In June of 1999, the physicians and staff members of Family Care Networks, a 17-site group without walls in Washington state, made a brave decision: to reinvent the way they care for their patients with diabetes — and to do so in just 13 months. They undertook a total system redesign that involved four key changes:
Create a registry to identify patients who have diabetes.
Implement a diabetes flowchart system to act as a reminder of care.
“Pre-plan” diabetes visits so encounters are more organized and meaningful.
Encourage patients to get more involved in their care by setting self-management goals.
(For more information regarding each of the four initiatives, see the previous articles in this series, listed below.)
The network began the project in three pilot sites and focused on a limited patient population. Just over a year later, the project was rolled out to all 17 sites, involving 45 physicians, their staffs and some 2,000 patients with diabetes. Although the project involved major changes and was not without its struggles, it was worth it, says Berdi Safford, MD, medical director of the network. “It has definitely improved the quality of care that our diabetes patients are getting. And in those offices that have fully implemented the changes, it’s now much easier for us to take care of those patients than it used to be.”
This is the sixth and final article in 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.
Previous 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.
At the outset of the project, Family Care Network outlined its goals, which were “definitely stretch goals for us,” says Safford. Because the project was just recently rolled out to all 17 sites, the most current performance data represents only the three pilot sites. It includes all of the pilot sites’ 950 patients who have diabetes — even new patients, whose outcomes may not yet have been affected. That said, here’s how the group performed:
1. HbA1c levels. The pilot sites collected data for three measures related to HbA1c levels and achieved the following results:
63.4 percent of patients with diabetes have current HbA1c levels of 8 percent or lower. (Goal: 70 percent)
7.7 percent of patients have HbA1c levels of 9.5 percent or greater. (Goal: no more than 15 percent)
75 percent of patients have had two or more HbA1c measures within the last year. (Goal: 90 percent)
One of the lessons the pilot sites learned was that sometimes goals can and should be revised. Originally, the first two goals were targeted at HbA1c levels that were “ 7 percent or lower” and “ 8.5 percent or greater,” respectively. The revisions were based on American Diabetes Association (ADA) recommendations that action is generally needed only if the HbA1c level is greater than 8 percent.1 “Even though, for a lot of people, we’re trying to get their glycohemoglobin less than 7, there are a fair number of elderly people, for example, who are fine with a glycohemoglobin of 8,” explains Safford.
2. Self-management. The pilot sites went from zero to 22 percent of diabetes patients having self-management plans documented in their charts. Although the goal was 60 percent, Safford does not view their performance as a failure. “Today, one out of every five patients has been thinking about a self-management goal with their physician. When you think about what a mind-set change that is, I’m not as discouraged as I might otherwise be. Helping patients set self-management goals is absolutely the hardest thing for us to do,” she says.
3. Flowcharts. Thanks to the implementation of a communitywide patient registry that includes flowchart data, 100 percent of patient records have a current diabetes flowchart that functions as a reminder of care. The goal was just 80 percent.
4. Retinal eye exams. The group’s goal was for 70 percent of diabetes patients to have had a retinal eye exam within 12 months, but the sites were unable to gauge their performance on this measure. “This is one of our learnings,” says Safford. “We have discovered that because of the way the field is set up in our registry, we’re not getting accurate data, so we have to revise that part of the program.”
5. Blood pressure. Here again, computer problems affected the quality of the data, but rough measurements showed that approximately 30 percent of the sites’ patients with diabetes had blood pressure levels of 130/85 or better at their most recent readings. The goal was 90 percent. The problem, says Safford, is that most physicians have not been trained to treat hypertension aggressively. “When a patient is on a lot of medicines and his or her blood pressure is, say, 138/78, it’s very difficult to get a doctor and a nurse to see that they have to give the patient medicine to change that. We’re so used to considering that successful,” she says.
