J. Willis Hurst
Internal
Medicine
Residency
Program
Show Me the Sugars!
Grady Health System, International Medical Clinic
Sol Aldrete, MD, Roger Alvarez, DO, Jeremy Chow, MD, Juan Ortega-Legaspi, MD, Lori Randall, MD, Amy Salerno, MD, Danny Treiyer, MD, Aida Venado, MD
Faculty Mentor: Nurcan Ilksoy
Problem
Diabetes is a problem that disproportionately
affects Hispanics in the United States, with a
prevalence of 7.9% compared to 5.1% in White
Americans (1). Not surprisingly, diabetes is one of
the most common problems among the patients of
the International Medical Center, most of whom are
Spanish speakers. While it was evident that blood
glucose logs could be invaluable in helping to attain
optimal glycemic control, patients often had to
create their own makeshift blood glucose log on
blank paper. There was no process in place to make
sure that there was a bilingual, three-meal glucose
log available for our patients, and that the providers
were having regular discussions of the blood
glucose values with their patients.
Figure 1: Discussions of & Compliance with
Glucose Log
Test of Change
Result
Placing glucose
logs in clinic
workroom for
residents to use
during
appointments.
Much higher
rate of giving
logs to patients
but still
inadequate rate
of patients
bringing in logs.
100
90
80
Percent
70
60
Discussions of Log
50
% Bringing Log
40
30
20
Barriers
10
1
2
3
4
5
6
7
Time (months)
Aim Statement
What Was
Learned
Need another
intervention to
remind patients to
bring logs (possibly
phone message) as
well as more time
for patients to
have had prior
appointments and
been given logs.
•Provider Factors: As seen in Figure 2 and 3,
the largest barriers in discussing logs and
patients bringing their logs, were the lack of
initiation of discussion by the physician, and the
failure to provide blood glucose logs.
•Patient Factors: Figure 3 shows that patient
factors such as forgetting to bring logs,
noncompliance with glucose checks, and lack of
supplies, also played a significant role.
0
(1) http://minorityhealth.hhs.gov/templates/content.aspx?lvl=2&lvlID=54&ID=3324
1. 80% of clinic visits with insulindependent diabetics at the Grady
International Clinic will have
documented discussion of glucose
log and a copy of blank log given to
patient.
2. At 60% of visits, patient will bring
glucose log (paper or glucometer).
Goal time period: to accomplish
this aim between October 2011
and April 2012.
Tests of Change
Measure
What changes might result in an improvement?
Figure 2: Barriers to Discussing Log
35
30
25
20
15
Physician
10
Patient
Lack of time
5
0
Bring log
Multiple complaints
Provider Didn’t
Mention
Visit Didn't Address Discussed at Prior Visit
DM
Figure 3: Barriers to Patients Bringing Log
No home BG Log
recorded in chart
Providing BG log
Making
copy for
chart
60
Staff
50
40
30
20
10
0
Pt not given
log
Pt forgot
DM not
addressed
Unknown
No testing
supplies
available
Not
compliant
with home
BG checks
Record BG
log
System
Upload information
to Epic
Scheduling close
f/u appointment
Lessons Learned
•Though physicians were close to meeting the 80% goal of having
discussions about the glucose log, the percent of patients who
brought their logs remained about 25%.
•Despite the conversations taking place, in >50% of physician
encounters, patients still were not given logs.
•Physician discussions need to result in the reflexive supplying of a
glucose log.
•This seems to be area of change that can have the largest impact.
Simple interventions, such as making logs more readily available in
each room, or having nursing staff hand them out to diabetics,
might improve the percent of patients who bring back logs.
Meanwhile, patient-specific factors can be worked on at an
individual level.
End-of-Life Care Planning
Improving Documentation of Advanced Directives in the Resident Clinic
using Electronic Medical Records
J. Willis Hurst
Internal
Medicine
Residency
Program
Grady Primary Care Center, Monday Purple Pod
Salim Hayek, Ria Nieva, Frank Corrigan, Amy Zhou, Uma Mudaliar, David Mays, Michael Massoomi, Erika Heard, Reza Hassanyar, Dejuan White
Faculty Mentors: Iris Castro, Nurcan Ilksoy
Problem
• End-of-life care planning has received and advocacy in
recent years. JCAHO requires that hospital medical
records document evidence of known advanced
directives (AD) and provide information about advance
care planning to all patients. Patient satisfaction is
increased when AD are discussed in clinic.
• Despite surveys showing patients prefer to discuss
advance directives with their primary care doctor, many
are completed during hospitalizations. Population
based-estimates of completed advance directives range
from 5% to 15%.
• Discussing end-of-life care in the outpatient setting is
perceived as challenging. One major obstacle reported
by physicians is lack of time and effective reminders to
address and document advanced directives.
Aim Statement
• Previously we assessed the effectiveness of emailmediated provider education and reminders in
improving documentation of AD. This initial test of
change (TOC1) showed a slight (1%) and temporary
increase in documentation of AD.
• Using the electronic medical records (EMR) system EPIC
we set to implement a reminder system for physicians
to document AD in a select population of patients with
chronic illnesses (see below), and assess the
percentage of patients meeting criteria which have
documented AD counseling within 6 months of the
main test change:
Adding “Advanced Directives Counseling” to the patient
problem list (ADPL).
• Patients must have one or more of the following
characteristics/diagnoses: Age > 65, Congestive Heart
Failure NYHA III, severe COPD (FEV1<30%), AIDS, any
diagnosis of malignancy, cirrhosis, ESRD, stroke.
