1. What changes might result in an improvement?
Show Me the Sugars!
Grady Health System, International Medical Clinic
Sol Aldrete, MD, Roger Alvarez, DO, Jeremy Chow, MD, Juan Ortega-Legaspi, MD, Lori Randall, MD, Amy Salerno, MD, Danny Treiyer, MD, Aida Venado, MD Faculty Mentor: Nurcan Ilksoy
Tests of Change
Problem
Measure
Test of Change
Result
What Was Learned
Placing glucose logs in clinic workroom for residents to use during appointments.
Much higher rate of giving logs to patients but still inadequate rate of patients bringing in logs.
Need another intervention to remind patients to bring logs (possibly phone message) as well as more time for patients to have had prior appointments and been given logs.
Diabetes is a problem that disproportionately affects Hispanics in the United States, with a prevalence of 7.9% compared to 5.1% in White Americans (1). Not surprisingly, diabetes is one of the most common problems among the patients of the International Medical Center, most of whom are Spanish speakers. While it was evident that blood glucose logs could be invaluable in helping to attain optimal glycemic control, patients often had to create their own makeshift blood glucose log on blank paper. There was no process in place to make sure that there was a bilingual, three-meal glucose log available for our patients, and that the providers were having regular discussions of the blood glucose values with their patients.
(1)
Barriers
Provider Factors: As seen in Figure 2 and 3, the largest barriers in discussing logs and patients bringing their logs, were the lack of initiation of discussion by the physician, and the failure to provide blood glucose logs.
Patient Factors: Figure 3 shows that patient factors such as forgetting to bring logs, noncompliance with glucose checks, and lack of supplies, also played a significant role.
Aim Statement
What changes might result in an improvement?
80% of clinic visits with insulin-dependent diabetics at the Grady International Clinic will have documented discussion of glucose log and a copy of blank log given to patient.
At 60% of visits, patient will bring glucose log (paper or glucometer). Goal time period: to accomplish this aim between October 2011 and April 2012.
Lessons Learned
Physician
Patient
Record BG log
Lack of time
Though physicians were close to meeting the 80% goal of having discussions about the glucose log, the percent of patients who brought their logs remained about 25%.
Despite the conversations taking place, in >50% of physician encounters, patients still were not given logs.
Physician discussions need to result in the reflexive supplying of a glucose log.
This seems to be area of change that can have the largest impact. Simple interventions, such as making logs more readily available in each room, or having nursing staff hand them out to diabetics, might improve the percent of patients who bring back logs. Meanwhile, patient-specific factors can be worked on at an individual level.
Multiple complaints
Bring log
No home BG Log recorded in chart
Providing BG log
Upload information to Epic
Making copy for chart
Scheduling close f/u appointment
Staff
System

2. Barriers to Documentation of Advanced Directives
End-of-Life Care Planning Improving Documentation of Advanced Directives in the Resident Clinic using Electronic Medical Records
Grady Primary Care Center, Monday Purple Pod
Salim Hayek, Ria Nieva, Frank Corrigan, Amy Zhou, Uma Mudaliar, David Mays, Michael Massoomi, Erika Heard, Reza Hassanyar, Dejuan White
Faculty Mentors: Iris Castro, Nurcan Ilksoy
Tests of Change
Problem
Methods and Measure
Test of Change
Result
What Was Learned
TOC1
Provider education through
Reminder s
Distribution of handouts on advanced directives
Ineffective. Improvement in documentation rate temporary at best and highly dependent on physician’s personal motivation
TOC2
Workshop on advanced directives discussion
No effect on documentation
TOC3
Added “Advanced Directives Counseling” to problem list
Provided .ADVDISC summary template for rapid documentation
Effective reminder, as well as easily accessible permanent record. Significantly increased documentation of AD
End-of-life care planning has received and advocacy in recent years. JCAHO requires that hospital medical records document evidence of known advanced directives (AD) and provide information about advance care planning to all patients. Patient satisfaction is increased when AD are discussed in clinic.
Despite surveys showing patients prefer to discuss advance directives with their primary care doctor, many are completed during hospitalizations. Population based-estimates of completed advance directives range from 5% to 15%.
Discussing end-of-life care in the outpatient setting is perceived as challenging. One major obstacle reported by physicians is lack of time and effective reminders to address and document advanced directives.
Yes No
A total of 588 patient charts were screened by 7 providers of Grady Clinics Purple Pod.
157 met the predefined criteria for AD documentation.
“Advanced Directives Counseling” was added to the problem list of 50% of patients who met criteria.
During the period of November 2011-April 2012; 64 patients were seen in clinic; 38 had AD on their problem list, 26 did not.
76% of charts with ADPL had documentation of AD. Only 11.5% of those without ADPL had AD documented.
Limitations
Sample size was relatively small and study of short duration. Will require longer term and larger population sample to assess sustainability of the improvement in documentation rate.
