High-quality diabetes care is hardly a lone endeavor. Instead, it is a combination of forces: a physician and staff who are knowledgeable about the disease and current treatment guidelines, a patient who is involved and empowered to improve his or her own health, and a practice whose systems are designed in such a way that they help, not hinder, the care process.
This third element, practice systems, may well be the richest area of improvement for most medical practices. One case in point is Family Care Network, a northwest Washington group without walls, which recently embarked on an ambitious 13-month diabetes quality improvement project. Very quickly, the group realized that its patient encounters, crucial to the delivery of high-quality diabetes care, were not living up to their full potential. As in many practices, patients arrived for their visits without having had the necessary lab work or other services performed in advance. As a result, the physicians did not have complete information to guide the visit, while patients gave very little thought to what they would like to accomplish regarding their disease. Post-visit, practices were left with tremendous follow-up work that included making phone calls to obtain or communicate the elusive test results. In short, visits were unplanned and participants were largely unprepared.
The solution to this problem for Family Care Network's three pilot sites was to implement a fairly simple system called “pre-planning.”
What is pre-planning?
Pre-planning involves creating systems within a practice to ensure that the staff, physician and patient are all prepared for the visit. “Instead of the patient showing up on your schedule and you scurrying around trying to get all the information you need, the visits are planned ahead of time, the patients have been contacted, and they have all their lab work and tests done before they come to your office,” explains Berdi Safford, MD, medical director of the group.
One of the greatest benefits of pre-planning is that it ensures physicians have current lab results and other patient data at the time of the visit on which to base their advice and treatment recommendations. Lacking this information, the physician may focus the diabetes visit incorrectly, for example, by reinforcing blood sugar control when a patient's real problem is controlling his or her cholesterol. “With pre-planning, the doctor has the full picture, all the pieces to the puzzle, and can be more focused on the patient's specific needs, resulting in a better interaction,” says Janet Kircher, RN, a nurse at one of the pilot sites.
The process of pre-planning essentially involves four steps:
1. Be proactive in finding patients who are due for diabetes visits. Using a computerized recall system, Kircher and her nurse colleagues print lists each month of the patients due for diabetes visits. Another practice site uses paper “tickler files,” kept by each of the nurses, to remind them when patients are due for appointments.
2. Contact patients with clear instructions. The Family Care Network sites accomplish this through reminder letters, which tell patients they are due for an appointment and list the specific tests to be completed before the visit. (The reminder letter is available for download.) The letter also encourages patients to take care of themselves and to do their part in improving their health. If patients do not already have appointments scheduled, the nurses assist them in doing so.
Tools in this article
3. Encourage patients to be involved in their own care. To help patients prepare for their visits and get them thinking about what they hope to accomplish, the practices give their patients an annual diabetes questionnaire to fill out in the waiting room. (The questionnaire is available for download.) The questionnaire helps patients assess their self-management success and identify areas in which they may need assistance. Giving thought to these issues before the visit makes the doctor-patient interaction more meaningful and productive, says Kircher, which ultimately improves outcomes. “That's really what this is all about: making the patient healthier,” she says.
4. Use standardized encounter forms to aid clinical staff. For Ferndale Family Medical Center, just one of 13 Family Care Network practice sites, the encounter form follows the “SOAP” format and provides a well-organized outline for the visit. Physicians may choose to focus the visit on a patient's particular needs, but the encounter form ensures that key issues are not overlooked. (The encounter form is available for download.)
Begin with one experiment
Improving diabetes visits, like any office improvement, can be made simpler by breaking it down into baby steps or small experiments a practice can then build upon. A first step for Safford's practice was to find just one patient with diabetes who was overdue for a checkup, to schedule an appointment for that patient, and to get the lab work done ahead of time. Gradually, as the practice learned what worked and what didn't, pre-planning was expanded to all diabetes visits.
Family Health Associates, another pilot site within the larger group, also approached pre-planning with a spirit of experimentation. When the nurses first began using the reminder letters, they didn't waste time and effort perfecting the mailing's appearance. Instead, they simply jumped in and tried it. Once they saw it was working, they invested in more professional-looking cards. “If we found that it was just more paperwork and it didn't make life easier for us or our patients, then we wouldn't keep doing it,” says Jody Fox, RN, triage nurse at the practice.
But Family Care Network has found pre-planned visits are worth doing. Physicians benefit from having the information they need at the time of the visit. Patients benefit from an encounter that is more in touch with their individual needs. And staff members, especially nurses, benefit from the efficiency and sense of order it brings to their work. “With this system, they [the nurses] feel like they're getting something done and really making a difference in patient outcomes,” says Kircher. “It still takes a lot of work and a lot of time to care for these patients, but the outcomes are tremendous and that makes the effort so much more rewarding.”
This article is part of an FPM series that followed Family Care Network, a northwest Washington state group without walls, as it tackled a 13-month quality improvement project focused on chronic disease care. The project was headed by the Institute for Healthcare Improvement and involved approximately 30 organizations nationwide.
Articles in the series are:
“Improving Chronic Disease Care in the Real World: A Step-by-Step Approach,” October 1999, page 38.
“Building a Patient Registry From the Ground Up,” November/December 1999, page 43.
“Helping Patients Take Charge of Their Chronic Illnesses,” March 2000, page 47.
“Using Flow Sheets to Improve Diabetes Care,” June 2000, page 60.
“Making Diabetes Checkups More Fruitful,” September 2000, page 51.
“13 Months of Quality Improvement: Did It Work?” January 2001, page 55.