PracticalDermatology

Quality—a word that should connote a positive sentiment in health care—has now started to develop a negative undertone. The Centers for Medicare & Medicaid Services (CMS) define quality measures as “tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care.”¹ While this definition may appropriately capture the ideal scenario, in practice, quality metrics often translate to increased administrative burdens that seem unconnected to the care that we provide. One example is the provision of tobacco cessation counseling in a dermatology clinic. Although there is no dispute that tobacco cessation tools should be provided to current smokers, the appointment for an annual full skin exam may not be the ideal time to address this topic, given the limited resources and the short appointment time.² Even as the American Academy of Dermatology (AAD) seeks to develop quality measures that are more relevant to dermatology, the current choices for quality metrics often seem outdated and unconnected to the true dermatologic care that we provide.³

Like many of you, I have yet to meet a dermatologist who considers the care they provide to be “low quality.” When asked to explain how their practice offers better care, dermatologists often revert to a similar group of answers: their practice is collaborative, their patients get better, and their patients are happy. It would seem straightforward to develop quality metrics based on the goals above of collaboration, clinical improvement, and patient satisfaction. However, this task is almost impossible given the paucity of standardized and widely accepted clinical outcomes, as well as the variability of patients’ and clinicians’ preferences in clinical care.^4,5 The tactical quality initiatives that various dermatologists suggested varied substantially by their practice mix, practice location, patients’ education level, number of years in practice, etc. Hence, we are back to the initial limitations of quality metrics being outdated and potentially irrelevant.

So, is there a standard of quality that most dermatologists can agree upon that is easy to demonstrate for others? Yes. We see this in our informal conversations with colleagues about various practices around us. We have a good sense of which practice to join, recommend our friends and family to, or how we want to build our own practices. We steer away from the practice across town that has the dermatologist who biopsies too much, the pathologist who overcalls, the culture that does not promote collaboration, the administration that decreases clinicians’ independence, or the patients who are not happy. Thus, even with all the debate about “quality” in healthcare, we all know a high-quality practice when we see it.

In my role as the Director of Clinical Strategy and Quality Assurance, I often face skepticism from other dermatologists about what constitutes a “high-quality” practice. Clinicians wonder if quality is just another hurdle or check box that must be filled for them to earn the entirety of their collections. Although this skepticism is understandable, I try to reframe the conversation to center on their personal definitions of quality and what they would ideally want in their practice. Instead of promoting the national quality measures as the center of the quality program, we have tried to reclaim quality by redefining what it means. Quality is mutually agreed upon with the dermatology clinicians to include many components of clinical practice: clinician independence, clinical support, continuous education, clinical collaboration, and relevant clinical endpoints. When I deliver on these broad metrics in an administrative capacity, clinicians often view quality as a necessary function of their practice, rather than a burdensome administrative nuisance.

How can dermatologists reclaim quality?

Clinical independence. It goes without saying that clinicians do not want to be told how to take care of their patients by administrators or others who are removed from the actual care delivery process. Therefore, one crucial function that must occur is the preservation of clinician independence by the inclusion of practicing clinician in the administrative decisions of the practice. This can be accomplished through the inclusion of clinician advisory panels for the major decisions that practices need to make. In addition, other active administrative roles that include practicing clinicians are crucial to ensuring that the clinician’s voice echoes through the design and operations of the practices. These roles of clinician advisory panels or clinicians with active administrative roles are different from the typical clinician leader roles that we often see where the clinician on the administrative team does not have experience practicing in the environment that they design. When the clinicians are involved in the practice leadership, there is often a push to maintain overall clinician independence to upload the level of care that is provided to patients.