Study does not assess completion rates of official AD document completion.
No conclusion can be made on the impact of improved AD documentation on inpatient management
TOC1
TOC2
TOC3
Data Collection
Aim Statement
Barriers to Documentation of Advanced Directives
Previously we assessed the effectiveness of -mediated provider education and reminders in improving documentation of AD. This initial test of change (TOC1) showed a slight (1%) and temporary increase in documentation of AD.
Using the electronic medical records (EMR) system EPIC we set to implement a reminder system for physicians to document AD in a select population of patients with chronic illnesses (see below), and assess the percentage of patients meeting criteria which have documented AD counseling within 6 months of the main test change:
Adding “Advanced Directives Counseling” to the patient problem list (ADPL).
Patients must have one or more of the following characteristics/diagnoses: Age > 65, Congestive Heart Failure NYHA III, severe COPD (FEV1<30%), AIDS, any diagnosis of malignancy, cirrhosis, ESRD, stroke.
Lessons Learned
EMR based reminders are effective in improving documentation rates of AD and may be applied for other purposes.
Obstacles remain, including the lack physicians’ initiative and knowledge in discussing AD, time limitations in the outpatient setting, as well as the unclear translation into changes in inpatient management.
Further research is needed to establish the sustainability of improved documentation over longer periods of time and in a larger population sample, as well as its impact on inpatient management.

3. What changes might result in an improvement?
Improving Influenza Vaccination Rates in an
Internal Medicine Resident Clinic
General Internal Medicine at 1525 Clifton Rd., Friday Resident Clinic
Turang Behbahani, Vivian Cheng, Ed Clermont, Tina Constantin, Patrick Hall, Farah Khan, Freny Nirappil, Julian Raffoul, Nathan Spell 3
Problem
Measure
Barriers
The number of seasonal influenza-associated deaths varies from year to year because flu seasons are unpredictable and often fluctuate in length and severity. The CDC estimates that from the season to the flu season, flu-associated deaths ranged from a low of about 3,000 to a high of about 49,000 people (1). In 2013, the CDC published a model to quantify the annual number of influenza-associated illnesses and hospitalizations averted by influenza vaccination during the 2006–11 influenza seasons (2). Using that model the CDC estimated that vaccination resulted in 79,000 (17%) fewer hospitalizations during the 2012–13 influenza season than otherwise might have occurred. Especially in the primary care setting, providers are facing increasing difficulties to clarify "influenza-myths" as well as to identify burdens which keep patients from choosing or receiving the valuable vaccination.
Lack of a standard process to address preventive care, in general, leading to creation of unique solutions to this problem
Perceived inability to influence patient wishes and misinformation
Relative little involvement of clinic staff
Goal
Actual
Lessons Learned
Standard process
Attd review
Doing an improvement project in isolation from the rest of the practice made it hard to create a standard way of checking vaccine status that would sustain itself
A standard process does not become the standard without effective training and reinforcement at first
Reliance on memory does not yield much improvement
We tended to make changes where we felt we had the most control, rather than trying to change patient beliefs, which was the greatest opportunity
Data collection should be built into the work flow or should come from a ready source
What changes might result in an improvement?
Aim Statement
By January 1, 2014, 70% of more of all patients seen in the Friday resident clinic at 1525 Clifton Road will be vaccinated during their appointment (if not already completed). 
References
Tests of Change
(1) Thompson MG et al., Estimated Deaths Associated with Seasonal Influenza - United states , Weekly, August 27, 2010 / 59(33);
(2) CDC. Prevention and control of seasonal influenza with vaccines. Recommendations of the Advisory Committee on Immunization Practices—United States, 2013–2014. MMWR 2013;62(No. RR-7).
Jan: Created standard process to let MD know patient’s status and wishes
Feb: Attending to review vaccine status during sign-out as detection and mitigation step.

4. What changes might result in an improvement?
Improving Hypertension Control
in the Patient Centered Medical Home
Grady Green Pod Clinic Team
Austin Chan, Maya Varthi, N. Thi Gunter, Patricia Hwang, Curtis Jamison, Bryant Chan, Arjun Nanda, Jessica Nave, Ravi Vora, Parth Joshi, Mahmoud Abdou, Danesh Kella, Greg Weston, Amirali Masoumi, Abhinav Koul, Abdullah Khan, Bradley Witbrodt, James Monaco, Vaishnavi Kundel, Yasamin Chowdhury, Danny Nguyen, Maria Lee, Anjan Deka, Phoebe Chi, Eric Shin, Aaron Gluth, Brian Heeke, Sandeep Krishnan, Anand Jain, Daniel Cucco, Vera Tate, Ula Abed Alwahab, Neal Bhatia, Kiran Valiani, Akshay Shetty, Shing-Yu “Cliff” Lin, Sara Turbow, Teresa Ingram, Katie Tipton, Robert McClung, David Dunhill, Valeria Cantos-Lucio, Joy Wortham, Shadi Yarandi, Nisha Joseph, Taylor Lebeis 
Faculty Mentors: Kalra, Girish L‎; Doyle, Joyce P‎; Bussey-Jones, Jada; Manning, Kimberly; Jones, Danielle‎; Schneider, Jason S; Adhyaru, Bhavin; Ilksoy, Nurcan
Green Pod Nurses and Staff
Tests of Change
Problem
What changes might result in an improvement?
