Tag Archives: QI

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!

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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!

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