1. ©2014 MFMER | slide-1 Going Against the Grain Improving Processes Related to Patient Comorbidities Alison M. Knight, P.E. IIE 2014 National Conference

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

3. ©2014 MFMER | slide-3 What is a Comorbidity and Why is it Important?

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

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

6. ©2014 MFMER | slide-6 Our Target Comorbidity: Diabetes

7. ©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

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

9. ©2014 MFMER | slide-9 Now that we know diabetes is important, how should care change?

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 <70 mg/dL in the adult diabetic surgical patient.

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)”

12. ©2014 MFMER | slide-12 Step 2: Create System to Support Clinical Guidelines How are we going to make this happen? Who? When?Where?

13. ©2014 MFMER | slide-13 What makes this implementation different from traditional projects?

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

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

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

17. ©2014 MFMER | slide-17 What were some specific challenges in designing this process?

18. ©2014 MFMER | slide-18 Challenge #1: Identification of a Diabetic Patient Multiple Sources of Information Diabetic All providers in process must identify

19. ©2014 MFMER | slide-19 Challenge #2: Rare sightings 10-20% of surgical patients are diabetic

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

21. ©2014 MFMER | slide-21 Overcoming the challenges to connect the clinical guidelines to the process and people

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

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 didn’t know upstream and downstream process – no system awareness

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

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

26. ©2014 MFMER | slide-26 Where are we now?

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

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”

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.

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

31. ©2014 MFMER | slide-31 Questions and Discussion