Battling through DSMES Accreditation with S.M.A.R.T. GOALS, Documentation,

and Quality Improvement Suzanne Higginbotham, PharmD, BCACP

Disclosures

• I, as the presenter of this material, have nothing to disclose relative to the content of this presentation

Learning objectives

• At the end of this session, the learner will be able to: • Develop S.M.A.R.T. behavioral goals for patients in diabetes self-management

programs with measurable follow up parameters

• Develop accurate and concise patient care documentation using a patient case example for both initial and follow-up care.

• Define continuous quality improvement (CQI) and explain the CQI process as it relates to DSMES

• Differentiate quality improvement programs and strategies for best practice utilization in DSMES programs

Developing S.M.A.R.T. Behavioral Goals for Patients in DSMES

What is a S.M.A.R.T. goal

• A goal is the object of a person's ambition or effort • An aim or desired result

• A S.M.A.R.T. goal is defined as one that is specific, measurable, achievable, results-focused, and time-bound

S.M.A.R.T.

What is a S.M.A.R.T. goal

• SMART goal setting brings structure and trackability into patient care

• In place of vague resolutions, SMART goal setting creates verifiable trajectories towards an objective, with clear milestones and an estimation of attainability

• Every goal or objective, from intermediary step to overarching objective, can be made

S.M.A.R.T. goal setting: Specific • Ask your patient what he or she wants to achieve?

• Questions to ask when goal setting with your patient are • What exactly do you want to achieve?

• Where?

• How?

• When?

• With whom?

• What are the conditions and limitations?

• Why exactly do I want to reach this goal?

S.M.A.R.T. goal setting: Measurable • Identify the measurable elements of the goal with the patient

• Providing concrete evidence of goals with your patient helps to frame the goal and help the patient work toward the goal

• Measuring the goal also helps to keep the patient on track and evaluate progress

S.M.A.R.T. goal setting: Attainable

• Investigating whether the goal really is acceptable to the patient

• Must be achievable by physical, emotional, and financial means

S.M.A.R.T. goal setting: Relevant

• Evaluate if the goal is relevant to the patient

• Baseline assessment of diabetes knowledge and motivation to change is important step in this section of goal setting

• The main questions to ask in this step is • Why do you want to reach this goal?

• What is the objective behind the goal?

• Will this goal really achieve that?

S.M.A.R.T. goal setting: Timely

• Make a tentative plan at each session and end goal

• Keep the timeline realistic and flexible so that patient morale is kept high

• Remember that goal achievement for the program is not patient success with objectives but rather patient completion

• There are no failures, rather attempts at success

GOAL TIPS

• S.M.A.R.T. goals should include the ACTION STEPS • AADE7 are not Goals

• Examples • “Patient will lose 5% of total weight in 6 months”

• ”Patient will decrease total cholesterol to 200mg/dl by end of program”

• Avoid making goals FOR your patient

• Involve patient in decision-making

• Goals should begin with “I will”

• Consider making a goal worksheet for your patient on visit #1

Examples of S.M.A.R.T. Goals

• “I will decrease caloric intake by 300 calories every day by decreasing bread consumption”

• “I will Increase activity by walking 15 minutes 3 days per week, take the stairs, park farther away”

• “I will check blood sugar 1-2 times per day, record results, and keep a journal”

• I will take the right amount of medication that was prescribed to me at the right time and learn how my medication works and what the side effects are”

Let’s Practice!

Developing Accurate and Concise Patient Care Documentation

Documentation of the Patient Visit

• If it isn’t documented, it isn’t done!

• Be sure to document • In a consistent way

• With each patient visit

Purposes of Documentation

• Serves as a record of what has been done

• Evaluates patient progress

• Legal requirement

• Billing purposes

• Form of communication among health care professionals

• Enhances continuity of care

• Standardizes the process of care

• Demonstrates value of DSME services

Types of Documentation

• There is no one standardized approach for documentation across all practice settings

• Formats may be • Structured

• Unstructured

SOAP NOTES

• Subjective, Objective, Assessment, and Plan

• Includes information pertinent to the patient interview

• Widely used in a variety of clinical settings

• May not be used when providing recommendations only to other healthcare providers

Parts of a Documentation Note-Subjective

• Information from patient perspective • Chief complaint (CC)

• History of present illness (HPI)

• Past medical history (PMH)

• Medication use and history

• Allergies

• Social or family history (SH or FH)

• Review of systems (ROS)

Parts of a Documentation Note-Objective

• Data that can be measured objectively • Vital signs

• Blood pressure, heart rate, respiratory rate, temperature, weight, height

• Screening results

• Risk assessment

• Laboratory test results • CBC, CHEM-7, Lipid panel, INR, serum drug concentration

