Jarrod Shapiro, DPM Practice Perfect Editor Mountain View Medical & Surgical Associates, Madras, Oregon

How do we know we practice the best medicine possible? This is the question I brought up in our last eZine. I managed to accuse every podiatrist (including myself) of not knowing whether we’re providing the best treatments for our patients or not. Now I’d like to discuss the solution. How can we know we’re truly providing the best care for our patients? Listed below are some of my thoughts on how we can improve performance through monitoring and analysis. If you don’t care whether or not you’re providing the best care for your patients, or you don’t agree with my premise that we need to have better methods to measure our performance, then stop reading. This isn’t for you. If you do care and are, like me, concerned about providing the best care possible for your patients then read on and participate by writing in to the podiatry.com eTalk.

	Tonight's Premier Lecture is Classification and Differential Diagnosis of Wounds by Marie Williams, DPM

1. Learn how others measure success.  The business community has been measuring performance for years.  In many ways, they are ahead of the curve.  Perhaps this is due to a certain Darwinian selection in the business world.  If you don’t perform efficiently, you don’t survive.  In medicine, this isn’t the case.  We’ve all heard stories of poor doctors or low quality hospitals that continue to exist in spite of their substandard care.  However, our hospitals have already moved toward measuring performance in the form of core measures.  I mentioned this previously, but for those interested follow this link for some specific core measures.  Consider others who measure performance: the education community (ex. No Child Left Behind), our government (ex. Government Accountability Office), and the entertainment industry (ex. the Nielson Ratings).  We need to look both within and outside the medical community to determine how best to measure our successes and failures in podiatry.
   
   
2. Participate in the Physician Quality Reporting Initiative (PQRI).  Not only can participation improve your care, it can also add a few dollars back to your practice.  ACFAS created an interesting presentation about the PRQI as it pertains to podiatrists.  The APMA also made available information about the program.  Follow this link for the APMA statement.  I applaud both of our national associations for helping podiatrists become participants in this program.  The PQRI will improve our patient care by making us more aware of certain issues and protocols.  For example, Measure 20 involves the timing of preoperative antibiotics.  By tracking these numbers, we’ll be more aware and may find a long term decrease in the rate of postoperative infections.  Do I know my personal  postop infection rate?  No.  Should I?  Yes. 
   
   
3. We need a national movement to measure performance in podiatry.  It’s not simply what each of us does in our isolated offices and practices that matter.  We need our national leadership to direct the way here.  We need to start with a panel of physician leaders to frame the problem and determine how best to measure our performance.  They may then create benchmarks for individual physicians to work towards.  Benchmarking would allow individual physicians to track how they compare.  For example, a benchmark may say, “Diabetic plantar wounds healed within 12 weeks.”  We could use this benchmark to then track national patterns of participating doctors, essentially creating a national database.  The numbers to calculate this benchmark are available.  Wound care centers around the country track this data.  A physician who finds his patients take 16 weeks to heal will know he’s not hitting the benchmark and may adjust his care accordingly.  Conversely, a doctor who consistently heals her patients in 10 weeks can help us all improve.  What is she doing that’s more effective than the benchmark?  This approach could potentially lead to great improvements in our community as a whole.  We also must involve our residency programs in this system.  Residencies would become “centers of excellence”, where data from large numbers of practicing physicians could be accumulated to further move our profession forward.  It would also be a nice way to compare residency programs!
   
   
4. Analyze your practice methods by counting.  Keep track of something.  For example, what is your personal nonunion rate of base wedge osteotomies?  How long until ulcer resolution after tendoachilles lengthening?  How long are patients pain-free after heel injections for plantar fasciitis?  What is your office wait time?  The list goes on and on.  Set up a system in your office to track whatever parameters you’re interested in.  What’s most important to you?  Get your office staff involved to “automate” the process.  You may be surprised how quickly you accumulate data – and how that data may reveal something important about your practice of medicine. 
   
   
5. Create algorithms for common pathologies and track the results.  To effectively count something, we need to be consistent.  Take your top 10 most commonly treated pathologies and create algorithms.  Treat every patient with a particular pathology the same - when possible – and track what you feel is most important.  For example, you inject all new Morton’s neuroma patients with a specific steroid mixture on their first appointment.  You might then track “duration of pain relief”, “level of pain relief”, and “recurrence”.  At some point, you may find your methods only provide six weeks of pain relief with full recurrence and alter your practice methods accordingly.  Start simple and work your way up in complexity. 
   
   
6. Survey your patients.  Improving patient care is the point, so it makes sense to involve patients in your efforts.  Have them fill out short surveys focused on those parameters you’re most interested in analyzing.  It may be anything from office wait times to pain relief after surgery.  Consider using any of the validated scoring systems such as the ACFAS Score, SF-36 questionnaire, or the Short Musculoskeletal Form Assessment (SMFA).  You might also use the ACFAS Scoring system to analyze your radiographs. 
   
   
7. Become an EBM expert. Let’s not forget the medical literature!  Well designed randomized controlled trials and evidence based medicine are the cornerstones of modern medicine.  We all need to master the effective use of the literature and incorporate it into our growing armamentarium of tools to improve medical care. 

What do you think?
Join in on any number of eTalk Topics taking place on PRESENT Podiatry, or create one of your own.

Keep writing in with your thoughts and comments or visit eTalk on PRESENT Podiatry and start or get in on the discussion. We'll see you next week. Best wishes!

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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