type 2 diabetes performance improvement initiative: chart reviews · and chronic, start with hypo-...

Type 2 Diabetes Performance Type 2 Diabetes Performance Improvement Initiative:Improvement Initiative:

Chart ReviewsChart Reviews

Participants in the ProgramParticipants in the Program

318 clinicians have registered318 clinicians have registered

192 have started the program192 have started the program

126 have started their initial chart review126 have started their initial chart review

26 have completed their initial chart review26 have completed their initial chart review

19 have submitted their action plans and 19 have submitted their action plans and are awaiting their followare awaiting their follow--up chart reviewup chart review

Performance ImprovementPerformance Improvement

•• Enrolling in this PI program is the Enrolling in this PI program is the 11st step in improving care for your step in improving care for your patientspatients

•• Key component to improvement is Key component to improvement is chart reviewchart review

–– Simple way to look at baseline measures of your Simple way to look at baseline measures of your practicepractice

–– Very act of reviewing charts can be illuminatingVery act of reviewing charts can be illuminating

Chart Review ChallengeChart Review Challenge

•• Biggest challenge = timeBiggest challenge = time

•• Ways to overcome this barrier:Ways to overcome this barrier:

•• Ask support staff to review patients seen in past month Ask support staff to review patients seen in past month with any ICD 9 code for diabetes and pull charts, or with any ICD 9 code for diabetes and pull charts, or review electronic medical recordreview electronic medical record

•• Make a plan to complete this chart reviewMake a plan to complete this chart review

–– Recruit another member of your team to helpRecruit another member of your team to help

–– Schedule 2 oneSchedule 2 one--hour sessions over the next week hour sessions over the next week using administrative time or your lunch hourusing administrative time or your lunch hour

Type 2 Diabetes ProjectType 2 Diabetes Project

Make a commitment to yourself and to your Make a commitment to yourself and to your patients to work toward improving care!patients to work toward improving care!

Complete the chart review as soon as possible Complete the chart review as soon as possible as your first step toward improvementas your first step toward improvement

If you are having trouble completing the chart If you are having trouble completing the chart reviews, please let us know. We can help!reviews, please let us know. We can help!

If you have any questions, please eIf you have any questions, please e--mail us at mail us at [email protected]@bu.edu or call us at or call us at 617.638.4605617.638.4605

Patient EducationPatient Educationand Promoting and Promoting

SelfSelf--Care in Care in Type 2 Diabetes Type 2 Diabetes

Jane Jeffrie Seley,MPH, MSN, GNP, CDEDiabetes Nurse Practitioner

New York Presbyterian-Weill Cornell Medical Center

New York, NY

Diabetes Self-Management Education(DSME)(DSME)

Provides skills, knowledge, and the ability to perform self-care

Helps patients make informed decisions and practice problem-solving skills

Funnell MM, et al. Diabetes Educ. 2007;33:599-600, 602-604.

DSME (contcont’’d)d)

Encourages collaboration with health care team

Improves clinical outcomes and quality of life

Core Components of DSMECore Components of DSME

Educational needs assessmentLearning preferences, health literacyBarriers to learning, following regimenDeveloping education planBehavioral goal-settingPractice skillsNeed for ongoing support & outcome measurement

Content Areas to Cover Over TimeContent Areas to Cover Over Time

Disease process & treatment optionsNutritionPhysical activityOptimizing medicationsMonitoring glycemic controlPattern managementPreventing complicationsPsychosocial issues co-existing with diabetesPromoting behavior change & self-care

RecommendationsRecommendations

Disease process & treatment options: Type 1 vs Type 2, multiple defects in diabetes, glucose metabolism

Physical activity: What? When? How long? How often? Be specific!

