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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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, FACPMCanadian Diabetes Association -Chair in Diabetes ManagementIan McWhinney Chair of Family Medicine StudiesProfessor-Schulich School of Medicine & Dentistry, The University of Western Ontario

Rick Ward MD, CCFP, FCFPCalgary Foothills Primary Care Network

Patsy Smith MN, RNPLS Consulting Inc.Canadian Nurses Association

CONTRIBUTORSMaureen Clement MD CCFPMedical Director, Diabetes Education Centre Vernon Jubilee HospitalAssistant Clinical Professor, University of British Columbia

Alice Y.Y. Cheng, MD, FRCPC EndocrinologistCredit Valley Hospital and St. Michael's HospitalAssistant Professor, Dept of MedicineUniversity of Toronto

Steve Szarka, B. Eng, M. Eng, MD, CCFPAssistant Clinical Professor, McMaster University, Faculty of Family MedicineHamilton 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

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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.

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Facilitators

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

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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

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Clinic Team Introductions

• Clinic “Champion” and Clinic Team Members

• What does your Clinic Team hope to achieve today?

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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

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Pathways to Diabetes ManagementProgram 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 deliveryTeams require practical, implementable approaches to care delivery

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Step 1

Step 2

Step 5

Step 3

Step 4

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Practical Strategies, Tools & Materials

Diabetes Practice Management

Practice Guide

Participant Workbook

Canadian Nurses Association Patient Education Toolkit

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

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The Clinical Challenge

• Diabetes Care in Family Practice

• CDA Guidelines: Therapeutic Goals and Organization of Care

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Diabetes Care in Family Practice

• The challenge: Diabetes is a complicated, growing disease:

– More than 9 million Canadians live with diabetes or prediabetes1

– Risk of CV death is 2-4 times greater than in the general population2

– 25% of patients with diabetes suffer from depression2

– 11% of patients with diabetes have 3 or more co-morbidities2

1. Canadian Diabetes Association. http://www.diabetes.ca/diabetes-and-you/what/prevalence.2. Canadian Diabetes Association – 2008 Clinical Practice Guidelines. http://www.diabetes.ca/files/cpg2008/cpg-2008.pdf

“Despite increasing evidence about the benefits of effective management, little progress has been made in providing effective care” —CDA Guidelines Committee

“Despite increasing evidence about the benefits of effective management, little progress has been made in providing effective care” —CDA Guidelines Committee

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Primary Care Challenge

• Average practice has between 100-200 patients with diabetes1

• Patients with diabetes visit their family physician on average 8 times per year2

• 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 study2

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%

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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 solutionsFew mechanisms exist to implement practical solutions

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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 Physicians2

• 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: http://health.gov.on.ca/en/ms/diabetes/en/about_diabetes_care_rep.html

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CDA Recommended Diabetes Surveillance

1. Harris S., Lank C. eds. Elsevier 2008.

Timely screening for complications and aggressive management of risk factors are integral parts of diabetes management.

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CDA Organization of Care Guidelines

1. Clement M. Organization of Care: Key elements from the CDA 2008 Clinical Practice Guidelines.2008. http://www.diabetes.ca/documents/for-professionals/Fact_Sheet_FINAL_FOR_WEBSITE.pdf.

Good Outcomes for people living with diabetes depend on:The “System”….. A Team Based Approach

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Team Approach

• Impact on Patient Outcomes: What does the data show us?

• Team Effectiveness

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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 physician1

• Attachment, or the frequency that a patient seeks services from the same medical practice, keeps patients healthier and reduces costs1

• 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): 32-44.2. Steering Group Communications.

3. Noffsinger EB. The Permanente Journal 1999 ; 3 (3): 58-67.

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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): 32-44.

$ (C

DN

)

Percentage of Attachment

Diabetes and CHF – RUB 5 (2007-2008)

$13,250

DiabetesCongestive Heart

Failure (CHF)

Proportion of Total Cost Attributable to Hospital Costs

65%

Cost Reduction Attributable to Attachment

$16,114

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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 costs1

1. Hollander MJ. et al. Healthcare Quarterly 2009;12(4): 32-44.

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

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

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Shared Medical Appointments Based on the Chronic Care Model

A Quality Improvement Project to Address the Challenges of Patients with Diabetes with High CV Risk1

•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;16:349-353.

AIM:Improve outcomes for patients with diabetes at high cardiovascular

risk via Group Patient Visit (GPV) implementation

AIM:Improve outcomes for patients with diabetes at high cardiovascular

risk via Group Patient Visit (GPV) implementation

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Better Cardiovascular Risk Reduction was Observed in Patients Attending Group Patient Visits (GPV)1

1. Kirsh s, et al. Qual Saf Health Care 2007;16:349-353.

Patients participating in GPV experienced greater benefits in HbA1c, LDL-c and SBP levels compared to usual core patients.

