Researchers at Vanderbilt School of Nursing are pioneering plans for improving the quality of care for low-income patients with type 2 diabetes, taking a lesson from the aviation and engineering industry.
The team of researchers is compiling checklists and protocols, similar to those of the airline industry, to streamline delivery of care for chronic illnesses like diabetes.
The clinical improvement project is a joint endeavor with the Meharry-Vanderbilt Alliance, bringing together the Vanderbilt School of Nursing and the Nashville Consortium of Safety Net Providers.
Cathy Taylor, M.S.N.,DrPh, assistant professor of Nursing at VUSN and director of the Disease Management Program with the Meharry-Vanderbilt Alliance, is the program director. Bonnie Pilon, D.S.N., senior associate dean for Practice Management, is the principal investigator, and Amy Minert Salunga, M.S.N. is the clinical coordinator for the project.
Taylor says improving service delivery and outcomes for people with diabetes requires the entire health care team to make changes.
"They (airlines) have models that involve different kinds of checklists and prompts so that they rely less on human elements and more on procedurally based protocols," said Taylor. "In the outpatient setting, if we don’t provide recommended care, that’s an error. Models designed to prompt the right action every time could help us."
For example, Taylor says the aviation industry wanted to decrease the number of plane crashes. So they investigated accidents and discovered that at some point in almost every crash someone either chose to disregard a protocol or didn’t know the protocol.
"Just like the airlines, we have clear protocols and they’re not being followed based on our surveys and our staggering statistics," Taylor said. "We are using some lessons learned by the airlines. The first is that everyone has responsibility for reporting to one another if they see anything that might lead to an error or an omission."
So Taylor and her team went to work designing flowcharts for five of the city’s safety net clinics: Cayce, Matthew Walker, Waverly Belmont, Vine Hill Community Clinic, and the Internal Medicine Outpatient Clinic at Nashville General Hospital at Meharry. They mapped out what happens to each patient the minute they walk in for an appointment, to the minute they leave, and identifying problem spots or gaps in care and spreading the accountability.
Similar to findings in national studies, the project found ineffective systems of health care delivery at the clinics?clinics struggling to care for a swelling number of patients, many of whom have no health insurance, have been dropped from TennCare, and have little money to pay for services.
"What we found was most of the patient’s actual care, or action taken, was at the end of each visit, and relied heavily on the provider," she said. "So we have tried to spread out the responsibility to each person in the process of the patient’s visit, including the patient. And we’ve installed prompts that remind everyone which tests need to occur at each visit."
Why diabetes? The U.S. Surgeon General’s office has labeled diabetes one of "the big six" chronic illnesses in the United States.
"The Centers for Disease Control and Prevention (CDC) tells us that diabetes care is sub-standard across the nation," Taylor said. "We decided that if we could work out a model for safety net patients that improves our care delivery, uses the science and the evidence that we have available to us now and improves our standard of care for diabetes, it could help us impact other areas as well."
Davidson County mortality rates from 2000, the most recent data available, shows 31.2 per 100,000 adult deaths were from complications of diabetes. Among African-American men the number jumps to 71.6 per 100,000.
"The numbers are really staggering. Not only are we having an increased number of deaths related to diabetes in the white population, but we have just an indescribably awful increase in the number of deaths associated with diabetes in the African-American population. And in these figures we only have white and black because, until now, we didn’t have large numbers of other minorities in Nashville," Taylor said.
Health care providers are forced to attend to acute problems quickly, with little to no time to discuss chronic problems like diabetes with patients.
"In these under-resourced clinics, you’ve got seven to 10 minutes with a patient who typically presents with multiple problems. There are providers out there who are working harder than they’ve ever worked. The current primary care system is simply inadequate for providing standard of care to chronically ill diabetic patients," Taylor said.
Marilee Weingartner, M.S.N., instructor in Clinical Nursing and family nurse practitioner at the Vine Hill Community Clinic, says she and her colleagues were surprised to find out from the improvement team that their clinic outcomes with diabetic patients were not as good as they thought.
"We had already been looking at our outcomes and thought we were doing a good job providing recommended tests and screens for our diabetics, but the improvement team found areas that were low and not improving. Really focusing on the numbers has already helped us raise our awareness and outcomes," Weingartner said.
Dr. Donald Boatwright, director of the Internal Medicine Outpatient Clinic at Nashville General Hospital at Meharry, says he wasn’t shocked at the drastic outcomes in his clinic.
"I wasn’t that surprised. It’s an epidemic that’s begged to be noticed," he said. "It became too much of a problem before we really noticed. A lot of time has been spent on the patho-physiology of diabetes and less on clinical outcomes. So it sprang up and we may have gotten behind the curve on it, so there is some catching up to do."
With that new philosophy of delivery of health care in mind, the improvement team also began working on basic quality improvement methodology for patients with diabetes.
"What we discovered in our clinics, in the beginning, was that only about 25 percent of people with diabetes were getting eye exams. The national average is 60 percent," Taylor said.
The team purchased two state-of-the-art digital retinal cameras, with a grant from the HCA Foundation, to offer on-site eye exams to patients. Vanderbilt Ophthalmology was contracted to provide interpretations of the digital pictures.
The cameras use telemedicine technology to capture a digital image of the retina while the patient is the clinic. The images zip through a high speed digital subscriber line to the Vanderbilt Ophthalmology Department, where they are evaluated and the information is then sent back to the provider.
"What we discovered from using these cameras is that we have a very high rate of eye disease that was previously undetected," Taylor said.
Kidneys were the next point of concern for the improvement team. Standards of care require an annual kidney function test for people with diabetes.
Again, the team found wide gaps in the standards of care at each clinic.
Feet were the final piece of the diabetes improvement puzzle, so the shoes came off. Taylor says teaching other members of the health care team and people with diabetes to examine their feet has resulted in marked improvements in foot check rates, up to 80 percent better in most clinics.
Minert, the project clinical coordinator, says incorporating all of these standards with a new approach will take time for everyone.
"Change is slow," Minert said. "The average time for adaptation to any new standard by a health care provider is seven years."
"We don’t have that luxury in this epidemic with diabetes. We have to find a way to introduce new technology and support providers in being able to use these standards much more rapidly than we’ve been able to do in the past. And we have to educate the next generation of providers," said Taylor.
The team is hopeful that applying the aviation principles to health care delivery will begin to turn Davidson County’s low numbers around.
"If we work this model out, what we know by looking at the application in these other settings, they’ve done it, and they’ve been able to reliably get the outcomes they expect. We can do that, too," Taylor said. "If we can do it for diabetes, we can do it for cardiovascular disease, we can do it for cancer, we can do it for pre-natal care. This is the foundation…taking what we have learned and beginning to develop and apply the intervention that will ultimately lead us to the outcomes we know are possible."
Funding for the diabetes improvement team is provided by the Memorial Foundation.
Media Contact: Heather Hall, (615)-322-3894 heather.l.hall@vanderbilt.edu