Diabetes Best Practices Symposium Sponsored by AMGA and Merck & Co., Inc. October 21-22, 2009 Detroit, MI Allina Medical C...
Medical Group Profile <ul><li>The Allina Medical Clinic is a multi-specialty medical group serving more than 40 communitie...
Diabetes Goals & Objectives <ul><li>Deliver the best care that science has to offer. </li></ul><ul><li>Achieve top 10 perc...
Diabetes Population & Registry <ul><li>All patients with type 1 or 2 diabetes based on ICD-9 codes </li></ul><ul><li>Only ...
Diabetes Population & Registry <ul><li>2009 registry currently includes 20,200 unique patients. </li></ul><ul><li>Captures...
 
Criteria Change Criteria Change
State Average
Improvement Model <ul><li>Establish the  “why”   and create a tangible vision </li></ul><ul><li>Align   leadership  -  set...
Establish the “Why” & Create a Tangible Vision <ul><li>Present the evidence: </li></ul><ul><li>Controlling glucose aggress...
Align Leadership <ul><ul><li>Engage a “guiding coalition” </li></ul></ul><ul><ul><ul><li>Diabetes Clinical Action Team </l...
Develop and Execute a Communication Plan <ul><ul><li>Craft simple, consistent messages that are meaningful and transmissib...
Develop and Execute a Communication Plan <ul><ul><li>Plan dissemination to all audiences – be specific. </li></ul></ul><ul...
Educate Physicians: Establish a Common Knowledge Base (Required CME for all new hire and low performing physicians) <ul><u...
Educate Physicians: Establish a Common Knowledge Base <ul><ul><li>Practice Management </li></ul></ul><ul><ul><li>How to wo...
Implement Process Changes Be Specific About the “What” &  the “Who” <ul><ul><li>Rooming standards for clinical assistants ...
Implement Process Changes Be Specific About the “What” & the “Who” <ul><ul><li>Quick Start Insulin Program – on-site RN pa...
Check Back <ul><li>Leader rounding </li></ul><ul><li>Check in with every care team </li></ul><ul><li>“ A policy not observ...
Provide Transparent Feedback <ul><ul><li>Share data at team meetings with all physicians and staff monthly </li></ul></ul>...
 
 
Provide Transparent Feedback <ul><ul><li>Comparative data is powerful; however, physicians tend to doubt “the numbers” </l...
 
Coach for Improvement <ul><li>Focus on individual patients  </li></ul><ul><li>rather than numbers </li></ul><ul><li>“  At ...
Teach Leaders to Lead <ul><li>Communicating the evidence and importance </li></ul><ul><li>Influencing skills </li></ul><ul...
Lessons Learned <ul><li>Systems can support practice and improve care. </li></ul><ul><ul><li>“  Consistency breeds reliabi...
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Allina Medical Clinic

