PDSA worksheet - PDF - PDF by thederelict12


									                                   PDSA worksheet
 plan - do - study - act - plan - do – study – act - plan - do - study - act

Project Lead        David Rometo                Title         DM screening and obesity
Team                Annie, Rob, Amy, Dr.        Change        Develop algorithms to drive
                    Keyserling, Dr. Gilchrist                 prompts for provider tool
Date Range          9/11 – 12/12/2008           Cycle #       2
                                                Key Words

BACKGROUND: What led you to start this project? Is this cycle a continuation of another
cycle? Why is this topic relevant? Include any baseline data that has already been collected.
Include relevant information from literature.
This is a continuation of “Obesity screening and action plan”. Our clinic and staff do not have
systematic way to screen for diabetes or treat obese patients according to respected
guidelines and evidence. A CQI with a systematic approach can address these issues to
meet guidelines and appropriately care for our overweight/obese patients minimizing the
number “falling through the cracks”.
Aim/Objective Statement for this cycle What do you hope to learn? What are you trying to
improve (aim), by how much (goal) and by when (timeframe)?
To create a systematic approach to addressing overweight and obesity. Categorizing patients
as diabetic, pre-diabetic, and non-diabetic for this purpose will require an appropriate
screening program. Designing a “High-intensity Lifestyle Intervention” and creating a
“Roadmap to Weight-Loss Surgery”.

Specific questions to address in this cycle:
1. What is the best way to program our available database to identify patients for whom
diabetes screening, HLI, and WLS are appropriate.
2. How would a “Yellow sheet for all” convey this info to nurses and providers?
3. How would the provider’s plan be carried out to address DM screening and obesity

Predictions/Hypotheses (What do you think will happen?)
Algorithms will be programmed into database, identifying the number of clinic patients who
fall into each category of recommended screening/treatment.

Plan for change/test/intervention
Who (target population): All IM patients w/ BMI > 25, Shaun MacDonald
What (change/test): Creation of algorithms, programming of database
When (dates of test): 9/11 – 10/21

PDSA2_obesity.doc                               page 1 of 7                         12/12/2008
                             PDSA worksheet
 plan - do - study - act - plan - do – study – act - plan - do - study - act

Where (location):
How (description of plan):

Measures (What will you measure in order to meet your aims? How will know that a change
is an improvement? Will you use outcome or process measures?)
Plan for data collection
Who (will collect): Dave Rometo, Shaun MacDonald
What (measures): How many patients fall into each category (Age, Race, BMI, DM status,
risk factors, comorbidities) and how many will require intervention/day.
When (time period): 9/11 – 10/21
Where (location): ACC IM clinic
How (method): Computer programming.

DO: Carry out the change/test. Collect data.
Note when completed, observations, problems encountered, and special circumstances.
Include names and details.

PDSA2_obesity.doc                          page 2 of 7                         12/12/2008
                                     PDSA worksheet
 plan - do - study - act - plan - do – study – act - plan - do - study - act

   Diabetes Screening: BMI > 25

   Age:                     > 45                                 < 45

   Race:                                          Non-White               White

   DM RF:                                                              Yes         No

   Prompt:                                    2                                       1*

     * Nursing Section:
     Does patient have any of the following risk factors for diabetes? Circle all that apply:
     Parent or sibling with DM       Physical inactivity (less than 30 min/day of light activity)
     (female only:) Hx of > 9 lb baby      Hx of DM during pregnancy
     No risk factors

     1: No increased risk for DM. Screening not indicated.

     2: Increased risk for DM. Screen with Fasting Plasma Glucose per ADA guidelines.

     DM RF = Diabetes risk factors:
     From ICD-9: Pre-diabetes (790.21, 790.22, 790.29), Cardio/Cerebrovascular disease (390-
     445.X), PCOS (256.4), Gestational diabetes (648.8X, 648.0X), Acanthosis Nigricans (701.2)
     From WebCIS: BMI > 40, HDL < 35, Triglycerides > 250
     From Nurse Survey: Parent or sibling with DM, Hx of > 9 lb baby, Hx of DM during
     pregnancy, Physical inactivity

     Recommended Action:
     FPG at next AM visit                          [ ]      If not, why?________________

PDSA2_obesity.doc                                        page 3 of 7                                12/12/2008
                                   PDSA worksheet
 plan - do - study - act - plan - do – study – act - plan - do - study - act

   High-intensity Lifestyle Intervention Algorithm: BMI > 25

   DM Status:                DM                      Pre-DM                               No DM

     BMI:                                                                         >30              25-30

   Prompt:                   4                           3                          2                    1

     1: Counsel to lose or maintain weight.

     2: Weight loss and lifestyle changes reduce morbidity. Refer for High-intensity Lifestyle Intervention.

     3: High risk for DM. Weight loss and lifestyle changes reduce risk and morbidity. Refer for High-
     intensity Lifestyle Intervention.

     4: Weight loss and lifestyle changes improve DM control and reduce morbidity. Refer for High-intensity
     Lifestyle Intervention.

     Recommended Action:
     High-intensity lifestyle intervention [ ]           If not, why?________________

PDSA2_obesity.doc                                      page 4 of 7                                   12/12/2008
                                     PDSA worksheet
 plan - do - study - act - plan - do – study – act - plan - do - study - act

   Bariatric Surgery Algorithm: BMI > 35

   DM Status:              DM                   Pre-DM                            No DM

   BMI:                    >35             >40            35-40             >40            35-40

   BSCM:                                            Yes           No                 Yes           No

   Prompt:                 4               3                                2                          1

     1: Not eligible for weight loss surgery.

