#MEQAPI – Tweetchat Oct 19-2017 3:00ET #ChoosingWisely

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement, and you can visit us at http://www.meqapi.org.

I want you to look at the following chart. It categorizes the current level of waste in the U.S. Healthcare system in billions of dollars, per year.


The “good” news is that we aren’t missing too many opportunities to prevent illness – only $55 Billion dollars a year are lost because we didn’t effectively address a preventable illness.

The rest of the news is pretty appalling. We waste more on fraud and abuse than missed opportunities, and even knowing that medical prices in the U.S. are exorbitant, excessive prices are easily outstripped by how inefficiently we deliver care. And then there is oversupply. $210 Billion in oversupply is a stunning number, made even more ironic because even with that, we still had the $55 Billion worth of missed opportunities.

One component of a solution to bringing down these embarrassing numbers is to partner with patients in a value-based and patient-centered approach to using evidence-based medicine in a way that addresses the patients health goals.

Let’s unpack that jargon-stew.

  • Patient partnership: plainly put, if the patient isn’t part of the team, then chances are they won’t comply at a very high rate, and the care plan will address something other than what the patient sees as priorities. Priorities must be a joint effort, and not dictated by the physicians if we want the patients to comply with the plan and have a sense of ownership, and not left to the patient if we want the plan to be medically sound.
  • Value-based: The alternative option is Fee-for-Service, which prioritizes profit over patient well-being, and nothing will shut down patient trust and partnership faster than the thought that the selection of the care plan is about profits rather than health.
  • Patient-Centered:  IOM (Institute of Medicine) describes patientcentered care as: “Providing care that is respectful of, and responsive to,  individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.”
  • Evidence-based medicine: This is about using things that work, and updating practice to stay in line with what we can prove is working. Masic et al, describe EBM is follows “… the conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patients. EBM integrates clinical experience and patient values with the best available research information.

The American Board of Internal Medicine (ABIM) has launched the “Choosing Wisely” campaign as an attempt to move us down this path.

Choosing Wisely aims to promote conversations between clinicians and patients by helping patients choose care that is:

  • Supported by evidence
  • Not duplicative of other tests or procedures already received
  • Free from harm
  • Truly necessary


The following pertinent articles have been provided by Physician’s Weekly:

We will take a QI approach, and discuss the topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat.


Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:

    • Methods
      • Policies: office, organization, or national policies, including, etc
      • Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
      • Quality Improvement Policies
      • Subsidies and funding
      • Facility Policies
      • Specialty Policies
      • Employment policies
      • National and State Laws
      • Training
      • Navigable processes and policies
      • Patient Centeredness
      • Evidence Based Medicine
      • Value-based Care
    • Machines (incl equipment, EHR)
      • Personal Safety Equipment
      • Real Time Locator Systems (RTLS)
      • Med Equipment
      • Equip Ergonomics
      • Interoperability
      • EHR/Software
      • TeleHealth
      • Home Equipment
      • Access Control
      • Office Equipment
      • Product tracking
      • Outcomes tracking
    • People
      • Staffing: sufficient and qualified staff
      • Patients – objectives, attitudes, ability to cope, beliefs, power-distance, health literacy
      • Subject Experts
      • Malpractice suits
      • Role Models, celebrity influence
      • Peer support/conflict
      • Training
      • Vendors
      • Friends/Family
      • Patient participation
      • Attitudes/Bullying
    • Materials
      • Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
      • Supplies: medical or office, inferior fax paper,
      • Data: ability to securely share with correct patient, specialist, lab, etc., and Access to Information
      • Patient self-care materials including checklists and how-to instructions, contact information for questions, and self-care consumables
      • Internet sources and access
      • Checklists, SoPs
      • Uniforms, footwear, personal protective equipment
      • Costed consumables
    • Measurement
      • Health outcomes
      • KPIs: operational metrics required by practice, local government, state, federal
      • Quality and safety metrics
      • Targets: set by practice, insurer, etc. as well as patient goals
      • Gini Index
      • Incentives and rewards
      • Adverse Eventss reporting
      • Effectiveness of measurement
      • Productivity Metrics
      • Patient Goals
    • Environment
      • Noise: distracting noises, sound levels too high, etc. due to computer systems
      • Space: Cramped, uncomfortable work space etc.
      • Time: Too little time per patient or order, too little time in a day, too many demands
      • Location: things where they should be on the screen, click distance, and location of workstation relative to point of care and patient
      • Control: the degree to which the individual can control their workload and how to accomplish it
      • Fairness: the perception that the burdens and rewards, the effort and outcomes are spread amongst stakeholders in an equitable way
      • Temperature: too cold, too hot, too variable
      • Interruptions
      • Political climate
      • Social norms and group identity
      • Electrical Power
      • Climate and weather
      • Income inequality
      • Time
      • Direct marketing to patients

Some of the authors of the works cited above may be responding to the following topics, and participants are invited to describe their experiences of medication errors, and offer their insights and observations.


  1. What METHODS increase or reduce risks related to achieving the aims of #ChoosingWisely
  2. What MACHINE factors increase or reduce risks related to achieving the aims of #ChoosingWisely
  3. What PEOPLE issues increase or reduce risks related to achieving the aims of #ChoosingWisely
  4. What MATERIALS increase or reduce risks related to achieving the aims of #ChoosingWisely
  5. What MEASUREMENT factors increase or reduce risks related to achieving the aims of #ChoosingWisely
  6. What ENVIRONMENTAL factors increase or reduce risks related to achieving the aims of #ChoosingWisely


MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.



Published by

Matthew Loxton

Healthcare Analyst using Lean Six Sigma, Knowledge Management, & Organizational Learning to improve healthcare http://linkedin.com/in/mloxton

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