Using process improvement and systems redesign to improve rheumatology care quality in a safety net clinic

Objective To develop and evaluate interventions to improve quality of care in four priority areas in an urban safety net adult rheumatology clinic serving a racially/ethnically and socioeconomically diverse patient population. Methods The Institute for Healthcare Improvement’s Model for Improvement was used to redesign clinical processes to achieve pre-specified benchmarks in the following areas from 2015-2017: 13-valent pneumococcal conjugate vaccine (PCV13) administration among immunocompromised patients; disease activity monitoring with the Clinical Disease Activity Index (CDAI) for patients with rheumatoid arthritis (RA); latent tuberculosis infection (LTBI) screening for new biologic users with RA; and reproductive health counseling among women receiving potentially teratogenic medications. We measured performance for each using standardized metrics, defined as the proportion of eligible patients receiving recommended care. Results 1,205 patients were seen in the clinic between 2015 and 2017. 71% were women, 88% identified as racial/ethnic minorities and 45% were eligible for at least one of the quality measures. Shewart charts for the PCV13 and CDAI measures showed evidence of improved healthcare delivery over time. Benchmarks were achieved for the CDAI and LTBI measures with 93% and 91% performance, respectively. Performance for the PCV13 and reproductive health counseling measures was 78% and 46%, respectively, but did not meet pre-specified improvement targets. Conclusion Through an interprofessional approach, we were able to achieve durable improvements in key rheumatology quality measures largely by enhancing workflow, engaging non-physician providers and managing practice variation.