As participants in IHI’s Idealized Design of Clinical Office Practices (IDCOP) initiative, management had learned the steps required to implement advanced access, a scheduling system that eliminates appointment backlogs and allows patients to be seen when they want, including the same day. But they also knew it was not as simple as 1-2-3. “We knew we couldn’t get to open access without dealing with quality,” says Sue Kancir, RN, Quality Management Specialist and collaborative team member.

And so that is precisely the route they took, improving care for patients with diabetes, hypertension, and coronary artery disease (Figure 1) while dramatically improving access.

The VA Connecticut (VACT) Healthcare System — located on two campuses and in six community-based outreach clinics ­— includes a tertiary hospital affiliated with Yale University and University of Connecticut Schools of Medicine. VACT cares for approximately 42,000 primary care patients. The VACT Primary Care Practice has been monitoring HgbA1c, blood pressure, and LDL control for nearly three years as part of its effort to improve care management for patients with diabetes, hypertension, and coronary artery disease (CAD).

Connecting Quality to Access

For Luz Vasquez, MD, VACT’s Advanced Clinic Access Coach, the connection between advanced access and quality of care was clear. Since the advanced access model can mean seeing patients less often because visits are more comprehensive, “the physicians and mid-level providers were worried that their patients would fall through the cracks if they weren’t coming in every three months. We had to convince them that our systems wouldn’t let that happen.”

The most critical element in a system that supports continuous care management is good data. To that end, Kancir developed a computerized registry and feedback mechanism that was unique in the VA system. Clinical data on all patients with diagnoses of diabetes, hypertension, or CAD were used to provide every primary care team with information about how their population of patients was doing against national benchmarks and targets.

“For the first time, providers could look at their lists and see which patients had an HgbA1c of more than 7.5, who has an LDL greater than 100,” says Vasquez. Moreover, she says, the five primary care teams could view each other’s data, a key motivating tool that appeals to physicians’ competitiveness, as well as their natural desire to take good care of their patients.

IHI CEO Donald Berwick, MD, MPP, says that one of the first and most common reactions physicians and other health care professionals have to population-based data on their patients is that the data are wrong. This was exactly what the VACT primary care physicians and mid-level providers thought.

“Data showed that the number of patients across all five teams whose blood pressure was less then 140/90 was around 45 percent,” recalls Raj Krishnamurthy, MD, VACT’s Director of Primary Care. “Everyone thought the data was wrong. So we reviewed it, and found that in fact, the data were right, and it wasn’t just older patients, it was young people too. We weren’t managing hypertension well.”

So they formed small work groups to assess and address care for hyptertensive patients. Simple awareness is an effective motivator to change, says Kancir. “The data is useful feedback that motivates physicians to treat their patients’ chronic conditions more aggressively,” she says.

Creating Better Care Processes

Using the Chronic Care Model, they began to look at how to improve care for patients with chronic conditions. “We started diabetic group visits,” says Krishnamurthy, “and began to aggressively educate and monitor our patients. We implemented a program where patients can monitor their glucose and blood pressure at home, and fax us their numbers so we can make medication adjustments by phone.”

Patients get reminder letters through an automated process when they need lab tests, and providers get a note so they know to look for the results. When they get the results, they can make a plan with the patient over the phone. It doesn’t always involve a one-on-one doctor/patient visit anymore.”

Krishnamurthy says there are three essential elements to making across-the-board changes of this nature. “Management has to make it clear that they care about quality,” she says. “Quality improvement is one of our strategic goals, and we meet regularly to talk about quality and processes of care.”

Second, she says, is an understanding of the techniques of making process changes. “From IHI we learned about PDSA (Plan-Do-Study-Act) cycles, small tests of change that help break down the overall resistance to change.” Through PDSA cycles, groups can test small changes, make adjustments and test again, and then spread to a larger venue when changes prove effective.

The third essential ingredient for change, says Krishnamurthy, is producing and disseminating provider-specific data. “The underlying message is that this is really important to us and it appeals to their natural desire to do well and take pride in their work.”

Vasquez confirms the psychological importance of having and seeing data across teams. “Looking at each other’s numbers really made a difference,” she says. “A little competition is healthy.”

Now, says Vasquez, there are bi-weekly multidisciplinary meetings across teams, during which the groups review their progress toward their goals, and set new goals. “We have become a well-oiled machine for process improvement,” says Vasquez.  Having projects ongoing at both campuses fuels the improvement process, she says, because they trade ideas and keep one another motivated. Keeping the groups multidisciplinary helps too, she says. “Everyone comes to the table so we get a 360-degree view. This keeps the perspective and the workload evenly distributed.”

And, Improving Access

As for instituting advanced access, says Vasquez, they are making good progress, particularly now that systems are in place to support quality. “Our different locations have taken slightly different approaches to open access,” she says, “and we are trying to integrate them into one.”

Kancir says that, though they are not yet at “the true model of open access,” in which same day appointments are routinely available, patients can be seen within a week of calling for a primary care appointment, many within a few days. “Three years ago our next available appointment was 90 days, so this is a huge improvement, particularly when you consider that we have had a significant increase in patients without an increase in staff.”