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Continuous Quality Improvement in Diabetes Care

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Continuous Quality Improvement in Diabetes Care

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    1. Continuous Quality Improvement in Diabetes Care Julie Day, MD – Medical Director for Quality Annie Mervis, MSW – Quality Manager University of Utah Health Care: Community Clinics Diabetes Telehealth Series October 15, 2008

    2. UUHC Community Clinics 10 clinics 70 primary care providers 25 specialists 550 support staff 215,000 primary care visits (annually) 110,000 active patients (18 months) 4500–5000 patient with diabetes (annually)

    4. Presentation Objectives At the end of this presentation, participants will have an understanding of Continuous quality improvement tools and processes and how these were applied to improve diabetes care the importance of data in evaluating effectiveness of interventions the need to continue through multiple cycles of the Plan, Do, Study, Act cycle of improvement

    5. Presentation Overview Key QI concepts and differences Review of FOCUS-PDSA cycle Case study demonstrating how we applied the process and tools Results What we learned Our next steps

    6. Key QI Concepts Improving work processes Quality is everyone’s job Teams and teamwork are critical People doing the job know best how to improve it QI uses a systematic approach to analyze opportunities and design changes to drive improvement Meeting and exceeding customer expectations New Mexico IN-FOCUS Teleconference Series, The Nuts and Bolts of QI, New Mexico Medical Review Association

    7. Differences between QA and QI

    8. FOCUS-PDSA Focus – Find an opportunity to improve Organize a team Clarify understanding of process needing improvement Understand variation, root causes, and barriers Select an opportunity and strategy Plan intervention Do intervention Study the results Act to hold the gains or continue to improve on

    9. Find an opportunity FOCUS-PDSA

    11. Why? National priority from 2003 Institute of Medicine Report UUHC priority set by Board of Directors Impact on patient quality of life (misery index) Ability to successfully intervene in an outpatient setting

    12. Organize a team FOCUS-PDSA

    13. The Diabetes Quality Group Includes: 3 Patients 7 Providers 3 Health Educators 2 HealthInsight staff 1 Epic and 1 Data Support staff 2 Support staff 1 Health Plan staff

    14. Aim Statement Over the next 12 months we will improve care by: Identifying our diabetic population Establishing targets for selected diabetic parameters Devising appropriate interventions to enable us to meet our improvement goals for our diabetic population

    15. Clarify understanding of the process FOCUS-PDSA

    16. Baseline Data and Goals for Improvement Measure* Baseline (1/04) Initial Goal HgbA1c ordered 2x annually 71% 85% HgbA1c <7% 47% 62% LDL <100 43% 60% BP <130/80 28% 45% Microalbumin ordered annually 54% 63% *ADA, UHC

    17. Process Flow Diagram

    18. Process Analysis – Key Questions Are patients coming in regularly? Are providers ordering needed tests according to guidelines? Are patients following through with provider recommendations and taking ownership of self-management? Are A1c, LDL and BP where patient and provider would like them to be?

    19. Understand variation, root causes, and barriers FOCUS-PDSA

    20. Cause and Effect Diagram

    21. Select an opportunity and strategy FOCUS-PDSA

    22. Barriers Patient: ownership and self-management Providers: competing priorities Process: variation between clinics Environment: obesity increasing Systems: not maximizing EMR capabilities

    23. Plan an intervention and Do it FOCUS-PDSA

    24. Interventions Provider CME – Feb 04 EMR-based tools to support providers in the exam room – Feb 04 Patient Awareness Materials – Feb 04 Monthly measurement and feedback to providers – Feb 04 Registries – May 04 Outreach letters to patients – May 04

    25. Registry

    26. Blood Sugar Control Chart

    27. Feedback Reports at Clinic Level

    28. Study the results FOCUS-PDSA

    29. Process Results

    30. Outcome Results

    31. Results – PDSA Cycle 1

    32. Act to hold gains or continue to improve FOCUS-PDSA

    33. Next Steps Identify additional barriers that may be affecting improvement Develop new interventions to address identified barriers Expand population to include patients not see as regularly Ongoing efforts sustain registry work

    34. Plan PDSA Cycle 2

    35. Project Overview – PDSA Cycle 2 Initiated July 2005 System-wide approach and interventions Target population - patients with diabetes being seen less regularly 1 diabetes visit in 12 months 3,800 – 4,300 patients annually Support for registry management Patient self-efficacy and self-management