Nutrition: Identifying carbohydrates in meals, portion sizes, servings per meal, spaced meal times

Recommendations Recommendations (cont(cont’’d)d)

Optimizing medications: How anti-diabetes agents work, best times to take, when not to take, review skills

Monitoring glycemic control: Review skills, upgrade meter prn, determine best times to check BG on ongoing basis


Pattern management: Work toward patient participation in modifying meals, physical activity, dose of insulin according to current BG


Preventing complications: both acute and chronic, start with hypo- and hyperglycemia

Psychosocial issues living with diabetes: screen for depression, anxiety

Promoting behavior change & self-care through education, practicing skills, setting realistic goals, encouragement

Steps to SuccessSteps to Success

Provide education AND supportEncourage patient empowerment by facilitating self-care behaviorsSet realistic, achievable, short-term goalsMonitor outcomes and adjust treatment plan as neededPlan for difficult situationsMotivate, motivate, motivate!

Common Barriers to SelfCommon Barriers to Self--CareCare

Depression: up to 2x more common in patients with diabetes1

Denial/despair around diagnosisMyths/poor understanding/culture“I’ve got a little sugar”Little social supportHigh cost of meds/suppliesLack of physical & cognitive ability

1. Brown et al. Diabetes Care. 2005;28:1063-1067.

Tools to Encourage SelfTools to Encourage Self--CareCare

Knowledge is power

Back to basics: Re-assess prior knowledge & skills

Look at all meds and supplies: Askpatients exactly what they do and when

Tools to Encourage SelfTools to Encourage Self--Care Care (cont(cont’’d)d)

Focus on comfort: examine & modify blood glucose and injection supplies

Evaluate feasibility of treatment regimen in relation to patient ability and quality of life


Set short-term BGM goals based on current medications and potential treatment changesReview and discuss log book at each visitConsider periodic review of log by fax or phone between visits

Blood Glucose Monitoring (BGM)Is a Motivating Tool


Create library of written materials to reinforce teaching

More is NOT better: Choose 1 or 2 simple handouts on each main topic


Read all handouts first to determine accuracy, reading level, cultural appropriateness, etc

Free patient education materials available at National Diabetes Education Program (NDEP)—http://ndep.nih.gov/

Improving Care in Improving Care in Your PracticeYour Practice

Elaine Fleck, MDAssociate Clinical Professor of Medicine

Director, Internal MedicineNew York Presbyterian Hospital-

Columbia University Medical CenterNew York, NY

What gaps do you see between care as it is and care as it could and should be for patients with type 2 diabetes?

Identify goals that you would like to accomplish over the next 2 weeks to 3 months

Understand and implement techniques that can change the nature of care delivery in your practice

What can you do to plan, do, study, and act?

Institute for Healthcare Improvement. Available at: http://www.ihi.org/IHI/Topics/ChronicConditions/AllConditions/Changes/. Accessed December 4, 2008.

Identifying Practice Gaps and Identifying Practice Gaps and Setting GoalsSetting Goals

Act Plan

Study Do

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in an improvement?

Plan, Do, Study, Act (PDSA) Cycles

Is the Change Being Implemented an Improvement?

Improvement is not about measurement, though measurement plays an important role– Key measures are required to assess progress

– Specific measures can be used for learning during PDSA cycles

– Balancing measures are needed to assess whether the system as a whole is being improved

A General Approach to A General Approach to Developing MeasuresDeveloping Measures

• Try to collect data before and after making changes

• Multiple measures are almost always required to assure that the system as a whole is improved

• Fewer than six measures is ideal; maximum of 10

• Develop a list of measures that are useful and manageable

• Mix of outcome, process, balancing

• Feasible!

Langley K, et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass Publishers; 1996.

Types of Measures in Types of Measures in Improvement ProjectsImprovement Projects

– Process measure - How often is a question asked? • How often is an A1C being drawn?