Tests of Change
Methods and Measure
Test of
Change
Result
Yes
No
TOC1
TOC2
• A total of 588 patient charts were screened by 7 providers
of Grady Clinics Purple Pod.
• 157 met the predefined criteria for AD documentation.
“Advanced Directives Counseling” was added to the problem
list of 50% of patients who met criteria.
• During the period of November 2011-April 2012; 64 patients
were seen in clinic; 38 had AD on their problem list, 26 did
not.
• 76% of charts with ADPL had documentation of AD. Only
11.5% of those without ADPL had AD documented.
TOC3
What Was
Learned
• Provider education through
email
• Reminder emails
• Distribution of handouts on
advanced directives
• Workshop on advanced
directives discussion
• Added “Advanced Directives
Counseling” to problem list
• Provided .ADVDISC summary
template for rapid
documentation
Ineffective. Improvement
in documentation rate
temporary at best and
highly dependent on
physician’s personal
motivation
No effect on
documentation
Effective reminder, as
well as easily accessible
permanent record.
Significantly increased
documentation of AD
Limitations
TOC1
TOC2
TOC3
Barriers to Documentation of Advanced Directives
Data Collection
• Sample size was relatively small and study of short
duration. Will require longer term and larger population
sample to assess sustainability of the improvement in
documentation rate.
• Study does not assess completion rates of official AD
document completion.
• No conclusion can be made on the impact of improved
AD documentation on inpatient management
Lessons Learned
• EMR based reminders are effective in improving
documentation rates of AD and may be applied for other
purposes.
• Obstacles remain, including the lack physicians’ initiative
and knowledge in discussing AD, time limitations in the
outpatient setting, as well as the unclear translation into
changes in inpatient management.
• Further research is needed to establish the sustainability
of improved documentation over longer periods of time
and in a larger population sample, as well as its impact
on inpatient management.
Improving Influenza Vaccination Rates in an
Internal Medicine Resident Clinic
J. Willis Hurst
Internal
Medicine
Residency
Program
General Internal Medicine at 1525 Clifton Rd., Friday Resident Clinic
Turang Behbahani, Vivian Cheng, Ed Clermont, Tina Constantin, Patrick Hall, Farah Khan, Freny Nirappil, Julian Raffoul, Nathan Spell
Problem
The number of seasonal influenza-associated
deaths varies from year to year because flu
seasons are unpredictable and often fluctuate in
length and severity. The CDC estimates that from
the 1976-1977 season to the 2006-2007 flu
season, flu-associated deaths ranged from a low
of about 3,000 to a high of about 49,000 people
(1). In 2013, the CDC published a model to
quantify the annual number of influenzaassociated illnesses and hospitalizations averted
by influenza vaccination during the 2006–11
influenza seasons (2). Using that model the CDC
estimated that vaccination resulted in 79,000
(17%) fewer hospitalizations during the 2012–13
influenza season than otherwise might have
occurred. Especially in the primary care setting,
providers are facing increasing difficulties to clarify
"influenza-myths" as well as to
identify burdens which keep patients from
choosing or receiving the valuable vaccination.
Aim Statement
By January 1, 2014, 70% of more of all
patients seen in the Friday resident clinic at
1525 Clifton Road will be vaccinated during
their appointment (if not already
completed).
Tests of Change
1. Jan: Created standard process to let
MD know patient’s status and wishes
2. Feb: Attending to review vaccine
status during sign-out as detection
and mitigation step.
Barriers
Measure
Goal
Actual
- Lack of a standard process to address
preventive care, in general, leading to
creation of unique solutions to this
problem
- Perceived inability to influence patient
wishes and misinformation
- Relative little involvement of clinic staff
Lessons Learned
Standard
process
Attd
review
What changes might result in an improvement?
- Doing an improvement project in isolation
from the rest of the practice made it hard to
create a standard way of checking vaccine
status that would sustain itself
- A standard process does not become the
standard without effective training and
reinforcement at first
- Reliance on memory does not yield much
improvement
- We tended to make changes where we felt
we had the most control, rather than trying to
change patient beliefs, which was the
greatest opportunity
- Data collection should be built into the work
flow or should come from a ready source
References
(1) Thompson MG et al., Estimated Deaths Associated
with Seasonal Influenza - United states 1976-2006,
Weekly, August 27, 2010 / 59(33);1057-1062
(2) CDC. Prevention and control of seasonal influenza
with vaccines. Recommendations of the Advisory
Committee on Immunization Practices—United States,
2013–2014. MMWR 2013;62(No. RR-7).
Improving Hypertension Control
in the Patient Centered Medical Home
J. Willis Hurst
Internal
Medicine
Residency
Program
Grady Green Pod Clinic Team
Austin Chan, Maya Varthi, N. Thi Gunter, Patricia Hwang, Curtis Jamison, Bryant Chan, Arjun Nanda, Jessica Nave, Ravi Vora, Parth Joshi, Mahmoud Abdou, Danesh Kella, Greg Weston, Amirali Masoumi, Abhinav Koul, Abdullah Khan, Bradley Witbrodt, James
Monaco, Vaishnavi Kundel, Yasamin Chowdhury, Danny Nguyen, Maria Lee, Anjan Deka, Phoebe Chi, Eric Shin, Aaron Gluth, Brian Heeke, Sandeep Krishnan, Anand Jain, Daniel Cucco, Vera Tate, Ula Abed Alwahab, Neal Bhatia, Kiran Valiani, Akshay Shetty, ShingYu “Cliff” Lin, Sara Turbow, Teresa Ingram, Katie Tipton, Robert McClung, David Dunhill, Valeria Cantos-Lucio, Joy Wortham, Shadi Yarandi, Nisha Joseph, Taylor Lebeis
Faculty Mentors: Kalra, Girish L; Doyle, Joyce P; Bussey-Jones, Jada; Manning, Kimberly; Jones, Danielle; Schneider, Jason S; Adhyaru, Bhavin; Ilksoy, Nurcan
Green Pod Nurses and Staff
Problem
In our urban primary care center, a
disproportionately large percentage of patients
have uncontrolled hypertension compared to the
general population.
