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1. 2 PROGRAM FACULTY This program and enduring materials are aligned with Consensus Guidelines and have been developed by the Program Faculty with input.

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Presentation on theme: "1. 2 PROGRAM FACULTY This program and enduring materials are aligned with Consensus Guidelines and have been developed by the Program Faculty with input."— Presentation transcript:

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2 2 PROGRAM FACULTY This program and enduring materials are aligned with Consensus Guidelines and have been developed by the Program Faculty with input from Inter-Disciplinary Practice Teams, other diabetes experts and healthcare professionals including Physicians & Allied Health Practitioners involved in Family Health Teams (Ontario) and Primary Care Networks (AB). as well as Associations e.g. CDA,, MoHLTC, Ontario FHT’s, Professional Associations etc. Stewart B. Harris MD, MPH, FCFP, FACPM Canadian Diabetes Association -Chair in Diabetes Management Ian McWhinney Chair of Family Medicine Studies Professor-Schulich School of Medicine & Dentistry, The University of Western Ontario Rick Ward MD, CCFP, FCFP Calgary Foothills Primary Care Network Patsy Smith MN, RN PLS Consulting Inc. Canadian Nurses Association CONTRIBUTORS Maureen Clement MD CCFP Medical Director, Diabetes Education Centre Vernon Jubilee Hospital Assistant Clinical Professor, University of British Columbia Alice Y.Y. Cheng, MD, FRCPC Endocrinologist Credit Valley Hospital and St. Michael's Hospital Assistant Professor, Dept of Medicine University of Toronto Steve Szarka, B. Eng, M. Eng, MD, CCFP Assistant Clinical Professor, McMaster University, Faculty of Family Medicine Hamilton Family Health Team, Hamilton ON John McDonald MD CCFP – Lead Physician - PrimCare Family Health Team President and Chair – Association of Family Health Teams of Ontario Durhane Wong-Reiger BA, MA, PhD Institute for Optimizing Health Outcomes, Canada

3 3 Disclaimer: The following information may refer to drugs or indications that have not been approved by Health Canada. While AstraZeneca has provided financial support for the program, this presentation was created by an independent steering committee and accredited by an independent accrediting body. AstraZeneca does not endorse any use of its products other than in accordance with the current version of the Health Canada approved labeling.

4 4 Facilitators Provide names and credentials of the facilitators for this specific clinic session

5 5 Disclosure of Potential for Conflict of Interest Financial Disclosure Grants/Research Support- XYZ Pharma Co Speakers Bureau/Honoraria Consulting Fees: XYZ Company Other: Employee of XXY Hospital Group

6 6 Clinic Team Introductions Clinic “Champion” and Clinic Team Members What does your Clinic Team hope to achieve today?

7 7 Learning Objectives Primary Objectives: Following this program, participants will be able to: –Apply principles of chronic disease management to their panel –Manage Diabetes Mellitus (DM) patients as a team based on the agreed upon Pathway –Establish outcomes to assess changes made as a result of this process –Develop and implement an action plan utilizing strategies and tools that will optimize type 2 diabetes patient management in their clinic Secondary Objectives: Following this program, participants will be able to: –Maximize interdisciplinary team based care using available resources –Increase trust within team –Provide new models and options for managing DM within a primary care team using Chronic Disease Management (CDM) principles

8 8 Pathways to Diabetes Management Program Goals: Provide interdisciplinary diabetes health care (DHC) teams with a structured, step-wise approach to develop individualized, practical Diabetes Action Plans using guidelines-based strategies and tools to: Improve Patient Health outcomes Promote team effectiveness Optimize practice efficiency Increase patient access to treatment Teams require practical, implementable approaches to care delivery

9 9 PROGRAM OVERVIEW Step 1 Step 2 Step 5 Step 3 Step 4

10 10 Practical Strategies, Tools & Materials Diabetes Practice Management Practice Guide Participant Workbook Canadian Nurses Association Patient Education Toolkit

11 11 Today’s Agenda [to be customized based on event’s start and end time]