– Outcome measure - What is actual result? • A1C level

– Balance measure - Looking at a system from all directions/dimensions. What happens to the system as we improve the outcome and process measures? • ie, costs rise dramatically for minimal improvement

patients not seen for other teaching because nurse is using time for diabetes teaching

Integrate Data Collection Integrate Data Collection for Measures in Daily Workfor Measures in Daily Work

• Include the collection of data with another current work activity (for example, data from office visit flow sheets)

• Develop an easy-to-use data collection form . . . spend 10 minutes creating a form or make Information Systems input and output easy for clinicians

• Clearly define roles and responsibilities for ongoing data collection; or offer pizza for a lunch chart review

• Set aside time to review data with those who collect it . . . give back information to everyone . . . people like to know

Example of Data Collection:Example of Data Collection:Is Depression Screening, Evaluation, and Treatment Occurring inIs Depression Screening, Evaluation, and Treatment Occurring in

Patients With Type 2 Diabetes?Patients With Type 2 Diabetes?

Patient screened for depression in past 12 months? Yes ________No ________History of diabetes?_____________________________History of depression? __________________________

Treatment for depression in past?______________If patient’s screen positive:– Was patient treated with medication? Y_______N__________

– Was patient referred to social worker, psychologist, psychiatrist, or none? (Circle one)

– If patient was treated, was there follow-up? Y________N______

– Time frame to follow-up visit?_________________________

Results of Chart Review on DepressionResults of Chart Review on Depression

45If patient was treated, was there follow up?

5. . .psychiatrist?3. . .psychologist?2Was patient referred to social worker?

113If patient's screen was positive, waspatient treated with medication?

8316Treatment of depression in past4817History of depression documented

21History of diabetes

217Intake form used2012Screened for depression in past 12 months

32Patients

Nodocumentation

NYDepression Screening and Evaluation

Next Steps:Next Steps:Set AIM Statement and Attainable GoalsSet AIM Statement and Attainable Goals

AIM Statement: Improve rates of yearly screening for depression to 90% in patients with diabetes over next 3 months– We will do this by giving feedback to providers on results, ie, only

60% screened yearly presently

– Incorporate flow sheet (already in existence but first one did not have depression screen) into paper chart, and ensure screening questions are in electronic medical record

– Educate providers and staff on evaluation, treatment, and referral options. Incorporate social workers and psychologists into plan

– Repeat chart review in 3 months

Interventions in Patients at Risk for Interventions in Patients at Risk for ComplicationsComplications

EvidenceEvidence--Based MedicineBased Medicine

Patients with microalbuminuria are at greater risk for cardiovascular (CV) mortality.1 Intensified treatment intervention aimed at risk reduction in patients with type 2 diabetes and microalbuminuria reduces the risk of CV and microvascular events by about 50%.2

How are our process and outcome measures of BP, A1C, LDL cholesterol in patients with microalbumin >30?

– Use electronic registry and paper chart review– Results of chart review: Assigned to a resident (n=11)

• 36% with adequate BP control• 91% on angiotensin II receptor blockers• 67% A1C >9 (vs. 13% in patient population at large)• 36% LDL <100• 67% had nutrition referral, or education documented

1. Bell DS. Endocr Pract. 2008;14:924-932 2. Gaede P, et al. N Engl J Med. 2003;348:383-393.

Creating AIM Statement for Creating AIM Statement for Practice ImprovementPractice Improvement

AIM statement:

We will improve A1C control in patients with microalbuminuria and A1C >9 by 50% in next 4 months, using American Diabetes Association guidelines and patient-centered approach to care

We will accomplish this by . . .

Next Steps: Set Attainable GoalsNext Steps: Set Attainable Goals

Giving feedback to providers of chart review results . . . send e-mail and provide one-on-one feedback

Identify patients with A1C >9 through registry; each house staff reviews own patients

Educate providers: Discuss intensifying therapy if A1C >9

Use flow sheet in each chart

Call patients to come in for nurse education

Consider social work referral and VNS referral for better assessment of learning and identification of barriers to care

Return to practice within one month of intervention

Steps to Success in PromotingSteps to Success in PromotingSelfSelf--Care and Practice Improvement Care and Practice Improvement

Set realistic, achievable short-term goals

More is NOT better: Choose 1 or 2 simple interventions to make change

Monitor outcomes and adjust intervention plan as needed

Plan for difficult situations

Knowledge is Power

type 2 diabetes performance improvement initiative: chart reviews · and chronic, start with hypo-...

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