The CareSouth Carolina team is a participant in IHI’s Learning and Innovation Community on Redesigning the Clinical Office Practice.

Lynne Williams, MOA, PECS Data Entry
Shannon Barbour, MOA
Cheri Childress, MOA, Front Office
Motsy Hill, MOA, Coder Rhonda Harvley, MOA, Medical Records
Corie Teal, LPN, Staff Nurse
Theresa McGuirt, LPN, Staff Nurse
Cassie Channell, LPN, Care Manager
Belinda Diane Caulder, Lab
Daronda Rollins, Patient Advocate
Angela Lovelady, Outreach
Cheryl Watson, LCSW, Behavioral Health
Christina Biester, MD
Susan Robins, DO
Peggy Foster, Site Manager

Sponsor/Key Contacts:
Ann M. Lewis, CEO
Bobby Scott, PI Director

The CareSouth Carolina Chesterfield Office provides primary care, laboratory, and behavioral health care services to over 2,000 patients per year with two microsystems/care teams. We will redesign care for patients with diabetes and with cardiovascular disease, with the goal of achieving greater than 95 percent reliability and improving both patient and staff satisfaction to 90 percent on standard survey instruments.

The essential elements of the diabetes care reliability process are as follows:

• Recording body-mass index (BMI)
• Diabetes mellitus (DM) education
• Two hemoglobin A1c (HbA1c) measures in past year
• LDL cholesterol measure in last year
• Patients on statin (if over 40)

These elements were also used to audit and calculate composite and all-or-nothing scores, and became the foundation for the improvement work.

The essential elements of the hypertension care reliability process are as follows:

• Patients on aspirin (ASA)
• Recording BMI (note standardization)
• Two blood pressures in last year
• Lipid test in last year
• Basic metabolic panel (yearly)
• EKG in last year

These elements were also used to audit and calculate composite and all-or-nothing scores, and became the foundation for the improvement work.

Data for individual physicians are tracked, as well as data for the clinic as a whole. Note that several reliability measures are not tracked monthly for every physician, unless they fall below goal.

• Diabetes Composite Score: Percentile score created from the actual number of evidence-based care process opportunities met (numerator), divided by the total number of opportunities to provide the care processes (denominator). For example, the actual number of diabetic patients over 40 on a statin compared with the total number of diabetic patients seen.

• Diabetes All-or-Nothing Measure: Percentile score created from the actual number of diabetic patients who received all evidence-based indicated care (numerator), divided by the total number of diabetic patients seen.

• Hypertension Composite Score: Percentile score created from the actual number of evidence-based care process opportunities met (numerator), divided by the total number of opportunities to provide the care processes (denominator). For example, the actual number of hypertension patients with two blood pressure checks in the last year compared with the total number of hypertension patients seen.

• Hypertension All-or-Nothing Measure: Percentile score created from the actual number of hypertensive patients who received all evidence-based indicated care (numerator), divided by the total number of hypertensive patients seen.

• Patient and Staff Satisfaction: Percentile score compiled from the two standard survey instruments provided to CareSouth from IHI.

Applying Evidence-Based Care: 

The site made a concerted effort to standardize the implementation of evidence-based care. This was primarily accomplished through three identified methodologies. These included:

• Implementing a Disease Management “Core Elements” Form: This form gave every member of the care team visual prompts of each of the key assessment and care processes that the evidence suggests leads to good outcomes. These visual prompts significantly improved the chances that each of the processes occurred during the visit. The form has been revised and refined significantly to follow the patient flow and to be more functional with the patient visit.
• Expanding the Use of Standing Orders: Standing Orders have been in place for years; however, the reliability process has identified a much more expansive use for these, as care team members can become much more productive members since they can provide evidence-based care to patients who need it without taking up valuable provider time. Additionally, the adoption of these standings orders has been proven to save lives and this fact has driven adoption even further and faster.
• Optimizing the Care Team: The combination of the Core Elements form and the expanded Standing Orders has forced the site to look very hard at the members of the care team very closely and reevaluate what each member is doing and whether they are being utilized to their fullest potential. As a result, the site has moved staff around to co-locate care team members together as well as looked at individual team members’ responsibilities to ensure that the work is being done as effectively and efficiently as possible. Additionally, team members such as laboratory, care managers, and behavioral health have had their responsibilities expanded to allow them to do much more without a individual provider order.

Detecting Failures Through the Audits: 

The Chesterfield site quickly became the catalyst for organization-wide change in terms of failure detection through the reliability audit process. The methodology for auditing, problem identification, resolution testing, and even spread has quickly been adopted organizationally in both the clinical and administrative divisions of the organization. Generally speaking, the site/organization has been able to achieve 10^-2 (1 defect per 100 attempts) or greater results within four months of the first audit. The key appears to be having staff involved in the work perform the audits as well as having a mechanism for routine follow-up and tracking. Thus far, the organization has spread the reliability audit construct to more than six key organizational processes and ALL have reached 10^-2 results or greater at the organization-wide level.

Redesigning Processes and Workflows: 

Once staff have detected a failure to meet the established standard, the inevitable question “WHY?” gets asked and their own familiarity with the situation aids in the problem-solving process. The identification process itself has forced individuals to make seemingly insignificant changes in their work practices that have had a tremendous impact in whether the processes occur or not. Additionally, it has forced staff and management alike to challenge their own assumptions about what is going on at the front lines where the work is getting done. These challenges have resulted in a number of procedural changes and modifications which either eliminate steps or give more clear guidance on how to proceed in certain given circumstances. It has also allowed the organization to repair some seemingly minor technical and other infrastructure problems (telephones, information technology, etc.) which had become particularly problematic.

Process Standardization: 

The largest area where the organization is getting demands as a result of the auditing process is in standardization of key organizational processes. The audits are identifying variation as a key culprit in the failures that occur and, as a result, the organization has been feverishly standardizing processes for initial patient workup, standing orders, laboratory, integration with other departments (i.e., Pharmacy, Laboratory, Behavioral Health, Medical Records, Imaging, etc.).

Proactive Population Management: 

CareSouth has always been strong in performing proactive population management. Performing “drill-down” reports from its registry program to identify those patients in need of specific evidence-based care, making contact with those patients, and prompting them to come in to be seen has been a foundational element of CareSouth’s performance Improvement program for many years. However, when combined with the other elements of the reliability work, it becomes an extremely effective methodology for squeezing out the defects in the panel as a whole (back side), while the audit and related processes work on the patients that present at the clinics. This multilevel validation process really filters out the system failures, validates the data within the system (also at 10^-2+), and keeps the entire patient panel as optimal as we can keep them at the current point in time.

• Reliability audits MUST be conducted by those who do the work. The lessons learned and the problem solving that occurs as a result of self-confrontation are priceless. This is communication that simply cannot be replicated through any other means.
• Standing orders for laboratory and nursing can be extremely effective, particularly when they have provider support.
• The concepts of reliability, once learned, can be applied to nearly any process (clinical or administrative).
• It is better to tackle small increments of your goals rather than the whole picture at once.

Ann Lewis, CEO 
ann@caresouth-carolina.com

Bobby Scott, PI Director
bobby.scott@caresouth-carolina.com