KDJ Consultants had the privilege of assisting HealthTexas Provider Network (HealthTexas) in their commitment to improve the quality of care delivered to patients. Through a strategy of Clinical Transformation, HealthTexas began by measuring how well they deliver preventive services. Then they trained groups of physicians, nurses and administrators to be quality champions, and moved to the development of the Patient-Centered Medical home model. HealthTexas made remarkable progress in developing and implementing effective quality improvement initiatives.

HealthTexas is a multi-specialty, physician-led, patient-centered medical group practice established in 1994 with more than 500 primary and specialty care physicians across Texas. It is a subsidiary of Baylor Scott and White Health Care System. HealthTexas’ passion is the continuous improvement of quality of care for the people they serve. Their mission is to achieve excellence in the delivery of accessible, cost-effective, quality health care, resulting in demonstrated customer satisfaction regarding the value delivered to patients, payers, and the community.

HealthTexas’ Adult Preventive Healthcare Services (APHS) initiative was based on a Patient Safety report published by the Institute of Medicine which points out that patients lose their lives in the ambulatory care setting by errors of omission as well as by errors of commission. That is, lives are lost not only because of what is done to patients, but also because of what is not done for patients. Based on this evidence, HealthTexas put APHS processes in place that enabled physicians to monitor patient follow-through in obtaining a recommended service that could result in early detection of chronic or potentially fatal diseases.

In the early stages of HealthTexas’ APHS initiative, the Best Care Committee designed a study to audit the medical records of all primary care physicians for the following evidence-based adult preventative measures (USPSTF):

• tobacco use and counseling,
• cholesterol,
• colorectal cancer screening,
• breast cancer screening,
• cervical cancer screening,
• osteoporosis,
• hypertension,
• adult immunizations for flu and pneumonia.

Initially, all the HealthTexas practice audits were performed by practice administrative staff, but HealthTexas later enlisted KDJ Consultants to continue the APHS study on a contract basis.

KDJ Consultants began working with HealthTexas in 1997 and had a proven track record of success with their Credentialing department. Upon review of the APHS data abstraction process, the Best Care Committee recommended that HealthTexas use KDJ nurses to abstract data for the APHS audits. All KDJ nurses were trained on HealthTexas APHS guidelines by the HealthTexas Director of Clinical Excellence. Inter-rater Reliability (IRR) was completed to validate the nurses’ training and understanding of the study guidelines.

A new flow sheet was created and attached to every medical chart. It reminded physicians, nurses, and office staff to check on the need for preventative services at each patient visit. With the flow sheet in place, the APHS audit was repeated on 50 records. Following the audit, the data was reviewed and significant improvement in the results was seen.  It was found:

• The use of KDJ Registered Nurses rather than HealthTexas practice administrators improved the accuracy of the data collected and increased physician confidence in the results.
• KDJ nurses went beyond just abstraction and spent time with HealthTexas corporate staff and providers giving valuable insight regarding medical record content.
• Some improvement was attributed to the “Hawthorne Effect”, defined as the alteration of behavior by the subjects of a study due to their awareness of being observed.

Detailed guidelines for the APHS study were written and annual updates done, based on current preventive services literature and input from KDJ nurses. These guidelines and IRR results were reviewed annually by the Best Care Committee and given to the KDJ nurse reviewers as training updates.

HealthTexas and KDJ Consultants continued to monitor physicians’ quality scores but soon noticed that HealthTexas had reached a plateau, and quality scores were not improving.  After reviewing the data, they realized that APHS services could be improved by bringing a new focus on physicians getting patients to complete their recommended services. To accomplish this several interventions took place:

• Scoring methodology was updated so physicians received positive marks of “yes” or “done” ONLY if the patient actually got the service as recommended by the physician.
• “Recommended” and “refusal of services” were scored as a “no” or “not done”. Providers were advised to use every patient visit to address preventive services.
• HealthTexas unblinded the audit results for all clinics, creating a competitive environment.
• As questions arose regarding the validity of data at the clinic level, IRR was done with the care provider.  These one-on-one meetings became an opportunity to share new information with the care provider and build their trust.
• Rapid cycle improvement projects were initiated and resulted in the creation and distribution of tools and processes which were then shared across all HealthTexas clinics, facilitating further improvement in the delivery of preventive services.

As a result of this study and the ongoing education, HealthTexas providers improved their preventive health scores from the low of 57% to an average of 98%. This study continued for eleven years.

*Original article written by Chris Felton of HealthTexas and Kay Jones. Special article contributions from Barbara Hinds and Becky Headley.