Critical Path Network: National model begun at regional level

IHI’s model improves care of diabetes patients

The Breakthrough Series Collaborative model effectively employed by the Institute for Healthcare Improvement (IHI) on a national level has been translated successfully to the regional level in the state of Washington, achieving significant improvement in the self-care efforts of diabetes patients and clinical improvements in areas such as blood sugar and cholesterol.

The initiative, whose accomplishments were reported in two articles in the February 2004 Joint Commission Journal on Quality and Safety, was cosponsored by Qualis Health of Seattle, the Washington State Department of Health, and the MacColl Institute for Healthcare Innovation at Group Health Cooperative of Puget Sound. One article reported on statewide diabetes collaboratives, while the other focused on two participating clinic teams.

In the statewide collaborative report, there was a 50% improvement in the number of diabetes patients who received foot exams; a 49% improvement in the number of patients who received blood pressure readings; and a 35% improvement in the number of patients who received blood cholesterol tests. Outcome measures showed improvement of 12% among patients whose blood sugar dropped; 13% in the number who lowered their LDL; and a 7% improvement in the number who lowered their blood pressure readings.

"Most collaboratives have been done nationally by IHI, and only by people with heavy financial resources," notes Connie Davis, ARNP, MN, associate director for clinical improvement/improving chronic illness care at the Center for Health Studies, part of the Puget Sound Cooperative. The Center also directs the MacColl Institute.

The group worked with state health plans and developed a statewide support system for the chronic disease self-management program. It also brought rural clinics into the effort.

Just what was this IHI-inspired model the state groups implemented? "It’s a learning model that uses what is known about how adults learn best," Davis explains.

"You bring people together four times over the course of a year with experts who teach you how to make changes, and between meetings you have calls, monthly reporting, ways of sharing information, and a web site with downloadable tools."

This approach, she says, keeps everyone in the cohort engaged. "It’s very complicated to try to do this, but clearly there were improvements, and we’re very definitely pleased with the results."

There were several keys to success, Davis says.

"You teach the teams they can’t just add on to the system; they have to redesign it, and we teach them how to do it," she explains. They are taught, she says, to be efficient, plan ahead, and reach out and not wait for disaster to happen. "This is a whole different way of thinking."

The teams were provided with a structure; each of the clinic settings had teams comprised of representatives from administration, physicians, and nurses. Implementation was based on a chronic care model with evidence-based principals. "The team members did not have to grope around; we gave them something that would work for them," Davis notes. The approach is based on incremental improvement, she explains. "You try it with one patient; if it works, you go, and so on. All the while, you are measuring."

A learning collaborative, Davis emphasizes, "is a very powerful implementation tool." Peer pressure and peer support are key. "You know you will see them again in three months, and they’ll ask you how you did," she observes. This "all teach, all learn" approach uses a number of creative techniques, such as story boards, to share information.

The final ingredient for success, she says, was "great clinical expertise." The top endocrinologists passed on their knowledge to family physicians, and in this manner, Davis says, "raised all the boats."

The two participating teams highlighted in the second article — Olympic Physicians, a rural clinic in Shelton, WA, and The Polyclinic, a large urban specialty clinic in Seattle, also achieved impressive results, but perhaps just as important was the recognition that "You don’t treat every clinic like they’re all the same," says Donna M. Daniel, PhD, epidemiologist and project director for the process improvement support center at Qualis Health, and lead author of the article.

"You must recognize that each has a local environment that is so powerful, and a basic tool kit will not meet all needs," she adds.

At Olympic, the keys to success included understanding the importance of the chronic care model provided by Davis’ group.

"It’s an incredible framework for directing and guiding health care professionals who want to create the best care for their patients," Daniel says. "It’s very easy to grasp and to use to guide their work, and the small-scale test of change can work for any improvement you create in an organization."

The team also attributed its success to the ability to provide routine feedback. "By integrating the clinical information systems of the various organizations [through the Diabetes Electronic Management System, or DEMS], we were now able to give reports to the caring team — we could identify those patients whose hemoglobin A1c [rates] are unacceptable, who has had heart failure, and so on," Daniel says.

In addition, Olympic was able to hook up with a local hospital that had a diabetes wellness center and shared resources. "Community linkages and resources are part of the chronic care model," Daniel notes.

The other collaborative had an entirely different set of success keys. One, for example, was "an extremely vocal medical director."

"One of the things that does not get written down enough is personalities. If you have a strong — but not necessarily aggressive — individual who commands incredible respect and passion, and who demands that care be the best it can be, they can be an incredibly powerful key to an intervention like this moving forward," Daniel explains.

The promotion of collaborative methods also was considered critical. "This started with one or two docs and their patients; then we rolled it out to the other docs who had not been so enthusiastic," she points out. "This spread of practitioners can be very motivating."

The partnership with a health plan provided significant financial and staff support. "DEMS is one of the resources that needs to be provided," Daniel adds. "But for it to be a viable option, you need to have someone enter the data in for the patient — from paper to electronic — and this can be time-consuming. Many clinics got creative; they used reception staff when times were slow to enter chart information. They used folks from local colleges; nurses would come in on weekends, as well as physicians. In this situation, the health plan partnering with the clinics ponied up the necessary funds."

Later, she explains, the clinics figured out ways to get grants from pharmaceutical companies to fund data extraction.

Strong on model

Daniel also is a strong supporter of the collaborative model. "The face-to-face meetings provide opportunities for people to develop trusting relationships," she says. "During these meetings, teleconferences, and e-mails on a daily basis, and creating story boards — all these modalities for sharing create a situation where the most change and improvement can occur."

Is this model replicable anywhere else? "That’s the overall message," she says. "It’s hard to participate in national collaboratives, but we did it on our level with minimal registration fees, much less travel, and we tried to minimize time out of the office by having meetings on Mondays and Tuesdays. We were able to realize results similar to those of the national collaborative, and we believe it can be replicated."

In fact, she says, the Washington group went to the Centers for Medicare & Medicaid Services and told it they thought the model could be replicated in a quality improvement organization (QIO) program. "Currently, over 100 IHI-like collaboratives are being reported from the QIO community on statewide and regional levels," Daniel reports.

[For more information, contact:

  • Donna M. Daniel, PhD, Qualis Health, P.O. Box 33400, Seattle, WA 98133. Phone: (206) 364-9700 #2376. E-mail:
  • Connie Davis, ARNP, MN, Associate Director, Clinical Improvement/Improving Chronic Illness Care, Center for Health Studies, 1730 Minor Ave., Suite 1600, Seattle, WA 98101. Phone: (206) 287-2900. E-mail: Web site:]