improving quality of care for patients with diabetes
TRANSCRIPT
Improving Quality of Care for Improving Quality of Care for Patients with Diabetes MellitusPatients with Diabetes Mellitus
Ghassan F. Salman, MD, MPH, FACPGhassan F. Salman, MD, MPH, FACPAustin Diagnostic ClinicAustin Diagnostic Clinic
Austin, TXAustin, TXPhone (512) 901 4009, Fax (512) 901 3909Phone (512) 901 4009, Fax (512) 901 3909
Email: [email protected]: [email protected]
Improving Quality of Care for Patients with Improving Quality of Care for Patients with Diabetes MellitusDiabetes Mellitus
Aim statement and teamAim statement and team
Graphical presentation of the process Graphical presentation of the process
Baseline dataBaseline data
Leverage Point and Change ConceptLeverage Point and Change Concept
ImplementationImplementation
Results: SPC chartsResults: SPC charts
Future plansFuture plans
Aim StatementAim Statement
To increase the proportion of diabetic To increase the proportion of diabetic patients with yearly cholesterol testing patients with yearly cholesterol testing from 77% to 85% in internal medicine from 77% to 85% in internal medicine
outpatient clinic over two monthsoutpatient clinic over two months
Austin Diagnostic ClinicAustin Diagnostic Clinic
Team membersTeam members
picturepicture
Significance of the ProblemSignificance of the Problem
Why is this project important?Why is this project important?Sixth leading cause of death by diseaseSixth leading cause of death by disease
Prevalence: 18% patients age >60 yrPrevalence: 18% patients age >60 yr
What impact will it have?What impact will it have?Saving lives & complicationsSaving lives & complications
Why are we choosing this project?Why are we choosing this project?Variation in cholesterol testingVariation in cholesterol testing
We are below the national averageWe are below the national average
Cholesterol TestingCholesterol TestingVariation within Internal MedicineVariation within Internal Medicine
0%10%20%30%40%50%60%70%80%90%
100%
#1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11
IM Providers
Cholesterol TestingCholesterol TestingNational AverageNational Average
0%10%20%30%40%50%60%70%80%90%
100%
ADC-IM National
Meeting with IM ProvidersMeeting with IM ProvidersBrainstormingBrainstorming
Six out of eleven IM providersSix out of eleven IM providers
Emphasize patient focusEmphasize patient focus
Improve quality of care for DMImprove quality of care for DM
Present data Present data (Variation, IM Vs. National)(Variation, IM Vs. National)
Consensus: Yearly cholesterol testingConsensus: Yearly cholesterol testing
Process of care and CauseProcess of care and Cause--Effect AnalysisEffect Analysis
Process of CareProcess of CareConceptual Flow DiagramConceptual Flow Diagram
MACheck In
MDEncounter
Check out
MDEncounter BP ?
Exam
History
Open chart
Rx Plan
ChartReview
ChartReview
HbA1c ?
Cholesterol ?
Eye Exam ?
Feet Exam ?
UrineAlbumin ?
Cholesterol ?
Order Lab
Clinic Visit
Flow sheet
Lipid Panel
Date of latest test
Patient with DM
MA (CC + Vitals)
Provider H&P
Lipid profile? Outside Lab? Order Lipid profile
Within 1 yrOrder Lipid
profile
Document in Flow sheet
NO NO
NO
YES
YES
Decision Flow chart•• Process is standardizedProcess is standardized
In flow-sheet?
YES
NO
YES
Continue DM care
Variation inCholesterol
Testing for DM
Poor Documentation
Poor Patient Compliance Lack of Agreement
Causes of Variation
Multiple Guidelines
Patient education
Difficult to monitor
In progress note
Multiple templates
Multiple medical issues
Lack of Awareness No Reminders
Rely on Memory
Endocrinology
Not part of culture
Rapid turnover ofInformation
Frequency of Causes of VariationFrequency of Causes of VariationProviders’ SurveyProviders’ Survey
0%
5%
10%
15%
20%
25%
30%
35%
PoorDocumentation
LackAgreement
PatientCompliance
LackAwareness
No Reminders
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
No Reminders PoorDocumentation
PatientCompliance
Lack Agreement Lack Awareness
Cumulative FrequencyCumulative FrequencyPareto ChartPareto Chart
Data CollectionData Collection
Key Quality Characteristics (KQC)Key Quality Characteristics (KQC)Proportion of DM patients with yearly cholesterol Proportion of DM patients with yearly cholesterol testingtesting
Query of data collectionQuery of data collectionProviders = internal medicineProviders = internal medicinePatients = DM patients seen per week Patients = DM patients seen per week (IDX)(IDX)
Clinical data = cholesterol testing Clinical data = cholesterol testing (EMR)(EMR)
Time range for cholesterol testing = 1 yearTime range for cholesterol testing = 1 year
Proportions of Patients with Yearly Cholesterol Testing
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4 5 6
Week of Measurement
Pro
port
ion
Baseline
Patient with DM
MA (CC + Vitals)
Provider H&P
Lipid profile? Outside Lab? Order Lipid profile
Within 1 yrOrder Lipid
profile
Document in Flow sheet
NO NO
NO
YES
YES
In flow-sheet?
