Rx for Primary Care

Sheldon D. Horowitz, M.D., a special advisor to the president of the American Board of Medical Specialties and principal investigator of the Improving Performance in Practice (IPIP) initiative, writes about an effort to give small physician practices the tools they need to improve quality.

Today is National Doctors Day, a day set aside to thank physicians for all they do in applying modern medical science and technology to the special calling of preventing and treating people’s injuries and illnesses. It seems appropriate, then, to recognize a program devoted to helping doctors in primary-care practices do that more effectively.

The program, called Improving Performance in Practice (IPIP), provides practices with tools, support, coaching and a collaborative learning environment in which they can assess their performance and engage systematically in quality-improvement activities using their own practice data. Doctors can also compare their data to others in their cohort groups as benchmarks.

As everyone involved in quality improvement knows, translating the latest and best medical techniques and protocols into practice is easier said than done. That’s especially true for the small offices where 60 percent of U.S. physicians work. Compared to big hospitals and integrated group practices, they typically have fewer resources available for quality-improvement efforts. IPIP fills the resource gap for small practices in seven states by giving them process-improvement kits based on the Chronic Care Model and providing quality-improvement coaches, typically registered nurses, to guide practices through the steps involved in taking full advantage of the program’s resources.

To enroll, practices choose a focus area—asthma or diabetes in most cases—and commit to using a registry or electronic medical records to manage their patient populations, if they don’t already. Then they begin providing monthly data on a set of quality measures covering care processes and outcomes.

Such measurement and reporting are essential. As one Colorado doctor told IPIP staff, “Until I saw my data, I thought I was providing excellent care. Now I see we have a lot of work to do.”

Among other things, coaches help practices improve their division of labor and work flow by relentlessly asking the question: “Is this physician work or non-physician work?” If a doctor isn’t needed for a particular task—say, administering an annual sensory exam to diabetics to test for nerve damage—then someone else in the office should take care of it so doctors can focus on the things that only they can do. These work-flow improvements help practices get more done—and also improve job satisfaction. “I was considering leaving the profession,” Dr. Tracy Hofeditz of Lakewood, Colo., told IPIP staff. “But now I have rediscovered the joy of practicing medicine.”

One key benefit of participating in the program is that it helps practices comply with ABMS Maintenance of Certification®, professional recognition for quality and pay-for-performance programs.

Patients, meanwhile, get more effective care. For example, in the 16-month period between June 2008 and October 2009, Pennsylvania IPIP practices saw a 15-percentage-point increase in the share of diabetes patients with blood pressure of 140/90 or less—an important threshold level to stay below.

That kind of success helps explain why IPIP, which began as a small pilot program in Fall 2006, has quickly grown to serve more than 350 practices with 1,400 doctors and 350,000 asthma and diabetes patients from Colorado to North Carolina.

For more about IPIP, which is sponsored in part by the Robert Wood Johnson Foundation and convened by the American Board of Medical Specialties, download a copy of its recently released program brief.