2014 MFMER | slide-1 Going Against the Grain Improving
Processes Related to Patient Comorbidities Alison M. Knight, P.E.
IIE 2014 National Conference
Slide 2
2014 MFMER | slide-2 Agenda What is a Comorbidity? Target
Comorbidity: Diabetes The Plan Why is this Process Improvement
unique? Challenges Solutions Lessons Learned
Slide 3
2014 MFMER | slide-3 What is a Comorbidity and Why is it
Important?
Slide 4
2014 MFMER | slide-4 Comorbidity Comorbid* (adj): Existing
simultaneously with and usually independently of another medical
condition Examples: Hypertension Anemia Sleep Apnea Diabetes
*Source: merriam-webster.com
Slide 5
2014 MFMER | slide-5 Comorbidities add risk Comorbidities might
not be the cause for surgery, but they add risk Example: Patient
has elective knee replacement and has diabetes
ProcedureComorbidityOutcome
2014 MFMER | slide-7 Patients with diabetes deserve attention!
Increased odds of postoperative complications Increased risk of
postoperative mortality The diabetic patient is a high risk
surgical patient Major driver of: Prolonged length of stay,
Increased resource utilization, and Increased cost Postoperative
complications
Slide 8
2014 MFMER | slide-8 The Data for Surgery Blood Glucose Level
> 180 mg/dL (Hyperglycemia) Increased Risk of Postoperative
Complications Importance of Perioperative Glycemic Control in
General Surgery; Ann Surg, 2013:257 Perioperative management of
diabetes: Translating evidence into practice; CCJM, 2009 Blood
Glucose Level < 70 mg/dL (Hypoglycemia) Increased Risk of
Mortality
Slide 9
2014 MFMER | slide-9 Now that we know diabetes is important,
how should care change?
Slide 10
2014 MFMER | slide-10 Step 1: Create Clinical Guidelines
Subject Matter Experts develop clinical guidelines to answer What
do we need to do? Goal for Clinical Guidelines: Establish a
framework for the development of processes and protocols at each
Mayo Clinic site to maintain a random blood glucose (BG) < 180
mg/dL without increasing rates of symptomatic hypoglycemia, or
blood glucose levels
Slide 11
2014 MFMER | slide-11 Examples of Clinical Guidelines Patients
need to have a blood glucose checked upon admission, and then every
1-2 hours while fasting For blood glucose levels 70 mg/dL,
institute the Treatment for Hypoglycemia Protocol Postoperatively,
check blood glucose level upon arrival to unit, before meals, and
at bedtime or four times per day (if fasting)
Slide 12
2014 MFMER | slide-12 Step 2: Create System to Support Clinical
Guidelines How are we going to make this happen? Who?
When?Where?
Slide 13
2014 MFMER | slide-13 What makes this implementation different
from traditional projects?
Slide 14
2014 MFMER | slide-14 Traditional Quality & Process
Improvement Problem Analysis within Specialty Easily Implemented
Problem Identified within 1 Surgical Specialty Process Mapping and
interventions for patients in that specialty Patients are organized
by Specialty, ORs, Nursing Units
Slide 15
2014 MFMER | slide-15 Our operational change is based on
service line. SurgerySpecialty #1 Quality Intervention 1.1 Quality
Intervention 1.2 Specialty #2 Quality Intervention 2.1 Quality
Intervention 2.2 Specialty #3 Quality Intervention 3.1 Quality
Intervention 3.2
Slide 16
2014 MFMER | slide-16 Designing a process based on comorbidity
means the process shall: Be standard across all specialties Cut
through traditional organization boundaries Center around the
patient and not the service line Surgical Practice Comorbidity
Intervention Surgical Specialty #1Surgical Specialty #2Surgical
Specialty #3
Slide 17
2014 MFMER | slide-17 What were some specific challenges in
designing this process?
Slide 18
2014 MFMER | slide-18 Challenge #1: Identification of a
Diabetic Patient Multiple Sources of Information Diabetic All
providers in process must identify
Slide 19
2014 MFMER | slide-19 Challenge #2: Rare sightings 10-20% of
surgical patients are diabetic
Slide 20
2014 MFMER | slide-20 Challenge #3: Mix of standard and non-
standard processes Pre- hospital (Out- patient Clinic) Pre-op Area
Intra- operative Post Anesthesia Care Unit General Care Unit
Discharge Standard processes across specialties Non-standard
processes & resources, defined by each specialty
Slide 21
2014 MFMER | slide-21 Overcoming the challenges to connect the
clinical guidelines to the process and people
Slide 22
2014 MFMER | slide-22 The Strategy of Implementation Care must
be seamless across process steps Build safety nets into the system;
Mistakes happen Use tools to promote communication Standard
processes + standard measurement = data-driven improvements in
patient outcomes
Slide 23
2014 MFMER | slide-23 Example of Clinical Guideline
Implementation Check blood glucoses at least every 2 hours from
pre-operative area to arrival on post-operative floor Current State
Findings Each area had its own process for monitoring diabetic
patients Each area didnt know upstream and downstream process no
system awareness
Slide 24
2014 MFMER | slide-24 Pre- Operative Area Operating Room Post
Anesthesia Care Unit General Care Unit Question #1: Does each area
have the capacity and resources to check a blood glucose every 2
hours on every diabetic patient? Challenge Solution Lack Capacity
Currently RNs use meters Trained nursing assistants to use meters
Lack Capacity OR Lab could not support 2 hour tests OR Lab changed
staffing model using sweep method Lack Capacity Lab staff on- call
for as needed tests RNs trained to use meters No change
required
Slide 25
2014 MFMER | slide-25 Question #2: How do you maintain every 2
hour glucoses throughout 4 distinct areas and integrate into
current workflow? Pre-Operative Area Operating Room Post Anesthesia
Care Unit General Care Unit Nursing Protocol Hourly rounding
Surgical safety checklist Hourly Sweep Alerts/Pop-ups Nursing
Protocol PostOp BG Order
Slide 26
2014 MFMER | slide-26 Where are we now?
Slide 27
2014 MFMER | slide-27 What have we done? Pre- hospital (Out-
patient Clinic) Pre-op Area Intra- operative Post Anesthesia Care
Unit General Care Unit Discharge Implemented solutions across
standard processes first
Slide 28
2014 MFMER | slide-28 What will success look like? Metrics
Process Metrics: Are we following the guidelines? Ex. Blood glucose
checks every 2 hours Outcome Metrics : Do our guidelines improve
outcomes? Ex. Number of blood glucoses > 180 Ex. Reduced
surgical site infections Small Successes in Process Design New
sweep staffing model in OR Lab Blood glucose checks happen like
magic
Slide 29
2014 MFMER | slide-29 What have we learned? Biggest Challenge:
Identifying patients throughout the process A new standard process
implementation will find gaps in other processes. People want to do
the right thing, but it must be easy Information has to be
available in the right place and right time, and must be
reliable.
Slide 30
2014 MFMER | slide-30 Summary Clinical Guidelines + Systematic
Implementation = Standard Patient Care Designing processes for a
subset of patients goes against the grain of traditional
operational change Challenges: patient identification and current
process fragmentation