Primary care provider uses PHA's Lean Daily Improvement to better A1c measures

Elwood Family Medicine, an independent practice located 30 miles north of Indianapolis, successfully used an emerging lean tool to improve the A1C levels of its patient population.

Through funding from the Great Lakes Practice Transformation Network, Purdue Healthcare Advisors was tasked with helping Elwood Family Medicine and several other groups improve the health of their patient population by selecting a chronic care condition and applying Lean Daily Improvement (LDI) to improve related scores.

In the case of Elwood Family Medicine, Practice Manager Nancy Bolds noticed that the percentage of the clinic’s patients with uncontrolled hemoglobin A1c was not ideal. The measure provides an index of average blood glucose for the previous three to four months, and it can signal the onset of diabetes or alert patients to problems with their ongoing management of the disease.

Bolds knew the higher-than-expected rate of patients with uncontrolled A1C fell short of optimal patient care and, left uncorrected, would lead to lower cost reimbursements from the Centers for Medicaid & Medicare Services (CMS). She decided to join an optional GLPTN cohort to receive training from Purdue in LDI, which is a continuous improvement process run at the point of service. LDI Facilitators know how to choose a key performance metric; collect and display data visually; run team huddles to get to root causes; assign corrective actions; and keep the process moving.

“By the time the diabetic patients get to us, many are extremely sick,” Bolds said. “Because they come to us from multiple sources such as Veterans Offices, local employer-owned clinics, and other specialists, we have been challenged with collecting their health information, especially with regard to chronic care management.”

With the help of a PHA lean coach, Bolds began to apply LDI to the A1C problem. Her goal was to capture the A1C score of incoming patients at a rate of 100% (process measure) and to decrease the rate of patients with uncontrolled A1C (outcome measure). The standardized process she created involves running reports on all diabetic patients each Monday. Clinic providers then review paper labs and consults, and mark “record” for patients with an A1c test result included in their file. Clinical staff record A1c test results from external providers in the Electronic Health Records (EHR) system.

A follow-up A1C report is run on all diabetic patients, allowing clinical staff to reconcile the EMR charts for patients’ missing A1C data. Reports in the scanned folder not initialed “record” and dated by clinical staff are returned for proper documentation. Finally, patients without a recent document A1C test are called and scheduled for a recheck. A patient/results tally posted at the triage desk is a visual management reminder of their commitment to the process.

Since the process was implemented earlier this year, Elwood Family Medicine has reached their goal of capturing 100% of A1c patients. The work has enabled the clinic to decrease the percentage of its patients with A1c scores outside the preferred range from 16% to 12%, and helped it reach an important CMS quality benchmark.

The clinic has embraced LDI and spread it to another pain point, lipids management. “It makes you focus on just one thing and then you fix it. You develop your process,” Bolds said. “It sounds simple, but you have to take the time to fix the problem. Then you get excited. Now when we have a problem, the first solution that comes to mind is LDI.”