Fletcher Allen, a Vermont university hospital and medical center, serves all of
Vermont and the northern New York region. Located in Burlington, Fletcher Allen is a regional, academic healthcare center and teaching hospital in alliance with the University of Vermont.
2011 Quality Improvement Initiatives
Act 53 Quality Improvement Initiatives
- Inpatient Diabetes Care Improvement Project
- Reducing Duplication of CT Films
- The Vermont Blueprint for Health
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Project Name: Inpatient Diabetes Care Improvement Project
Time Frame: 2010 -
Description/Problem:
Blood sugar control is important in patients who are hospitalized. A systematic approach to controlling high blood sugar among inpatients has been shown to reduce complications, length of stay and costs.
Project Goals:
The aim of this project is to ensure that Fletcher Allen meets the American Diabetes Association Best Practice Guidelines and the Joint Commission standards for Disease-Specific Quality Care.
Specific goals of the project include:
1. Increase identification of patients with diabetes on admission.
2. Increase routine ordering of Hemoglobin A1c (HbA1c) and availability of testing. (The goal for people with diabetes is HbA1c less than 7%).
3. Increase patient compliance with treatment goals.
4. Decrease inappropriate use of oral and injectable medications to treat high blood sugar levels.
5. Enhance the diabetes consult service for routine admissions.
6. Improve discharge planning and continuity of care.
Interventions:
1. Implementation of a systematic process for identifying the diabetic patient on admission to the hospital.
2. Subcutaneous insulin order sets have been updated to reflect the latest best practice guidelines.
3. Implementation of an evidence-based protocol for treating patients with hypoglycemia (low blood sugar).
4. Implementation of a glycemic management protocol for patients before, during and after surgery.
5. Implementation of treatment protocols for ketoacidosis, a potentially life-threatening complication of diabetes.
6. Enhancement of our education program for physicians and nurses.
Results:
We are now doing glucose screening or blood glucose tests on a large percentage of admitted patients, with the goal of screening 100% of inpatients. By screening 100% of our inpatients, we hope to identify patients with previously undiagnosed diabetes and treat them before the adverse effects of diabetes are evident.
1. Before the project, 22% of diabetes patients were identified upon admission; post-project, 96.4% of diabetes patients are being identified on admission.
2. Before the project, 14.5% of patients with a blood glucose level greater than 180 had an HbA1c ordered; post-project, 83% of patients with a blood glucose level greater than 180 have an HbA1c ordered.
3. Before the project, 0% of diabetes patients were on a recommended carbohydrate-controlled diet; post-project, 71% of patients are on a carbohydrate-controlled diet.
4. Before the project, 0% of patients had basal/bolus insulin coverage; post-project, 75% of patients have basal/bolus insulin coverage.
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Project Name: Reducing Duplication of CT Films
Time Frame: 2009-2010
Description/Problem:
Over a year ago, the Radiology Department received feedback from referring hospitals that we were performing repeat CT scans on trauma patients referred to us from hospitals in Vermont and northern New York.
Project Goals:
1. To determine why we were repeating CT scans in this patient population.
2. To evaluate whether the repeat scans actually helped bring about a more accurate diagnosis.
3. To investigate how repeat scans affected patient safety.
4. To look at costs to health care systems.
Interventions/Evaluation:
1. All patients transferred to our Emergency Department were eligible to enroll in the study.
2. Subjects came from 18 hospitals; 107 patients were enrolled in the study; 29 received duplicate CT scans.
3. The study was performed under the auspices of the University of Vermont Institutional Review Board.
4. Questionnaires were given to the providers who were ordering the repeat CT scans and to the individuals in the hospital who were responsible for following the patients after their visit.
5. To determine the amount of radiation each patient received, we gathered information from radiation dose tools and Fletcher Allen’s billing department.
