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									                               PDSA worksheet
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Project Lead     Regina Boone                 Title           Nurse Tracking
Team             Enhanced Care DM             Change          Change Measures/Assess
                                                              Walkie-Talkie Intervention
Date Range       January-April 2008           Cycle #         2
                                              Key Words       Nurse, monofilament, PHQ,
                                                              smoking cessation



BACKGROUND:
In cycle one we determined the nursing staff was able to reach and maintain an overall
completion rate of 90% or higher for items indicated for action on the yellow sheet. In this
cycle we will focus on specific items on the yellow sheet and determine if an intervention is
needed.
______________________________________________________________________________
PLAN:
Aim/Objective Statement:
Assess monofilament completion rates and proper nurse to care assistant (CA) follow-up for
positive yellow sheet measures; PHQ-2 and Tobacco Cessation. Also evaluate the
effectiveness of the walkie-talkie intervention as a means to increase nurse to care
assistant follow-up rates.

Specific questions to address in this cycle:
1. Are the nurses achieving a completion rate of 90% for monofilaments?
2. Does follow-up occur when a patient screens 3 or more on the PHQ-2?
3. Does follow-up occur when a patient desires to quit smoking in 30 days?
4. Will the walkie talkie system be an effective intervention to increase follow-up rates?

Predictions/Hypotheses (What do you think will happen?)
The specific yellow sheet measures (monofilament, PHQ-2/Tobacco follow-up) will be below
the clinic goal of 90%. After our intervention, there will be an increase in the number of
completed monofilaments and follow-up rates.

Plan for change/test/intervention
Who (target population): Diabetes patients attending visits in the UNC Internal Medicine
Clinic
What (change/test): Review all the yellow sheets weekly; assess monofilament completion
and care assistant follow-up rates
When (dates of test): January-April 2008.
Where (location): UNC Internal Medicine Clinic
How (description of plan): Specifically, track the completion rates for monofilaments and
follow-up rates for the PHQ-2 and Tobacco. Identify any barriers hindering completion/follow-
up goals and develop an intervention to increase efficiency.



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

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): Regina Boone, Diabetes CA
What (measures): Weekly review all the yellow sheet data for monofilament completion
rates; PHQ-2 and Tobacco care assistant follow-up rates for positive screens
When (time period): 1/17/08-4/30/08
Where (location): UNC Internal Medicine Clinic
How (method): Front desk staff collects all the yellow sheets at the end of each day. The
blank yellow sheets are separated and discarded. The remaining sheets are placed in a
designated area and collected each Monday for assessment. The data is collected and
maintained in an excel spreadsheet.
_____________________________________________________________________________
DO: Carry out the change/test. Collect data.
Note when completed, observations, problems encountered, and special circumstances.
Include names and details.

TIMELINE OF MAJOR EVENTS:
1/17/08: I met with the nurses. The aims of the meeting were to present the yellow sheet
completion rates and the positive screen follow-up rates; reinforce clinic goals; review follow-
up processes; receive feedback and introduce a possible intervention (walkie talkie system)
to improve follow-up rates. At that time the overall completion rate was 90% and the follow-
up rates for both the PHQ-2 and Tobacco Counseling were 0%.

Outcome: Addressed questions about the follow-up process, explained the WT concept,
continue to post weekly graphs at nursing stations, CA’s to initial yellow sheet to verify
follow-up and as a collective group agreed to improve follow-up rates.

2/11/08: Started tracking only monofilament rates on instead of all opportunities.
         See figure 1.

2/19/08: Walkie Talkie System Initiated
Robert Malone ordered walkie talkie systems for the nursing staff and the care assistants.
Each nursing station share one walkie talkie and each allotted area for care assistants has
one walkie talkie. The east and west wing were programmed to individual frequencies. The
care assistants’ walkie talkies were calibrated to access both frequencies. The steps for
using the walkie talkies are:
       1. Identify a positive screen based on the criteria
       2. Check the provider schedule to see if the patient is assigned to a CA
       3. If the patient is not assigned to a CA, notify the CA on walk-ins by using the WT
       4. The nurse reports the following information: East or West wing and the room
          number
       5. CA responds “got it”
       6. CA initials the yellow sheet.



PDSA2-Gina.doc                                 page 2 of 5                            5/22/2008
                                                                                                                                                                                  PDSA worksheet
 plan - do - study - act - plan - do – study – act - plan - do - study - act

4/11/08: Another meeting with Regina Boone, Annie Whitney, Judy Martin and the nursing
staff was held. The purpose of this meeting was to discussed missed opportunities with
monofilaments and PHQ-2/Tobacco positive screens; reinforce goals and expectations;
receive feedback on the WT intervention and set a group goal for a four week period. We
also discussed improving rates of smoking advice. Nurses should advise all current smokers
to quit smoking. We are planning to apply for the Diabetes Physician Recognition Program
through the NCQA in the near future. One area to receive points towards recognition is
providing advice to quit smoking to current smokers. In order to receive points this measure
must be > 80%. We track this measure in the monthly diabetes report.