YES
NO
YES
Continue DM care
Leverage Point• KPV - customer is MA
Implementation Implementation ((PPDSADSA--01)01)Testing Change ConceptTesting Change Concept
Aim:Aim: Medical assistant to remind providers of cholesterol testing Medical assistant to remind providers of cholesterol testing Measure:Measure: # nurse intake with reminder / total nurse intake (wk)# nurse intake with reminder / total nurse intake (wk)Change:Change: Add quick text “.dm” to nurse intakeAdd quick text “.dm” to nurse intake
Need to refine methods
• 50% of nurse intakes have reminders• Problem identifying DM patients
• MAs Identify DM patients• Add quick text to nurse intake
• Disseminate to MAs• Try it for week
Implementation Implementation ((PPDSADSA--02)02)Testing Change ConceptTesting Change Concept
Aim:Aim: Medical assistant to remind providers of cholesterol testing Medical assistant to remind providers of cholesterol testing
Measure:Measure: # nurse intake with reminder/ total nurse intake (wk)# nurse intake with reminder/ total nurse intake (wk)
What:What: Modify nurse intake: PopModify nurse intake: Pop--up button for DMup button for DM
Need to update Problem List
• 60% nurse intakes have reminders• Still not capturing all patients
MA press button on nurse intake(reminder for the reminder)
All MAs try it for a week
Proportion of Nurse Intakes with Proportion of Nurse Intakes with RemindersReminders
0%10%20%30%40%50%60%70%80%90%
100%
6 7 8 9 10 11 12
Week of Measurement
Patient with DM
MA CC + Vitals
Decision Flow Chart (KPV)
Banner forDM reminder?
Does patienthave DM?
Press Button Insert reminder“.dm “
Usual careNONO
YESYES
Who updatesProblem List?
Lipid profile? Outside Lab? Order Lipid profile
Within 1 yr Order Lipid profile
Document in Flow sheetIn flow-sheet?
Continue DM care
Provider H&P
Implementation Implementation ((PPDSA)DSA)Internal Medicine ProvidersInternal Medicine Providers
PLANPLANTangible aspect of implementationTangible aspect of implementation
Make it easy to do the right thingMake it easy to do the right thing
Changing physicians’ behavior (Buy In)Changing physicians’ behavior (Buy In)Increase awareness of the problemIncrease awareness of the problem
Motivate themMotivate them
Link quality to productivityLink quality to productivity
ImplementationImplementation (P(PDDSA)SA)Internal Medicine ProvidersInternal Medicine Providers
DODOPut reminders on nurse intake Put reminders on nurse intake Add quick text that Add quick text that automaticallyautomatically pulls all pulls all necessary informationnecessary informationShow providers variations of careShow providers variations of careCompare performance Compare performance (within IM & national average)(within IM & national average)
Discuss pay for performanceDiscuss pay for performanceUse informal leaderUse informal leader
Implementation Implementation (PD(PDSSA)A)Internal Medicine ProvidersInternal Medicine Providers
STUDYSTUDYThe quick text needs clarificationThe quick text needs clarification
Some providers did not give their feedbackSome providers did not give their feedback
Some providers did not attend the meetingsSome providers did not attend the meetings
RemindersReminders--Problem listProblem list
Results in SPC chartsResults in SPC charts
ResultsResults
Part I: Users of electronic medical recordsPart I: Users of electronic medical recordsParticipated in meetingsParticipated in meetings
Gave their inputGave their input
Reviewed the dataReviewed the data
Whose problem lists are updatedWhose problem lists are updated
Part II: Total internal medicine providers Part II: Total internal medicine providers
Proportions of Patients with Cholesterol Testing Part I - Users of EMR
30%
35%
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
1 2 3 4 5 6 7 8 9 10 11 12
Week of Measurement
Prop
ortio
n
Intervention
Baseline Implementation
30%
35%
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
1 2 3 4 5 6 7 8 9 10 11 12
Week of Measurement
Pro
port
ion
InterventionBaseline Implementation
Proportions of Patients with Cholesterol TestingPart II - Total Providers
ImplementationImplementation (PDS(PDSAA))Internal Medicine ProvidersInternal Medicine Providers
ACTACTNeed to have a plan to involve providers who Need to have a plan to involve providers who did not participatedid not participate
Need to implement a process to update Need to implement a process to update “Problem List”“Problem List”
Future PlansFuture Plans
Dealing with resistance/complacencyDealing with resistance/complacencyBuild relationships (One on One)Build relationships (One on One)
Show them the results of this projectShow them the results of this project
Show them their own data (quarterly results)Show them their own data (quarterly results)
Give providers lists of patients that need testingGive providers lists of patients that need testing
Surface, Honor, Explore, and Recheck resistanceSurface, Honor, Explore, and Recheck resistance
DM outcome measuresDM outcome measuresLDL controlLDL control
Holding the GainsHolding the Gains
Quarterly feedback to providersQuarterly feedback to providers
Annual Quality FairAnnual Quality Fair
List of patients who need cholesterol testingList of patients who need cholesterol testing
Display results at work stations Display results at work stations (Internal transparency)(Internal transparency)
Continuous input from providersContinuous input from providers
EMREMR--Problem list improvement project Problem list improvement project
Rewards physicians and MA/RN!Rewards physicians and MA/RN!