12 12 The Clinical Challenge Diabetes Care in Family Practice CDA Guidelines: Therapeutic Goals and Organization of Care

13 13 Diabetes Care in Family Practice The challenge: Diabetes is a complicated, growing disease: –More than 9 million Canadians live with diabetes or prediabetes 1 –Risk of CV death is 2-4 times greater than in the general population 2 –25% of patients with diabetes suffer from depression 2 –11% of patients with diabetes have 3 or more co-morbidities 2 1.Canadian Diabetes Association. 2.Canadian Diabetes Association – 2008 Clinical Practice Guidelines. “Despite increasing evidence about the benefits of effective management, little progress has been made in providing effective care” —CDA Guidelines Committee

14 14 Primary Care Challenge Average practice has between patients with diabetes 1 Patients with diabetes visit their family physician on average 8 times per year 2 Thus, the burden on the clinic is significant (this does not even include the burden of those with cardiometabolic risk) 1 Most recent A1C test results (n = 2,337) DICE: Diabetes in Canada Evaluation study 2 1.Steering Group Communications. 2.Harris SB, et al. Diabetes Res Clin Pract 2005; 70:90-7. Controlled A1C 51% Uncontrolled A1C 49% One in two type 2 diabetes patients in Canada are not at target (< 7%) Mean A1C = 7.3%

15 15 Chronic disease management for diabetes and vascular disease could result in the avoidance of annually…… 1 8,000 heart attacks 4,000 strokes 8,000 unnecessary deaths 1,200 cardiac bypass and balloon angioplasties 369 amputations 1.Q Monitor, Ontario Health Quality Council 2008 Report On Ontario’s Health System. Few mechanisms exist to implement practical solutions

16 16 Therapeutic Goals CDA Guidelines: 1 Goal of treatment is to minimize the risks of the macrovascular and microvascular complications of diabetes by aiming for the following metabolic targets Ontario Ministry of Health: Quality Targets for Primary Care Physicians 2 Example: Baseline Diabetes Dataset Initiative Targets 1.The Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada., Can J Diabetes. 2008;32(suppl 1):S1-S201 2.Ontario Ministry of Health- Quality Targets for Primary Care Physicians:

17 17 CDA Recommended Diabetes Surveillance 1.Harris S., Lank C. eds. Elsevier Timely screening for complications and aggressive management of risk factors are integral parts of diabetes management.

18 18 CDA Organization of Care Guidelines 1.Clement M. Organization of Care: Key elements from the CDA 2008 Clinical Practice Guidelines Good Outcomes for people living with diabetes depend on: The “System”….. A Team Based Approach

19 19 Team Approach Impact on Patient Outcomes: What does the data show us? Team Effectiveness

20 20 Hollander Report: Primary Care Practices Are the Cornerstone of Effective Chronic Disease Management Health outcomes are a function of continuity of care by the same family physician 1 Attachment, or the frequency that a patient seeks services from the same medical practice, keeps patients healthier and reduces costs 1 Group Patient Visits may facilitate attachment by enhancing patient access, time with the medical team, and supportive services provided 2,3 1.Hollander MJ, et al. Healthcare Quarterly 2009;12(4): Steering Group Communications. 3.Noffsinger EB. The Permanente Journal 1999 ; 3 (3):

21 21 Increasing Value for Money in the Canadian Health- care System: New Findings on the Contribution of Primary Care Services 1.Hollander MJ, et al. Healthcare Quarterly 2009;12(4): $ (CDN) Percentage of Attachment Diabetes and CHF – RUB 5 ( ) $13,250 Diabetes Congestive Heart Failure (CHF) Proportion of Total Cost Attributable to Hospital Costs 65% Cost Reduction Attributable to Attachment $16,114

22 22 Primary Care is Essential for Optimal Chronic Disease Management Individuals with a primary care practitioner that they saw on a regular basis had lower rates of hospital use, specialist use and costs 1 1.Hollander MJ. et al. Healthcare Quarterly 2009;12(4): Attachment to a practice was the best predictor of a patient’s overall healthcare costs – more so than other variables such as patient age, gender, income or physician gender and practice span. 1