Outcome: As a group the nurses decided to make a collective effort to do better overall but
also set a goal to achieve the monofilament clinic goal over the next month. Over a four
week period the nurses engaged in a “battle of the stations” to see which station would
have the highest percentage in monofilaments and PHQ-2 and Tobacco follow-up rates.

The data collection was time consuming but was assessed and completed without much
difficulty.
______________________________________________________________________________
STUDY: Summarize and Analyze data (quantitative and qualitative). Include charts, graphs.

Figure 1. Monofilament Completion Rates
                                                                                                                                                                                                      Percent Nursing Opportunities Complete

                                                                                                                                                                           Percent Nurs ing Complete                                                                                                           Goal                                            Percent Monofilament Complete

    100%

     90%

     80%

     70%

     60%

     50%

     40%                                                                                                                                                                                                                                                                                                                                                   4/1
                                                                                                                                                                                                                                                                                                                                                          meeting
     30%

     20%

     10%

      0%
           12/29/2007
                        1/1/2008
                                   1/4/2008
                                              1/7/2008
                                                         1/10/2008
                                                                     1/13/2008
                                                                                 1/16/2008
                                                                                             1/19/2008
                                                                                                         1/22/2008
                                                                                                                     1/25/2008
                                                                                                                                 1/28/2008
                                                                                                                                             1/31/2008
                                                                                                                                                         2/3/2008
                                                                                                                                                                    2/6/2008
                                                                                                                                                                               2/9/2008
                                                                                                                                                                                          2/12/2008
                                                                                                                                                                                                      2/15/2008
                                                                                                                                                                                                                  2/18/2008
                                                                                                                                                                                                                              2/21/2008
                                                                                                                                                                                                                                          2/24/2008
                                                                                                                                                                                                                                                      2/27/2008
                                                                                                                                                                                                                                                                  3/1/2008
                                                                                                                                                                                                                                                                             3/4/2008
                                                                                                                                                                                                                                                                                        3/7/2008
                                                                                                                                                                                                                                                                                                   3/10/2008
                                                                                                                                                                                                                                                                                                               3/13/2008
                                                                                                                                                                                                                                                                                                                           3/16/2008
                                                                                                                                                                                                                                                                                                                                       3/19/2008
                                                                                                                                                                                                                                                                                                                                                   3/22/2008
                                                                                                                                                                                                                                                                                                                                                               3/25/2008
                                                                                                                                                                                                                                                                                                                                                                           3/28/2008
                                                                                                                                                                                                                                                                                                                                                                                       3/31/2008
                                                                                                                                                                                                                                                                                                                                                                                                   4/3/2008
                                                                                                                                                                                                                                                                                                                                                                                                              4/6/2008
                                                                                                                                                                                                                                                                                                                                                                                                                         4/9/2008
                                                                                                                                                                                                                                                                                                                                                                                                                                    4/12/2008
                                                                                                                                                                                                                                                                                                                                                                                                                                                4/15/2008
                                                                                                                                                                                                                                                                                                                                                                                                                                                            4/18/2008
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        4/21/2008
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    4/24/2008
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                4/27/2008
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            4/30/2008
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        5/3/2008
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   5/6/2008
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              5/9/2008
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         5/12/2008
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     5/15/2008
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 5/18/2008
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             5/21/2008
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         5/24/2008
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     5/27/2008
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 5/30/2008




Starting 2/11/08, I stopped tracking overall completion rates and solely focused on
monofilaments (represented by the pink line). The graph now tracks the number of possible
monofilaments exams compared to the number of monofilaments exams completed. From
February 2008 to April 2008, the monofilament completion goal increased from 75% to
94%.
Figure 2. Care Assistant Follow-up Rates for PHQ2




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                                                                                                        PDSA worksheet
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                                                                                                          Percent Nurse/CA Follow-up Complete-PHQ

                                                                                                                                            Percent PHQ Complete                                          Goal

     100%

      90%

      80%

      70%

      60%

      50%
                                                                                                                                                                                                                                                                           4/1
      40%                                                                                                                                                                                                                                                                 Meeting

