UW Health: Setting the Stage for Diabetes Improvement

1. UW Health: Setting the Stage for Diabetes Improvement  AMGA Diabetes Learning Collaborative April 5, 2007 Gale Garvey, Project Manager-QI Karen Block, Health Education and Nutrition Manager Patrice Udelhofen, NP, MS

2. UW Health  University of Wisconsin School of Medicine and Public Health University of Wisconsin Hospital and Clinics (UWHC) University of Wisconsin Medical Foundation (UWMF)

3. UWMF Medical Group Profile 1,007 faculty physicians representing 98 primary care, medical and surgical specialties 30 primary and specialty care clinics Support 7 DFM clinics Faculty also practice at 9 UWHC locations Provide outreach service to communities in Wisconsin and Northern Illinois Serve over 366,000 patients each year: More than 1.7 million outpatient visits 35,200 surgical procedures 40,600 admissions to Meriter and UW Hospitals

4. UW Health Diabetes Improvement:  Problem identified: Only 41% of UW Health diabetes patients have HbA1C <7 optimal control levels Data Validation (July, 2006): UW Health data collection (WCHQ denominator methodology): Approximately 7,400 ambulatory UW Health managed diabetes patients Results publicly reported on WCHQ.org Ranked 14th of 16 Wisconsin health systems reporting A1C <7 Clinic Breakdown: > 50 diabetes patients demonstrate variation in practice in A1C control (n = 23): Low Clinic: 28.2% of patients w/ A1C < 7 (N = 1) High Clinic: 63.2% of patients w/ A1C < 7 (N = 1) Most clinics cluster around 41%

5. Measurement to Link Process of Care to Outcome

6. UW Health System-Wide Data Assessment Goal: Continue to integrate data necessary to identify care process needs and monitor performance over time. Data Available: Professional encounter data (UWMF and UWHC billing dates for labs and UWMF diabetes education; UWMF lab data available on Epic; UWHC lab data available from data feed) UWMF and UWHC A1C pre/post A1C results for diabetes education (aggregate). Data Needs: Lab values from “outside labs”, UWHC diabetes education encounters, optometry/ophthalmology, other recent values for external care site encounters, establish criterion for clinic inclusion.

7. Diabetes Improvement Team Formed Goals: Improve patient self-management skills: Increase % of patients completing diabetes education classes by 10% (after further analysis, deemed a future priority) Develop diabetes website to provide meaningful and consistent diabetes information available to patients in real time Improve patient testing for improved control levels: Test re-design process to improve % of patients receiving A1C and LDL-C (assess impact of patient incentives) Test re-design process to improve % of patients receiving A1C and LDL-C (assess impact of clinic site financial rewards)

8. “Textbook” QI … but not so “Textbook” People Management  A Promising Start: Began to build case for change Diabetes team formed Project plan, goals, timeline Measures of success But, Near Fatal Errors: UW Health’s independent operations & goals did not inspire a sense of urgency for diabetes improvement This led to ... Challenges in securing commitment for staff resources to support key roles and, a … Project scope not clearly defined. Resulting in. Several false starts Solution: Senior leadership communicates a system sense of urgency and provides resources to support re-design for results

9. Riding the Boundaries for success: Creative people and process management Patient Lab Reminders (Patient Incentive) Process directs patients to lab for missing tests Nurse coordinator enter labs and reminder letter in EPIC to enable staff efficiencies Lab staff test patients and provide education packets with $10 gas card Healthline (after hours call center) contacts non-responders and tracks barriers Patient Lab Reminders (Staff Incentive) Merge project with Department of Family Medicine (DFM) QI plan where diabetes goals and process are aligned.

10. Diabetes Education: Key Barriers Identified Challenge: How do we “increase patient access by 10%?” Solution: Industrial engineering student project Finding: System not ready to address this challenge Abbey Marquette and Mitch Claven (graduate students) identified education barrier root causes: UW Health “branches” operate independently Unstructured communication Several opportunities for patients to get “lost” in system Improved program coordination results: UWHC & UWMF merged diabetes support groups into one Diabetes education programs now share one name “Healthy Living with Diabetes” Communication piece on system education provided to clinics, diabetes website, UConnect and provider links

11. Missed A1C and LDL-C Reminder Test Pilots with $10 Gas Card Outcomes (November 2006 – January 2007) Denominator: 161 letters sent Improved process flow as evidenced by 50.3% response rate (vs. 34% cycle 1) 50.3% overall response rate (81/161 patients) 56.7 % A1C rate 34.6 % LDL-C

12. DFM: A1C, LDL-C Improvement Project Led by DFM clinic staff ($ Incentive)

13. Voice of Our Customer Diabetes Website 30 patients provide feedback on educational content, site organization, and design over 10 week test period Allowed project to proceed due to ability to minimize “up-front” diabetes educator time Using our customers to guide process enabled us to achieve goal and build a patient friendly and meaningful website

14. System diabetes: “Align, integrate, manage chaos” October 2006 - Present UWMF Operations Quality Subgroup led by Bryan Becker, MD embraces diabetes care improvement as a system imperative Town Hall review of “39” diabetes initiatives within UWMF, UWHC, DFM (Held 2, 3-hr sessions) Inventoried initiatives and placed within CCM framework (6 key components) Identified known gaps in diabetes care and prioritized improvement focus Began using CCM to guide system change, along with IHI Learning, and QI models

15. Diabetes “Town Hall” Alignment of Existing Initiatives 11/06: 39 improvement initiatives presented Assessment: Data: To what extent are data used to drive decisions? Integration: What is the optimal integration of change projects and how should integration occur? Common Vision: Do the initiatives, taken as a whole, powerfully reinforce the vision – or are there initiatives that pull the organization off track? Process: What initiatives support a process for improved testing and control of A1C, LDL-C?

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20. System Transformation: Goals toward a Preferred Future Moving away from: Isolated improvement projects to system-wide change that impacts all diabetes patients who enter our system Acute Care Model to a Chronic Care Model (changing the way our care team interacts with patients) Autonomy and practice variation to collaboration and standardization

21. We Thank You For Your Support! ..And welcome your questions or Comments: Gale.Garvey@uwmf.Wisc.edu Karen.Block@uwmf.wisc.edu Patrice.udelhofen@uwmf.wisc.edu