Dec - To improve the accuracy of BP measurement and better identify patients who require intensification, at each visit, a manual BP is repeated in patients who are hypertensive, the physician is notified, and the value is recorded within the EMR.
Feb – To improve patient adherence, the remark “For High Blood Pressure” is added to the sig line of prescriptions for antihypertensives.
Mar – Within our Epic EMR, a “dot phrase” reminder is added to the primary clinic note template that prompts physicians to address HTN.
In our urban primary care center, a disproportionately large percentage of patients have uncontrolled hypertension compared to the general population.
Moreover, among academic primary care clinics within the Grady Memorial Hospital Primary Care Center, a recent report revealed that our Green Pod practice ranked last in blood pressure control. In Green Pod patient encounters in June 2012, only 57.2% had a SBP < 140 mmHg, compared to 65.2%, 65.4%, and 70.4% in the Orange Pod, Purple Pod, and Yellow Pod clinics, respectively.
We sought to re-design our approach to hypertension management by identifying reasons for poor blood pressure control and devising interventions to help us more successfully treat our patients.
Figure 1. Fishbone diagram addressing barriers to effective BP control.
Three key barriers were addressed in our study: one physician factor, one nursing factor, and one patient-related factor.
Additional Pitfalls
Additional barriers contributing to suboptimal blood pressure control and possible decreased effectiveness of our interventions included:
Erratic participation by providers
Time constraints within a busy primary care clinic
Patient resistance to the addition of medication and physician uneasiness with intensifying therapy in the setting of possible non-adherence.
Limited patient finances and possible low literacy.
Measure
Figure 2. Percentage of return patients with SBP < 140 mmHg
Among patients who have been seen in the clinic 2 or more times in the preceding six months, the percentage of visits with a systolic BP < 140 mmHg.
n = return visits examined among Green, Orange, and Purple clinics.
Note that these figures should not be compared to the percentages cited from the June report, which examined all patients.
Aim Statement
Lessons Learned
Over 6 months, we aim to increase the percentage of Green Pod patients with hypertension who meet a systolic blood pressure goal of < 140 mm Hg to over 70%.
Three simple, low-cost interventions showed varying degrees of benefit in helping our patients achieve BP control.
Utilizing support staff in the clinic appeared to be the most effective intervention, though the practice of preferentially obtaining manual BP assessments when the initial automated reading is high likely introduced some bias.
We were only partially able account for patients who were uncontrolled and then had meds changed.
Ensuring physician participation in a busy clinic setting without providing additional incentive was challenging.
Baseline
TOC #1
TOC #2
TOC #3
n = n = n = n = n = n = 599

5. Improving Hepatitis C Screening in a Primary Care
Internal Medicine Resident Clinic
1525 Clifton Road Emory Clinic Friday Team
Freny Nirappil MD, Vivian Cheng MD, Tina Constantin MD, Edward Clermont MD,
Patrick Hall MD, Michael Lava MD, Rachel Anquez MD
Faculty Advisor: Nathan Spell III MD
Background
In 2012, the CDC recommended that everyone born between 1945 and 1965 should get screened for Hepatitis C. Hepatitis C is the leading cause for liver transplantation in the United States, and up to 75-80% of patients infected with HCV can go on to develop chronic infection. Given the morbidity associated with this illness, we sought to improve our screening for HCV.
Measures of Screening
Tests of Change
Result
What was learned
Provider reminder sticky sheet on computers
Easy to miss on computer screens
Reminders are easy to overlook and short lived
Pre-test patient information handout given to each Friday clinic patient
Many patients did not receive the handouts, so screening wasn’t done.
We needed a better implementation plan to increase adherence
Test of Change #2
Barriers to screening
It is difficult to screen patients who have acute visits as opposed to those coming in for a physical as acute visits do not usually require bloodwork.
Reminder systems relied solely on the physician to implement screening.
We did not have enough PIP conferences to discuss ongoing issues with the project.
Aim Statement
By April 12, 2013, 80% or more of patients born between  seen for a visit in the Friday resident clinic at 1525 Clifton Rd. will have been screened for hepatitis C infection.