10

10.5

9.5

8.5

11

9

8GVPControl

2.2

GVPControl2.1

2.3

2.4

2.5

2.6

2.7

2.8

2.9

GVPControl130

135

140

145

150

155

= -0.30 = 1.44 = 0.14 = 0.41 = 2.54 = 14.83

HbA1cP= 0.002

LDL-cP= 0.29

SBPP= 0.04

Baseline Follow-up Control n= 35 GPV n=44

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Team Effectiveness in Diabetes Treatment

• Why a team?

• What are the attributes of an effective team?

• Why is this important?

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Team Efficiency1-5

Common challenges

• Time

• Pressure to provide both acute and preventive care

• Volume pressure

• Fee-for-service

• After hour access

• Long wait times

• Focus on task substitution vs. teamwork

• Underutilization of interprofessional health team

Common challenges

• Time

• Pressure to provide both acute and preventive care

• Volume pressure

• Fee-for-service

• After hour access

• Long wait times

• Focus on task substitution vs. teamwork

• Underutilization of interprofessional health team

1. EICP - Enhancing Interdisciplinary Collaboration in Primary Health Care. April 2005. 2. McMurchy D. CIHR, 2009; retrieved from: www.chsrf.ca

3. Barrett et al. CHSRF. 20074. Kirsh S, et al. Qual Saf Health Care 2007;16:349-353.

5. 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

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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; 157:22-30.2. Sperl-Hillen et al. JT Comm J Qual Saf. 2004;30(6):303-309

3. Vargas RB et al. J Gen Intern Med . 2007;22(2);215-2224. McMurcahy D. CIHR, 2009;.5. Barrett et al. CHSRF. 2007.

6. Steering Group Communications.

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Diabetes Care Teams….A System ChangePoints to consider:

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Diabetes Care Teams….A System Change

Working together as a team includes…

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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 treatment100%

Pre-CHAMP Post-CHAMP0%

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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-CHAMP Post-CHAMP

15%

5%

10%

0%

20%

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Summary

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CLINIC WORKSHOP SESSION

Optimizing Practice Efficiency to Promote Team Effectiveness

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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 WorkbookMaterials are provided in the Participant Workbook

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STEP 1: Clinic AssessmentSummary of YOUR Clinic Assessment

Do you agree?

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Diabetes Resource Inventory

What resources did you identify?

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• 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

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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


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STEP 2: Clinic Diabetes Registry

Develop or Access Clinic Diabetes RegistryACTIVITIES

• 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 GuideMaterials available in Diabetes Practice Guide

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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.2008. http://www.diabetes.ca/documents/for-professionals/Fact_Sheet_FINAL_FOR_WEBSITE.pdf.

Does your clinic have a Diabetes Clinic Patient Registry?

The Role of the Clinic Diabetes Registry

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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

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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. 2006 Apr;13(4):47-52. retrieved from: www.aafp.org.

• 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)

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• 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


Diabetes Registry Next Steps

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Clinic Team Regroup

• Share key learnings

– Clinic diabetes registry development or assessment

– Overall input/collaboration with other Clinic Teams


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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)

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• 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?


Step 3A: Validation of Priority Patient Type

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• What resources can we utilize to help manage this patient type?

• What resources are we missing?

Step 3A: Review of Diabetes Resource Inventory


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Diabetes Team Activity Checklists are provided in the Participant Workbook

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

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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


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For more information see the Diabetes Practice GuideFor 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

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• 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


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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


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• 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)


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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


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• 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”


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• 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?


Scheduling Method Selection

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Clinic Team Regroup

• Share

– Scheduling Method(s) selected and rationale

– Expected outcomes

– Concerns/outstanding information needs

• Discuss experiences and potential solutions with the group


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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 OutlineSet specific goals, task, roles, timelines and measurements

All materials can be found in the Participant WorkbookAll materials can be found in the Participant Workbook

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STEP 4: ACTION PLAN

Your Clinic Action Plan

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STEP 4: ACTION PLAN

Clinic Action Plan: Sample #1 Registry

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STEP 4: ACTION PLAN

Clinic Action Plan: Sample #2 New DM Diagnosis

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STEP 4: ACTION PLAN

Clinic Action Plan: Sample #3 Ongoing DM Management

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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

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Action Plan Presentations

• Each Clinic Team will review their Clinic Action Plan

– Ask questions

– Make suggestions

– Share experience


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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 OutlineImplement, track progress and evaluate

All materials can be found in the Participant WorkbookAll materials can be found in the Participant Workbook

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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

The process is flexible…Engage in continual planning, study and refinements at all stages

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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?

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ACTWhat changes

are to be made?Next cycle?

PLANObjectiveQuestions and predictions (why)Plan to carry out the cycle (who, what, where, when)

STUDY Complete the

analysis of the dataCompare data to

predictionsSummarize

what was

learned

DOCarry out the planDocument problemsand unexpectedobservationsBegin analysis of the data

The PDSA Cycle for Learning and Improvement

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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

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Clinic Diabetes Management Dashboard

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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.

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• 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

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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?


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Wrap up

• Parking lot

• Measuring Effectiveness – Complete CHE Evaluation Form and hand in prior to leaving

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

Documents

diabetes experts

diabetes mellitus

diabetes patient management

primary care team

care delivery slide

organization of care

canada slide

family health teams