23 23 Shared Medical Appointments Based on the Chronic Care Model A Quality Improvement Project to Address the Challenges of Patients with Diabetes with High CV Risk 1 Setting: Primary care clinic High CV risk defined as one or more of the following: –A1C levels >9% –Systolic Blood Pressure (SBP) > 160 mm Hg –Low Density Lipoprotein cholesterol (LDL-C) >3.53 mmol/L Patient characteristics for each group were similar 1.Kirsh S, et al. Qual Saf Health Care 2007;16: AIM: Improve outcomes for patients with diabetes at high cardiovascular risk via Group Patient Visit (GPV) implementation

24 24 Better Cardiovascular Risk Reduction was Observed in Patients Attending Group Patient Visits (GPV) 1 1.Kirsh s, et al. Qual Saf Health Care 2007;16: Patients participating in GPV experienced greater benefits in HbA1c, LDL-c and SBP levels compared to usual core patients Mean % GVPControl 2.2 Mean mmol/L % GVPControl Mean mm Hg GVPControl = -0.30= 1.44= 0.14= 0.41= 2.54= HbA1c P= LDL-c P= 0.29 SBP P= 0.04 BaselineFollow-upControl n= 35GPV n=44

25 25 Team Effectiveness in Diabetes Treatment Why a team? What are the attributes of an effective team? Why is this important?

26 26 Team Efficiency EICP - Enhancing Interdisciplinary Collaboration in Primary Health Care. April McMurchy D. CIHR, 2009; retrieved from: 3.Barrett et al. CHSRF Kirsh S, et al. Qual Saf Health Care 2007;16: Steering Group Communications. Features of high performing teams The delegation of key roles to non-physicians Coordinated patient flow strategies: Triaging, multiple access points, advanced access, EMR registry recall, case management Group visits/shared medical appointments Disease-specific targeted “Mini” Clinics Integration of specialist care when appropriate Features of high performing teams The delegation of key roles to non-physicians Coordinated patient flow strategies: Triaging, multiple access points, advanced access, EMR registry recall, case management Group visits/shared medical appointments Disease-specific targeted “Mini” Clinics Integration of specialist care when appropriate

27 27 Team Effectiveness results in… 1-5 Improvement in: Practice efficiency Professional satisfaction Patient access– reduced wait time Care coordination Comprehensiveness of care Preventative care Achievement of metabolic targets Self-care capacity System navigation/health literacy Quality of life Follow-up (less falling through the cracks) Patient satisfaction Improvement in: Practice efficiency Professional satisfaction Patient access– reduced wait time Care coordination Comprehensiveness of care Preventative care Achievement of metabolic targets Self-care capacity System navigation/health literacy Quality of life Follow-up (less falling through the cracks) Patient satisfaction Reduction in: Hospital admissions ER use Outpatient visits Blood pressure Cholesterol Risk of complications Reduction in: Hospital admissions ER use Outpatient visits Blood pressure Cholesterol Risk of complications 1.Aschner P, et al. Int J Clin Pract Suppl. 2007; 157: Sperl-Hillen et al. JT Comm J Qual Saf. 2004;30(6): Vargas RB et al. J Gen Intern Med. 2007;22(2); McMurcahy D. CIHR, 2009;. 5.Barrett et al. CHSRF Steering Group Communications.

28 28 Diabetes Care Teams….A System Change Points to consider:

29 29 Diabetes Care Teams….A System Change Working together as a team includes…

30 30 Aspirin Statin Beta-blocker ACE Inhibitor 80% 60% 40% 20% 92% 86% 78% 61% 56% 12% 6% 4% Protocol Setting — what does the data tell us? CHAMP Results 1.Fonarow GC, et al. Am J Cardiol 2001;87:819–822. The UCLA Medical Center’s Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) increased guideline intervention Increase in use of therapies in post MI treatment 100% Pre-CHAMPPost-CHAMP 0%