Test of Change # 2
Tally Sheet
Reasons why screening is not done
Prior to intervention
After Test of Change #1
Patient refuses
||||
Lack of prior records | ||
Not MD priority / awkward
Not patient priority
|||
MD forgets to mention / consider
|||| ||
|||| |||| |
MD forgets to order
Too little time to explain
MD unaware of recommendation
Concerns about insurance coverage / cost
Fishbone Diagram
Lessons Learned
More frequent evaluations of the success of our tests of change would have allowed for more prompt corrections to those changes.
Lasting change is easier to accomplish when focusing on larger issues because it forces the individual to focus on the system as a whole in order to implement appropriate steps towards establishing long-lasting change.  The narrow focus of our clinical question may have limited the progress of our project 
specifically because it focused on one small step in the process of improving screening within our clinic.

6. Improving Counseling for Tobacco Cessation
in a Resident Primary Care Clinic
Grady Primary Care Center, Friday Purple Pod
Jane Titterington, Robert Kung, Zahi Mitri, Jeff Chen, Kyle James, Jenna Kay, Wendy Neveu, Reema Dbouk, Anthony Gamboa,
Faculty Mentors: Sanjukta Chatterjee, Nurcan Ilksoy
Problem and Background
Test of Change
Result
#1 – Nurses:
Screened patients for tobacco use during triage.
- There was a significantly increased rate of screening for tobacco use amongst all clinic patients.
- Documented with triage vital signs.
#2 – Physicians:
“Tobacco counseling” section added to standard progress note template.
There was a significantly increased rate of smoking cessation counseling by physicians
Documented in progress note.
#3 - Patients:
Receive tobacco cessation handout containing the Georgia tobacco quit hotline number. and information on tobacco cessation classes at Grady.
- Patients left the clinic visit with information to obtain more tobacco cessation counseling with resources to help them quit smoking.
Outcomes
Barriers
Cigarette smoking is the leading preventable cause of mortality in the United States, responsible for over 400,000 deaths annually1.
Up to one-half of all tobacco users can be expected to die from a tobacco-related disease2.
The economic burden of tobacco use is estimated to be $197 billion per year1.
Smoking cessation is associated with clear health benefits and should be a major health care goal3.
Screening all patients for tobacco use and providing all smokers a brief smoking cessation intervention is one of the three most cost-saving clinical preventive services3.
Less than half of all patients (48.7%) report receiving advice from health professionals to quit 4.
Most common physician barriers were: forgetting to address smoking status, not having enough time to address it or having too many other active medical problems to address, or failure to document in the progress note that tobacco cessation counseling occurred.
Lack of patient education materials was also a barrier to proper counseling.
RN barriers included lack of documentation of screening for tobacco use during triage, as well as having patients roomed before triage could occur.
Test of
Change #1
Test of
Change #2 and #3
Lessons Learned
Screening for tobacco use by clinic nurses increased when incorporated into routine triage procedures.
Tobacco cessation counseling occurred significantly more frequently when providers were prompted by a standardized progress note template. Documentation of intervention was also more likely to be completed.
Having patient education materials readily available appeared to promote tobacco cessation counseling by providers, and ensured patients left clinic with specific resources to help them quit smoking.
What changes might result in an improvement?
Aim Statement
Fishbone Diagram
Potential problem or barrier
Count
MD forgot to discuss smoking status 13
MD forgot to document smoking in history 3
MD did not document counseling in progress note 9
MD had too many active issues at current visit
MD had no time to address 4
RN Did not add smoking status to triage vitals 23
RN sent to room before triage and screening 1
RN reviewed but did not update smoking status 5
Patient tired of repeated counseling 7
Smoking cessation not a priority to patient
Patient just wants treatment and not counseling
Patient discouraged by repeated attempts that failed
Tobacco use not automatically placed on problem list
Counseling materials not readily available
1. We aim to screen 100% of our Friday Purple Pod patients for current tobacco use with corresponding documentation in EPIC by January 2012.
2. We aim to improve tobacco cessation counseling rates to greater than 80% of our population of current smokers, as measured by both documentation in clinic notes; as well as by including tobacco cessation resources in the patient’s after visit summary by May 2012.
Physician
Patient
Hospital System
Counseling
Ancillary Staff
Lack of counseling materials
Not in problem list in Epic
Not triaged
Not documented
Prior status not updated
Lack of time
Forgets to discuss
Forgets to document
Other more urgent issues
No template in Epic
Tired of counseling
Other more urgent concerns
Not disclosing smoking status
Only wants treatment
References
(1) MMWR Morb Mortal Wkly Rep Nov 14;57(45):
(2)
(3) Maciosek MV et al. Am J Prev Med 2006; 31:52.
