Primary Care Population Health Improvement Work

The mission of Stanford Health Care's Primary Care and Population Health department is to serve the community through caring, learning, and innovation for the whole person through all stages of life.

Situation

Increasing Quality and Performance

At the start of 2017, Stanford’s primary care department was underperforming in four critical measures that related to quality of care and medication safety compared to the national benchmark.

HgA1c screening rate of diabetics - 33%
Nephropathy screening rate - 25%
Renal function testing for patients on ACE/ARBs - 50%
Renal function testing for patients on diabetics - 50%

Background

Quality Improvement

The primary care department strives to be a national leader in delivering high quality care, using 16 care measures to compare our quality vs other organizations. Using HEDIS benchmarks, the primary care department can ascertain its performance relative to the leading organizations. The department’s quality improvement group was tasked with improving upon one measure in which they were underperforming in. Instead of selecting one, they took on all four measures.

Impact

Leveraging Technology

Developing brand new processes, protocols, patient search algorithms, IT tools, and an outreach model, the quality improvement group brought each of the four measures to a sustained 95th percentile performance level relative to the national benchmark. Using our new outreach model the department cut down on provider and medical assistant work, increase patient engagement, and realize a cost savings relative to the previous decentralized process.

Conclusion

Timely and Effective Care

Patients are now sent a reminder prior to becoming overdue for lab monitoring tests critical to their care. The process outcome further validates the concept that utilizing a combination of data analytics and a team-based approach to delivering health care is critical in ensuring timely and effective care. Additionally, the data-gathering and outreach process has considerably enhanced continuity of care between SHC and other organizations. These improvements advance Stanford’s mission to be a national leader in delivering high quality care.

Jimmy Dang, BSN, RN, Population Health Nurse & RN Case Manager, presented the Primary Care and Population Health improvement work at the Institute for Healthcare Improvements (IHI) National Forum on Quality Improvement in Health Care in Orlando, Florida in 2017.

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Contributed by:

Jimmy Dang, BSN, RN