Teachers and Preachers of Quality Improvement

In 1999, the Institute of Medicine, now known as the National Academy of Medicine (NAM), issued a thought-provoking report titled, “To Err is Human: Building a Safer Health Care System.” The report illuminated the toll on patient morbidity and mortality that could be attributed to preventable errors and care gaps in American hospitals. This was followed in 2001 by another report, “Crossing the Quality Chasm,” which identified six foundational aims that should be the basis of re-engineering the health care system to foster quality. They stated that health care should be safe, effective, patient-centered, timely, efficient, and equitable. These reports were a call to arms for health systems and professional societies, and ASH, always at the forefront, responded with a re-commitment to high-quality care and continuous quality improvement as central tenets of our mission. In the ensuing 20 years, ASH created a standing Committee on Quality and with support from a talented group of ASH staff with training and expertise in quality improvement (QI), made substantial investments in creating and providing tools for our members and trainees to help them cross the quality chasm. The many QI efforts of ASH include actively participating in the American Board of Internal Medicine Foundation “Choosing Wisely” campaign and highlighting members’ efforts in this domain with a special session at our annual meeting. We have produced pocket guides for clinicians focused on important hematologic disorders, developed the ASH Clinical Practice Guidelines App (available for mobile devices and via web interface), created educational materials addressing specific training and knowledge gaps such as sickle cell disease, and enhanced popular features in our publications, such as “How I Treat” and “Ask the Hematologist.” Most recently, we began developing a series of 20 evidence-based clinical practice guidelines on the topics of venous thromboembolism (VTE; 10 guidelines), sickle cell disease (SCD; 5 guidelines), von Willebrand Disease (2 guidelines), immune thrombocytopenia, and acute myeloid leukemia in older adults. The VTE and SCD guidelines are multiyear projects that are well on the way to completion, with the first six VTE guidelines published in December 2018 in Blood Advances, and the others expected to be published in 2019 and 2020. Special recognition should be given to Adam Cuker, MD, MS, Chair of the VTE Guidelines project, for his leadership of this complex project.

I would also like to acknowledge Holger Schünemann, MD, PhD, who led the systematic review and methods teams in a process that included a strong commitment to principles and standards outlined by the Institute of Medicine Health Care Quality Initiative. These principles include transparency, rigorous management of conflicts of interest, no support from industry, soliciting both external review and the voice of the patient, and perhaps most importantly, using systematic reviews and an evidence-based, highly structured system for rating strength of recommendations and for standardizing reporting. The final publications represent successful collaborative efforts among a team of ASH-member volunteer content experts and contracted methodology experts. ASH is exploring how the guidelines can be maintained as living documents with continuous re-assessment and updating. So far, the response to the first set of published VTE guidelines has been nothing short of amazing. In the four months since publication they rank near the top of all the Society’s online content, including from Blood and Blood Advances. The ASH VTE Guideline on optimal management of anticoagulation therapy was downloaded more than 14,000 times in its first month online. Yet, the work does not end with publication. The next phase, already well underway, is a coordinated, comprehensive plan to disseminate them and maximize their “real world” implementation. This includes promotional materials at www.hematology.org/VTE, in our publications, and at ASH meetings as well as meetings of other relevant societies. Resources such as pocket guides and smartphone apps, and PowerPoint slide sets that provide members with teaching tools to spread the word, are currently available, with more in development. At some point we may also use the guidelines to inform clinical decision support in electronic health records. I just returned from a highly successful Highlights of ASH in Latin America (HOA-LA) meeting in Lima, Peru. There, I had the pleasure of watching a dedicated group of hematologists from South and Central America work together in a one-day workshop, using a highly structured process to adopt and adapt the ASH VTE guidelines in the context of the resources and clinical scenarios relevant in Latin America. The adoption/adaption process (now termed “adolopment”*), along with two specific examples, was presented to the nearly 600 attendees from 13 countries at the HOA-LA general sessions and received an exceptionally positive response.

The ASH clinical practice guidelines project is an outstanding example of the commitment of our Society to the core mission of helping hematologists conquer blood diseases worldwide. Importantly, in addition to QI, the project touches our global outreach, education, training, and research missions. Helping hematologists become effective teachers and preachers of continuous QI and adding both QI and implementation science to our repertoire of research efforts further enriches the Society. We should celebrate these efforts and take great pride in the cutting-edge approaches ASH is taking to advance clinical quality.