    36. Baseline – PDSA Cycle 2

    37. Barriers – PDSA Cycle 2 Registries Inaccurate or out-dated PCPs Patients followed elsewhere for diabetes care Time and support for registry management Barriers to enhanced self-management skills Limited exam room time and time for visit planning

    38. Do PDSA Cycle 2

    39. Interventions – PDSA Cycle 2 Provider Training – Jul 05 On-site Diabetes Education Courses – Nov 05 Centralized Support for Registry Management – Feb 06 Provider feedback and flag on registry for patients followed elsewhere PCP Assignment – MA workflow – Feb 06 Shared Medical Appointments – Feb 06 Screening for Depression (PHQ9) – Apr 06

    40. Interventions – PDSA Cycle 2 Practice Redesign “Care by Design” - ongoing Templates and workflows for Pre-Visit and Visit Planning (acute and chronic) – Oct 06 Patient Activation through mutual goal setting and motivational interviewing - Oct 06 System-wide Staff Development Institute Templates for goal setting Patient education information imbedded in EMR “Pay for Performance” incentive plan to work registries - Jan 07

    41. Study PDSA Cycle 2

    42. Results – PDSA Cycle 2

    43. Results – PDSA Cycle 2

    44. Lessons Learned Provider and MA commitment to Shared Medical Appointments is critical to ongoing success Registries and visit planning should be part of care process, not an add-ons Incentive provides initial boost, but hard to sustain Implementation of new tools and processes requires consistent (and constant) support and feedback Need regular on-site support More timely and meaningful feedback reports

    45. Lessons Learned Hard to compare our performance to others when everyone uses different measurement definitions Practice redesign (Care by Design) appears to support expanded care processes better than traditional model Need to begin addressing need for cross-condition care, rather than condition-specific silos

    46. Act PDSA Cycle 2

    47. Next Steps Sustain the work started by centralized registry support and clinic incentives Address time and competing priorities Maintain accurate PCPs Continue expansion of SMAs Consistently implement “Care by Design” with visit planning processes and tools delivered by Care Teams in all 10 clinics

    48. Plan PDSA Cycle 3

    49. Project Overview – PDSA Cycle 3 Began participating in CMS Care Management Demonstration Project (P4P) in July 07 DM, CAD, HF, and Preventive Care Project provided standardized definitions for 26 measures We revised our quality reports to be consistent Provided visibility and priority status for system-wide quality improvement and resource allocation Initiated assessment of implementation status of Care by Design Obtained resources to support SMAs and patient self-management

    50. Baseline – PDSA Cycle 3

    51. Barriers – PDSA Cycle 3 Registries Quarterly paper registries cumbersome and not timely Diabetes only - contributing to silos rather than integrated care Registry work not a priority for clinic staff Hard to keep track of everything needing to be done for each patient at the time of visit Practice Redesign not fully implemented in every clinic Visit planning tools and goal setting not being consistently utilized No formalized process to assess implementation of Care by Design

    52. Barriers – PDSA Cycle 3 Limited support for patient self-efficacy and self-management training Performance feedback not provider specific PCPs out-dated (again)

    53. Do PDSA Cycle 3

    54. Interventions – PDSA Cycle 3 Expanded Best Practice Alerts in EMR to support 26 key aspects of care – Jan 08 Evaluation of level of implementation of Care by Design – May 08 On-line clinic and provider feedback reports – Aug 08 Hired Practice Enhancement Coordinator – Sep 08 Oversight of registries and visit planning processes and tools Patient self-management trainings Shared Medical Appointments On-line, multi-condition registry integrated at patient level – Oct 08 Un-blinded provider detail reports – Nov 08

    55. Study PDSA Cycle 3

    56. Measurement – PDSA Cycle 3 In progress now CBD Implementation Status assessment Team Survey Measurement of Q indicators (new reports)

    57. Summary Challenges: Using EMR data in new ways than before Changing measure definitions Limited programming support slowed progress on reports and registries Resources for vision and planning, but limited for implementation support across system

    58. Summary Successes Increased provider and staff awareness of quality improvement efforts Some incremental improvement over time in traditional model Preliminary data suggests Care by Design, when fully implemented, supports better care and outcomes Preparation for the future if payors move to models of pay for performance

    59. Questions? Contact Information Julie Day, MD, Medical Director for Quality University of Utah Health Care: Community Clinics julie.day@hsc.utah.edu (801) 587-6307 Annie Mervis, MSW, Quality Manager University of Utah Health Care: Community Clinics annie.mervis@hsc.utah.edu (801) 587-6327

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