(4) MMWR Morb Mortal Wkly Rep Nov 11;60(44):

7. What changes might result in an improvement?
Improving the Documentation and Interventions of Obesity in a Resident Primary Care Clinic
Grady Primary Care Center, Monday Orange Pod
Kobina Wilmot MD, Justin Cheeley MD, Jessie Torgerson MD, Jia Shen MD, Anita Saraf MD, Jenny Luke MD, Meena Prasad MD, Thomas Runge MD, Arash Harzand MD, Hassan Imam MD, Jessica McDermott MD,
Faculty Mentors: Jada Bussey-Jones MD, Stacie Schmidt MD ,Nurcan Ilksoy MD 7
Tests of Change
Problem
Measure
Test of Change
Result
What Was Learned
Height added to nursing triage template to be able to calculate BMI
Significant improvement in documentation and sustainability observed
Interdisciplinary team work with system change made the process sustainable.
Documentation of obesity on the problem list
increase documentation on the problem list
Periodically reminders are needed. Also new physicians in clinic need to be accounted for.
Initial informative and and flyers encouraging obesity plans & obesity clinic referral program
Increase trend in obesity documentation in problem list and interventions described in problem list
Visual reminders and site to send patients increases interventions for patients
with obesity
Another informative sent
Continual trend upward in documentation in problem list and interventions
Once again reminders help but not enough for reliable process improvement
Obesity is defined as a BMI of >30.
More than 1/3 (35.7%) of U.S. adults are obese. The rate in Fulton County is 23.2%, in Dekalb County 27.4%.
Obesity is an increasing problem. Currently, >30% of the population is obese in 12 states. In 2000, no state had an obesity rate >30%.
The average hospital length of stay for obese patients is 60% longer than for normal weight individuals nationwide.
The annual cost of obesity in Georgia is $2.4 billion (or $250 per Georgian each year), including direct health care costs and lost productivity.
Obesity places patients at greater risk for diabetes, heart disease and some types of cancer. It is the #2 cause of preventable death in the United States.
After increasing obesity documentation in our clinic last year, we noted that despite documentation, interventions were often not addressed. The obesity clinic instituted by Dr. Schmidt became an additional resource to obese patients this year, in addition to nutrition classes and diet/exercise education by the health care practitioner.
Barriers
Making BMI more visible in EMR
Time for physicians to make and offer specific education on diet and exercise
Assuring patients who are referred to obesity clinic have message sent to and received by clinic scheduler
Patients referred to obesity clinic actually are able to be reached to attend sessions
Enough sessions are available to accommodate the large number of obese patients in our primary clinic
What changes might result in an improvement?
Process Improvement Chart with possible interventions for improvement of outcome
Patient arrives
Nursing enters biometric data
BMI documented and reviewed by MD
Obesity entered on problem list
Obesity plan initiated
Lessons Learned
EMR has facilitated BMI as being listed as part of a patient’s vital signs for each visit, helping to prompt a response for an abnormal BMI
Though BMI is automatically calculated in EMR, obesity is still often overlooked by providers as a separate medical problem
If obesity is listed as a separate problem, an intervention is often proposed
Nutrition and obesity clinic referrals offer concrete actions providers can take to address obesity. Diet and education handouts may be helpful for providers to more readily access.
Aim Statement
We aim :
To continue to improve documentation of BMI in problem list to 75% by March 2012.
To have at least 50% of patients documented with obesity (BMI >30) to have an intervention of exercise, diet, or obesity referral by March 2012 in Orange Pod Monday clinic.
- BMI auto-populated with .phrase
- BMI reference charts displayed in clinic rooms
- Circulating periodic reminders to MDs to document obesity
- MD education of obesity plan options:
• Diet/exercise
• Nutritionist referral
• Obesity Clinic referral

8. Barriers to Documentation of Advanced Directives
End-of-Life Care Planning Improving Documentation of Advanced Directives in the Resident Clinic using Electronic Medical Records
Grady Primary Care Center, Monday Purple Pod
Salim Hayek, Ria Nieva, Frank Corrigan, Amy Zhou, Uma Mudaliar, David Mays, Michael Massoomi, Erika Heard, Reza Hassanyar, Dejuan White
Faculty Mentors: Iris Castro, Nurcan Ilksoy
Tests of Change
Problem
Methods and Measure
Test of Change
Result
What Was Learned
TOC1
Provider education through
Reminder s
Distribution of handouts on advanced directives
Ineffective. Improvement in documentation rate temporary at best and highly dependent on physician’s personal motivation
TOC2
Workshop on advanced directives discussion
No effect on documentation
TOC3
Added “Advanced Directives Counseling” to problem list
Provided .ADVDISC summary template for rapid documentation
Effective reminder, as well as easily accessible permanent record. Significantly increased documentation of AD
End-of-life care planning has received and advocacy in recent years. JCAHO requires that hospital medical records document evidence of known advanced directives (AD) and provide information about advance care planning to all patients. Patient satisfaction is increased when AD are discussed in clinic.
Despite surveys showing patients prefer to discuss advance directives with their primary care doctor, many are completed during hospitalizations. Population based-estimates of completed advance directives range from 5% to 15%.
