Tag Archives: Primary Care

VA Quality Improvement Project #6

On 1/12/16 after a long hiatus for the holidays our group met again to discuss our progress thus far and to plan out our next PDSA cycle.

I won’t summarize all of the learnings from the last PDSA cycle, but highlight a few key issues that we identified as major obstacles that needed addressing to maximize our potential for success.

#) Unclear Front Line Buy-in:  Critical to behavior change is involving the front-line staff in developing the plan for the intervention.  Not only do these front line workers have the expertise about the nitty gritty involved in changing processes, but they also have the most at stake and need to feel like their opinion is valued. Early in the project we had tried to get LVNs to attend our meetings and work with the team, but this was quite difficult due to scheduling restraints and likely very different working cultures.  Nevertheless, given how important this step is, we decided to redouble our efforts to meet with the LVNs, explain the rationale behind the project, and incorporate all of their feedback into the process.  We also discussed giving them as much positive feedback and recognition as possible to help them get credit for helping with the project.

#) The Devil is in the Details: Our first PDSA pointed out multiple easily fixable but very relevant flaws in the execution of the plan.  Things like where to position the paper to best fit into the work flow, how to ensure the return of pens and clipboards, and how to gather these forms from providers all created barriers to implementation.  For our next phase of the project we are working to address these and make it easy to do the desired behavior.

#) The Importance of Stories: As time marches on projects inevitably begin to feel a bit old. Everyone gradually starts to lose enthusiasm and maintaining commitment and investment in something as difficult as behavior change becomes really important.  Today our group took a moment to reflect on why we think this project is actually very important.  A number of our group members shared stories of patients who didn’t have their top concern addressed, or situations where a “door knob” question came up that caused a provider to fall behind because of the delay and then have other patients leave unseen so they could catch the shuttle.  This served to reanimate the group and remind us of the overall goal of these QI projects- to improve the quality of care we provide to our veterans here in the clinic.

We plan on launching PDSA #2 soon.  Stay tuned for details and results!

Previous QI Post


VA Quality Improvement Project #5

Last week our team took on our first iteration at a PDSA cycle.

To recap, a PDSA is where you Plan an intervention (in our case the agenda setting form), Do that intervention (try it out in the real world setting), See what happened (gather data, comments, feedback), and then Act to either adopt, adapt, or abandon the intervention based on what we learned.  Ultimately this is done with the hope of using these learnings to drive further PDSA cycles and come up with the best intervention possible.

First off, we learned a ton from just trying to operationalize this.  Building the agenda setting form was pretty straightforward, but trying to decide who would hand it out, when they would hand it out, who would collect it etc got much more complicated.  Also we would need pens- many pens that would largely disappear.

This PDSA cycle provided our group with a windfall of data that I have summarized below.

General feedback points:
-More surveys tended to be delivered in the AM than in the PM.  Some felt a bit of “survey fatigue” or “initiative fatigue.”
-Some forms were delivered by LVNs in the door with the other pre-visit forms, others were brought in by the patients themselves

Comments on the form itself:
-The boxes are a bit too small to write out an entire statement
-The number 1 is written twice on the form, which can be confusing
-The form doesn’t actually say if you should save it and give it to your doctor, or to the LVN, or to the front desk
-It looks nice and official

Feedback from LVNs:
Overall, quite polarizing. One out of three surveyed thought that the forms were not helpful and that we should not do this again.  They felt like patients get so many forms and that they were tired of filling out surveys.  Notably, even this person stated that it didn’t take too long to hand out.  The other two LVNs actually liked the forms quite a bit and thought that they would help patients and were open to continuing to trial the intervention. One of the two LVNs who was supportive of the initiative was particularly enthusiastic and engaged.

Feedback from providers (about half were members of the QI project, the others were not):
Providers across the board seemed to think that the forms were helpful to patients and to themselves. They noted that only a minority of their patients arrived with these new forms, but that for those who did, it was easier to set an agenda and it streamlined the visit.  Others also noted that it was nice to have a “to do” reminder at the end of the visit to remember an eye clinic referral or refills if the patient also wanted something quick. None of the six providers we surveyed thought that the form actually made the visit take longer and all of the providers thought we should continue to hand out the form. Indeed, several non-group members were really excited about the project.

The Data:
The number of patients from the trial day was a bit smaller because of vacation days and illness, but out of a total of 11 in-person patients among our group, 7 had documented agendas, for a rate of 64%, much higher than our baseline rate and higher than our goal!  Notably, out of these 7 patients with documented agendas, 4/7 (57%) were from our intervention (the agenda setting forms), the remainder were from the appointment making system and pre-visit phone calls that already existed.  The documented agenda matched the actual agenda in all 7 cases.