To improve in this area, Family Care Network is stressing to physicians the importance of aggressive treatment of hypertension in diabetes and has written a sample protocol on the subject. (For more information, see the American Diabetes Association’s consensus statement “Treatment of Hypertension in Diabetes,” available at www.diabetes.org/diabetescare/supplement/s107.htm.) Controlling blood pressure in patients who have diabetes is perhaps more important than controlling blood sugar, says Safford, referring to findings from the National Institutes of Health (NIH).2 “To get patients and doctors to understand that is quite a stretch,” says Safford. “And now the target has gotten even lower. When we started, we used the ADA goal of 130/85. Now the NIH is recommending 130/80.”
Having lived through the ups and downs of an intense quality improvement project, Safford offers these words of advice to other practices:
Focus on the patient. Nothing motivates physicians and brings a clearer sense of purpose to any project than “emphasizing the potential improvement in patient outcomes, bringing people back over and over again to how we’re helping patients,” says Safford.
Establish a team. To bring about positive change that will last, “involve everyone that’s involved,” says Safford. Her team included not only the physicians and clinical staff but the office manager, the reception staff and even the patient. “So often in health care, we’re deciding what the patient needs without asking the patient,” she says.
Pilot everything. “Try every new idea in a small setting first to see how well it works,” says Safford. “Then modify it as needed.” This cycle is often referred to as the “Plan-Do-Study-Act” cycle for rapid improvement.
Secure support. The physicians of Family Care Network demonstrated their support by committing a percentage of their own incomes to hiring a part-time nurse to help implement the project. This support from the top is crucial, says Safford. “When we run into struggles, we don’t have to worry. We know the commitment is always there.”
Balance consistency with creativity. “With 45 different doctors, we found it was very important to have consistent expectations but to give people the freedom to try different approaches,” says Safford. The pilot sites have been able to show the other sites what has worked for them, but physicians are free to come up with their own methods for getting the desired results.
Find a champion. Each of Family Care Network’s 17 sites has a “champion” who serves as the key contact and helps spread enthusiasm for the project. In one case, the champion is a receptionist particularly interested in the project because her grandfather had diabetes.
Reward people. The key with rewards, says Safford, is making sure that everyone who is involved receives one. Recently, when two doctors met all of their diabetes goals, not only were they rewarded, but their staff members were given a luncheon to celebrate their success as well.
While Family Care Network’s pilot sites are performing better than national averages when it comes to diabetes care, Safford admits “it’s still a work in progress.” The next big step for the network is to “institutionalize the change, so it’s not just a project,” she says.
One of the barriers to improvement for the pilot sites was what Safford describes as “multiple competing priorities.” For example, when the network first began the diabetes project, it was also implementing a new computer system in all 17 sites. “I think that kept us perhaps from being even more successful. There was just too much change going on all at one time,” she says. “I’m really optimistic that in this next year we’re going to do a lot to consolidate our gains.”
One change Safford believes will help motivate physicians is simply giving them and their nurses the ability to print their own performance data at any time from their own computers. That change will take effect within the next two months, enabling physicians to gauge their own success and focus on individual areas of improvement.
Family Care Network is also working to develop community resources for patients with diabetes and other chronic illnesses. The network recently helped their community pilot a patient class called “Living a Healthy Life With Chronic Conditions.” The program, which originated at Stanford University, teaches patients how to set their own health care goals and how to be empowered when living with chronic conditions. Although developing such community resources is additional work for the network, Safford believes having better resources will make their jobs much easier.
With such an intense year-and-a-half of quality improvement activities now behind them, it would be easy to justify a break from such activities, but Safford and her colleagues are continuing forward. They understand the continuous nature of quality improvement and, in fact, are now talking about taking on hypertension care, using the same chronic disease model they followed for improving diabetes care.
“It’s been work, but it’s been fun,” says Safford. “And I think we are starting to see the results of our hard work.”
What began as “the journey of a thousand miles” is not over yet, but it has become much shorter through the diligent single steps of 45 physicians, hundreds of staff members and some 2,000 patients who have learned that improvements in health care are possible.