Quality Improvement in Primary Care Settings Eboni Price Haywood, MD, MPH Chief Medical Officer, Tulane Community Health Medical Director, Tulane Community Health @ Covenant House
Team Approach to Quality Improvement Programs Team organization is the key to success Plan ahead Allot protected time Emphasize team approach Review policies and procedures periodically Communicate quality improvement standards with clinic providers and staff
Step 1: Identify Key Stakeholders Create a team of important stakeholders Medical Director Clinic Manager Lead clinicians Care Management Team (SWs, Nurses) Quality Improvement Personnel Information Technology Personnel
Step 2: Establish Core Team Members Clearly define roles and responsibilities Team leader Project coordinator Policies and procedures Care coordination Care management Evidence based disease management Data collection & analysis Performance reporting
Step 3: Assess Information Technology What system do you use to organize data? Practice management: paper or electronic? Medical records: paper or electronic? Can you create a registry to identify patients with select criteria? Retrospective vs. prospective? What resources can you use for data analysis? IT personnel? Data analyst? Other clinic staff?
Step 4: Identify Evidence Based Conditions Identify clinically important conditions Choose & explain method by which these conditions are determined to be most important Most prevalent diagnosis Most clinic visits Greatest cost Establish written guidelines, disseminate, and start data collection
Step 5: Disseminate Written Guidelines Key components of guideline Policy statement Purpose statement Procedures clearly defined Measurable objectives Specific Quantitative Reasonable & feasible outcome measures
Step 6: PDSA Cycle Plan Prioritize area of interest Take into consideration clinic work flow Specify measurable objectives Generate and disseminate policies & procedures Do Enable clinic staff to efficiently adhere to policy Study Collect and analyze data Link outcome measures to stated objectives Act Revise policy, procedures, objectives & outcome measures periodically (e.g. every 3 4 months)
Diabetes Care Management Study period: Sept. 1, 2008 to Nov. 30, 2008 vs. March 1, 2009 and May 31, 2009 Intervention: intensive teaching with nurse practitioner using standard EMR template Objectives: Increase the percentage of diabetic patients with at least 1 HgbA1C to 70% Increase the percentage of diabetic patients with at least 1 LDL to 50% Increase the percentage of diabetic patients with at least 1 microalbumin:creatinine ratio to 50%
Diabetes Care Management TUCHC Diabetes Management Percent Diabetes Seen in Study Period 100 90 80 70 60 50 40 30 20 10 0 48.87 85.8 31.58 81.4 27.07 at least 1 A1c at least 1 LDL at least 1 microalb:cr ratio Laboratory Measures 62.3 Sept-Nov 2008 Mar-May 2009
Hypertension Care Management Study period: Sept., 2008 to Nov. 30, 2008 Intervention: intensive teaching with the nurse practitioner using standard EMR template Objectives: Increase the percentage of hypertensive patients with a b/p < 140/90 Increase the percentage of poorly controlled hypertensive patients (B/P >140/90) obtaining a 20% reduction in blood pressure. Increase the number of patients screened for lipid disorders
Hypertension Care Management Seen by MD Numerator Denominator % Avg. Range SBP >=140 564 587 96 160 140-230 DBP >=90 350 587 60 98 90-131 At least 1 LDL 267 587 46 124 41-224 Avg # visits 1.33 1-1.89 Referred to NP (n=23) Average Reductions Range Change in SBP -24% -19 to -80 Change in DBP -13% +6 to -45
Depression Care Management Study period: September 1, 2008 to November 30, 2008 Intervention: Standard nurse triage & PHQ9 templates Objectives: Administer 2 question depression screener to 100% patients Increase # patients with PHQ9 if diagnosed with depression to 100% Increase # patients with a PHQ9 documented that also have a score recorded in the vitals to 50% Increase #patients with a score documented in vitals, have a PHQ9 score > 10, & have a repeat PHQ9 documented during the study period to 50%
Nurse Triage Note
PHQ9
Depression Screening Numerator Denominator % # screened with 2 question screener 1336 1336 100.00 # with PHQ 9 clinic note 259 1336 19.39 # with PHQ 9 clinic note & diagnosis of depression 186 259 71.81 # PHQ 9 documented in vitals flow sheet 161 259 62.16 # with PHQ 9 score of > 10 in vitals flow sheet 115 161 71.43 # PHQ 9 score > 10 with at least 1 repeat PHQ 9 score 30 115 26.09