November 27, 2014

Stories

Turning tough times into an unexpected success

An Ohio internal medicine team used momentum from a challenging situation to improve quality of diabetic care

Union co-lead Rita Yanus, LPN, of OPEIU Local 17; department manager Joyce Todd; Donna Kaczorowski, RN, of ONA, and Mike Wertman, MD, were invited to discuss their team’s success at the 2009 national quality conference.

Out of a crisis, good things
can come.

For the Strongsville internal medicine team in Ohio, that “crisis” came last year, when they lost three of their five care providers within eight monthsaround the same time Ohio’s diabetes control program launched.

The department faced challenges in maintaining access and patient flow, much less increasing focus on chronic care management. But the team refused to be daunted. As a result, Strongsville internal medicine not only sustained their quality, they achieved some of the highest scores in diabetic maintenance in the region.

Pulling it all together

Tools the Strongsville team used and changes they made to improve their care
of diabetic patients

  • Clinical pharmacists and pharmacy technicians helped flag patients for follow-up
  • Registered nurses assumed more responsibility for care management and education
  • Telephone visits
  • Educational visits
  • Workflow changes gave RNs and LPNs more opportunity to increase outreach and inreach
  • “Plan, do, study, act” tests of change
  • RNs actively used information from POINT, a clinical program that collects key data from KP HealthConnect, claims, pharmacy, lab and other departments, to identify diabetic patients and provide a complete medical picture of those patients already identified as diabetic
  • ALL project ensuring every diabetic patient is taking the trio of drugs (Aspirin, Lisinopril and a lipid-lowering medicine) that have been shown to minimize diabetes-related illness such as heart attacks, stroke and kidney failure

In March 2008, 62% of Strongsville diabetic patients’ cholesterol was under control. By September that number climbed to 74%. That was well above Ohio’s regional target of having 60% of patients in a panel with an LDL level below 100.

Don’t wait for perfection

“You never have perfect staffing or a perfect group of peoplebut you can still do it well,” Nick Dreher, MD, said. “We should never use lack of perfection as a reason to not improve.”

The percentages dipped slightly in October around the time the third doctor left, but the percentages have since rallied.

“Everyone’s awareness had to increase and everyone had to be involved more,” said Mike Wertman, MD, physician co-lead of the Strongsville LMP triad group. “The connecting thread was staff connection with the patient.”

Much of the groundwork, it turned out, had been laid by the proactive work of Donna Kaczorowski, RN, an ONA member who’d been regularly monitoring diabetic patients and building a rapport with them. The small tests of change launched by the team got everyone involved in working toward the common goal.

“It helped us through the time when we had fewer doctors,” Kaczorowski said, because the connections made losing their doctor less dramatic for members.

Teamwork stronger than a lone provider

The Strongsville department made a number of small tests of change:

  • Work flow changes allowed RNs to assume more responsibility for care management and patient education. As a result, nurses conducted more outreach via telephone visits to check patients’ progress, schedule visits and keep the line of communication open with diabetic patients.
  • LPNs schedules were altered so that they could start accepting walk-in patients for blood pressure checks.
  • LPNs also became diligent in combing through patient charts to ensure that lab tests were completed and results available before an appointment with the physician.

“We’re all trying to nail these things,” said Dr. Dreher, who is also Ohio’s assistant medical director for Critical Care and Hospital Services. “It’s about all these people doing a lot of work. No individual doctor, even if they’re busting their butt, could do all that.”

The effort reached beyond the internal medicine department, too: Strongsville’s pharmacy and lab departments worked in concert with the team, expanding the opportunities to connect with diabetic patients.

If a patient picked up a prescription and the medical record showed that he or she hadn’t seen a physician recently, the pharmacist or pharmacy technician would forward the name to the registered nurses, who would then contact the patient for a blood pressure check with an LPN.

The collaboration worked particularly well at Strongsville, where the small size of the medical center may have made it easier to coordinate with other departments.

Level playing field

One result of being a close-knit team, Dr. Dreher said, is that everyone is on a level playing field.

“Nurses will not tolerate us not doing it right,” he said. “If a doctor isn’t being diligent and doing all the things, they’ll come and tell you that….When it comes to quality there’s no hierarchy. When it comes to quality, we expect to push each other.”

Building on their success with diabetes control, the team is now looking at using similar techniques to address heart failure and hypertension.