• Findings from other tests

Parts of a Documentation Note-Assessment and Plan • Summarizes the pharmacist’s evaluation

• Current status of patient

• Based on subjective & objective data

• Provides rationale for plan

• Goals set utilizing evidence based medicine (and referenced)

Take Away Pearls

• Track at least one S.M.A.R.T. goal with follow up and measured achievement for each patient

• Document at least 1 clinical outcome measure to evaluate the effectiveness of the educational intervention

• Communicate goals, recommendations, and education provided to patient back to referring provider with each visit

• Consistently document each patient visit using a structured template in your facility health record platform

Define continuous quality improvement (CQI) and explain the process as it relates to DSMES

Standard 10 in DSMES Accreditation Materials

• DSMES providers must have a procedure in place to collect, aggregate, analyze, and report clinical and process outcomes and behavioral goal achievement

• Evidence of this achievement needs to be submitted at the time of application • Process outcomes

• Clinical outcomes

• Behavioral outcomes

Continuous Quality Improvement (CQI)

• Systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups

• The Institute of Medicine (IOM) defines quality in health care as a direct correlation between the level of improved health services and the desired health outcomes of individuals and populations

Goals of CQI in DSMES

Three fundamental questions should be answered by the CQI project 1. What are we trying to accomplish? 2. How will we know a change is an improvement? 3. What changes can we make that will result in an improvement?

QI Principles

• A successful QI program should incorporate the following four key principles • QI work as systems and processes

• Focus on patients

• Focus on being part of the team

• Focus on use of the data

A CQI Model: Plan-Do-Check-Act

• A four-step model for carrying out change

• The PDCA cycle should be repeated with each CQI project or cycle as a planning tool

PDCA

• Plan: Recognize an opportunity and plan a change

• Do: Test the change

• Check: Review the test, analyze the results and identify what you’ve learned

• Act: Take action based on what you learned in the study step. If the change did not work, go through the cycle again with a different plan. If you were successful, incorporate what you learned from the test into wider changes. Use what you learned to plan new improvements, beginning the cycle again

Example of DSMES CQI Project

• Plan : Many of our DSMES participants have Low HDL and High LDL. We plan to implement revisions to improve DSMES participants’ lipid values.

• Do : In attempt to increase HDL and decrease LDL levels the team reviewed current service’s resources and added a DSMES that addresses foods to avoid that have trans fats or are high in saturated fat and cholesterol and foods to incorporate in their meal planning that are rich sources of soluble fiber, omega 3 fatty acids and plant stanols/sterols. Each participant completed the “Eat My Way to a Healthy Heart” activity sheet that included selecting at least 2 meal planning changes to help move their cholesterol values toward their target. A cholesterol tutorial was also shown on the waiting room television.

Example of DSMES CQI Project cont.

• Check : We will be monitoring the HDL and LDL levels on a quarterly basis

#of Part. (Pts.)

#Pts HDL Goal of >50

% Pts meeting HDL Goal of >50

#Pt. LDL Goal

of <100

% Pts meeting LDL Goal of <100

Baseline 62 42 68% 2 35%

Quarter 1 53 37 70% 2 43%

Quarter 2 48 39 81% 2 44%

Quarter 3 65 56 86% Reported on App. As Lipids

3 55% Reported on

App As

Other/LDL

Example of DSMES CQI Project cont.

• Analysis of data: • The DSMES service application reflects the reporting period was 3

months = Quarter 3.

• HDL Normal Value >50 DSMES service goal = 75%

• Pts at goal for 3rd quarter = 86%

• LDL Normal Value <100 DSMES service goal = 75%

• Pts at goal for 3rd quarter 55%.

• The DSMES service outcomes for both LDL and HDL are both moving in the target direction as one would want a QI project and outcome data to do, however the LDL outcome is still not meeting target

Example of DSMES CQI Project cont.

• Act: Based on the results, the team plans to implement other revisions to assist the participants with meeting their cholesterol goals. • Add to medication portion of the curriculum and interactive activity that

addresses participants consistently taking their statin as prescribed (adherence parameters and follow up)

• Adapt motivational interviewing method so participants can make their own S.M.A.R.T. goals in first meeting time

Take Away Pearls

• Have one procedure in place to collect aggregate patient data (a process, clinical measure, or behavioral outcome) in order to analyze and report continuous quality improvement

• Follow the PDCA cycle using a template (available on the PPA toolkit)

• Submit with Standard 10 in the application packet

• Continue your quality improvement cycle yearly and involve your DSMES team in the process

Questions????