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Allina Medical Clinic

  1. 1. Diabetes Best Practices Symposium Sponsored by AMGA and Merck & Co., Inc. October 21-22, 2009 Detroit, MI Allina Medical Clinic Improving Diabetes Outcomes Bruce McCarthy MD, MPH – Chief Medical Officer Bev Reiman – Director of Quality
  2. 2. Medical Group Profile <ul><li>The Allina Medical Clinic is a multi-specialty medical group serving more than 40 communities in Minnesota at 44 clinic locations and 14 hospitals. </li></ul><ul><li>Part of a not-for-profit health system, The Allina Medical Clinic grew from mergers and acquisitions of independent practices in the 1990s. </li></ul><ul><li>3,800 clinic employees, including 575 physicians (400 primary care physicians and 175 specialists) and 170 advanced practice clinicians (Nurse Practitioners, Physician Assistants, etc.) We provide over 2.7 million out-patient visits annually. </li></ul><ul><li>From 2004-2008 we implemented an EMR (Epic) to manage care seamlessly across the continuum by connecting offices, emergency departments, and hospitals. </li></ul>
  3. 3. Diabetes Goals & Objectives <ul><li>Deliver the best care that science has to offer. </li></ul><ul><li>Achieve top 10 percentile national performance in control of each diabetes risk factor (HEDIS): </li></ul><ul><ul><li>A1c < 8% </li></ul></ul><ul><ul><li>LDL < 100 </li></ul></ul><ul><ul><li>BP < 130/80 </li></ul></ul><ul><li>Achieve top 10 percentile performance in Minnesota for “Optimal Diabetes Care”: </li></ul><ul><li>Percent of patients with all risk factors controlled (i.e. A1c < 8 and LDL < 100 and BP < 130/80 and ASA use and tobacco free) </li></ul>
  4. 4. Diabetes Population & Registry <ul><li>All patients with type 1 or 2 diabetes based on ICD-9 codes </li></ul><ul><li>Only pts. age 18 – 75 are included in quality measures </li></ul><ul><li>Demographics (population included in quality measure): </li></ul><ul><ul><li>21% Medicaid, 30% Medicare, 47% Commercial/FFS, 20% Charity Care </li></ul></ul><ul><ul><li>25% age 18 – 49 and 75% age 50 –75 </li></ul></ul><ul><ul><li>16% urban, 55% suburban, 29% rural </li></ul></ul><ul><ul><li>Significant ethnic groups include Hispanic, Russian, Hmong, Somali, Northern European </li></ul></ul>
  5. 5. Diabetes Population & Registry <ul><li>2009 registry currently includes 20,200 unique patients. </li></ul><ul><li>Captures PCP, clinical, lab, medication and visit data. </li></ul><ul><li>Reports are produced for the group overall as well as for district, site and individual physicians. </li></ul>
  6. 7. Criteria Change Criteria Change
  7. 8. State Average
  8. 9. Improvement Model <ul><li>Establish the “why” and create a tangible vision </li></ul><ul><li>Align leadership - set and focus on goals </li></ul><ul><li>Develop and execute a communication plan </li></ul><ul><li>Educate physicians - establish a common knowledge base </li></ul><ul><li>Implement process changes - be specific about the “what” and the “who” </li></ul><ul><li>Check back on the implementation (be tenacious) </li></ul><ul><li>Provide transparent feedback </li></ul><ul><li>Coach for improvement </li></ul><ul><li>Teach leaders to lead </li></ul>
  9. 10. Establish the “Why” & Create a Tangible Vision <ul><li>Present the evidence: </li></ul><ul><li>Controlling glucose aggressively early in the course of diabetes reduces the risk of cardiovascular events by 15 – 42% and retinopathy and nephropathy 50%. Follow up on cohorts in the DCCT and UKPDS studies Lower is better . Each 20/10 mmHg decrease in BP is associated with 50% decrease in risk of vascular disease across the entire BP range from 115/75 to 185/115. Roccella E, Kaplan N. Hypertension Primer: The Essentials of High Blood Pressure: 2003.pp. 126-7 </li></ul><ul><li>Multiple risk factor control reduces the risk of MI and death by 25 – 50%. STENO-2 NEJM 2007, CARDS Lancet 2004 </li></ul><ul><li>Present the evidence for system redesign </li></ul>
  10. 11. Align Leadership <ul><ul><li>Engage a “guiding coalition” </li></ul></ul><ul><ul><ul><li>Diabetes Clinical Action Team </li></ul></ul></ul><ul><ul><ul><li>Clinical Practice Council </li></ul></ul></ul><ul><ul><ul><li>Use opinion leaders </li></ul></ul></ul><ul><ul><li>Set goals </li></ul></ul><ul><ul><ul><li>Administrative and MD leaders have same clinical and operational goals </li></ul></ul></ul><ul><ul><ul><li>Threshold goals vs. relative improvement </li></ul></ul></ul><ul><ul><li>Focus, focus, focus </li></ul></ul>
  11. 12. Develop and Execute a Communication Plan <ul><ul><li>Craft simple, consistent messages that are meaningful and transmissible. </li></ul></ul><ul><ul><ul><li>“ Optimal risk factor control reduces risk of MI and death by 25 – 50%” </li></ul></ul></ul><ul><ul><li>Tailor messages to audience: evidence-based vs. impact on patients. </li></ul></ul><ul><ul><ul><li>3-5 yr impact of better diabetes control for 17,000 pts. </li></ul></ul></ul><ul><ul><ul><ul><li>130 fewer strokes </li></ul></ul></ul></ul><ul><ul><ul><ul><li>400 fewer heart attacks </li></ul></ul></ul></ul><ul><ul><ul><ul><li>200 fewer deaths </li></ul></ul></ul></ul><ul><ul><ul><ul><li>300 fewer cases of diabetes eye disease </li></ul></ul></ul></ul>