31 31 Protocol Setting — what does the data tell us? CHAMP Results Death or Recurrent MI% 1.Fonarow GC, et al. Am J Cardiol 2001;87:819–822. CHAMP protocol reduced death or recurrent myocardial infarction 14.8% 6.4% Pre-CHAMPPost-CHAMP 15% 5% 10% 0% 20%

32 32 Summary

33 33 CLINIC WORKSHOP SESSION Optimizing Practice Efficiency to Promote Team Effectiveness

34 34 STEP 1: Clinic Assessment WORKSHOP OUTLINE Step 1A - Priority Patient Population Step 1B - Patient Management Needs Step 1C - Team Readiness Step 1D – Diabetes Resource Inventory ACTIVITIES: Review results of Clinic Assessments Validate/align the direction and outcomes of the assessments with the team Fine-tune the direction (if required) MATERIALS: Summary of Clinic Assessment Results Diabetes Resource Inventory Materials are provided in the Participant Workbook Note MBC on 15 July that not directional enough and Mike to advise - CHECK

35 35 STEP 1: Clinic Assessment Summary of YOUR Clinic Assessment Do you agree?

36 36 STEP 1: Clinic Assessment Diabetes Resource Inventory What resources did you identify?

37 37 STEP 1: Clinic Assessment What did you learn about your patients? Your team? Clinic efficiency gaps and opportunities? Do any of the results surprise you? Do you agree that, by focusing on the areas highlighted in the Clinic Assessment Summary, your team can make a difference in the treatment of DM patients? Priority Patient Type – goals and outcomes Build a Registry (if required) or assess Improved team care Scheduling Methods Is your team READY to develop and implement a team-based diabetes management program? MAKE ACTION PLAN NOTES Team Reflection and Alignment Exercise

38 38 Clinic Team Regroup Share key learnings from Team Reflection and Alignment Exercise –Learnings about your patients, your team and clinic efficiency gaps and opportunities Highlight any areas in which your Clinic Team would benefit from feedback/input from the larger group MAKE ACTION PLAN NOTES

39 39 STEP 2: Clinic Diabetes Registry Develop or Access Clinic Diabetes Registry ACTIVITIES Do you have a Clinic Diabetes Registry? Why is it important? Review EMR and Manual registry options MATERIALS Diabetes Practice Guide Workshop Outline Materials available in Diabetes Practice Guide

40 40 STEP 2: Clinic Diabetes Registry As indicated by the CDA’s Organization of Care Guidelines, a Diabetes Patient Registry is a very important step in patient management. 1.Clement M. Organization of Care: Key elements from the CDA 2008 Clinical Practice Guidelines Does your clinic have a Diabetes Clinic Patient Registry? The Role of the Clinic Diabetes Registry

41 41 STEP 2: Clinic Diabetes Registry Track patients using appropriate “data searches” 1.Identify and categorize “specific” patients by category or billing information 2.Identify patients who require intervention by conducting a data search based on disease- specific clinical outcomes or problems list Examples: A1C > 7%; BP >130/80 mm Hg; Elevated cholesterol levels 3.Facilitate outcomes measurement ** Is your EMR an effective/optimal Registry tool? If not, contact your EMR provider for assistance Diabetes Registry Fields EMR Patient Registry

42 42 STEP 2: Clinic Diabetes Registry Manual Patient Registry Track patients via commercially available spreadsheets Registry could be populated… –at diagnosis –when reviewing charts or at patient’s next appointment –when lab results or consultation reports are received EXCEL Diabetes Patient Registry Ortiz D. Family Practice Management, Fam Pract Manag Apr;13(4): retrieved from: Notes: –Registry management should be assigned to one team member to ensure it is updated –Although a registry is a key element, some “patient practice” changes can be made while the registry is being developed (e.g. scheduling patients more efficiently)