Discussing end-of-life care in the outpatient setting is perceived as challenging. One major obstacle reported by physicians is lack of time and effective reminders to address and document advanced directives.
Yes No
A total of 588 patient charts were screened by 7 providers of Grady Clinics Purple Pod.
157 met the predefined criteria for AD documentation.
“Advanced Directives Counseling” was added to the problem list of 50% of patients who met criteria.
During the period of November 2011-April 2012; 64 patients were seen in clinic; 38 had AD on their problem list, 26 did not.
76% of charts with ADPL had documentation of AD. Only 11.5% of those without ADPL had AD documented.
Limitations
Sample size was relatively small and study of short duration. Will require longer term and larger population sample to assess sustainability of the improvement in documentation rate.
Study does not assess completion rates of official AD document completion.
No conclusion can be made on the impact of improved AD documentation on inpatient management
TOC1
TOC2
TOC3
Data Collection
Aim Statement
Barriers to Documentation of Advanced Directives
Previously we assessed the effectiveness of -mediated provider education and reminders in improving documentation of AD. This initial test of change (TOC1) showed a slight (1%) and temporary increase in documentation of AD.
Using the electronic medical records (EMR) system EPIC we set to implement a reminder system for physicians to document AD in a select population of patients with chronic illnesses (see below), and assess the percentage of patients meeting criteria which have documented AD counseling within 6 months of the main test change:
Adding “Advanced Directives Counseling” to the patient problem list (ADPL).
Patients must have one or more of the following characteristics/diagnoses: Age > 65, Congestive Heart Failure NYHA III, severe COPD (FEV1<30%), AIDS, any diagnosis of malignancy, cirrhosis, ESRD, stroke.
Lessons Learned
EMR based reminders are effective in improving documentation rates of AD and may be applied for other purposes.
Obstacles remain, including the lack physicians’ initiative and knowledge in discussing AD, time limitations in the outpatient setting, as well as the unclear translation into changes in inpatient management.
Further research is needed to establish the sustainability of improved documentation over longer periods of time and in a larger population sample, as well as its impact on inpatient management.

9. What changes might result in an improvement?
Improving Influenza Vaccination Rates in an
Internal Medicine Resident Clinic
General Internal Medicine at 1525 Clifton Rd., Friday Resident Clinic
Turang Behbahani, Vivian Cheng, Ed Clermont, Tina Constantin, Patrick Hall, Farah Khan, Freny Nirappil, Julian Raffoul, Nathan Spell 9
Problem
Measure
Barriers
The number of seasonal influenza-associated deaths varies from year to year because flu seasons are unpredictable and often fluctuate in length and severity. The CDC estimates that from the season to the flu season, flu-associated deaths ranged from a low of about 3,000 to a high of about 49,000 people (1). In 2013, the CDC published a model to quantify the annual number of influenza-associated illnesses and hospitalizations averted by influenza vaccination during the 2006–11 influenza seasons (2). Using that model the CDC estimated that vaccination resulted in 79,000 (17%) fewer hospitalizations during the 2012–13 influenza season than otherwise might have occurred. Especially in the primary care setting, providers are facing increasing difficulties to clarify "influenza-myths" as well as to identify burdens which keep patients from choosing or receiving the valuable vaccination.
Lack of a standard process to address preventive care, in general, leading to creation of unique solutions to this problem
Perceived inability to influence patient wishes and misinformation
Relative little involvement of clinic staff
Goal
Actual
Lessons Learned
Standard process
Attd review
Doing an improvement project in isolation from the rest of the practice made it hard to create a standard way of checking vaccine status that would sustain itself
A standard process does not become the standard without effective training and reinforcement at first
Reliance on memory does not yield much improvement
We tended to make changes where we felt we had the most control, rather than trying to change patient beliefs, which was the greatest opportunity
Data collection should be built into the work flow or should come from a ready source
What changes might result in an improvement?
Aim Statement
By January 1, 2014, 70% of more of all patients seen in the Friday resident clinic at 1525 Clifton Road will be vaccinated during their appointment (if not already completed). 
References
Tests of Change
(1) Thompson MG et al., Estimated Deaths Associated with Seasonal Influenza - United states , Weekly, August 27, 2010 / 59(33);
(2) CDC. Prevention and control of seasonal influenza with vaccines. Recommendations of the Advisory Committee on Immunization Practices—United States, 2013–2014. MMWR 2013;62(No. RR-7).
Jan: Created standard process to let MD know patient’s status and wishes
Feb: Attending to review vaccine status during sign-out as detection and mitigation step.

10. Statistical Measures and Analysis Cause and Effect Analysis
Increasing Problem-Specific Educational Materials to Patients at the Emory Clinic
Elizabeth Wiles DO, Paul F. La Porte MD PhD, Emory Hsu MD, Ross Deppe MD,
Samantha Shams MD, Blake Anderson MD and Naveen Bellam MD MPH
Faculty Mentor: David Propp MD
The Emory Clinic at 1525 Clifton Rd, Emory University School of Medicine, Atlanta, GA
Problem
Statistical Measures and Analysis
Barriers
Full schedules, clinic time constraints, or PCPs writing notes at the end of clinic did not benefit from computer-based educational templates.
