Quality & Safety Initiatives
Direct Access Colonoscopy Program
A collaborative effort between Gastroenterology and Internal Medicine to ensure that patients age 50 and older meeting certain safety criteria have access to a colonoscopy procedure, without a separate GI visit.
Retention in Care
An interdisciplinary team effort is underway to schedule patients for appointments, call patients who cancel or fail to show for an office visit. Reports of patients meeting these criteria are run on a monthly and weekly visit respectively and are equally divided and distributed among the nurse practitioner, office coordinator, and front desk staff for telephone calls to these patients. If contact cannot be made after two attempts by phone or if the phone number is incorrect/disconnected, staff will mail a form letter to the patient. Staff are also working to verify telephone number and email when making telephone calls and when patient arrives.
High-risk Diabetes Program
An MA-trained Health Coach oversees the High-Risk Diabetes Program. The MA-trained Health Coach performs pre-visit planning for 1) appointments, 2) DM lab draws, 3) retinal eye exams. The Health Coach began populating the list with high-risk diabetic patients from Team 1 beginning in July 2012 through January 2013. The list was expanded to high-risk diabetic patients from Teams 2 and 3 beginning in late winter/early spring 2013. Outcomes being tracked are improved performance in HbA1c, LDL, and microalbumin screening, retinal eye and foot exams for patients with diabetes
Transitions of Care Coordinator Initiative
This initiative is examining process measures related to quality hospital discharges, including:
• Correct PCP identified for every patient
• Communication with the PCP during the admission
• Assignment of a PCP to patients admitted without primary care
• Rates of PCP follow up appointments arranged at discharge
• Forwarding of discharge information to PCP by team
The aim is to decrease LOS, reduce readmissions, and increase patient satisfaction. The first Transition of Care Coordinator was hired September 2012, and since then has been embedded on two of the four Green Medicine teams. A second TOC coordinator was added in October 2013. The TCC’s focus is solely on patients’ transitions into and out of the hospital, following a standardized but modifiable protocol. Data is collected via flow sheets for each patient on a continuous basis in order to measure the TCC’s effectiveness at achieving various process measures. Outcomes can be compared between the teams the TCC is embedded on and the other two teams who follow the standard of care.
Patient-Centered Specialty Practice Quality Initiatives
As part of the application process for NCQA’s Patient-Centered Specialty Practice Recognition, the following quality initiatives are being implemented:
• Documentation of patient smoking status
• Rate of spirometry in patients newly diagnosed with COPD/asthma
• Rate of follow-up CT scanning for patients with solitary pulmonary nodules.
• Pneumococcal vaccination in patients with COPD/asthma