some of these include improving responsiveness of care for Medicaid and other underserved patients; and creating and implementing an anti-racism plan, among others (Access the list of dermatology-related improvement activities).

Dr. Porter and her colleagues have started thinking about how they can improve the scheduling of patients who tend to not show up for appointments but who need to be seen for high-risk medication monitoring or debilitating skin diseases. “While we’ve started looking at the data, we still need to dig into the optimal scheduling algorithm for patients you know will always show up late without having to turn them away.”

Improving melanoma patient care

“I selected a QI project based on the need of timely follow-up of some patients in my practice,” said Amanda Marsch, MD, FAAD, who led the AAD VMX Quality Improvement Symposium. “I adapted a melanoma patient care agreement form from an AAD meeting I had previously attended,” she explained. “The form is meant to be reviewed in-person with a patient when they have a new melanoma diagnosis. It reviews their stage, prognosis, recommended follow-up intervals, and their individualized treatment plan.”

“We have the patient sign and date the form, and I include it in their chart and the patient receives a copy as well. I now have all patients come into the office for melanoma results for a sit-down discussion.” While every patient did not want to come in for a sit-down discussion, Dr. Marsch found that most patients were willing to come in and have their questions answered.

Additionally, Dr. Marsch wanted to improve the speed at which newly diagnosed melanoma patients have their wide local excisions. “My aim was to have all melanoma patients receive appropriate melanoma surgical follow-up within target time goals we developed for each presentation and level of invasiveness found.”

“I updated my schedule template to allow at least one excision per day and hired a third medical assistant. I also reached out to colleagues in my area to allow direct and timely communication when an urgent referral is needed. The result was that all patients were getting their excisions done within a timely manner.”

Quality improvement activities are not without challenges. One of the biggest obstacles for Dr. Marsch was that she was not in control of the general, plastic, or Mohs surgeons to whom she would refer certain patients. “I had to build relationships with these individuals and have personal phone calls with them.”

“Another obstacle was getting buy-in from my staff who generally do not like scheduling surgeries because they require more time to clean and turn over a room,” she added. “I had to help them see that not only is this better for the patients, but it’s less work for them in the long run as it saves time faxing path reports and photos to outside surgeons. They also were spending a significant amount of time calling other offices to get final path reports faxed over to us.”

In addition to better clinical patient care, Dr. Marsch had improved the overall patient experience as well. “While there were challenges to overcome, my patients were very satisfied knowing that I either ‘worked them in’ to my schedule or ‘pulled strings’ with a colleague to get their appointment faster.”

Breaking down the process

“A lot of times with process improvement, we talk about using a Plan-Do-Study-Act (PDSA) cycle,” Dr. Strowd said. “Planning something, enacting it, doing it over a short period of time, and assessing whether it worked. If it didn’t work, is there anything we can do to optimize the process or to find a more permanent fix?” While Dr. Strowd’s projects were smaller in scale, they were things she identified that needed to be improved for better patient care. “They were meaningful to me and my practice, even though they weren’t the giant quality projects that hospital systems are capable of.”

“We are all super busy and these projects don’t have to be formal,” Dr. Marsch said. “Taking a more bite-sized approach, you can start with a very targeted patient population. For example, in my melanoma project, I could have started with just invasive melanomas with Breslow depth greater than 0.8 mm. You can then build on prior projects in a successive fashion.”

“It’s important to choose something that is important to your team and organization,” Dr. Smith said. “Having people invested in what you’re going to work on is key to the success of the project.” Dr. Parra suggests getting buy-in from a detail-oriented employee, whether that’s an office manager, PA/NP, or even a medical assistant.

“We also want to make sure that the projects we choose don’t increase burdens and worsen burnout,” Dr. Smith said. “With quality improvement, you don’t have to get it right the first time. It’s a process of continuous improvement.”

Each year, the Academy holds the Quality Improvement and Innovation Symposium at its Annual Meeting. “It’s a great opportunity to hear what other people have done and get ideas and inspiration for your own projects,” Dr. Strowd said. “Sometimes you can just take a project you’ve heard about, go home, and model it yourself.”

“If you start to look at your practice and how it’s operating through a lens of safety and quality, you will find little things that really would benefit from going through a small process improvement project,” she added. “Ultimately, it ends up making things more efficient and getting rid of problems that you might have spent time dealing with intermittently in your practice — and it’s better for patient care. When you solve a problem, you feel good; it’s a bonus that it can count toward MIPS.”

Keep things simple, recommended Dr. Khodosh. “QI science is just the scientific method. We often overcomplicate it. Focus on what is most important to your team and organization while making measurement part of your daily work.”

Additional DermWorld Resources