There remains minimal incentive to create additional templates.
While desktop reminders were useful at first, physical notes could be lost , misplaced, or ignored.
Nurses had variability in providing reminders due to the multitude of patient tasks and multiple residents in clinic.
Patient illness complexity may not have had appropriate EMR-specific resource (i.e. providing education on PEG tube use, or proper explanation of more rare diseases).
Physicians do not always effectively communicate medical problems or treatment plans to their patients and retention of education performed by the physician is an issue even among highly educated patients. Difficulty with understanding medical disease has been hypothesized to contribute to lower compliance with medication and activity regimens,
increased calls to nursing staff, higher repeat visits, and worse medical outcomes. 
In 2012, the Center for Medicare/Medicaid Services (CMS) created the objective to use Electronic Health Records (EHR) to provide at least 10% of patients with electronically generated educational resources as part of their meaningful use criteria. Given a possible cost savings of $289 billion dollars from improved medication compliance alone, providing problem specific resources in a timely and appropriate fashion has potential to improve patient satisfaction and compliance in regards to their medical plans.
Results Analysis Compared to CMS Objective as well as against Primary AIM Statement
Baseline period (Prior to Test of Change): Rate = 8.0%
Likelihood of 8.0% rate below CMS 10% rate?; p = 0.097
- It cannot conclusively be stated say that we were not already meeting “Meaningful Use” criteria
1st test of change: Handout rate 8.0% (before), 37.4% (after)
% change over pretest period = 29.4% ( %)
LR = p < % rate compared to CMS 10% goal; p <<
- During test of change 1, it cannot conclusively say we met our target of 30% absolute increase in handouts (CI is between )
2nd test of change: Handout rate 8.0% (before) vs 50.7% (after)
% change over pretest period = 42.7% ( )
LR = p < % rate compared to CMS 10% goal; p <<
- During test of change 2, we can conclusively say we met our target of 30% absolute increase in handouts (CI is between )
2nd test of change vs 1st test of change: Handout rate 37.4% (before) vs 50.7% (after)
% change over 1st test of change period = 13.2 ( )
LR 1.35 ( ) p =
- Based on a p-value of less than 0.05, it can be stated there was a measurable difference between test of change 2 and 1 (i.e. MA reminders)… p =
- The LR is significant compared to the p-value (double-checked with a different procedure) possibly due to separate calculations in software
Baseline Study Data Data Chi-Squared Statistics
Pretest
TOC 1
TOC 2
Patient Materials Provided 34 85 35
Total Patients In Study Period
424
227 69
0.0801
0.3744
0.5072
Chi-square table for TOC 1
Handout
Yes No
Total
cross-check %
Before 34
390
424
8.02%
After 85
142
227
37.44%
diff
29.43%
Chi-square table for TOC 2 35 69
50.72%
13.28%
Cause and Effect Analysis
Tests of Change
Test of change (TOC) 1: Educating physicians regarding use of standardized computer-based education format and use of a desktop reminder at each computer.
Test of change 2: Require nurses reminders during their portion of the patient depart process if we had not chosen education for the patient using the above computer selected format.  
Lessons Learned
A multifactorial and team-based approach can lead to improved patient awareness and education at a time cost not overly detrimental to clinic flow. Cost-effectiveness may be theorized to be appropriate and beneficial in improving patient outcomes; however, we do not have financial data to support this assertion.
Importantly, focusing our intervention on an existing element not requiring any modification to the resident workflow was a key to success. 
MD Factors
Forgetting to offer educational resources
Nursing Factors
Not remembering to provide / print education via depart process
Checking out patients without nursing assistance
Time constraints not allowing for nursing reminder
Aim Statement
Clicking on “Patient Education” opens all available educational resources based on diagnosis code, or per prompted search
Acute visit time constraint
Providing Patient Education
Ease of Use
Lack of insight
To increase patient education handouts by 30% during the study period Nov Feb 14th 2014 (compared to July-October 2013), through entering education related to patient diagnoses in General Clinic note.