Clinical support. Good clinical support can dramatically increase the productivity, safety, and quality of care that a dermatologist can provide. This is likely due to the variety of procedures and fast pace of a dermatology clinic. When clinicians feel supported, they can focus on what really matters: clinical care. However, there many obstacles that prevent the provision of the ideal clinical support. This is where a practice can differentiate itself by creatively providing reliable clinical support to the clinicians. Medical assistant retention programs and other innovative processes can distinguish a practice as high quality. With clinicians focusing on clinical care, they can spend the required time it takes to evaluate, treat, and educate patients.

Continuous education. The ideal scenario is that all clinicians work at the top of their degree to tickle the academic curiosity that sparked our interest in medicine. Many of us continue to be interested in groundbreaking therapies to ensure that we continue to provide our patients with the best care. We also want to learn about how other colleagues deal with complex, and sometimes routine, cases. In a typical practice, there is little professional interaction amongst your colleagues for that enriching intellectual exchange. Many clinicians have to rely on external meetings and conferences to keep up with the advances in dermatology. However, we have found that clinicians highly value group practices that can provide an avenue for relevant continuous education. In some academic practices, this is in the form of grand rounds. For the majority of dermatologists in private practice, attending grand rounds is not possible or feasible. Therefore, practices that create internal medical education meetings for the clinicians provide an effortless avenue to continue our academic curiosity.

Clinical collaboration. Medicine is a team sport. Having a robust network of clinicians who are experts in their respective fields in dermatology to refer patients to or even to curbside can greatly improve the quality that a clinician can provide. The COVID-19 pandemic highlighted this need. We saw many clinicians reaching out to their peers to check if the clinical scenarios that they encountered could potentially be related to the pandemic. In our experience, fostering clinician communication through internal communication tools can highly increase the perception of quality in a practice. The clinicians who are able to seek advice or learn from their surrounding peers find that this improves the quality of care that they provide. Clinicians in more bureaucratic or isolated practices anecdotally reported less satisfaction.

Relevant clinical endpoints. We all know that feeling when your patient achieves the clinical endpoint that they desire. This might be the acne patient who is completely clear, or the one who was able to get almost clear on just topical medications because of their intolerance to pills, or the one who is proud to have decreased their breakouts with only “natural” ingredients. Endpoints differ for various patients, so we need to recognize this heterogeneity in our quality metrics. For example, we have found that both clinicians and payers respond favorably when they understand that biologics are prescribed for patients with high disease burden or a large negative impact on their quality of life. This is precisely why higher quality practices tend to focus on metrics that are relevant to the clinician. If a metric is too heterogeneous and will not be seen to improve care, it is either not pursued or not emphasized for the clinicians. We have found that clinicians highly value when they are not being tasked with metrics that are not relevant for them to provide care. Conversely, clinicians are highly motivated to perform well on metrics that are specific to their dermatological practice and will improve care.

Reclaim “Quality”

Overall, quality may be subjective, but dermatologists can often agree upon a high-quality practice when they see one. Simplifying quality into a few validated metrics does not generally capture the complexity and the subjectivity of the work that we do. In the context of increasing cost pressures in medicine, dermatologists may eventually need to demonstrate that our chosen quality measures will lead to cost savings or cost neutrality in the system. However, before we can even begin to discuss value in medicine, we need to reclaim what quality means to us in dermatology.

1. CMS.gov. Quality Measures. 2020; https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures. Accessed 12/07/2020, 2020.

2. Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. The Cochrane database of systematic reviews. Mar 31 2017;3:CD001292.

3. American Academy of Dermatology A. QUALITY MEASURES. 2020; https://www.aad.org/member/clinical-quality/measures. Accessed 12/7/2020, 2020.

4. Elman SA, Merola JF, Armstrong AW, et al. The International Dermatology Outcome Measures (IDEOM) Initiative: A Review and Update. Journal of drugs in dermatology : JDD. Feb 1 2017;16(2):119-124.

5. Gottlieb A, Salame N, Armstrong AW, et al. A provider global assessment quality measure for clinical practice for inflammatory skin disorders. Journal of the American Academy of Dermatology. Mar 2019;80(3):823-828.