  12. 13. Develop and Execute a Communication Plan <ul><ul><li>Plan dissemination to all audiences – be specific. </li></ul></ul><ul><ul><ul><li>Newsletter </li></ul></ul></ul><ul><ul><ul><li>Quarterly Leadership Meeting </li></ul></ul></ul><ul><ul><ul><li>Local leaders trained to deliver the message at site meetings </li></ul></ul></ul><ul><ul><ul><li>Lunch & Learns for staff done by local MD experts (nephrology, endocrinology) </li></ul></ul></ul><ul><ul><ul><li>Repetition: create a “drum beat” </li></ul></ul></ul><ul><ul><ul><li>Leader rounding </li></ul></ul></ul><ul><ul><li>Check that the message got through. </li></ul></ul><ul><ul><li>“ Every physician and staff member should </li></ul></ul><ul><ul><li>be able to articulate the ‘why’.” </li></ul></ul>
  13. 14. Educate Physicians: Establish a Common Knowledge Base (Required CME for all new hire and low performing physicians) <ul><ul><li>The evidence for tight risk factor control </li></ul></ul><ul><ul><li>Algorithm-based approaches to clinical challenges – e.g., resistant HTN </li></ul></ul><ul><ul><li>Increasing the tempo of treatment </li></ul></ul><ul><ul><li>How to maximize patient adherence </li></ul></ul><ul><ul><ul><li>E.g., address cost concerns, keep regimen simple, printed instructions, how to ask about adherence </li></ul></ul></ul><ul><ul><ul><li>Understand the patient experience (e.g., self injection of saline using insulin syringe) </li></ul></ul></ul>
  14. 15. Educate Physicians: Establish a Common Knowledge Base <ul><ul><li>Practice Management </li></ul></ul><ul><ul><li>How to work as a team with nursing staff </li></ul></ul><ul><ul><li>1:1 collaboration with RN Certified Diabetes Educator for low performing physicians </li></ul></ul><ul><ul><ul><li>Specific advice based on chart reviews </li></ul></ul></ul><ul><ul><ul><li>Strategies for motivating patients </li></ul></ul></ul>
  15. 16. Implement Process Changes Be Specific About the “What” & the “Who” <ul><ul><li>Rooming standards for clinical assistants </li></ul></ul><ul><ul><ul><li>Chart prep for last A1c, LDL </li></ul></ul></ul><ul><ul><ul><li>Standing orders for pre-visit point-of-care A1c testing, LDL testing and DM education </li></ul></ul></ul><ul><ul><li>Give patient “score card” with current lab values and goals with follow-up instructions </li></ul></ul><ul><ul><li>Schedule future labs, visits and CDE appts. before the patient leaves </li></ul></ul><ul><ul><li>Rx refill policy: limit refill of diabetes meds to 6 months </li></ul></ul>
  16. 17. Implement Process Changes Be Specific About the “What” & the “Who” <ul><ul><li>Quick Start Insulin Program – on-site RN patient education </li></ul></ul><ul><ul><li>RN CDE Medication Management (titration) visits </li></ul></ul><ul><ul><li>MAs “work” the registry report </li></ul></ul><ul><ul><ul><li>Update registry (deceased, transferred care) </li></ul></ul></ul><ul><ul><ul><li>Contact patients who are due for labs and/or a visit </li></ul></ul></ul><ul><ul><ul><li>Schedule BP check nurse visits </li></ul></ul></ul>
  17. 18. Check Back <ul><li>Leader rounding </li></ul><ul><li>Check in with every care team </li></ul><ul><li>“ A policy not observed </li></ul><ul><li>is worse than no policy at all.” </li></ul>
  18. 19. Provide Transparent Feedback <ul><ul><li>Share data at team meetings with all physicians and staff monthly </li></ul></ul><ul><ul><li>Use un-blinded site and physician-specific data </li></ul></ul>
  19. 22. Provide Transparent Feedback <ul><ul><li>Comparative data is powerful; however, physicians tend to doubt “the numbers” </li></ul></ul><ul><ul><li>Individual patient data is more powerful; when the focus is brought down to the care of individual patients there can be no excuses. </li></ul></ul>
  20. 24. Coach for Improvement <ul><li>Focus on individual patients </li></ul><ul><li>rather than numbers </li></ul><ul><li>“ At some point all change requires one </li></ul><ul><li>clinician to talk to another.” </li></ul>
  21. 25. Teach Leaders to Lead <ul><li>Communicating the evidence and importance </li></ul><ul><li>Influencing skills </li></ul><ul><li>Dealing with resistance </li></ul><ul><li>Checking back and leader rounding on staff </li></ul><ul><li>Coaching skills for 1:1 meetings with physicians </li></ul>
  22. 26. Lessons Learned <ul><li>Systems can support practice and improve care. </li></ul><ul><ul><li>“ Consistency breeds reliability” </li></ul></ul><ul><li>The power of nursing </li></ul><ul><ul><li>More than just team work, nursing staff helped drive system changes. </li></ul></ul><ul><li>Culture through action </li></ul><ul><ul><li>“ Culture is everything you promote and everything you tolerate.” </li></ul></ul><ul><li>Leadership is everything </li></ul><ul><ul><li>Financial incentives are not necessary if there are strong moral and social incentives. </li></ul></ul>

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