Goals of Medical Performance Improvement

Understanding Best Clinical Practices

By Brent A. Metfessel; MD, MSbiz-book

The major goals of medical performance improvement are twofold: First, for a particular practice pattern measure, the desire is to narrow the practice variation around the present health care mean. For instance, the spread of the distribution of a cost variance measure should decrease with process improvement.  Second, clinical guideline-based “best practices” can be utilized to move the entire provider population mean toward better cost-efficiency and quality.


Although best-practices may be guideline-based, they should be adapted to local considerations and evaluated periodically through actual outcomes analysis. Such outcomes measures may include:

  • Cost-efficiency improvement, showing a decrease in resource utilization.
  • An increase in the performance of preventive measures, such as childhood immunizations and various screening tests such as breast and cervical cancer screening.  This may increase costs initially but will more than pay for itself through a decreased illness burden and cost in the future.
  • A decrease in episode length, usually implying a quicker resolution of symptoms.
  • A decrease in emergency room visits and unplanned hospital admissions.
  • A decrease in the rate of “sentinel events” such as status asthmaticus, hemorrhage during pregnancy, diabetic ketoacidosis, and ruptured appendix.

Many of these measures can be obtained using commonly available claims and administrative databases, although supplementation with clinical and functional status data will only increase the reliability and scope of outcomes analysis.


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In order to see significant performance improvement in response to quality improvement initiatives, one must be patient.  Two to three years may be needed to see this improvement.  Trending of measures helps analysts to determine whether such improvement is occurring.  Trending of data, however, can be quite resource-intensive since there must be an adequate data set – usually requiring storage of data for several years of experience. 


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2 Responses

  1. A wise dentist once advised me to move to a new community to practice at least once: so you don’t have to live with your f-ing dumb mistakes throughout your entire g-damn career.

    Preachers are encouraged to do the same.

    D. Kellus Pruitt; DDS


  2. Common sense trumps Pay for Performance

    I submitted this to be posted on Dentalblogs.com following a comment by someone named Gtdentistry.

    D. Kellus Pruitt DDS

    Dear Robert from Gtdentistry:

    On May 28th, you casually mentioned that you expect analysts to assess quality in dentistry, so I asked you for more information about it.


    I scan the news closely for stakeholders’ plans for quality control in dentistry just like you refer to. My most recent sighting of information about national intentions was a commentary by Dr. James D. Bader in the December 2009 edition of the JADA titled “Challenges in quality assessment of dental care.”


    Dr. Bader – a fervent supporter of Evidence-Based Dentistry as well as paperless practices – describes an oppressive, micromanaged future for dentistry. The operative dentistry instructor reasons that quality assessment is important so that real dentists can prove to the nation that their care is better than almost-dentists. I say that is a lame reason for interference in dentist-patient relationships.

    The first time I heard about the connection between HIPAA and quality control was in February 2006 when an employee in the ADA Department of Dental Informatics accidentally hinted at those plans in an email. When I asked him to elaborate, just like you, he failed to respond. I then pressed the issue like I often do, and ultimately, a Senior ADA Vice President requested that I stop asking his employees questions about HIPAA and to write a letter to the editor of the JADA if I wasn’t satisfied with evasion. So as you can see, that is why I’m hoping you will be more forthcoming with what you know, Gtdentistry. I get tired of the runaround.

    I don’t come empty handed.

    Since you show an interest, let me share some recent information about the progress of the national plan for quality control in healthcare that appeared a few days after you brought up the topic on dentalblogs.com.

    “Clinical Analytics: Can Organizations Maximize Clinical Data?” was published on June 7, by HIMSS Analytics. It doesn’t look good for HIT and analytics stakeholders like Dr. Bader.

    Click to access Clinical_Analytics.pdf

    Today, Bernie Monegain, Editor of Healthcare IT News, posted his opinion of the results that were released yesterday “Study reveals limited expectations for use of clinical data”


    In Monegain’s opinion, there are serious IT problems that might or might not be successfully solved before application of an imperfect quality control system to physicians’ practices. Personally, I think Monegain wrote a happy article. If the US government has this much difficulty accessing physicians’ patients’ private data for their biased algorithm tricks, dental practices in the nation will prove to be impossible to micromanage, and Pay for Performance will continue to be only stakeholders’ fantasy of utopia.

    After all, our fees are much less than physicians’, and because of the nature of our work, the NPI number cannot be used to leverage our practices from the free market. Some of us will always accept full payment at the time of service as part of the deal with consumers who prefer to see dentists of their choice anyway – not the dentists preferred by HHS computers.

    We should be thankful that Adam Smith’s theories of economics he described at the time of the American revolution against tyranny over two hundred years ago still trumps Bush/Obama’s plans for an artificial healthcare market. Healthy competition with colleagues naturally weeds out almost all HIT parasites in American dentistry. It’s difficult to sell digital interoperability when a dentist using a pegboard, ledger cards and the US mail can already sell dentistry cheaper and safer than paperless dentists – even while clearing more profit per procedure.

    To tell you the truth, Gtdentistry, I hope Dr. James Bader and other stakeholders who depend on eDRs never succeed. For every dollar we are forced to raise our fees for even good ideas, someone in our community, likely a child with a toothache, can no longer afford our care. Let’s not carelessly assist others to cause our patients harm. What do you say, Gtdentistry?

    D. Kellus Pruitt; DDS


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