Transcript Internal Medicine PILDP Team

Internal Medicine PILDP
Team
February 18, 2011
Getting a Leg Up on
Diabetes Control
Team Members & Roles
Members
Roles
• Dr. Jim Koller, MD
• Leader/Front Line
• Amanda Lewis,
LPN
• Team Member/Front Line
• BJ Boshard, RN,
MS
• Facilitator/Recorder
• Divya Gupta, MD,
Resident
• Team Member/Front Line
• Jyotsna Reddy,
MD, Resident
• Team Member/Front Line
Team Supporters
• Advisors
– Kristin Harlan
– Lynn Keplinger, MD
• Sponsors
– Dr. David Fleming
– Dr. Bob Lancey
02/17/2011
• 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
Six Hat Thinking by Edward De Bono
Blue = Thinking/Facilitating
Red = Emotional
White = Information/Data
Black = Logic
Green = Creativity
Yellow = Hopeful/Optimistic
DeBono
02/17/2011
E, Six Thinking Hats, Little, Brown, & Co, Boston, 1985
Purpose of 6 Hat Thinking
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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!”
Problem
Change Hypotheses
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
Providing data will:
• Increase effective care (based
on standards of care/evidencebased medicine)
• Increase the patient
partnership in their own care
• Create a culture of quality
measurement in physician
practice
• Comply with ACGME
02/17/2011
Relationship to Strategic
Goals of Institution or
Department
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Service and Quality
Use of EMR to achieve patientcentered 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
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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
Business Case
Patient Costs:
Other Costs:
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• 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
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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 RevenueContinuity Clinic FY 2011
$470,000
UMHC 1990 Review***
$17:$1
*(ADA) Cost Calculator 2007:
http://www.diabetesarchive.net/advocacy-and-legalresources/costof-diabetesresults.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)
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11% of all direct medical spending
by Missourians is on
diabetes care**
The Project
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.
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Evolving AIM
1. 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%
DM2 from 77%
DM3 from 70%
DM4 from 82%
DM5 from 73%
DM6 from 71%
DM7 from 61%
DM8 from 36%
to 95%
to 90%
to 90%
to 90%
to 90%
to 90%
to 90%
to 70%
(HgA1c)
(HgA1c < 9)
(BP < 140/90)
(LDL)
(LDL <130)
(Microalbumin)
(eye)
(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.
02/17/2011
Process Flow Chart
02/17/2011
Fishbone
02/17/2011
Brainstorming Interventions
PILDP Team-Ideas
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
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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
Effort
High
High
Low
1, 2, 3, 4, 5,
4, 5(low for those
(high for those who type), 7, 8, 9,
who dictate)
10*
Yield
*Clinic QI Comm. –
already in process
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Low
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Numbers correlate with brainstorming interventions-
Key Driver Diagram
Goal
1. Improve
group resident
performance in
all IM Resident
Otpt Clinics for
8 DM
performance
measures and
improve pt DM
disease control
Primary
Drivers
1. Data
2. Culture
3. Education
4. Patient Compliance
02/17/2011
Secondary Drivers
1. Computer Resources (EMR,
email, Access, Excel)
• Ability to use systems
• Ability of systems to
perform
• Methods of
documentation
2. Provider practice/supervisor
practice, Clinic flow/appt
times
3. Resident knowledge of
DM performance
measurements and
appropriate
documentation
4. Pt knowledge,
beliefs, supports,
insurance, health
literacy
Specific
Interventions:
1. Provided comparative
data on monthly basis for
all 8 measures for each
resident compared to all
residents and goal
2. 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
3. A. Conferences, residents
sent to IT, provide with
info on all 8 measures
B. Draft e-mail demo
proper
documentation of abn
foot exam
4. Talk and partner with
pt, give information
Stakeholders
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Patients
ACGME
Residents
IT
Attendings
Department of IM
Education Office
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VA
UMHC
Nurses
PSRs
SOM
Divisions/Fellowship
How Do We Get
Data?
HELP Has Arrived!
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THEN!
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Baseline Data – 9/28/10
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DM1: 91%
DM2: 77%
DM3: 70%
DM4: 82%
DM5: 73%
DM6: 71%
DM7: 61%
DM8 : 36%
02/17/2011
(HgA1c)
(HgA1c < 9)
(BP < 140/90)
(LDL)
(LDL <130)
(Microalbumin)
(eye)
(foot)
(Cerner Analytics with
Manual Copy/Distribution)
NOW – Koby-ized!
02/17/2011
IM Resident DM Performance Data
September 28, 2010 - February 14, 2011
100%
90%
80%
70%
60%
09/28/2010
11/23/2010
50%
12/23/2010
01/27/2011
40%
02/14/2011
30%
20%
10%
0%
HbA1c
HgA1c<9
BP<140/90
LDL
LDL<130
Microalbumin
Eye Exam
Foot Exam
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Obstacles/Barriers
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Lack of IT support
Missing key stakeholders
VA access and follow-up
Residents non-responsiveness to emails 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
02/17/2011
02/17/2011
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
02/17/2011
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
02/17/2011
Questions?