Asset-Based Quality Improvement Report & Tip Sheet

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Volume 48, No. 11, November 2022 601 reviews and conversations between peer reviewers and the HCPs under review, allowing the HCPs to provide clinical context to the event. Peer reviewers typically reviewed 0 to 2 events per month. By reviewing adverse events, the peer review committee's goal was to improve the quality of care provided by the organization's HCPs. This committee pre- dominantly focused on care at the outpatient health centers, as each hospital's medical staff operated its own peer review committee. In 2014 the ambulatory peer review committee reviewed 68 cases, and this volume increased to 88 cases in 2017. However, in subsequent years, case volumes steadily de- clined, with 57 cases in 2019. Given the increasing size of the medical group and large number of patient encounters, peer review committee leadership was concerned that these declining case volumes were, at least in part, secondary to adverse event underreporting. This opinion was bolstered by negative feedback that committee members regularly re- ceived from HCPs undergoing peer review. Such feedback included the following statements: "I wouldn't have sub- mitted this incident report had I known it would result in a peer review investigation" and "I'm glad to be retiring soon – I won't have to deal with peer review anymore." Some HCPs refused to communicate with peer review committee members and referred the committee to lawyers. Ultimately, the committee believed that its AER processes, although necessary for quality assurance, may be detracting from the organization's quality improvement goals and unintention- ally contributing to an emotionally negative culture among HCPs. Given the negative sentiment surrounding the peer re- view process, the medical group's peer review committee investigated ABQI as a complementary quality improve- ment approach to AER. The hope was that ABQI would surface impactful quality improvement topics, and by high- lighting stories of excellence it would counteract HCPs' negative sentiments toward the medical group's quality ini- tiatives and promote a positive culture. 15 The ABQI pi- lot project was sponsored by organizational executive lead- ership and supported by medical group physician leader- ship, with the intent to expand throughout the organiza- tion pending results of the pilot. The ABQI planning group included physicians from the peer review committee, med- ical group physician leaders, quality improvement nurses, patient safety nurses and staff, and information technol- ogy staff who support the peer review process. The ABQI group was called the Appreciative Inquiry Team (AIT) be- cause their mentality was inspired by the appreciative in- quiry technique. 13 Tool Creation, Iterative Improvement, and Integration into Reporting Platform The AIT initiated planning in late 2019 ( Figure 1 ). Their objective was to create a tool into which frontline HCPs in- put stories describing consistent clinical excellence involv- ing themselves and/or colleagues. The AIT would then use the tool to analyze these stories with just as much rigor as the peer review committee analyzes adverse events. These analyses included direct communication with the reported HCPs, as these conversations would add personal context to the stories and provide immediate positive feedback to the frontline HCPs. Elicited best practices and operational efficiencies would then be shared organizationwide. Our institution uses Converge Platform (RLDatix, Chicago) for its AER tracking and management. Thus, the AIT engaged with RLDatix to adapt Converge Platform for its ABQI project. The AIT first drafted a series of ques- tions that HCPs would answer when inputting stories of excellence—the front-end component of the ABQI tool. To facilitate frontline HCP participation, the planning group prioritized ease of use. Therefore, the HCP questionnaire consisted of mostly one-click answers and minimal open- ended questions that required typing answers. Drafts of this questionnaire were streamlined through iterative feedback with peer review committee physicians and medical group physician leaders. For the analysis portion of the ABQI pro- cess, the AIT drafted a questionnaire for AIT team members to complete after their review of the submitted stories and direct conversations with the reported frontline HCPs—the back-end component of the ABQI tool. The aim was to cre- ate open-ended questions that catalyzed AIT team member reflection and team discussions. These back-end compo- nent questions were inspired by just culture methodology, 21 which is currently employed by the medical group's peer review committee. Drafts of these analysis questions were iteratively edited using feedback from peer review commit- tee physicians and medical group physician leaders. When finalized, RLDatix incorporated the front-end and back- end component questionnaires into an AIT program within Converge Platform, thereby creating our ABQI tool. To en- sure functionality, the AIT extensively tested the tool by in- putting fictitious stories and simulating analyses. Implementation: Target Sites, Team Recruitment and Training, Organizational Communication After the tool was operational, the AIT planned for launch in January 2021. The ABQI tool would be accessible on the organizational intranet for use by frontline HCPs and staff. Importantly, because this project originated from the med- ical group's ambulatory peer review committee, the AIT planned to pilot the ABQI tool systemwide within all out- patient health centers. To perform the ABQI story analyses, the AIT recruited a multidisciplinary team of nine medical group–employed primary care and specialist HCPs as well as six nurses. Team membership was voluntary, and to facilitate project imple- mentation, all initial team members intentionally had cur- rent or previous roles in quality and safety improvement teams. Eight AIT members were concurrent members of the peer review committee. Over two orientation sessions,

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