Mindy Carroll, R.N., examines the feet of patient Robert Kolb at Vanderbilt's Adult Primary Care Clinic. (photo by Susan Urmy)
New protocol helps boost chronic care management
Vanderbilt's Adult Primary Care Center (APCC) recently caught a measure of national attention for bettering its management of chronic disease, including diabetes and cardiovascular problems.
Over two days in late fall, the center opened its doors to some 25 visitors representing the federal government's Agency for Healthcare Research and Quality, a Washington, D.C., patient safety coalition called the Delmarva Foundation and the Association of American Medical Colleges (AAMC).
The visit came after the APCC was recognized as one of four top groups among the 22 around the nation that are participating in the AAMC's Academic Chronic Care Collaborative.
Jim Jirjis, M.D., M.B.A., the APCC's medical director and VUMC's chief medical information officer for outpatient clinics, explained that the center has been using a practice improvement formula called the plan-do-study-act cycle, or PDSA cycle.
“It's an evidence-based model that works,” Jirjis said. “We've achieved some dramatic results by testing small changes one after another. It's helping us zero in on new processes that can support the lasting improvements we're seeking. We're going to continue with PDSA cycles — it's now our culture.”
He points to foot exams as an example. One study estimates that only about half of all patients with diabetes in the United States have their feet examined periodically for sores. Such exams can help prevent ulceration and help avoid the eventual need for amputation.
The APCC's documented rate of looking at the feet of patients with diabetes was nearly 80 percent. However, when a pilot group in the APCC adopted a clear, more stringent standard for foot exams, their practice data showed that only 17 percent of their patients with diabetes had a current exam of a type that met this recommended four-point standard.
So the pilot group launched a series of quick, small-scale PDSA cycles. The first involved provider education, to highlight recommended care and point out the gaps in care. This proved to have only a marginal effect.
Next, they placed diabetic foot exam awareness posters in exam rooms to prompt providers and patients. Again the effect was only slight.
Better progress came with the next cycles, involving electronic prompts to remind providers to do foot exams, and a new electronic form to standardize the documentation of exams.
“These PDSA cycles dramatically improved the rate of documented exams, and also helped us to discover many of the barriers that were preventing us from providing the care we wanted to provide,” said Waldon Garriss, M.D., M.S., assistant professor of Internal Medicine and Pediatrics and associate chair for ambulatory education in the Department of Medicine.
The next cycle used a team approach, starting with foot exam training for physicians and nurses.
“We realized, too, that we hadn't utilized another important part of our team — the patient care techs,” Garriss said. “We asked the techs, who situate patients in exam rooms, to begin to identify patients with diabetes and ask those patients to take off their shoes in preparation for an exam. The techs would then alert the nurses, who would do the exam, and the physicians were notified of the results. This freed up the physicians to be able to spend more time addressing other patient needs. This turned out to be a home run.”
Data gathered in August 2006 showed the compliance rate had reached 82 percent.
“This was truly a system approach to the problem. You're not just telling one person to work harder, you're instead changing for the better the routine processes used every day in the clinic,” said Bill Gregg, M.D., an internist and assistant professor of Biomedical Informatics who assists the center's improvement efforts.
In addition to the benefits for patient care, Garriss likes the way PDSA cycles help to satisfy new residency program requirements. Giving residents practice improvement know-how is a new accreditation requirement for graduate medical education programs.
“For now, our health care system remains oriented to treatment of acute disease,” Garriss said. “The better outcomes and lower costs that we're all seeking will involve halting and preventing the big chronic diseases — diabetes, heart problems, asthma, AIDS and the rest. A large part of the improvement will come by achieving better adherence to the already agreed standards of care, and PDSA cycles can be very helpful here.”
Jirjis said the APCC has also lowered blood sugar and blood pressure levels among patients with diabetes, improved self-management by these patients, and achieved improvements among patients with heart disease, including lower cholesterol levels and better adherence to medication standards after a heart attack.