Results:
We learned that the primary reasons for the duplicate CT scans were:
1. Insufficient data was transferred with the patient.
2. The area of interest wasn’t included in the scan.
3. The Fletcher Allen physician didn’t agree with the outside report.
4. Fletcher Allen providers were unable to open the CD that was sent with the patient.
5. The patient’s symptoms had progressed, leading Fletcher Allen physicians to recommend a repeat CT scan.
We also learned:
1. The repeat doses didn’t reach unsafe levels with the repeat CT scans.
2. The cost of the additional CT scans on the 29 patients was over $100,000.
Based on what we learned, we have made the following changes:
1. We have expanded the transmission of electronic images between hospitals, thereby reducing the potential problems with opening CD images.
2. Instead of repeating a CT scan when there is any doubt about the diagnosis, Fletcher Allen radiologists now do a second read on the existing scans first.
3. To address the problem of patients who arrive with insufficient data, we have started an informational educational effort to make sure that our referring hospitals understand what kind of images we need to make a correct diagnosis. For example, in patients who may have a fracture of the cervical spine, we need to see several layers of images in order to definitively see whether there is a fracture or not. While referring hospitals do get this level of detail in their CT scans, they don’t always send all these images to us. We’ve presented this information in discussions with referring providers and, more formally, in a recent presentation at the Vermont Radiological Society.
For next steps, we will be continuing this study and looking at repeat analyses to see whether our intervention worked.
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Project Name: The Vermont Blueprint for Health
Time Frame: 2007-2013
Description/Problem:
Fifty-one percent of all Vermont adults have one or more lifelong health conditions that likely require ongoing medical care. Eighty-eight percent of Vermonters older than 65 report one or more chronic conditions. Twenty-five percent of people with chronic conditions have limitations that restrict normal activities.
Nationally, chronic conditions lead to:
- 83% of health care spending
- 81% of hospital admissions
- 76% of physician visits
- 91% of pharmacy expenses
Project Goals:
The goal of the Vermont Blueprint for Health is to support Vermont’s efforts to develop a comprehensive, proactive system of care that improves the quality of life for people with, or at risk for, chronic conditions.
In support of that goal, the Blueprint project supports the efforts of primary care practices in Chittenden County to become patient-centered medical homes – health care settings that improve patient outcomes by improving quality, educating and empowering patients and fostering a team approach to care.
In a patient-centered medical home, patients receive care from a Community Health Team, which consists of a nurse (certified in diabetes education), a dietitian, a medical social worker and a health educator. This team works with the patient to help set realistic outcomes, goals and timelines and provides one-on-one support. They also work with a broad base of community services to provide each patient with individual support and care.
Interventions:
1. Fletcher Allen is working with practices in Chittenden County to improve their systems and processes so that they can receive recognition from the National Committee for Quality Assurance (NCQA) as a patient-centered medical home.
2. The practices we are working with are: Colchester Family Practice; Berlin Family Health; South Burlington Family Practice; Given Health Care Essex; Given Health Care Burlington, Appletree Bay Primary Care; Community Health Center of Burlington; Good Health PC; Dr. Eugene Moore and Dr. Chris Hebert.
3. We are also developing new Community Health Teams based on patient needs in each of the specific practices.
4. We are also teaching each clinic how to implement process improvement so they can maintain their NCQA-recognition status.
Evaluation:
1. We are looking at NCQA scores of specific practices and using these reports to help focus our process improvement efforts.
2. We have an evaluation plan in place that looks at the clinical, operational and financial data for patient-centered medical homes that are a part of Fletcher Allen to see how this new way of delivering care is affecting patient outcomes. For example, we are looking at mammogram screenings, colonoscopies, chronic disease management for diabetes and hospital and Emergency Department admissions.
3. We are also part of a statewide evaluation program of patient-centered medical homes, looking at the overall success of this way of delivering care around the state.
Results:
1. We have reduced Emergency Department visits among medical home populations by 15.78%.
2. Hospital admissions among medical home participants have dropped by 15.8%.
3. Participation in our community health teams continues to increase. We now have: 2,337 referrals, 216 active participants and 424 “graduates” of the program.
4. Of Fletcher Allen’s eight adult primary care practices, three have completed the NCQA accreditation process and we anticipate that the remaining five practices will be certified as patient-centered medical homes by July 1, 2011.
5. Going forward, Fletcher Allen will be working with over 30 practices to help them become patient-centered medical homes.
