New Strategies for Excellent Care in Internal Medicine


July 2013
-- As an academic department within an urban, comprehensive and advanced medical center, the Department of Internal Medicine provides care to a high volume of complex patients. In an effort to address that challenge, the department instituted its own Quality and Performance Improvement Program last year.

The director of the program is Dr. Sarah Hartigan, Assistant Professor and Hospitalist in the Division of General Internal Medicine, as well as recent graduate of the Intermountain Healthcare Advanced Training Program in Quality Improvement.

Dr. Sarah Hartigan is a Hospitalist in the Division of General Internal Medicine and is Director of Internal Medicine’s new Quality and Performance Improvement Program.


“Quality Improvement represents a fundamental shift in our idea of the work of healthcare. It is a commitment to the continuous pursuit of clinical and service excellence by driving change at the system level, rather than focusing on the performance of an individual clinician,” Dr. Hartigan explains. Each of the Department’s ten clinical divisions has a physician who serves as a Quality Improvement Representative and reports to Dr. Hartigan. This group of representatives meets monthly to identify ways to enhance the quality of care across the entire department and assess the effectiveness of their efforts.

The largest collaborative effort the group is undertaking is aimed at improving inpatient mortality. To do this, the group has initiated structured reviews of all deaths in the Department of Internal Medicine. To date, they have identified several opportunities for improvement and have ongoing efforts to address these, including:

  • Safe management of high risk medications, especially anticoagulants (Dr. Alice Wong) and opiates (Dr. Michael Bradley & Dr. Betsy Miller).
  • Ensuring evidence-based care of the septic patient (Partnership with an ongoing project led by Dr. Evan Meadors and the Performance Improvement Department)

The group is also focusing on publicly reported quality measures. “With the initiation of the CMS Hospital Readmissions Reduction Program, VCUHS faces reduced payments for excess readmissions, particularly for congestive heart failure patients,” says Dr. Hartigan. Dr. Keyur Shah has led an interdisciplinary effort to analyze current barriers to patient-centered care for this high-risk population. In partnership with the Performance Improvement Department, he has developed a proposal for expanding continuity of care to these patients through an innovative shared medical appointment model.

“Quality Improvement represents a fundamental shift in our idea of the work of healthcare. It is a commitment to the continuous pursuit of clinical and service excellence by driving change at the system level, rather than focusing on the performance of an individual clinician.”

In addition to focusing on publicly reported and externally mandated quality measures, Dr. Hartigan believes the department must also prioritize local improvement efforts. To this end, the hospitalist medicine service has developed an initiative to ensure patient centered, high value care for their diabetic patient population. The project is led by Dr. Michelle Brooks in partnership with the Division of Endocrinology and Metabolism. Currently, they are working to develop a more structured, collaborative approach to delivering patient education and ensuring seamless transitions of care for diabetic patients. In the next year, they will focus on improving inpatient glycemic control through use of protocols that reduce variation and ensure evidence-based practice.

Part of the success of these efforts will come from arming the department’s physicians with the necessary tools for success, including relevant internal performance data. “Like many other institutions with integrated electronic medical records systems, we are data rich but information poor. We must find a way to leverage the power of the EMR to provide front-line clinicians with real-time, meaningful data,” says Dr. Hartigan. The institution is working to create this type of data system. Dr. Hartigan hopes that this will empower all providers to participate in the department’s quality improvement mission. -- IM

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