Actually just doing this trial run taught us many places where the intervention could fail, which is exactly the point behind doing this micro-tests and trying to learn as much as possible upfront before making a major investment of time and effort in a project that has big flaws.

Our big steps for our next meeting will be analyzing this data to talk about what we learned and what we should adapt, adopt, or abandon and plan our next PDSA incorporating what we learned.  Hopefully after a few more small PDSA cycles we can roll out our intervention clinic-wide and improve the care we provide to the veterans we serve.

More updates to come!

Previous QI Project Post

VA Primary Care Quality Improvement Project #4

Today I attended another meeting for our VA primary care quality improvement projects group. Since the last update, the group has made tremendous strides in advancing their project to improve agenda setting in clinic.

After analyzing the process by which patient agendas are set in our last meeting, the group decided on an intervention using a worksheet for patients to fill out while in the waiting room before their visit.

Referring again to the IHI model for improvement, they planned out their small test of change. This involved creating a worksheet that elicits the patient’s agenda goals (Agenda Setting Questionnaire), making it available in the rooms where patients have their triage vitals taken, and getting buy-in from the front-line staff who could distribute these forms.

To test this change on a small scale, our group of four providers will gather some additional pre-intervention data only on their small group of patients today and implement their planned intervention next week. They will then use what they learn from their first small trial to adopt, adapt, or abandon parts of the intervention to come up with an improved intervention.

Stay tuned for pre and post intervention data and what we learned from this first test of change!

Previous QI Project Post

VA Primary Care Quality Improvement Project- Update #2

I went to my second meeting for one of the VA primary care quality improvement projects yesterday. Over the past month or so the team thought about some issues in clinic that they think are particularly troublesome for the patients and for the providers and identified improving agenda setting in clinic as a major priority.

They felt that often our veterans travel for several hours to see their primary care doctor and often leave without having had the chance to discuss the most important issue or issues to them. Additionally, they worried that poor agenda setting led to misused time during the visit and actually slowed down their overall clinic day, making them late for other patients and adding to an already overburdened day.   Indeed, the literature supports both of these suspicions and outlines the importance of eliciting and prioritizing patient agendas to improve patient care and communication (Epstein, AAFP http://www.aafp.org/fpm/2008/0300/p35.pdf).

Using the IHI’s Model for Improvement (http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx), the team defined their goal as “improving agenda setting in clinic” and selected an initial metric of “percentage of patients with a documented agenda prior to starting the visit” to actually know if that change is an improvement. They then spent the remainder of the meeting creating a process map in which they outlined all of the various steps that go in to a veteran having an appointment with their provider with the goal of identifying certain steps that could be improved upon to create better agenda setting.

The next steps are 1) Improving upon the team goal by making it “SMART” and 2) analyzing the process map that was created to identify a few possible small tests of change for a plan, do, see, act (PDSA) cycle.

The team is meeting again next week to continue to build upon this work and hopes to start trialing at least one small change then. Stay tuned for updates from the clinic!

Previous QI Project Post


Big thanks to Natalie Witek for joining us from neurology this morning to walk us through a great case of subacute combined degeneration. Oh the wonder of vitamin B12 deficiency!

  • We reviewed the importance of the neurology exam and spent some time discussing a couple of physical exam tests and maneuvers. I’ll focus on two here:
    • The funduscopic exam
      • The Standard Medicine 25, a team of physicians led by Abraham Verghese which has developed a website along with teaching seminars to review a collection of 25 bedside physical exam skills for internal medicine physicians, has a fantastic review of the funduscopic exam including tips for using the traditional ophthalmoscope vs. the PanOptic ophthalmoscope. Find the link to the website including videos of both the ophthalmoscopes in action: http://stanfordmedicine25.stanford.edu/the25/fundoscopic.html.
    • The head impulse test
      • Natalie, with the use of Geoff Buckle’s head, demonstrated the head impulse test. To recap:
        • Place hands gently on either side of the patient’s head and ask them to keep their eyes focused on your nose.
        • Turn their head quickly about 15 degrees to one side or the other.
        • The NORMAL response is that the eyes remain on the target. An ABNORMAL response is that the eyes leave the target towards the direction that the head has been moved and then they saccade back to the target.
        • You repeat the test on the other side.
        • If the test is abnormal, this implies a peripheral vestibular lesion (inner ear or vestibular nerve) on the side that the abnormal finding occurred.
      • The maneuver is commonly performed in the work-up of vertigo.
      • A pearl from Natalie is that even if it is abnormal, it is reassuring in that it implies a peripheral vs. central lesion.
  • Differential for dorsal column disease
    • Symptoms = loss of proprioception and vibratory sensation and variable weakness
    • Deficiencies
      • Vitamin B12 deficiency – subacute combined degeneration
      • Copper deficiency myeloneuropathy
      • Vitamin E deficiency
    • Toxins
      • Nitrous oxide inhalation – due to inactivation of vitamin B12
    • Infections
      • Syphilis – tabes dorsalis
      • HIV vacuolar myopathy – the most common cause of HIV-related myopathy!
    • Structural
      • Cervical  spondylotic myelopathy
      • Epidural metastases
    • Genetic
      • Friedreich’s ataxia
    • Systemic
      • Multiple sclerosis
  • We discussed the manifestations of vitamin B12 deficiency, reviewed macrocytosis and other peripheral smear findings, as well as touched on the therapy of vitamin B12. There is an interesting article in JGIM http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1831618/), which touches on outcomes in Vitamin B12 therapy of subacute combined degeneration (of note N=57). It highlights that B12 therapy is reported to stop progression and improve deficits though complete resolution of symptoms is rare.