     2: Eligible for weight loss surgery, which reduces morbidity. Discuss with patient and refer if

     3: Eligible for weight loss surgery, which prevents the development of DM and reduces morbidity.
     Discuss with patient and refer if interested.

     4: Eligible for weight loss surgery, which improves DM control and reduces morbidity. Discuss
     with patient and refer if interested.

     BSCM = Bariatric Surgery Co-Morbidities: HTN (401-405), OSA (327.2X, 780.57), OA (715.X)

     Recommended Action:
     Weight Loss Surgery referral                  [ ]     If not, why?________________

PDSA2_obesity.doc                                        page 5 of 7                                    12/12/2008
                              PDSA worksheet
 plan - do - study - act - plan - do – study – act - plan - do - study - act

STUDY: Summarize and Analyze data (quantitative and qualitative). Include charts, graphs.

Sheets were generated for overweight/obese non-diabetic patients from a day of residents’
clinic on 12/15/08.
The following numbers were obtained.

Intervention recommended                        Number of patients (out of 27)
Bariatric Surgery Decision Aid/Referral         9
Diabetes Screening with FPG                     26
High-intensity Lifestyle Modification           18

ACT: Document/summarize what was learned. Did you meet your aims and goals? Did you
answer the questions you wanted to address? List major conclusions from this cycle.
1. There are a significant number of overweight/obese, non-diabetic patients meeting
criteria for each of the 3 interventions.
2. Printed sheets had some errors, including nursing questionnaire populating on sheets
that already were prompting DM screening, and patients with BMI > 40 not meeting criteria
for DM screening.

Define next steps. Are you confident that you should expand size/scope of test or
implement? What changes are needed for the next cycle?
1. Implement sheet use in clinic, find sheet/algorithm/programming errors, and obtain
feedback from providers.
2. Based on volume of interventions requested by providers, create streamlined system to
make interventions happen.
3. Create High-intensity Lifestyle Intervention group class to alleviate costs for patients.

PDSA2_obesity.doc                             page 6 of 7                           12/12/2008
                                    PDSA worksheet
            plan - do - study - act - plan - do – study – act - plan - do - study - act

    Outcomes                            Key Drivers                                    Interventions

                                                                            -Develop algorithm for DM screening,
                                                                            High-intensity Lifestyle Intervention,
                                                                            and Weight Loss Surgery decision
                                                                            -pull info from WebCIS and create pt
                                                                            questionnaire to identify RF in
                                                                            -use database to place all overweight
                                                                            patients into an intervention category
                                                                            on each algorithm
                                         Categorization of patients
                                    -identify level of obesity, DM
                                    status, comorbidities, and risk
                                    factors to determine appropriate        -create yellow sheet that:
                                                                            1. identifies overweight and obese
                                                                            patients and their risk factors,
                                                                            2. prompts nurse to perform
                                                                            questionnaire, and
                                                                            3. prompts recommended
                                                                            -collect info from sheets to put into
                                             DM status/screen               -facilitate making physician-ordered
                                    -help place patient in correct          interventions happen
                                    risk/intervention category
                                    -early diagnosis and treatment to
                                    improve outcomes
                                    -better insurance, entitlement          -add fasting blood sugar to order sheet
                                    coverage of interventions               -add fasting blood sugar to A2K lab
                                                                            function screen
Improve care of overweight and                                              -have Care Assistant call pt on day
obese patients by:                                                          before appt to remind them to fast
-Identify diabetes status and                                               -front desk prompted by sheet to send
risk                                                                        pt to lab before visit
-Offer lifestyle intervention for                                           -CA ensures that results sent to PCP
weight loss                                                                 and that database is updated
-Educate eligible patients about
weight loss surgery                        Lifestyle Intervention
                                    -Offer patient specific options for
                                    weight loss, based on
                                    preferences, motivation, financial      -create 6 session HLI
Measures of Success:                status                                  curriculum
90% of patients eligible for        -assure association between
DM screening be screened            healthy lifestyle and health in a
                                                                            -secure location, trained staff,
in 1 year                           medical setting, supported by           billing procedure
100% of patients with DM            PCP                                     -enroll pts from Amy visit and
and pre-DM offered nutrition        -prompts so simplify physician          self-referral
referral for HLI                    role                                    -track progress on database
100% of eligible patients           -create ACC IM weight loss
                                                                            -give info sheets of
offered BSDA unless CI by
PCP.                                                                        commercial/county programs
                                                                            -frequent (2/mo x 3mo) RD
                                                                            visits if not in class or program

                                     Bariatric Surgery education/referral   -obtain Bariatric Surgery Decision
                                    -allow access to info to appropriate    Aid (BSDA) from Shepps staff
                                    pt                                      -obtain list of patients who have
                                    -break down physician barrier to        already seen BSDA and note in
                                    surgical weight loss                    database
                                                                            -Create list of patients referred on
                                                                            yellow sheets
                                                                            -Shepps staff to contact patient
                                                                            and set up viewing (pre-/post-
                                                                            MD/RD visit)
                                                                            -record who watched BSDA in
         PDSA2_obesity.doc                                   page 7 of 7                        12/12/2008
                                                                            -give patient self-referral info to
                                                                            WLS centers if interested

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