Better Care from the Bottom Up
Since 2012, the Department of Medicine at the University of Vermont Medical Center has challenged its faculty to initiate high-value care projects that use Choosing Wisely® recommendations to identify and reduce low-value care practices.
“Our chair viewed this as a priority for faculty members and gave them resources to pursue their quality question,” said Justin Stinnett-Donnelly, MD, who recently authored a quality improvement report in BMJ about this effort. “This program was different because all of the ideas, which the Choosing Wisely campaign seeded, were generated by physicians in direct patient care.”
Seeking ideas from physicians gave them ownership over the process and fostered collaboration among team members. This bottom-up approach placed the person who raised the idea for the project in the role of “clinical champion,” making them the change agent in their department and encouraging them to engage colleagues in the work.
“This novel approach changes the conversation a bit within a team, and I think that it really helps grease the wheels of change,” Dr. Stinnett-Donnelly said. “We want to be able to ask if each project is worth investing resources in, and determine the problem with the low-value care practice and its magnitude.”
Physicians’ bedside observations inspired project proposals, which were submitted to the Department of Medicine Operation Efficiency Committee. The committee evaluated more than 20 proposals on whether they were evidence-based, included an electronic measure and had potential for a meaningful outcome.
For each intervention the project team first determined a way to measure the frequency of the low-value care practice in question by pulling baseline data from electronic health records (EHRs). Due to the complicated nature of compiling this information, collecting metrics became a learning experience and shared effort involving inter-professional groups of lab technicians, nurses and imaging technicians.
“It’s tricky to find out what the right amount of a test or procedure is, so we encourage clinical experts to cite evidence that what they want to do is within the standard of care,” Dr. Stinnett-Donnelly said. “It is not a requirement that projects align with a Choosing Wisely recommendation, but it is helpful if they do because the recommendations are consensus statements from experts within a specialty.”
Most projects relied on a combination of physician education through mailings and meetings, best practice advisories within EHRs or redesigned paper and electronic order sets. These methods yielded successful results so far, including:
- 72 percent reduction in labs for patients with end-stage renal disease, based on the recommendation from the American Society of Nephrology.
- 90 percent reduction in DXA scans for patients younger than 65 with low risk for osteoporosis, based on the recommendation from the American College of Rheumatology.
- 71 percent decrease in portable chest X-rays in intubated patients, based on the recommendation of the Critical Care Societies Collaborative.
Projects are continuing to be monitored through quarterly status reports, and discussions have started on ways to make the program sustainable, expand interventions to other departments, and continue to engage key participants to further reduce waste and overuse.
“Resident and fellow involvement has been powerful,” Dr. Stinnett-Donnelly said. “They understand the nuts and bolts of what happens on a daily basis. Involving bedside nurses and other care providers has also been beneficial because they understand the system.”
