Internal Medicine PILDP Team February 18, 2011

1. Internal Medicine PILDP TeamFebruary 18, 2011 Getting a Leg Up on Diabetes Control

2. Team Members & Roles Members Roles Leader/Front Line Team Member/Front Line Facilitator/Recorder Team Member/Front Line Team Member/Front Line • Dr. Jim Koller, MD • Amanda Lewis, LPN • BJ Boshard, RN, MS • Divya Gupta, MD, Resident • Jyotsna Reddy, MD, Resident

3. Team Supporters • Advisors • Kristin Harlan • Lynn Keplinger, MD • Sponsors • Dr. David Fleming • Dr. Bob Lancey • Special Partners • UMHC • Koby Clements – Data Guru • Karen Broz – Resident IT Training Coordinator • VA • Tim Anderson – Patient Safety • Crystal Aholt – Patient Safety • Alan Villiers – IT Guru

4. Six Hat Thinking by Edward De Bono Blue = Thinking/Facilitating Red = Emotional White = Information/Data Black = Logic Green = Creativity Yellow = Hopeful/Optimistic DeBono E, Six Thinking Hats, Little, Brown, & Co, Boston, 1985

5. Purpose of 6 Hat Thinking • Promotes Parallel/Directional Thinking • Manages multiple “thoughts” • Allows one “think” at a time • Changes the direction of the train • Easy to use • Removes judgment about right or wrong • Allows us to focus on “what we can do!”

6. Problem Change Hypotheses Providing data will: Increase effective care (based on standards of care/evidence-based medicine) Increase the patient partnership in their own care Create a culture of quality measurement in physician practice Comply with ACGME We Would Like to Achieve Better: • Management of Chronic Diseases • Monitoring of Resident Performance • Compliance with ACGME Requirements for Chronic Disease Management and Preventive Care

7. Relationship to Strategic Goals of Institution or Department Intersection With Patient Centered Care Use of EMR by providers to know whether they are meeting established standards of care for patients/panels of patients with chronic diseases (DM) Use of EMR to be able to share with patients their management of diabetes for 8 performance measures Partner with patients to improve performance on diabetes measures Service and Quality • Use of EMR to achieve patient-centered outcomes through monitoring • Achieve standards of care for DM • Improve interactions with patients through informed, active patients • Focus on one of the top 7 health risk factors for Missouri

8. Business Case Patient Costs: Other Costs: Loss of accreditation Loss of Manpower at (VA & UMHC) Reputation Impact on School of Medicine Fellowships would disappear • Quality Care • Patient Retention • Patient Acquisition • Increased Hospitalizations • Increased Morbidity • Increased Mortality

9. The of Diabetes USA* $174,000,000,000 Missouri ** $2,720,000,000 Missouri, District 9* $305,800,000 Missouri Individual** $11,734 Proj. Generated Revenue- Continuity Clinic FY 2011 $470,000 UMHC 1990 Review*** $17:$1 *(ADA) Cost Calculator 2007: http://www.diabetesarchive.net/advocacy-and-legalresources/cost-of-diabetes-results.jsp?state=Missouri&district=2909&DistName=Congressional+District+9 **MODHSS, Diabetes Burden Report & State Plan, May 2009 http://www.dhss.mo.gov/living/healthcondiseases/chronic/diabetes/index.php ***For every $1 spent within the Diabetes Center for the care of a patient, that same patient “spent” $17 elsewhere within the UMHC system. (UMHC Diabetes Center) Diabetes hospitalizations for Missouri residents under 65 in 2006 considered preventable = 74%** MO Prevalence = doubled last 10 years from 4.4% to 8.0%** 11% of all direct medical spending by Missourians is on diabetes care**

10. The Project

11. Initial Aim – 8/27/10 • Specific Aim: Improve achievement of standards for chronic disease management and control, (pilot - specifically diabetes & mammography screening), by improving resident education and performance on ___ diabetes performance measures (which ones/or all) and ordering of mammograms for women 50 and older; and the ability of faculty to routinely (every 6 mos) evaluate and discuss resident performance on these measures by June 2011 in all IM resident continuity clinics.