43 43 STEP 2: Clinic Diabetes Registry If no Clinic Diabetes Registry: –PRIORITY FOR THE CLINIC ACTION PLAN SHOULD BE SETTING UP AN EMR OR MANUAL REGISTRY If Clinic Diabetes Registry is in place: –THINK ABOUT OPPORTUNITIES TO IMPROVE EFFICIENCY –FOCUS ON PRIORITY PATIENT TYPE DIABETES TEAM ACTIVITY CHECKLIST IMPLEMENTATION MAKE ACTION PLAN NOTES Diabetes Registry Next Steps

44 44 Clinic Team Regroup Share key learnings –Clinic diabetes registry development or assessment –Overall input/collaboration with other Clinic Teams MAKE ACTION PLAN NOTES

45 45 Optimizing Practice Efficiency to Promote Team Effectiveness CLINIC WORKSHOP SESSION

46 46 STEP 3: ORGANIZATION OF PATIENT CARE ACTIVITIES: Validate your Clinic’s Priority Patient Type Review your Diabetes Resource Inventory Complete the Diabetes Team Activity Checklist and Assign Team Roles Review and Select Scheduling Method MATERIALS: 1.Clinic Needs Assessment Summary 2.Diabetes Resource Inventory 3.Priority Patient Type - Diabetes Team Activity Checklist: (one of the following: Prediabetes, New Diagnosis, Ongoing Management, Insulin Starts, Complex Patient) Workshop Outline All materials can be found in the Participant Workbook. Descriptions of scheduling options are located in the Practice Guide. All materials can be found in the Participant Workbook. Descriptions of scheduling options are located in the Practice Guide. Priority Patient Type, Diabetes Team Activity Checklist, Scheduling Methods ACTIVITIES: Validate your Clinic’s Priority Patient Type Review your Diabetes Resource Inventory Complete the Diabetes Team Activity Checklist and Assign Team Roles Review and Select Scheduling Method MATERIALS: 1.Clinic Needs Assessment Summary 2.Diabetes Resource Inventory 3.Priority Patient Type - Diabetes Team Activity Checklist: (one of the following: Prediabetes, New Diagnosis, Ongoing Management, Insulin Starts, Complex Patient)

47 47 STEP 3: ORGANIZATION OF PATIENT CARE Using the criteria below for your Priority Patient type, describe a patient in your clinic practice that would fit this profile What are the major challenges faced when dealing with this patient? MAKE ACTION PLAN NOTES Step 3A: Validation of Priority Patient Type

48 48 STEP 3: ORGANIZATION OF PATIENT CARE What resources can we utilize to help manage this patient type? What resources are we missing? Step 3A: Review of Diabetes Resource Inventory MAKE ACTION PLAN NOTES

49 49 STEP 3: ORGANIZATION OF PATIENT CARE Diabetes Team Activity Checklists are provided in the Participant Workbook Utilize the Diabetes Team Activity Checklist for your identified priority patient type Assign roles to each task – think about the resources on the Diabetes Resource Inventory Considerations: Delegation of key tasks to non- physicians Coordinated patient flow strategies Integration of specialist care Utilization of interprofessional resources Diabetes Team Activity Checklists: Lists of CDA recommended activities for each patient type Step 3B: Complete the Diabetes Team Activity Checklist

50 50 Clinic Team Regroup Share –Priority Patient Type and rationale –Potential patient management changes based upon the Priority Patient Checklist Review Highlight any areas in which your Clinic Team would benefit from feedback/input from the larger group MAKE ACTION PLAN NOTES

51 51 Optimizing Practice Efficiency to Promote Team Effectiveness CLINIC WORKSHOP SESSION

52 52 STEP 3: ORGANIZATION OF PATIENT CARE For more information see the Diabetes Practice Guide Advanced Access –A structured and systematic method which ensures patients access to primary health care team at a convenient time “Diabetes Days” Batching –Organized and coordinated team-based care for DM patients –Utilize a “batching” scheduling strategy to manage populations of patients Group Patient Visits –An expanded medical appointment delivering most elements of an individual visit Coordinated Team Scheduling –MD and RN collaborative patient visits Interdisciplinary Patient Visits- Sample Visit Activities –The right clinician at the right time Step 3C: Scheduling Options