Moreover, among academic primary care clinics
within the Grady Memorial Hospital Primary Care
Center, a recent report revealed that our Green Pod
practice ranked last in blood pressure control. In
3648 Green Pod patient encounters in June 2012,
only 57.2% had a SBP < 140 mmHg, compared to
65.2%, 65.4%, and 70.4% in the Orange Pod, Purple
Pod, and Yellow Pod clinics, respectively.
Tests of Change
What changes might result in an improvement?
 Dec - To improve the accuracy of BP measurement
and better identify patients who require
intensification, at each visit, a manual BP is repeated in
patients who are hypertensive, the physician is
notified, and the value is recorded within the EMR.
Figure 1. Fishbone
diagram addressing
barriers to effective BP
control.
 Feb – To improve patient adherence, the remark “For
High Blood Pressure” is added to the sig line of
prescriptions for antihypertensives.
Three key barriers were
addressed in our study: one
physician factor, one
nursing factor, and one
patient-related factor.
 Mar – Within our Epic EMR, a “dot phrase” reminder is
added to the primary clinic note template that
prompts physicians to address HTN.
Additional Pitfalls
Additional barriers contributing to suboptimal blood
pressure control and possible decreased effectiveness of
our interventions included:
We sought to re-design our approach to
hypertension management by identifying reasons
for poor blood pressure control and devising
interventions to help us more successfully treat our
patients.
1. Erratic participation by providers
2. Time constraints within a busy primary care clinic
Measure
Figure 2. Percentage
of return patients
with SBP < 140 mmHg
Aim Statement
Among patients who have been
seen in the clinic 2 or more
times in the preceding six
months, the percentage of visits
with a systolic BP < 140 mmHg.
Over 6 months, we aim to increase the
percentage of Green Pod patients with
hypertension who meet a systolic blood
pressure goal of < 140 mm Hg to over
70%.
3. Patient resistance to the addition of medication and
physician uneasiness with intensifying therapy in the
setting of possible non-adherence.
4. Limited patient finances and possible low literacy.
Lessons Learned
1.
Three simple, low-cost interventions showed varying degrees
of benefit in helping our patients achieve BP control.
2.
Utilizing support staff in the clinic appeared to be the most
effective intervention, though the practice of preferentially
obtaining manual BP assessments when the initial automated
reading is high likely introduced some bias.
3.
We were only partially able account for patients who were
uncontrolled and then had meds changed.
4.
Ensuring physician participation in a busy clinic setting without
providing additional incentive was challenging.
n = return visits examined
among Green, Orange, and
Purple clinics.
Baseline
n = 292
TOC #1
n = 320
n = 268
TOC #2
n = 516
TOC #3
n = 594
n = 599
Note that these figures should
not be compared to the
percentages cited from the June
2012 report, which examined all
patients.
Improving Hepatitis C Screening in a Primary Care
Internal Medicine Resident Clinic
1525 Clifton Road Emory Clinic Friday Team
Freny Nirappil MD, Vivian Cheng MD, Tina Constantin MD, Edward Clermont MD,
Patrick Hall MD, Michael Lava MD, Rachel Anquez MD
Faculty Advisor: Nathan Spell III MD
Background
0.3
0.28
Test of Change #2
0.5
Ratio of patients screened
0.21
0.2
0.15
0.1
Tests of Change
0.6
0.28
0.25
Ratio of patients screened
In 2012, the CDC recommended that
everyone born between 1945 and 1965
should get screened for Hepatitis C.
Hepatitis C is the leading cause for liver
transplantation in the United States, and
up to 75-80% of patients infected with
HCV can go on to develop chronic
infection. Given the morbidity associated
with this illness, we sought to improve our
screening for HCV.
Measures of Screening
0.4
0.3
0.2
Test of Change #1
0.1
0
0.05
TOC #1 12/21/12 2/8/13
TOC #2 2/22/13 4/12/13
Aim Statement
By April 12, 2013, 80% or more of
patients born between 1945-1965 seen for
a visit in the Friday resident clinic at 1525
Clifton Rd. will have been screened for
hepatitis C infection.
Fishbone Diagram
What was learned
Provider reminder
sticky sheet on
computers
Easy to miss on
computer screens
Reminders are
easy to overlook
and short lived
Pre-test patient
information
handout given to
each Friday clinic
patient
Many patients did
not receive the
handouts, so
screening wasn’t
done.
We needed a
better
implementation
plan to increase
adherence
Barriers to screening
0
Baseline 8/4/12 10/26/12
Result
Test of Change # 2
Tally Sheet
Reasons why screening is Prior to
After Test of
not done
intervention Change #1
• It is difficult to screen patients who have acute visits as
opposed to those coming in for a physical as acute visits do not
usually require bloodwork.
• Reminder systems relied solely on the physician to implement
screening.
• We did not have enough PIP conferences to discuss ongoing
issues with the project.
Patient refuses
||||
||||
Lack of prior records
|
||
Lessons Learned
Not MD priority /
awkward
||
||
Not patient priority
|||
More frequent evaluations of the success of our tests
of change would have allowed for more prompt
corrections to those changes.
