Improving Process of Care for Women with Gestational Diabetes: Lessons From an Outpatient Obstetrics Clinic

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1 Improving Process of Care for Women with Gestational Diabetes: Lessons From an Outpatient Obstetrics Clinic Mary Emmett, PhD, 1 Dara Seybold, MAA, 1 Gina Wood, RD, LD 2, Byron Calhoun, MD 3 1 Center for Health Services and Outcomes Research, Charleston Area Medical Center Health Education and Research Institute 2 Bureau for Public Health, Office of Community Health Systems and Health Promotion 3 Department of Obstetrics and Gynecology, West Virginia University-Charleston Division, Charleston Area Medical Center Thanks: Staff at Women and Children s Hospital, Charleston, WV Supported by: National Association of Chronic Disease

2 Disclosure I have nothing to disclose. Before beginning, I want to thank the following organizations and individuals for their support and opportunity to collaborate on behalf of women and children: The Center for Disease Control (Michelle Owens- Gary) The Association of Chronic Disease Directors (Joan Ware) West Virginia Diabetes Prevention and Control Program (Peggy Adams, Gina Wood, Jessica Wright) West Virginia Gestational Diabetes Advisory Committee My colleague Dara Seybold

3 Partnerships: The Journey Phase 1 Reporting what WV learned from a study Pregnancy and Diabetes in West Virginia. Phase 2 Better Data, Better Care. A collaborative sponsored by Association of Chronic Disease Directors (ACDD) and CDC. (Michigan, Oklahoma, North Carolina, Utah, WV)

4 The Journey -- Continued Better Data, Better Care (approach) Women who reported having high blood sugar (diabetes) that started during this pregnancy on the Pregnancy Risk Assessment Monitoring System (PRAMS). These records were matched with the birth certificate data.

5 The Journey -- Continued Phase 2 Each of the states in the Better Data, Better Care group were asked to carry out an intervention. In West Virginia we choose to conduct a process improvement in one obstetrical practice.

6 A Quality Improvement Initiative Systems Goals Establish a systematic process for the identification and documentation of GDM Educate women with GDM about risk reduction of Type 2 Diabetes Improve postpartum testing Global Outcome Consistent care for women with GDM Reduce incidence of new onset Type 2 diabetes

7 Process of Change Interdisciplinary team Physician leader Nursing manager Public health expert Diabetes educator Facilitators Resident in OBGYN Rapid cycle process improvement Plan, Do, Study, Act (PDSA) cycles of change Institute for Health Care Improvement

8 Initial System Screening for GDM All patients screened at 24 to 28 wks with 1 hr non-fasting glucose test >140 triggers 3 hour glucose tolerance test >200 patient is considered GDM If 3 hr glucose tolerance test is positive (or fasting blood sugar >105), then GDM Baseline Data: 18% failed 1 hour (55% compliance with 3 hour testing) Cycle of Change Lab comes to clinic for blood draws when necessary (major policy change); working on having phlebotomist in clinic A1C testing or random glucose in clinic (>250) Weekly report data warehouse (patients tested and lab values) Measuring Change Year 1 Data: 18% failed 1 hour (72% compliance with 3 hour testing) Year 2 Data: 21% failed 1 hour (65% compliance with 3 hour testing)

9 Initial System Documentation Use ACOG prenatal form for testing documentation Cycle of Change Developed separate data collection form for project Fabricated GDM labels for charts Encounter form includes GDM in Diagnosis List Measuring Change Year 1:100% of patients EMR documented GDM Year 2: 100% of patients EMR documented GDM

10 Initial System Patient Education Provide educational materials and refer women with GDM to diabetes education class Baseline Data: 73% of chart had documentation of diabetes education Cycle of Change Additional educational materials that are more user friendly Patients with GDM sign a form educating them about GDM and the importance of the postpartum screening Encounter form check box for Diabetes education Measuring Change Year 1 Data: 95% of charts had documentation Year 2 Data: 92% of charts had documentation

11 Post-Partum Care 2 hr GCT ordered on encounter form (written in) Baseline data Initial System 50% show rate for postpartum visit 10% labs ordered 0% completed labs Cycle of Change Incentivized post-partum lab test completion Encounter form has all glucose testing labs listed (check box) Adding prenatal care and delivery information on postpartum chart Changing discharge orders--automatically document follow-up visits Providing education about what to do during a post-partum visit Measuring Change Year 1 Data: 89% show rate for postpartum visit 39% labs ordered 22% completed labs Year 2 Data: 69% show rate for postpartum visit 46% labs ordered 8% completed labs (1 visit in January, 2012)

12 Promote Adherence to Process Simplification of processes (e.g., bins for forms and stickers, data forms left in charts) Champion of cause Outside evaluation Extensive education with management, residents, nurse practitioners, nurses, and staff Program participants receive and sign form that they are part of this initiative

13 Lessons Learned Observations should be substantiated with data if they are to inform project Need to evaluate if change resulted in improvement Some changes take longer than others, go after the low hanging fruit first There are structural and overarching policies that may make change difficult Sometimes need a change of mindset or skills building (ex: postpartum visit is important time to provide comprehensive care and make referrals) Need champions of the cause

14 The Journey -- Continued Phase 3 Extending the collaboration Chronic Disease and Maternal and Child Health working in partnership to prevent Type 2 diabetes and have healthy mothers and babies. Ohio, Missouri and West Virginia developed strategic plans under the leadership of CDC, Chronic Disease Directors, and the Association of Maternal and Child Health.

15 The Journey -- Continued Strategic Plan for West Virginia Promote provider awareness of appropriate GDM testing, diagnosis, treatment and followup care. Promote patient awareness of GDM as a major risk factor for Type 2 diabetes and the necessity of postpartum glucose testing and referral for follow-up care. State-wide Advisory Committee

16 The Journey Continued State-wide Advisory Recommendations State guidelines for testing distributed to physician offices Dissemination of data to physicians Immunization project (see flyer) combining information on childhood immunization and post-partum care Major presentation by Dr. Dietz at Diabetes Conference, October 2011 WIC project to learn about challenges women face in obtaining post-partum care (see assessment)

17 The Journey -- Continued Phase 3 Spread Developing a national collaborative with other states to improve care for women and children. Use partnerships to share successes and learn from each other how to overcome challenges. How to initiate, develop, manage and sustain change