53 53 STEP 3: ORGANIZATION OF PATIENT CARE A structured and systematic method which ensures patients access to primary healthcare team at a convenient time Same Day Bookings ~80% of all appointments: Patients call and book an appointment “today” Advanced Booking ~20% of all appointments Preventative appointments- e.g. quarterly appointments for DM Labs pre-appointment Self care and goal setting Six elements/conditions: 1.Understand the supply/capacity and demand 2.Balance supply and demand 3.Reduce the number of appointment types 4.Develop contingency plans to sustain the system 5.Reduce and shape the demand for visits 6.Increase effective supply: transfer physicians’ functions that can be done by someone else Advanced Access For more information see the Diabetes Practice Guide

54 54 STEP 3: ORGANIZATION OF PATIENT CARE Organized and coordinated team-based care for patients with DM: “Diabetes Days” apply a “batching” scheduling strategy for patient with DM, improving patient access to care and improving practice efficiency and effectiveness. Logistics: –Allows for scheduling preventative care during regular and advanced access appointments –Type 2 diabetes “batching” on specific days weekly Labs pre-appointment No long appointments scheduled on “batching” days Strong emphasis on patient’s role as team member Team: –Effective for small or larger teams –MD and team agree on roles –Standardized/consistent team roles and documentation –Exam rooms for each team member and MD moves between rooms –Use of flow sheet or EMR for quick assessment of patient status, outcome tracking and as a teaching tool “Diabetes Days” Batching For more information see the Diabetes Practice Guide

55 55 STEP 3: ORGANIZATION OF PATIENT CARE Expanded medical appointment delivering most elements of an individual visit, including –Personal examinations (e.g. collection of vital signs, history-taking, physical exam) –Formal and informal education –Social and psychological support Practice effectiveness and efficiency which… – Increases capacity to care for more chronically ill patients in less time – Increases efficiency as a result of staff working in appropriate roles and assuming appropriate responsibilities –Improves job satisfaction among staff –Improves delivery of quality patient care Patient Self- mgmt Group Patient Visits (GPV) For more information see the Diabetes Practice Guide

56 56 STEP 3: ORGANIZATION OF PATIENT CARE RN Role: Focuses on time-consuming diabetes management appointments MD has dual role: Urgent care needs and typical family practice visits Joins the nurse’s visit (if required) to review the plan and sign prescriptions Coordinated Schedule Example Coordinated Team Scheduling For more information see the Diabetes Practice Guide

57 57 STEP 3: ORGANIZATION OF PATIENT CARE Sample Visit Activities: Detailed interdisciplinary patient visits checklists/plans are provided in the practice guide for the 5 DM patient groups as follows: Prediabetes New Diagnosis Ongoing Management Insulin Starts Complex DM Patients Checklists are aligned to the CDA Clinical Guideline Surveillance Schedule Interdisciplinary Patient Visits: “Right clinician” at the “Right Time” For more information see the Diabetes Practice Guide

58 58 STEP 3: ORGANIZATION OF PATIENT CARE Which scheduling method/methods do you believe will be most effective and efficient to manage your Priority Patient Type? Do you need more information? How/where will you get more information? MAKE ACTION PLAN NOTES Scheduling Method Selection

59 59 Clinic Team Regroup Share –Scheduling Method(s) selected and rationale –Expected outcomes –Concerns/outstanding information needs Discuss experiences and potential solutions with the group MAKE ACTION PLAN NOTES

60 60 Optimizing Practice Efficiency to Promote Team Effectiveness CLINIC WORKSHOP SESSION

61 61 STEP 4: ACTION PLAN ACTIVITIES Overview of Clinic Action Plan Expectations Complete Clinic Action Plan: Determine Action Plan GOALS Define 2-3 SPECIFIC TASKS Document ACTIVITIES required Identify the OWNER and the KEY SUPPORT team Determine the TIMELINES Determine MEASUREMENT Targets MATERIALS –Summary of Clinic Assessment Results –Diabetes Resource Inventory –Priority Patient Type Diabetes Team Activity Checklist –“Action Plan Notes” taken during the session –Blank Action Plan Template Workshop Outline Set specific goals, task, roles, timelines and measurements All materials can be found in the Participant Workbook