MD forgets to mention /
consider
|||| ||
MD forgets to order
|||
||
Too little time to explain
|||
||||
MD unaware of
recommendation
|
Concerns about
|
insurance coverage / cost
|||| |||| |
||||
Lasting change is easier to accomplish when focusing
on larger issues because it forces the individual to
focus on the system as a whole in order to implement
appropriate steps towards establishing long-lasting
change. The narrow focus of our clinical question
may have limited the progress of our project
specifically because it focused on one small step in
the process of improving screening within our clinic.
J. Willis Hurst
Internal
Medicine
Residency
Program
Improving Counseling for Tobacco Cessation
in a Resident Primary Care Clinic
Grady Primary Care Center, Friday Purple Pod
Jane Titterington, Robert Kung, Zahi Mitri, Jeff Chen, Kyle James, Jenna Kay, Wendy Neveu, Reema Dbouk, Anthony Gamboa,
Faculty Mentors: Sanjukta Chatterjee, Nurcan Ilksoy
Problem and Background
• Cigarette smoking is the leading preventable
cause of mortality in the United States,
responsible for over 400,000 deaths annually1.
• Up to one-half of all tobacco users can be
expected to die from a tobacco-related
disease2.
• The economic burden of tobacco use is
estimated to be $197 billion per year1.
• Smoking cessation is associated with clear
health benefits and should be a major health
care goal3.
• Screening all patients for tobacco use and
providing all smokers a brief smoking
cessation intervention is one of the three most
cost-saving clinical preventive services3.
• Less than half of all patients (48.7%) report
receiving advice from health professionals to
quit 4.
Test of Change
#1 – Nurses:
Screened patients for tobacco
use during triage.
#2 – Physicians:
“Tobacco counseling” section
added to standard progress note
template.
Outcomes
Result
- There was a significantly
increased rate of screening for
tobacco use amongst all clinic
patients.
20.0%
•Most common physician barriers were: forgetting to
address smoking status, not having enough time to
address it or having too many other active medical
problems to address, or failure to document in the
progress note that tobacco cessation counseling
occurred.
•Lack of patient education materials was also a
barrier to proper counseling.
•RN barriers included lack of documentation of
screening for tobacco use during triage, as well as
having patients roomed before triage could occur.
10.0%
Lessons Learned
0.0%
• Screening for tobacco use by clinic nurses increased
when incorporated into routine triage procedures.
• Tobacco cessation counseling occurred significantly
more frequently when providers were prompted by a
standardized progress note template.
Documentation of intervention was also more likely
to be completed.
• Having patient education materials readily available
appeared to promote tobacco cessation counseling
by providers, and ensured patients left clinic with
specific resources to help them quit smoking.
100.0%
- Documented with triage vital
signs.
-There was a significantly
increased rate of smoking
cessation counseling by
physicians
- Documented in progress
note.
#3 - Patients:
Receive tobacco cessation
handout containing the Georgia
tobacco quit hotline number. and
information on tobacco cessation
classes at Grady.
- Patients left the clinic visit
with information to obtain
more tobacco cessation
counseling with resources to
help them quit smoking.
90.0%
80.0%
70.0%
60.0%
Test of
Change #1
50.0%
40.0%
Test of
Change #2 and #3
30.0%
OCT
NOV
RN screening
DEC
MD counseling
Potential problem or barrier
Fishbone Diagram
MD forgot to discuss smoking status
Count
13
MD forgot to document smoking in history
3
MD did not document counseling in progress note
9
Tired of counseling
MD had too many active issues at current visit
9
Other more urgent concerns
MD had no time to address
4
Not disclosing smoking status
RN Did not add smoking status to triage vitals
Only wants treatment
RN sent to room before triage and screening
1
RN reviewed but did not update smoking status
5
Patient tired of repeated counseling
7
Smoking cessation not a priority to patient
7
Patient just wants treatment and not counseling
1
Patient discouraged by repeated attempts that failed
5
Tobacco use not automatically placed on problem list
5
Counseling materials not readily available
4
Lack of time
Forgets to discuss
Forgets to document
Other more urgent issues
2. We aim to improve tobacco cessation
counseling rates to greater than 80% of our
population of current smokers, as measured
by both documentation in clinic notes; as well
as by including tobacco cessation resources in
the patient’s after visit summary by May 2012.
JAN
What changes might result in an improvement?
Aim Statement
1. We aim to screen 100% of our Friday Purple
Pod patients for current tobacco use with
corresponding documentation in EPIC by
January 2012.
Barriers
Counseling
Prior status
not updated
Lack of counseling materials
Not documented
No template in Epic
Not triaged
Not in problem list in Epic
23
References
(1) MMWR Morb Mortal Wkly Rep. 2008 Nov 14;57(45):1226-8.
(2) http://whqlibdoc.who.int/publications/2011/9789240687813_eng.pdf
(3) Maciosek MV et al. Am J Prev Med 2006; 31:52.
(4) MMWR Morb Mortal Wkly Rep. 2011 Nov 11;60(44):1513-9.
Improving the Documentation and Interventions of Obesity in a Resident
Primary Care Clinic
J. Willis Hurst
Internal
Medicine
Residency
Program
Grady Primary Care Center, Monday Orange Pod
Kobina Wilmot MD, Justin Cheeley MD, Jessie Torgerson MD, Jia Shen MD, Anita Saraf MD, Jenny Luke MD, Meena Prasad MD, Thomas Runge MD, Arash
Harzand MD, Hassan Imam MD, Jessica McDermott MD,
Faculty Mentors: Jada Bussey-Jones MD, Stacie Schmidt MD ,Nurcan Ilksoy MD
Problem
Aim Statement
We aim :
•To continue to improve documentation of BMI in
problem list to 75% by March 2012.
