In Part I of this series, we described the problem of inappropriate care in the United States and how solutions to cost and quality in health care can be effectively dealt with at the organizational level.

We began a consideration of the sequential phases of evidence-based quality improvement work, starting out with readying an organization for evidence-based quality improvement. Now, let’s look at details of using the five A’s (1) of evidence-based medicine to identify and close quality and cost gaps in health care organizations.

Once an organization creates the structural components, such as committees and work groups, and establishes processes for those groups, and once it ensures that staff have the needed knowledge, skills and tools to carry out the five A’s of evidence-based clinical improvement (Asking, Acquiring, Appraising, Applying, A’s Again), each group can begin to identify “fixable” or “closable” quality, cost, satisfaction and uncertainty gaps in clinical care.

The sequential steps in this evidence-based process are outlined in Table 1.

The Institute of Medicine outlined six quality domains (Table 2) which are useful in determining areas within an organization where there may be quality gaps and where quality may be improved. (2)

The size of the gap should justify the effort it will take to close it. To determine the size of the performance gap in a potential work area, groups need to compare internal organizational data (usually obtained from organizational databases) with the best available evidence (obtained from content resources, such as sources for guidelines, clinical recommendations or the medical literature itself.)

All the data must be appraised for validity unless they come from a trusted source such as Cochrane, Clinical Evidence or the Database of Reviews of Effects (DARE)–and must be updated and assessed for usefulness.

In Part I of this series, we indicated that frequently physicians, as well as quality improvement professionals and other decision-making health care professionals, lack the skills to effectively and efficiently search for, critically appraise and synthesize scientific evidence using processes that yield valid, useful and usable content likely to improve desired outcomes.

Individuals doing quality improvement work may benefit from training that can successfully provide the skills and tools for evaluating the medical literature. Training should improve competencies in finding and utilizing studies with appropriate designs, valid methods and useful results.

An approach we have found useful is to teach these skills using the five “A”s of evidence-based medicine:

* Ask — How to construct effective clinical questions

* Acquire — Tips and strategies for systematically capturing potentially useful content through awareness of the best sources for information, application of successful search techniques and filtering strategies

* Appraise — Concepts and methods for evaluating content for validity, usefulness and usability, along with organizational considerations (e.g., cost, legal, marketing, public relations and other value considerations)

* Apply — Using valid and useful content, how to synthesize the body of evidence, creating information, decision and action aids for use by clinicians, patients and others

* “A”s Again — When and how to repeat the process to ensure information is current

These sequential steps are summarized in Table 3 and can be made easier by utilizing various tools.

After completing the evidence synthesis, we strongly recommend making evidence-based estimates regarding local quality and cost outcomes followed by the development of information, decision and action tools, implementation plans and measurement plans. We will describe the details of these steps in Part III of this series. (Watch for it in the May/June 2005 issue of The Physician Executive.)