      30%

      20%

      10%

      0%
             11/16/2007


                           11/23/2007


                                        11/30/2007


                                                     12/7/2007


                                                                 12/14/2007


                                                                              12/21/2007


                                                                                           12/28/2007


                                                                                                         1/4/2008


                                                                                                                    1/11/2008


                                                                                                                                1/18/2008


                                                                                                                                             1/25/2008


                                                                                                                                                         2/1/2008


                                                                                                                                                                      2/8/2008


                                                                                                                                                                                  2/15/2008


                                                                                                                                                                                              2/22/2008


                                                                                                                                                                                                             2/29/2008


                                                                                                                                                                                                                           3/7/2008


                                                                                                                                                                                                                                      3/14/2008


                                                                                                                                                                                                                                                  3/21/2008


                                                                                                                                                                                                                                                              3/28/2008


                                                                                                                                                                                                                                                                             4/4/2008


                                                                                                                                                                                                                                                                                         4/11/2008


                                                                                                                                                                                                                                                                                                      4/18/2008


                                                                                                                                                                                                                                                                                                                   4/25/2008
The graph shows the follow-up rates (after the second nurse meeting) for the PHQ-2 began
to trend upward but quickly declined. The decline could be attributed to limited nursing
coverage during the week of 4/14-4/18. The following week the follow-up rate increased by
7%. The variability in this graph is also due to the relatively small number of patients who
need PHQ follow-up. An average of six patients need follow-up per week.

Figure 3. Care Assistant Follow-up Rates for Smokers Wanting to Quit
                                                                                                        Percent Nurse/CA Follow-up Complete-Tobacco

                                                                                                                                Percent Tob Cessation Complete                                                      Goal

     100%

      90%

      80%
                                                                                                                                                                                                                                                           4/1
      70%
                                                                                                                                                                                                                                                          meeting
      60%

      50%

      40%

      30%

      20%

      10%

      0%
            11/16/2007


                          11/23/2007


                                        11/30/2007




                                                                 12/14/2007


                                                                              12/21/2007


                                                                                           12/28/2007


                                                                                                         1/4/2008


                                                                                                                    1/11/2008


                                                                                                                                1/18/2008


                                                                                                                                             1/25/2008


                                                                                                                                                         2/1/2008


                                                                                                                                                                       2/8/2008
                                                     12/7/2007




                                                                                                                                                                                  2/15/2008


                                                                                                                                                                                              2/22/2008


                                                                                                                                                                                                             2/29/2008


                                                                                                                                                                                                                           3/7/2008


                                                                                                                                                                                                                                      3/14/2008


                                                                                                                                                                                                                                                  3/21/2008


                                                                                                                                                                                                                                                              3/28/2008


                                                                                                                                                                                                                                                                              4/4/2008


                                                                                                                                                                                                                                                                                          4/11/2008


                                                                                                                                                                                                                                                                                                       4/18/2008


                                                                                                                                                                                                                                                                                                                    4/25/2008




The follow-up rates for a patient that desires to quit smoking in 30 days is shown here. Over
the last four weeks the follow-up rate showed great improvement by remaining above 0%
and not dropping below 50%. Similar to PHQ follow-up, variability in this graph is also due to




PDSA2-Gina.doc                                                                                                                                                      page 4 of 5                                                                                                                                    5/22/2008
                               PDSA worksheet
 plan - do - study - act - plan - do – study – act - plan - do - study - act

the relatively small number of patients who need tobacco cessation follow-up. An average of
four patients need follow-up per week.

______________________________________________________________________________
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. Initially, we found the nursing staff was not achieving monofilament completion goals nor
using proper nurse to care assistant follow-up protocol for positive yellow sheet measures.
The walkie talkie system alone was not a successful intervention. Giving the nursing staff
the option to notify any available care assistant of a positive screen in addition to the walkie
talkie system seemed to produce better outcomes.

2. The monthly meetings with Regina Boone, the lead care assistant, were an effective tool
to involve the nursing staff in the decision making process, address concerns and receive
feedback. Also, the meetings contributed a great deal to the progress made from January to
April.
3. Setting small collective goals and engaging in activities to boost morale greatly improved
completion and follow-up rates. As a result of the “Battle of the Stations” competition, April’s
positive PHQ f/u rate increased from 36% to 52% (n=29). The follow-up rate for cessation
counseling greatly improved from 5% to 78% (n=16). At the 4/1/08 meeting the nursing
staff decided to target monofilament rates over a four week period. In the month of April the
monofilament completion rate increased to an average of 92%. The clinic goal is 90% for all
three areas, therefore improvement is needed. It is imperative to sustain open
communication and boost the morale among the nursing staff to maintain the monofilament
completion rate and improve upon the CA follow-up rates.


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. Involve nurses in the data collection process: Heather Michel, RN will help collect data
that has been collected by me up to now. This will help involve the nurses more in the
improvement project.
2. Assess barriers in physician completion rates




PDSA2-Gina.doc                                 page 5 of 5                             5/22/2008

								
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