•To have at least 50% of patients documented with
obesity (BMI >30) to have an intervention of
exercise, diet, or obesity referral by March 2012 in
Orange Pod Monday clinic.
Percentage of BMI Documentation in Obese patients
by Physicians in Monday Orange Pod
Per month
Percentage of Obesity Documentation in Problem List
by Physicians in Monday Orange Pod Per Month
Ratio of Obesity Addressed in Plan by Physicians
in Monday Orange Pod Per Month
120%
1.2
120%
100%
1
100%
Test of Change
Result
Height added to nursing
triage template to be able to
calculate BMI
What Was Learned
Significant improvement in
documentation and
sustainability observed
Interdisciplinary team work
with system change made the
process sustainable.
Documentation of obesity on increase documentation on
the problem list
the problem list
Periodically reminders are
needed. Also new physicians
in clinic need to be accounted
for.
Initial informative email and
and flyers encouraging
obesity plans & obesity clinic
referral program
Increase trend in obesity
documentation in problem list
and interventions described in
problem list
Visual reminders and site to
send patients increases
interventions for patients
with obesity
Another informative email
sent
Continual trend upward in
documentation in problem list
and interventions
Once again reminders help
but not enough for reliable
process improvement
80%
80%
0.8
60%
60%
0.6
40%
40%
20%
20%
0.4
0%
0%
0.2
0
July '11
August '11 September '11 October '11 December '11 January '12
March '12
Obesity Clinic Referral Results
Ratio of Diet intervention in Obesity Plan by
Physicians in Monday Orange Pod Per Month
35
30
0.7
30
Number of Patients
• Obesity is defined as a BMI of >30.
• More than 1/3 (35.7%) of U.S. adults are obese.
The rate in Fulton County is 23.2%, in Dekalb
County 27.4%.
• Obesity is an increasing problem. Currently, >30%
of the population is obese in 12 states. In 2000, no
state had an obesity rate >30%.
• The average hospital length of stay for obese
patients is 60% longer than for normal weight
individuals nationwide.
• The annual cost of obesity in Georgia is $2.4
billion (or $250 per Georgian each year), including
direct health care costs and lost productivity.
• Obesity places patients at greater risk for
diabetes, heart disease and some types of cancer. It
is the #2 cause of preventable death in the United
States.
• After increasing obesity documentation in our
clinic last year, we noted that despite
documentation, interventions were often not
addressed. The obesity clinic instituted by Dr.
Schmidt became an additional resource to obese
patients this year, in addition to nutrition classes
and diet/exercise education by the health care
practitioner.
Tests of Change
Measure
0.6
0.5
0.4
25
20
13
15
10
5
4
6
4
3
1
3
Barriers
0
0.3
0.2
•Making BMI more visible in EMR
•Time for physicians to make and offer specific education
on diet and exercise
•Assuring patients who are referred to obesity clinic have
message sent to and received by clinic scheduler
•Patients referred to obesity clinic actually are able to be
reached to attend sessions
•Enough sessions are available to accommodate the large
number of obese patients in our primary clinic
0.1
0
July '11
August '11 September '11 October '11 December '11 January '12
March '12
Outcome
What changes might result in an improvement?
Process Improvement Chart
with possible interventions for
improvement of outcome
Patient arrives
Nursing enters
biometric data
BMI documented
and reviewed by
MD
- BMI autopopulated with
.phrase
Lessons Learned
Obesity entered
on problem list
- BMI reference
charts displayed in
clinic rooms
- Circulating periodic
reminders to MDs to
document obesity
Obesity plan
initiated
- MD education of obesity
plan options:
• Diet/exercise
• Nutritionist referral
• Obesity Clinic referral
•EMR has facilitated BMI as being listed as part of a
patient’s vital signs for each visit, helping to prompt a
response for an abnormal BMI
•Though BMI is automatically calculated in EMR, obesity is
still often overlooked by providers as a separate medical
problem
•If obesity is listed as a separate problem, an intervention is
often proposed
•Nutrition and obesity clinic referrals offer concrete actions
providers can take to address obesity. Diet and education
handouts may be helpful for providers to more readily
access.
End-of-Life Care Planning
Improving Documentation of Advanced Directives in the Resident Clinic
using Electronic Medical Records
J. Willis Hurst
Internal
Medicine
Residency
Program
Grady Primary Care Center, Monday Purple Pod
Salim Hayek, Ria Nieva, Frank Corrigan, Amy Zhou, Uma Mudaliar, David Mays, Michael Massoomi, Erika Heard, Reza Hassanyar, Dejuan White
Faculty Mentors: Iris Castro, Nurcan Ilksoy
Problem
• End-of-life care planning has received and advocacy in
recent years. JCAHO requires that hospital medical
records document evidence of known advanced
directives (AD) and provide information about advance
care planning to all patients. Patient satisfaction is
increased when AD are discussed in clinic.
• Despite surveys showing patients prefer to discuss
advance directives with their primary care doctor, many
are completed during hospitalizations. Population
based-estimates of completed advance directives range
from 5% to 15%.
• Discussing end-of-life care in the outpatient setting is
perceived as challenging. One major obstacle reported
by physicians is lack of time and effective reminders to
address and document advanced directives.
Aim Statement
• Previously we assessed the effectiveness of emailmediated provider education and reminders in
improving documentation of AD. This initial test of
change (TOC1) showed a slight (1%) and temporary
increase in documentation of AD.