12. Evolving AIM • Improve group resident performance in all IM resident outpatient clinics (Fairview/Woodrail/VA) for all 8 Diabetes (DM) care performance measures - • from ____*to ____ by June 2011 • DM1 from 91% to 95% (HgA1c) • DM2 from 77% to 90% (HgA1c < 9) • DM3 from 70% to 90% (BP < 140/90) • DM4 from 82% to 90% (LDL) • DM5 from 73% to 90% (LDL <130) • DM6 from 71% to 90% (Microalbumin) • DM7 from 61% to 90% (eye) • DM8 from 36% to 70% (foot) • *UMHC IM Resident Performance Baseline on September 28, 2010 2. Improve the generation of resident improvement action plans for diabetes care by residents and attendings in all of the ambulatory clinics from 0% to 100% starting in December 2010 and every 6 months thereafter.

13. Process Flow Chart

14. Fishbone

15. Brainstorming Interventions PILDP Team-Ideas Complimentary Projects Underway by Clinic QI Committees 7. Nurses highlight exams needed & empty problem lists on pt summary sheet 8. PSR highlight incomplete measures (foot exams & microalbumin) 9. Nurses mark orders for microalbumin 10. Doctors repeat abnormal BPs/place on encounter form/Nurses chart new results* *Woodrail/Fairview QI Teams 1. Report given to residents on the 8 measures + perfect care monthly with process to discuss with attendings and create action plan 2. Residents get trained how to do problem lists and ensure correct PCP 3. Nurses to do and document diabetic foot exams 4. Nurses to document date of last eye exam 5. Use 2G note to document foot and eye exams 6. Residents to maintain lists of diabetic patients and keep their own performance measures

16. Numbers correlate with brainstorming interventions- those in green implemented by team

17. Key Driver Diagram • Primary Drivers • Data • Specific Interventions: • Provided comparative data on monthly basis for all 8 measures for each resident compared to all residents and goal Goal 1. Improve group resident performance in all IM Resident Otpt Clinics for 8 DM performance measures and improve pt DM disease control • Secondary Drivers • Computer Resources (EMR, email, Access, Excel) • Ability to use systems • Ability of systems to perform • Methods of documentation Created tool and automatic process for resident to meet with attending , create action plan and sign off & implemented sign-off in New Innovations each Dec and Jun Provider practice/supervisor practice, Clinic flow/appt times Culture • Education Resident knowledge of DM performance measurements and appropriate documentation A. Conferences, residents sent to IT, provide with info on all 8 measures B. Draft e-mail demo proper documentation of abn foot exam Patient Compliance Pt knowledge, beliefs, supports, insurance, health literacy 4. Talk and partner with pt, give information

18. Stakeholders • Patients • ACGME • Residents • IT • Attendings • Department of IM • Education Office • VA • UMHC • Nurses • PSRs • SOM • Divisions/Fellowship

19. How Do We Get Data?

20. HELP Has Arrived!

21. Then!

23. Baseline Data – 9/28/10 • DM1: 91% (HgA1c) • DM2: 77% (HgA1c < 9) • DM3: 70% (BP < 140/90) • DM4: 82% (LDL) • DM5: 73% (LDL <130) • DM6: 71% (Microalbumin) • DM7: 61% (eye) • DM8 : 36% (foot) • (Cerner Analytics with Manual Copy/Distribution)

24. NOW – Koby-ized!

27. Obstacles/Barriers • Lack of IT support • Missing key stakeholders • VA access and follow-up • Residents non-responsiveness to e-mails for training – implemented “consequences” • Team size • EMR complexity and education • Nurses cannot populate “problem lists” • Nurses unable to use 2 G note • PCP and problem lists incomplete • Sending out data before we solidified process • Traditionalists • CPOE priority

29. Next Steps • Continue to send monthly DM performance data to residents/attendings • Continue to refine improvement plans and document in NI • Continue IT Education • Begin monitoring Pneumovax and adding to action plan • Complete storyboard – post/maintain • Get the VA data • Evaluate for improvement in care • Apply these methods to other chronic diseases and preventive health screenings

30. Lessons Learned • Need key stakeholders on our team • IT/EMR support critical & not easily available • Solidify process before sending reports • Identify & build onto other QI projects • Simplify process • Importance of interdisciplinary teams • It is hard to describe your project in 15 minutes 6 Hat Thinking

31. Questions?