62 62 STEP 4: ACTION PLAN Your Clinic Action Plan

63 63 STEP 4: ACTION PLAN Clinic Action Plan: Sample #1 Registry

64 64 STEP 4: ACTION PLAN Clinic Action Plan: Sample #2 New DM Diagnosis

65 65 STEP 4: ACTION PLAN Clinic Action Plan: Sample #3 Ongoing DM Management

66 66 STEP 4: ACTION PLAN Work on Your Clinic Action Plan Hints: Changes should be easily actionable Simple changes often have the greatest impact Maximize use of interdisciplinary team Measurement… start with small steps- don’t try to measure everything Hints: Changes should be easily actionable Simple changes often have the greatest impact Maximize use of interdisciplinary team Measurement… start with small steps- don’t try to measure everything

67 67 Action Plan Presentations Each Clinic Team will review their Clinic Action Plan –Ask questions –Make suggestions –Share experience MAKE ACTION PLAN NOTES

68 68 STEP 5: IMPLEMENTATION ACTIVITIES Plan-Do-Study-Act Cycle Clinic Action Plan Implementation and Measuring Effectiveness Reflect upon the solutions generated today and how the team can be successful MATERIALS 1.Clinic Action Plan 2.Clinic Diabetes Management Dashboard 3.Participant Workbook Workshop Outline Implement, track progress and evaluate All materials can be found in the Participant Workbook

69 69 STEP 5: IMPLEMENTATION PLAN: DO: STUDY: ACT: identify and plan ahead for change, analyze and predict the results execute the plan, taking small steps in controlled circumstances check and study the results take action to improve the process Plan-Do-Study-Act Cycle The process is flexible… Engage in continual planning, study and refinements at all stages

70 70 Model for Improvement Three Questions –What are we trying to accomplish? –How will we know that a change is an improvement? –What changes can we make that will result in improvement? Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement?

71 71 ACT What changes are to be made? Next cycle? PLAN Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) STUDY Complete the analysis of the data Compare data to predictions Summarize what was learned DO Carry out the plan Document problems and unexpected observations Begin analysis of the data The PDSA Cycle for Learning and Improvement

72 72 Multiple Cycles to Implement a Change in Diabetes Care How can practice ensure feet are examined? Foot exam protocol in place within one month of initial test Cycle 1: Monofilament placed on exam table to prompt provider. Test with 5 patients on one day. No exams done. Provider ran out of time. Cycle 2: : Post sign to prompt patients to remove shoes and socks. Test with 5 patients next day. Most patients did not understand. Cycle 3: RPN rooming patient removes shoes and socks. Test w/ 5 patients next day. 4 of 5 feet examined. RPN forgot to one patient Cycle 4: Put foot care stamp in EMR to prompt RPN. Test. All patients received foot exam Cycle 5: Implement process for all patients as a clinic protocol Improving Diabetic Foot Exam Rates Learning

73 73 Clinic Diabetes Management Dashboard

74 74 Clinic Diabetes Management Dashboard: Narrative Report Key Changes –Describe changes made in the way you care for patients with diabetes PDSAs –List two or three critical PDSAs that helped you achieve the changes above Impact on Outcomes –Describe how you believe these changes impacted particular outcomes you are monitoring What next? –Describe what you will be doing regarding future improvements.

75 75 STEP 1: Clinic Assessment We've been working together for 3 hours today; what did we do best as a team? What enabled us to be successful in coming up with an Action Plan? What will enable us to be successful implementing the Action Plan? Team Implementation

76 76 Clinic Team Regroup Share –Clinic Team interaction –Action Plan development –Overall input/collaboration with other Clinic Teams What will enable successful implementation of the Clinic Action Plan? MAKE ACTION PLAN NOTES

77 77 Wrap up Parking lot Measuring Effectiveness – Complete CHE Evaluation Form and hand in prior to leaving


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