We were able to discuss the differential for solitary liver lesions, features on ultrasound that are concerning for complex cysts, discussion of radiologic features c/w various lesions, and Rabih Geha’s fabulous teaching on polycystic liver disease.

Here are the pearls:

Differential of Liver Cysts

We discussed the differential of solitary liver lesions, however, here let’s focus on the specific differential for cystic liver lesions. You can think about this as differential by splitting it into two categories: simple cysts vs. complex cysts. Simple cysts appearing as fluid-containing lesions (anechoic) without any evidence of complex internal features (internal septations, calcification, nodularity, wall thickening/irregularity, hemorrhagic/proteinaceous contents). Complex cyst contain one or more of the complex internal features above.

  • Simple cysts
    • Simple primary hepatic cysts (benign developmental hepatic cyst)
    • Bile duct hamartoma (von Meyenburg complex)
    • Polycystic liver disease
    • Caroli disease
      • Rare autosomal-recessive disorder characterized by multifocal saccular dilation of the intrahepatic bile ducts
  • Complex cysts
    • Neoplasm
      • Primary: biliary cystadenoma or cystadenocarcinoma, squamous cell carcinoma
      • Secondary: cystic metastases
      • HCC (would be atypical presentation)
    • Infectious
      • Abscess
      • Pyogenic
      • Amebic
      • Echinococcal cyst (hydatid cyst)
    • Posttraumatic/miscellaneous
      • Pseudocyst
      • Hematoma
      • Traumatic intrahepatic hemorrhagic/infarction

The Importance of Imaging

Here is a table with characteristic features of liver cysts pilfered from the Radiology journal.

  Ultrasound CT MRI Pattern of contrast enhancement
Simple hepatic cyst -Anechoic

-Thin walled

-Thin walled


-Homogenous (low intensity on TI, high intensity on T2) None
Cystadenoma -Anechoic

-Internal septations



-Homogenous (low intensity on TI, high intensity on T2) Wall enhancement
Echinococcal (hydatid) cyst -Internal septations +/-daughter cysts


-Thick walled


-Internal septations

-+/- daughter cysts

-Hypointense rim on T1 and T2 Wall may enhance
Polycystic liver disease Innumerable simple cysts Innumerable simple cysts -Homogenous (low intensity on TI, high intensity on T2) None

Polycystic Liver Disease

Attached is a review on autosomal dominant polycystic liver disease courtesy of Rabih. Here are the CliffsNotes:

  • Autosomal dominant polycystic liver disease (ADPLD) can exist as a separate entitiy as well as in conjunction with autosomal dominant polycystic kidney disease (ADPKD).
  • ADPLD presents with multiple cysts that are large, variable in size, and can present within the liver parenchyma but not in contact with the portal triad or be adjacent to the portal triad.
  • There is an age-dependent increase in the frequency of hepatic cysts in patients with ADPKD-associated ADPLD (20% in third decade à 75% by the seventh decade).
  • Women with ADPKD are more likely to have larger liver cysts and have more cysts than men.
  • Exposure to estrogen increases the likelihood for liver cysts in patients with ADPKD-associated ADPLD.
  • There is an association with vascular malformations in patients with isolated ADPLD namely cerebral aneurysm and aortic root dilation though causality has not been proven.
  • As was the case with the patient presented today, patients are often asymptomatic and once they develop symptoms these are usually secondary to mass effect from the cysts on nearby anatomic structures.