Critical Path Network: Diabetes QI program cuts complications by 60%
JCAHO honors program with Codman Award
Quality improvement projects can be especially challenging if you try to implement them on a systemwide basis across many health care institutions, but a diabetes project in Iowa shows that it can be done if you give people the tools and let individual organizations decide how best to use them.
The project to standardize and improve diabetes care grew out of the Des Moines-based Iowa Health Care System’s overall effort to unify as a system, says Tom Evans, MD, vice president and chief medical officer. With 11 hospitals in the system, he says it was a challenge to standardize clinical care, but everyone knew it was the way to improve quality and probably could help lower costs as well.
"It’s one thing to be together as a health care system, but what is our joint commitment to quality?" he asks. "In 1998, the system declared war on diabetes, singling out that area of care as one where we could see tremendous improvements if we all got together on what we should do. It’s been a wonderful journey, but we had to figure out how to do it."
Five years later, the Joint Commission on Accreditation of Healthcare Organizations is recognizing the system for successfully bucking the trend in Type 2 diabetes — one of the fastest growing health problems in the United States.
Iowa Health System recently received the Ernest A. Codman Award for helping its diabetes patients successfully manage their diabetes. By collecting and using data to improve care for 58,000 diabetics, served through its 11 hospitals, Iowa Health was able to reduce hemoglobin A1c (HbA1c) levels, which are higher for diabetics, to near-normal levels in most patients. The Codman Award recognizes health care organizations for excellence in the use of results measurement to improve quality of care.
Iowa Health System is the state’s first and largest integrated health care system. One of the state’s largest employers, as well as its largest health care provider, Iowa Health employs more than 17,000 people statewide. Last year, it saw nearly 270,000 individuals in its emergency departments and had close to 100,000 admissions.
Leaders from Iowa Health decided that the way to provide the highest possible quality diabetes care was by recognizing that education, nutrition, and lifestyle management are the keys to controlling diabetes. The outcomes achieved over the course of three years have occurred as a result of the system working together from eight communities for its patients across Iowa and parts of Illinois and Nebraska, says Sam Wallace, president and CEO of Iowa Health System. The system’s broad coverage meant that a diabetes quality improvement (QI) project could affect a huge number of patients, he says. Iowa Health serves about a third of all patients in Iowa. "We believed that as a health delivery system with statewide reach and broad-based clinical research capabilities, we could make a positive difference to those in our service area suffering from diabetes," he says.
Standardization was a key part of the initiative. Each hospital had diabetic teaching centers that, judged individually, were doing a fine job with their patients, Evans says. But the quality improvement team knew that standardizing the care would result in improvements across the board.
"Each teaching center had a lead diabetic educator or coordinator, so we recruited them to create a work team," he says. "We planned for three meetings. In the first, everyone talks about the wonderful things they’re doing. That’s sort of an inventory to get things out on the table and let people establish that they’re already doing good work. It’s important for them to establish that so that no one feels like they’re being dragged in because they’re substandard."
In the second meeting, the work team looked at what is standard in the industry for diabetes education, and what best practices are available. At that meeting, the work team also created a "joint-envisioned future" that detailed where Iowa Health wanted to be in the future regarding diabetes education.
"That was the ideal situation, the way we would handle diabetes education if nothing stood in our way. Then we came back with a third meeting to discuss the joint commitments that we will all use to get to that future," Evans says. "We distilled that into bullet points we could use to get to that future."
To reduce HbA1c levels and control chronic diabetes, the team took these steps:
- It adopted a standardized education curriculum for Type 2 diabetes for patients and caregivers.
- The team adopted uniform standards of care based on national quality standards.
- Iowa Health committed to providing staff training in patient education, data collection, chart abstraction, data entry, and behavior evaluation.
- The system introduced the use of reminder calls to patients for return appointments.
"The most important steps were using common metrics, common data collection techniques, and common definitions," Evans says. "We achieved most of that in the first year, making sure we were all using the same information and playing the same song."
Iowa Health’s new approach has been in place for about three years. As a result of this initiative, the average HbA1c, which measures blood sugar in diabetic patients, fell from 9.2% to 7% during the most recent six-month data analysis, Evans says. The reduction in HbA1c is estimated to reduce the risk of further patient complications by 30% to 60%. The work of the multidisciplinary team has paved the way for implementing other disease-specific quality improvement programs, including programs for asthma, congestive heart failure, community-acquired pneumonia, total joint replacement, and acute myocardial infarction, he says.
According to Evans, the rapid success of the program is the result of utilizing a consistent curricula along with a strategic plan implemented consistently across the system’s hospitals. Diabetes education centers at each of the hospitals have met the strict requirements for recognition from the American Diabetes Association, and they have implemented treatment standards consistent with those developed by the respected Minneapolis-based International Diabetes Centers.
In addition, Iowa Health realized some financial benefits. All of the diabetic teaching centers had been operating as loss leaders, so Evans challenged the QI team in 2001 with a new goal: remain open in 2002. The work team looked at cost per hour and exactly how each site was delivering the education to patients, with an eye toward improving efficiency. The biggest change to grow out of that focus was a switch to group sessions rather than individual patient education. In the first six months of 2002, that change and other improvements in efficiency lowered the operational costs of the clinics by 20% per hour.
Evans says an important part of the team’s work was standardizing expectations and methods while still leaving some degree of autonomy to each individual clinic. "Consistency in how we treat diabetes and how we measure the results allows us to determine which are the best practices and share them among all our hospitals and doctors," he says. "But health care is local, so you can’t just give everyone a recipe and tell them follow it. We tried to focus on identifying a common destination and then give them the tools to get there. We helped them figure out the route to get there, but we didn’t tell them the route."
Quality improvement projects can be especially challenging if you try to implement them on a systemwide basis across many health care institutions, but a diabetes project in Iowa shows that it can be done if you give people the tools and let individual organizations decide how best to use them.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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