A quality improvement committee based at a primary care clinic wishes to improve screening and follow-up of patients with obesity. Currently, 30% of patient encounters include documentation of BMI, and 10% of patients with BMI ≥30 kg/m² are scheduled for weight management follow-up appointments. The committee sets a goal to increase BMI documentation to 40% and BMI follow-up to 30% in 3 months. It decides to test the effectiveness of a clinical decision support tool in achieving this goal. The tool is designed for clinical providers and integrated into the electronic medical record; it includes a BMI calculator and a prompt to arrange follow-up when BMI is ≥30 kg/m². An email introducing the tool and its purpose is circulated to all clinical providers. Three months after implementation of the tool, the committee analyzes patient charts to determine changes in obesity screening and follow-up. They find that obesity documentation now occurs in 32% of patients and that follow-up is arranged for 12% of patients with BMI ≥30 kg/m². The clinic's providers report that, while the tool functions properly, they often overlook it because patient vital sign measurement, including weight, and arrangement of follow-up appointments are typically part of medical assistant workflow. Which of the following is the most appropriate subsequent action?

Question

Quizplus · Accepted Answer

Explanation: This quality improvement intervention sought to improve BMI documentation (to 40%) and follow-up (to 30%) by implementing a clinical decision support tool. However, chart analysis, representing the "Study" step of the Plan-Do-Study-Act (PDSA) paradigm, indicates the process failed to reach targets (eg, increase of only 2%) after 3 months. Provider feedback suggests that the tool may have performed poorly because it focused on clinicians rather than medical assistants, who collect BMI data points (eg, weight and height intake) and schedule follow-ups in this clinic. The next PDSA step, "Act," involves responding to lessons learned in the "Study" step to refine the intervention. In this case, the best action is to respond to provider observations by training and involving medical assistants in use of the tool. The tool should then be retested (ie, initiating a new cycle starting from "Plan") to assess whether the modified intervention improves the intervention's ability to reach specified goals. (Choices A and D) PDSA emphasizes an incremental approach that builds upon previous experiences to improve (rather than immediately discard) an intervention. Therefore, it is premature to discard this tool now or revise goals, as only one cycle has been completed, some improvement (ie, of 2%) was achieved, and no modified versions have been retested. Moreover, the current goals are already specific (eg, defined percentage increase over specified time frame). The tool should first be retested with modifications that address lessons learned (eg, lack of assistant involvement). (Choice B) Increasing clinician alerts is unlikely to improve the intervention because it does not address assistant workflow and may increase risk of alert fatigue. (Choice C) Retesting the tool without modifications that address lessons learned is unlikely to generate further improvements. Educational objective: As part of the Plan-Do-Study-Act paradigm of a quality improvement intervention, following implementation and assessment, the intervention should be refined based on lessons learned and subsequently retested. References: Applying the Plan-Do-Study-Act (PDSA) approach to a large pragmatic study involving safety net clinics. (http://www.ncbi.nlm.nih.gov/pubmed/28629348)

A Quality Improvement Committee Based at a Primary Care Clinic