Can not read
Krames Database having appropriate education related diagnoses
Patient feeling education
Is unnecessary
Implemenation Time and Time to Print Resources
Patient factors
System factors

11. What changes might result in an improvement?
Increasing End-of-Life Care Discussions, Including Code Status, in a Resident Run Urban Community Primary Care Clinic
Orange Pod Wednesday/Friday Team, Grady Primary Care Center
Rekha Thammana, MD, Andrew Ip, MD, Nurcan Ilksoy, MD, Shelly-Ann Fluker, MD, Dominique Cosco, MD
Fofie Akota, MD, Stephen Berger, MD, Matthew Darrow, MD, Kendrick Gwynn, MD, Racha Halawi, MD, Elisa Ignatius, MD, Moise Jean, MD, Emma Johns, MD, Poonam Kalidas, MD, Christine Kirlew, MD, Enoch Kotei, MD, Song Li, MD, Jason Perry, MD, Nikita Patel, MD, Priyesh Patel, MD, Roshan Patel, MD, Deep Shah, MD, Sana Shah, MD, Yoo Shin, MD, Geoffrey Southmayd, MD, Komal D’Souza, MD, Xiao Jing Wang, MD, Andrew Webster, MD
Problem
Measure
Barriers
Many elderly patients (defined as >65 years of age) do not have advanced directives on file
Discussing code status and end-of-life care is difficult given time constraints in our clinic visits
Residents have trouble initiating conversations about end-of-life care
Tests of change
Dot phrase added (TOC1)
To help providers remind about having code-status or advanced-directive discussions
Surveys passed in waiting room (TOC2)
Allows patients to ask provider questions about end-of-life-care
Not enough time! – patients often come in with a large agenda or have multiple chronic medical diseases
No standardized method to initiate code status discussions or end-of-life
Forgetting to implement dot phrase
No easy way to document code status in EPIC chart
Lessons Learned
What changes might result in an improvement?
Aim Statement
Education of providers on palliative care discussions
Need for easier documentation methods in EPIC for advanced directives or code status
Education of patients to help facilitate discussions in outpatient visits
Physicians have little time to discuss, thus other methods must be implemented (nurse or group visits)
PHYSICIAN
PATIENT
SYSTEM
I forget
Not enough time
I do not know how to initiate discussion
has not heard of 'code status' or AD
Would like to discuss with family first
Does not want to discuss
Not enough time in clinic visit
Assigned patients are too young
Lack of continuity with patients
Inadequate reminder system
Patients not prepared to discuss topic
We aim to increase the number of end-of-life care discussions, including code status documentations, in Grady Orange Pod patients older than 65 years, to 50% by April 2014
Acknowledgement
We would like to thank the nurses and support staff of the
Orange Pod Primary Care clinic for their assistance with the project.
End-of-Life care discussion has not been documented

12. Best Foot Forward
Improving Performance and Documentation of Diabetic Foot Exams
in an Urban Resident Primary Care Clinic
Grady Primary Care Center, Wednesday Purple Pod
James MacNamara, Matthew Dudgeon, Heather Batchelor, Annie Massart, Rahul Maheshwari, Jeffery Hedley, Maria Klimenko, Pooja Kotadia
Faculty Mentor: Nurcan Ilksoy
Problem
Measure
Test of Change
Result
What Was Learned
Increased focus on diabetic foot exam on individual level
Improved level of exams, but fell off over time
Need consistent method to help provider keep foot exam a priority
Monofilaments made available in clinic by faculty
Improved percentage of exams
Equipment is important for performance of exam
Placing concise but complete explanation of diabetic foot exam guidelines and techniques in rooms
Initially improved performance, but last data points indicates decline
Many diabetic patients present to the primary care clinic and go without consistent foot exams.
The American Diabetes Association recommends clinicians perform a comprehensive foot examination annually on patients with diabetes to identify risk factors for ulcers and amputation and perform a visual inspection of the feet at each visit.1
Lavery, et al demonstrated a combined minor and major amputations reduction from to 6.18 per 1000 patients per year with a diabetes foot prevention program.2 Others have shown significantly improved outcomes as well.3
First visit with pt, MD defers RHM til next visit
Barriers
Not enough publicity of the foot exam techniques and guidelines
Inconsistent documentation amongst providers’ exams and assessments
Patient do not like having shoes off while waiting for provider
Patients unaware of need for foot exams
Limited Monofilaments, no tuning forks available in clinic
What changes might result in an improvement?
Aim Statement
Our aim was to increase the documentation of last complete diabetic foot exams and current inspection for known diabetic patients at Purple Pod Wednesday Primary care clinic visits by 50% by March 30th, 2014.
Future Directions
A persisting method of encouraging exams is needed with involving nursing staff
A concise and complete dot phrase and may promote consistency amongst providers
Providing patients with information so they can advocate for the exam
Ensuring appropriate equipment is in every exam room
Boulton, et al Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care. 2008 Aug;31(8):
Lavery La, Wunderlich RP, Tredwell JL. Disease management for the diabetic foot: effectiveness of a diabetic foot prevention program to reduce amputations and hospitalizations. Diabetes Res. Clin. Pract.2005; 70(1): 31–37.
Ozdemir, et al Population-based screening for the prevention of lower extremity complications in diabetes. Diabetes Metab Res Rev. 2013 Mar;29(3):173-82
First visit with pt, MD defers RHM til next visit