The Doctor’s Advocate | Second Quarter 2012
An Ounce of Prevention

In Pursuit of Quality: Embedding Patient Safety into Practice

by Sara Olson, BSN, RN

Robin Diamond
Robin Diamond, JD, RN

Sara Olson, a registered nurse for more than 30 years, has led the development of the Quality Factor Program. Using this approach, Sara has coached more than 100 medical groups to improve patient safety and protect the practice of good medicine. In this article, she describes aspects of creating successful patient safety–focused quality initiatives.

—Robin Diamond, JD, RN; AHA Fellow–Patient Safety Leadership; Senior Vice President, Department of Patient Safety

The Quality Factor (QF) Program is an innovative approach that enables practices to implement and sustain patient safety improvements. Begun in 2004, the QF Program is now a national initiative for The Doctors Company. It is designed for groups that want to work on patient safety improvement projects and are willing to invest time to gain the skills needed for success.

Current Situation 
Physicians and management are under increasing pressure to develop and implement physician-led quality improvement (QI) programs. This expectation will only heighten as new reimbursement models come into play and professional medical organizations require QI projects as part of their specialty board certification and recertification.

The workload demands, financial challenges, conversion to electronic health records, and ever-increasing regulatory requirements that dominate daily activities in most practices make it difficult for them to develop and implement QI programs. Despite pressures, practices are finding ways to improve patient safety—including our QF Program.

Program Design
Projects are designed to close gaps in patient care standards and guidelines, follow-up systems, and communication. Key features of the QF Program include the following:

  • Groups identify and manage their own projects.
  • Project leadership is physician-driven, with strong management participation. One physician champion is selected to represent each group or site. Physician colleagues agree to support the work of their physician champion(s).
  • There are minimal reporting requirements and written project reports.
  • Physicians and managers are coached in developing skills specific to their chosen projects. Just-in-time coaching is offered specific to the group’s issues.
  • The program provides periodic interactive education and training on topics such as leadership skills and quality tools.
  • New processes are embedded using intensity, repetition, and interactive education.
  • Team-building skills are developed over time and foster a culture of safety.
  • The curriculum includes proven methods in QI and performance improvement initiatives.
  • The program is flexible, allowing for group size, changes in structure, and QI initiatives already under way.

Case Study
A primary care medical group with 27 practitioners at five independent sites merged 10 years ago, primarily for business negotiation purposes. The group had a traditional leadership structure with centralized administration and one medical director. All five sites had physician clinical directors. The group decided to have all sites participate in the QF Program. Each clinical director had varying degrees of authority. Each site operated independently, and disagreement about how to approach any given issue was common.

The group’s participation began with a discussion of current risk vulnerabilities, for patients and the group. Each participating site then identified the specific risks or concerns it wanted to address. Patient referral and lab tracking, as well as lack of clinical information, were frequently identified as high-risk processes.

Each site received specific education and coaching in process change and the skills needed to manage change. Each identified a physician champion, along with a management designee. An initial meeting with all the team members was held, providing interactive education to discuss the goals and tools of the QF Program.

Each site was then given an opportunity to identify projects and define performance measures. The sites agreed on individual initiatives and goals. The program also offered the different sites an opportunity to collaborate with physicians within the group. Through regular, scheduled reporting, the teams stayed on track and monitored their progress in implementing and improving the systems.

By using human factors and system approaches, there was less emphasis on individual blame and more focus on resolving system problems. With coaching and leadership skills training, physicians enhanced their communication and problem-solving abilities.

The group’s organizational structure underwent changes during its participation in the QF Program. It decentralized a number of the medical director’s duties by reassigning them to the clinical directors. As the group pressed forward with this plan, it became easier for physicians who didn’t wish to assume new responsibilities to return to their practice. Each site found a physician who was willing to learn new skills and take on new challenges. Overall, these changes took approximately 18 months.

A challenge arose in getting physicians to work together effectively and to hold each other accountable. The group invested in short-term consultants and occasional extra meetings to address these issues. At one particularly difficult meeting, the group created a specific plan for managing themselves when a physician leader didn’t adhere to the group agreements.

By setting performance metrics and providing reports to each practitioner, each site could compare itself with its peers. The group began to see its initiatives quickly and successfully integrated. Whenever a site struggled, the medical director and administrator, with support from the QF Program coach, worked directly with site leaders to help them develop an issue-specific plan.

Using team building skills, withholding individual blame, and learning communication skills allowed the group to continue to make process improvements. Today, the group is highly functioning. It is able to deal with issues and implement new processes more efficiently than many similarly structured ambulatory practices.

Quality Factor Program Benefits for Many Medical Groups
When evaluating the QF Program, groups identified these positive characteristics:

  • A time investment that is reasonable
  • Financial rewards, including reimbursement advantages and possible malpractice premium offsets
  • Continuing medical education (CME) credits
  • Patient care systems and processes with increased effectiveness
  • Tools that are transferable to other projects
  • A functional QI program embedded in the group’s systems and processes
  • Culture changes and an array of organizational improvements

Additional Results
The graph shown below reflects the accomplishments of five medical groups with historically high loss ratios.* All have participated in the QF Program since 2004. The time period captured is 1999 through 2008. Accordingly, all are considered mature claims years. The years 1999 through 2003 include results that occurred prior to participating in the QF Program. The years 2004 through 2008 reflect the results that occurred while participating in the QF Program.

The groups shown here vary in organizational size and structure and include a large multispecialty group, a small internal medicine group, a medium family practice group, a small family practice group, and a small specialty group with an ambulatory surgery center (ASC).

Loss Ratios of Five Groups Before and After Starting QF Program

Summary
The Doctors Company resolutely believes in advancing the practice of good medicine. By implementing The Doctors Company Quality Factor Program, physician groups are able to successfully make patient safety and quality improvements. Physicians and managers can be more effective and apply their leadership skills in other arenas. As they solve problems more efficiently, they will be in a better position to navigate the changing health care environment safely. For more information, contact the Patient Safety Department at (800) 421-2368, extension 1243.

Here’s what our members are saying about the Quality Factor Program:

“It has given us tools to do risk management that are simple, effective, and have been readily accepted by our staff.”

“The Quality Factor Program makes practices dedicate a specific time to risk management and its implementation. It is important that both an MD leader and business manager attend the meetings because changes almost always involve both the office and medical staff.”

“The QF Program has provided a very usable framework around which we organize projects that investigate and improve the quality of workflow in our offices.”


The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.

The Doctor’s Advocate

Second Quarter 2012

Director's Forum
Electronic Health Record Risks

An Ounce of Prevention
In Pursuit of Quality: Embedding Patient Safety into Practice

Politically Speaking
Supreme Court: PPACA Ruling Expected in June 2012

Foundation News
2012 Winners of the Young Physicians Patient Safety Award

Southern California Physician Advisory Board Update

Seminars and Webinars to Meet Your CME Needs

The Back Page
Industry and Company News

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