In the spring of 2001, the leadership at Physicians Clinic of Iowa decided to develop a quality program. PCI, a 50-physician multispecialty clinic in Cedar Rapids, Iowa, offers services in an array of specialties -- cardiac surgery, otolaryngology, general surgery, neurology, orthopedic surgery, podiatry, rheumatology, thoracic surgery, urology and vascular surgery.
After an evaluation of healthcare options and a review of industry quality systems, the clinic decided to pursue ISO 9001 certification. PCI leadership had joined the local chapter of the American Society for Quality and participated in chapter events. This relationship enabled PCI leadership to gain insight into quality-management systems used in industry, and the information helped in choosing ISO as the quality system for PCI to pursue.
The clinic -- which employs 200 people at five care sites -- and its physicians manage about 98,000 evaluation and management encounters per year and perform more than 52,000 surgical procedures annually.
The ISO-implementation process involves a number of work activities that include establishing a controlled document system for more than 400 policies and procedures, training employees to perform internal auditing within the organization, writing and performing corrective and preventive action plans, and establishing a management review structure to oversee the quality system.
During the ISO implementation process a physician council was established to help develop the clinical quality program and identify key quality indicators. One physician was chosen from each specialty at PCI, and the council was asked to determine metrics of value to each specialty. The council identified 55 indicators among 10 specialties. In evaluating the indicators, it became apparent that operational definitions were unclear, the process of data collection was difficult, and PCI was unable to collect indicators without the help of the two community hospitals.
A second quality panel, the database committee, was therefore established with quality-improvement representatives from both hospitals and PCI. The committee reviewed the requested data and decided to focus on what the hospitals already collected.
Many physicians have an interest in antibiotic administration, and this interest coincides with a project of the Iowa Foundation for Medical Care, or IFMC, the quality-improvement organization in Iowa.
The committee chose to work together on the national Surgical Infection Prevention project sponsored by Medicare, with the idea that the project would be a combined effort of all three groups. The Surgical Infection Prevention indicators were: antibiotic administration within one hour of a surgical incision; use of an appropriate antibiotic; and discontinuation of the antibiotic within 24 hours.
Mercy Medical Center and St. Luke's Hospital agreed to collect data on the three indicators while PCI would provide the rate of surgical-site wound infection after discharge from the hospitals.
This ability to track wound infections in the clinic setting improved the overall understanding of community infection rates and was implemented by developing an ISO document for tracking wound infections. This document is maintained by nurses in each PCI surgical office.
Initial results of the collaborative effort have been very favorable with improved timing, appropriateness and discontinuation of antibiotics in the peri-operative period as compared with baseline data.
A joint presentation by representatives of PCI and both hospitals was given at the annual IFMC quality conference in November 2003. Results of the Surgical Infection Prevention indicator project were presented and the group described the concept of using an ISO quality-management system to serve as a framework of cooperation within a community of diverse and competing providers.
Joseph Levett, M.D., is chief medical officer of Physicians Clinic of Iowa in Cedar Rapids.