• Using the electronic medical records (EMR) system EPIC
we set to implement a reminder system for physicians
to document AD in a select population of patients with
chronic illnesses (see below), and assess the
percentage of patients meeting criteria which have
documented AD counseling within 6 months of the
main test change:
Adding “Advanced Directives Counseling” to the patient
problem list (ADPL).
• Patients must have one or more of the following
characteristics/diagnoses: Age > 65, Congestive Heart
Failure NYHA III, severe COPD (FEV1<30%), AIDS, any
diagnosis of malignancy, cirrhosis, ESRD, stroke.
Tests of Change
Methods and Measure
Test of
Change
Result
Yes
No
TOC1
TOC2
• A total of 588 patient charts were screened by 7 providers
of Grady Clinics Purple Pod.
• 157 met the predefined criteria for AD documentation.
“Advanced Directives Counseling” was added to the problem
list of 50% of patients who met criteria.
• During the period of November 2011-April 2012; 64 patients
were seen in clinic; 38 had AD on their problem list, 26 did
not.
• 76% of charts with ADPL had documentation of AD. Only
11.5% of those without ADPL had AD documented.
TOC3
What Was
Learned
• Provider education through
email
• Reminder emails
• Distribution of handouts on
advanced directives
• Workshop on advanced
directives discussion
• Added “Advanced Directives
Counseling” to problem list
• Provided .ADVDISC summary
template for rapid
documentation
Ineffective. Improvement
in documentation rate
temporary at best and
highly dependent on
physician’s personal
motivation
No effect on
documentation
Effective reminder, as
well as easily accessible
permanent record.
Significantly increased
documentation of AD
Limitations
TOC1
TOC2
TOC3
Barriers to Documentation of Advanced Directives
Data Collection
• Sample size was relatively small and study of short
duration. Will require longer term and larger population
sample to assess sustainability of the improvement in
documentation rate.
• Study does not assess completion rates of official AD
document completion.
• No conclusion can be made on the impact of improved
AD documentation on inpatient management
Lessons Learned
• EMR based reminders are effective in improving
documentation rates of AD and may be applied for other
purposes.
• Obstacles remain, including the lack physicians’ initiative
and knowledge in discussing AD, time limitations in the
outpatient setting, as well as the unclear translation into
changes in inpatient management.
• Further research is needed to establish the sustainability
of improved documentation over longer periods of time
and in a larger population sample, as well as its impact
on inpatient management.
Improving Influenza Vaccination Rates in an
Internal Medicine Resident Clinic
J. Willis Hurst
Internal
Medicine
Residency
Program
General Internal Medicine at 1525 Clifton Rd., Friday Resident Clinic
Turang Behbahani, Vivian Cheng, Ed Clermont, Tina Constantin, Patrick Hall, Farah Khan, Freny Nirappil, Julian Raffoul, Nathan Spell
Problem
The number of seasonal influenza-associated
deaths varies from year to year because flu
seasons are unpredictable and often fluctuate in
length and severity. The CDC estimates that from
the 1976-1977 season to the 2006-2007 flu
season, flu-associated deaths ranged from a low
of about 3,000 to a high of about 49,000 people
(1). In 2013, the CDC published a model to
quantify the annual number of influenzaassociated illnesses and hospitalizations averted
by influenza vaccination during the 2006–11
influenza seasons (2). Using that model the CDC
estimated that vaccination resulted in 79,000
(17%) fewer hospitalizations during the 2012–13
influenza season than otherwise might have
occurred. Especially in the primary care setting,
providers are facing increasing difficulties to clarify
"influenza-myths" as well as to
identify burdens which keep patients from
choosing or receiving the valuable vaccination.
Aim Statement
By January 1, 2014, 70% of more of all
patients seen in the Friday resident clinic at
1525 Clifton Road will be vaccinated during
their appointment (if not already
completed).
Tests of Change
1. Jan: Created standard process to let
MD know patient’s status and wishes
2. Feb: Attending to review vaccine
status during sign-out as detection
and mitigation step.
Barriers
Measure
Goal
Actual
- Lack of a standard process to address
preventive care, in general, leading to
creation of unique solutions to this
problem
- Perceived inability to influence patient
wishes and misinformation
- Relative little involvement of clinic staff
Lessons Learned
Standard
process
Attd
review
What changes might result in an improvement?
- Doing an improvement project in isolation
from the rest of the practice made it hard to
create a standard way of checking vaccine
status that would sustain itself
- A standard process does not become the
standard without effective training and
reinforcement at first
- Reliance on memory does not yield much
improvement
- We tended to make changes where we felt
we had the most control, rather than trying to
change patient beliefs, which was the
greatest opportunity
- Data collection should be built into the work
flow or should come from a ready source
References
(1) Thompson MG et al., Estimated Deaths Associated
with Seasonal Influenza - United states 1976-2006,
Weekly, August 27, 2010 / 59(33);1057-1062
(2) CDC. Prevention and control of seasonal influenza
with vaccines. Recommendations of the Advisory
Committee on Immunization Practices—United States,
2013–2014. MMWR 2013;62(No. RR-7).
Increasing Problem-Specific Educational Materials
to Patients at the Emory Clinic
J. Willis Hurst
Internal
Medicine
Residency
Program
Elizabeth Wiles DO, Paul F. La Porte MD PhD, Emory Hsu MD, Ross Deppe MD,
Samantha Shams MD, Blake Anderson MD and Naveen Bellam MD MPH
Faculty Mentor: David Propp MD
The Emory Clinic at 1525 Clifton Rd, Emory University School of Medicine, Atlanta, GA
Problem
Statistical Measures and Analysis
60.00%
In 2012, the Center for Medicare/Medicaid
Services (CMS) created the objective to use
Electronic Health Records (EHR) to provide at
least 10% of patients with electronically
generated educational resources as part of their
meaningful use criteria. Given a possible cost
savings of $289 billion dollars from improved
medication compliance alone, providing problem
specific resources in a timely and appropriate
fashion has potential to improve patient
satisfaction and compliance in regards to their
medical plans.
Results Analysis Compared to CMS Objective as
well as against Primary AIM Statement
50.00%
40.00%
Percentage 1/100
Physicians do not always effectively
communicate medical problems or treatment
plans to their patients and retention of education
performed by the physician is an issue even
among highly educated patients. Difficulty with
understanding medical disease has been
hypothesized to contribute to lower compliance
with medication and activity regimens,
increased calls to nursing staff, higher repeat
visits, and worse medical outcomes.
Patients receiving
Education
30.00%
Baseline period (Prior to Test of Change): Rate = 8.0%
Likelihood of 8.0% rate below CMS 10% rate?; p = 0.097
- It cannot conclusively be stated say that we were not already meeting “Meaningful Use”
criteria
20.00%
10.00%
0.00%
Patients receiving
Education
Pretest
Test of
Change 1
Test of
Change 2
8.01%
37.44%
50.72%
Baseline Study Data Data
Pretest
Patient
Materials
Provided
Total
Patients
In Study
Period
Chi-Squared Statistics
TOC 1
34
Chi-square table for TOC 1
Handout
TOC 2
85
35 Before
Yes
After
424
0.0801
227
0.3744
crossNo
Total
check %
34
390
424
424 8.02%
85
142
227
227 37.44%
diff
29.43%
Chi-square table for TOC 2
Handout
69
0.5072
Yes
Before
After
crossNo
Total
check %
85
142
227
227 37.44%
35
34
69
69 50.72%
diff
13.28%
2nd test of change vs 1st test of change: Handout rate 37.4% (before) vs 50.7% (after)
% change over 1st test of change period = 13.2 (-0.1-26.7)
LR 1.35 (1.02-1.80)
p = 0.0491
- Based on a p-value of less than 0.05, it can be stated there was a measurable difference
between test of change 2 and 1 (i.e. MA reminders)… p = 0.0491
- The LR is significant compared to the p-value (double-checked with a different procedure)
possibly due to separate calculations in software
Tests of Change
Test of change (TOC) 1: Educating physicians
regarding use of standardized computer-based
education format and use of a desktop reminder
at each computer.
MD Factors
Nursing Factors
Not remembering to provide /
print education via depart
process
Time constraints
not allowing for
nursing reminder
Checking out
patients without
nursing assistance
Acute visit time
constraint
Providing Patient
Education
Lack of insight
To increase patient education handouts by 30%
during the study period Nov 1 2013-Feb 14th
2014 (compared to July-October 2013), through
entering education related to patient diagnoses
in General Clinic note.
2nd test of change: Handout rate 8.0% (before) vs 50.7% (after)
% change over pretest period = 42.7% (30.6-54.7)
LR = 6.32
p < 0.0001
- 50.7% rate compared to CMS 10% goal; p << 0.0001
- During test of change 2, we can conclusively say we met our target of 30% absolute
increase in handouts (CI is between 30.6-54.7)
Cause and Effect Analysis
Forgetting to offer
educational resources
Aim Statement
1st test of change: Handout rate 8.0% (before), 37.4% (after)
% change over pretest period = 29.4% (22.6-36.2%)
LR = 4.67
p < 0.0001
- 37.4% rate compared to CMS 10% goal; p << 0.0001
- During test of change 1, it cannot conclusively say we met our target of 30% absolute
increase in handouts (CI is between 22.6-36.2)
Clicking on “Patient Education”
opens all available educational
resources based on diagnosis
code, or per prompted search
Ease of Use
Can not read
Patient feeling education
Is unnecessary
Krames Database
having appropriate
education related
diagnoses
Implemenation
Time and Time
to Print
Resources
Patient factors
System factors
Test of change 2: Require nurses reminders
during their portion of the patient depart process
if we had not chosen education for the patient
using the above computer selected format.
Barriers
1. Full schedules, clinic time constraints, or
PCPs writing notes at the end of clinic did
not benefit from computer-based educational
templates.
2. There remains minimal incentive to create
additional templates.
3. While desktop reminders were useful at first,
physical notes could be lost , misplaced, or
ignored.
4. Nurses had variability in providing reminders
due to the multitude of patient tasks and
multiple residents in clinic.
5. Patient illness complexity may not have had
appropriate EMR-specific resource (i.e.
providing education on PEG tube use, or
proper explanation of more rare diseases).
Lessons Learned
A multifactorial and team-based approach can
lead to improved patient awareness and
education at a time cost not overly detrimental to
clinic flow. Cost-effectiveness may be theorized
to be appropriate and beneficial in improving
patient outcomes; however, we do not have
financial data to support this assertion.
Importantly, focusing our intervention on an
existing element not requiring any modification
to the resident workflow was a key to success.
J. Willis Hurst
Internal
Medicine
Residency
Program
Increasing End-of-Life Care Discussions, Including Code Status,
in a Resident Run Urban Community Primary Care Clinic
Orange Pod Wednesday/Friday Team, Grady Primary Care Center
Rekha Thammana, MD, Andrew Ip, MD, Nurcan Ilksoy, MD, Shelly-Ann Fluker, MD, Dominique Cosco, MD
Fofie Akota, MD, Stephen Berger, MD, Matthew Darrow, MD, Kendrick Gwynn, MD, Racha Halawi, MD, Elisa Ignatius, MD, Moise Jean, MD, Emma Johns, MD, Poonam Kalidas,
MD, Christine Kirlew, MD, Enoch Kotei, MD, Song Li, MD, Jason Perry, MD, Nikita Patel, MD, Priyesh Patel, MD, Roshan Patel, MD, Deep Shah, MD, Sana Shah, MD, Yoo Shin, MD,
Geoffrey Southmayd, MD, Komal D’Souza, MD, Xiao Jing Wang, MD, Andrew Webster, MD
Problem
• Many elderly patients (defined as
>65 years of age) do not have
advanced directives on file
60%
TOC 1
50%
TOC 2
40%
• Discussing code status and endof-life care is difficult given time
constraints in our clinic visits
• Residents have trouble initiating
conversations about end-of-life
care
30%
20%
10%
0%
December
Jan-Feb
March
PHYSICIAN
Acknowledgement
We would like to thank the nurses and support staff of the
Orange Pod Primary Care clinic for their assistance with the project.
• Tests of change
• Dot phrase added (TOC1)
• To help providers remind
about having code-status
or advanced-directive
Yes
discussions
No
• Surveys passed in waiting
Not enough time
room (TOC2)
• Allows patients to ask
provider questions about
end-of-life-care
What changes might result in an improvement?
Aim Statement
• We aim to increase the number
of end-of-life care discussions,
including code status
documentations, in Grady
Orange Pod patients older than
65 years, to 50% by April 2014
Barriers
Measure
I do not know
how to initiate
discussion
Not enough
time
I forget
Assigned
patients are
too young
Patients not prepared
to discuss topic
has not heard of
'code status' or
AD
Would like to
discuss with
family first
End-of-Life care
discussion has not
been documented
Lack of
continuity with
patients
SYSTEM
• No standardized method to initiate
code status discussions or end-of-life
• Forgetting to implement dot phrase
•No easy way to document code status
in EPIC chart
Lessons Learned
•Education of providers on palliative
care discussions
PATIENT
Does not want to
discuss
•Not enough time! – patients often
come in with a large agenda or have
multiple chronic medical diseases
Not enough
time in clinic
visit
Inadequate
reminder
system
•Need for easier documentation
methods in EPIC for advanced
directives or code status
•Education of patients to help facilitate
discussions in outpatient visits
• Physicians have little time to discuss,
thus other methods must be
implemented (nurse or group visits)
Best Foot Forward
Improving Performance and Documentation of Diabetic Foot Exams
in an Urban Resident Primary Care Clinic
J. Willis Hurst
Internal
Medicine
Residency
Program
Grady Primary Care Center, Wednesday Purple Pod
James MacNamara, Matthew Dudgeon, Heather Batchelor, Annie Massart, Rahul Maheshwari, Jeffery Hedley, Maria Klimenko, Pooja Kotadia
Faculty Mentor: Nurcan Ilksoy
Problem
• Many diabetic patients present to the
primary care clinic and go without
consistent foot exams.
• The American Diabetes Association
recommends clinicians perform a
comprehensive foot examination
annually on patients with diabetes to
identify risk factors for ulcers and
amputation and perform a visual
inspection of the feet at each visit.1
• Lavery, et al demonstrated a combined
minor and major amputations reduction
from 12.89 to 6.18 per 1000 patients per
year with a diabetes foot prevention
program.2 Others have shown
significantly improved outcomes as well.3
Measure
Increased focus on
diabetic foot exam
on individual level
Monofilaments
made available in
clinic by faculty
First visit with pt, MD defers RHM til next visit
Placing concise but
complete
explanation of
diabetic foot exam
guidelines and
techniques in rooms
Improved level of
exams, but fell off
over time
Need consistent
method to help
provider keep foot
exam a priority
Improved percentage Equipment is
of exams
important for
performance of
exam
Initially improved
Need consistent
performance, but
method to help
last data points
provider keep foot
indicates decline
exam a priority
Barriers
What changes might result in an improvement?
Aim Statement
• Our aim was to increase the
documentation of last complete diabetic
foot exams and current inspection for
known diabetic patients at Purple Pod
Wednesday Primary care clinic visits by
50% by March 30th, 2014.
1. Boulton, et al Comprehensive foot examination and risk assessment: a
report of the task force of the foot care interest group of the American
Diabetes Association, with endorsement by the American Association of
Clinical Endocrinologists. Diabetes Care. 2008 Aug;31(8):1679-85
2. Lavery La, Wunderlich RP, Tredwell JL. Disease management for the
diabetic foot: effectiveness of a diabetic foot prevention program to reduce
amputations and hospitalizations. Diabetes Res. Clin. Pract.2005; 70(1): 31–37.
3. Ozdemir, et al Population-based screening for the prevention of lower
extremity complications in diabetes. Diabetes Metab Res Rev. 2013
Mar;29(3):173-82
Test of Change Result
What Was
Learned
• Not enough publicity of the foot exam
techniques and guidelines
• Inconsistent documentation amongst
providers’ exams and assessments
• Patient do not like having shoes off while
waiting for provider
• Patients unaware of need for foot exams
• Limited Monofilaments, no tuning forks
available in clinic
Future Directions
First visit with pt, MD defers RHM til next visit
• A persisting method of encouraging
exams is needed with involving nursing staff
• A concise and complete dot phrase and
may promote consistency amongst
providers
• Providing patients with information so
they can advocate for the exam
• Ensuring appropriate equipment is in
every exam room