In a positive environment where the entire culture challenges people to go above and beyond, and where those who do accept the challenge are recognized often and enthusiastically, it’s not too hard to keep improving a worthwhile - if imperfect - program. So says Chelsea Revoir, Quality Improvement Coordinator for HealthPoint’s Auburn (WA) clinic. “In a perfect world, our rollout of this extensive program would have come with an official ‘roll-out package,’ openly identifying barriers that we might face, and offering those solutions outright,” Chelsea admits. “It would have been preferable to begin this journey with a designated, permanent screening room, an ample number of certified photographers, and fundamental training on diabetic retinopathy for all staff members. But our staff was pioneering this program. There was no other healthcare organization in the area they could learn from.”
But who gets it perfect from the start, especially when it’s cutting-edge technology and a whole new program and skill set for staff? While HealthPoint Auburn had to learn as they went, their quality data now show they have, indeed, learned how to manage a successful Diabetic Retinopathy (DR) screening program. And they have lessons learned and innovative approaches to share.
In 2012, when Community Health Plan of Washington (CHPW), a nonprofit organization founded by local community health centers, offered to place portable digital retinal cameras in its member clinics to screen for DR, HealthPoint Auburn Medical clinic volunteered to go first. Five years later, now systematically screening 65% of its 775 diabetic patients each year, and inching toward the CHPW goal of 70%, this clinic has identified barriers, implemented creative solutions and worked out some winning policies and procedures to keep moving the needle forward.
Early Barriers to Success
When they got their digital retinal camera in November 2012, HealthPoint Auburn’s diabetic screening rate was at 28%. Their Health Center Assistant Manager, Yvonne Paschke, was trained and certified as a photographer, a trainer and the on-site administrator of the program. She, in turn, trained the two Lab MAs as photographers. As time went on, more staff were trained; now the clinic has 13 certified photographers and two more in training.
Today at HealthPoint Auburn Medical clinic, the daily photographer schedule requires two certified photographers to rotate as the retinal photographers for the day. Assigned retinal photographers are announced daily at the morning huddle and listed on the daily MA schedule which is sent to all staff. This allows staff to easily identify whom to call when a patient needs screening for diabetic retinopathy.
Another early barrier was placement of the camera, which needs a dark space for optimal performance. It sat in a procedure room or exam room, taking up needed space and necessitating a complicated schedule of the room’s availability. It would often move from place to place - not optimal.
Program leadership also realized that staff and diabetic patients were not always well informed of the importance of the retinal screening.
Got challenges? Meet Chelsea! As the Quality Improvement Coordinator at HealthPoint Auburn, Chelsea Revoir strives to implement quality process improvement workflows in order to enhance up to 30 measures in any given year. She welcomes the opportunity to execute creative, upbeat solutions. When the Wright Center’s DO Residency Program left the HealthPoint Auburn Medical clinic to start a new clinic, several of the photographers transferred to the new start-up clinic. HealthPoint Auburn’s DR screening numbers dropped significantly. Chelsea saw three avenues for recovery: Urge all interested staff to become certified photographers; educate the staff on the importance of retinal screening; and get meaningful educational materials into the hands of diabetic patients - all while continuing to identify and resolve related barriers.
Soon HealthPoint Auburn had a colorful quarter-sheet flyer with images, communicating to diabetic patients the great importance of annual retinal screening – offered in several languages.
A little nook at the end of a hallway on fourth floor was converted into a permanent home for the eye camera and screening process - a place where photographers assigned for DR screening on that day could meet patients and perform the exam. A few of the initial problems were now resolved.
Consistent, ongoing quality improvement
Within three months of that dip in screening rates, when the residency left, the clinic saw its numbers creeping back up. But nothing is perfect, right? Committed to maintain quality, Chelsea performs chart audits and meets one-on-one with the MAs to continuously find areas for improvement. One thing she discovered was that patients were not making their way up to fourth floor where the exam is performed.
As a multi-floor clinic, HealthPoint Auburn needed to create an easier flow for patient movement. Initially, the MA would simply tell the patient to head to the 4th floor for the exam – and also instruct them where to go to complete their blood draw, pick up their prescriptions, etc. When patients focused on the latter, they sometimes left the clinic without completing the DR exam.
A fairly easy solution was to make use of a special small waiting area near the lab. This helped reduce the number of patients sitting in the lobby, waiting, and/or leaving the clinic without having their retinal screening. As the lab MAs came out to get patients, they easily identified the DR screening patients and shepherded them to the screening room.
Eventually staff noticed that, once again, some patients were failing to make it to that special waiting area, so Chelsea whipped out some hot pink card stock and came up with another simple solution: She created a most visible little card for DR screening patients to carry with them in the clinic. The card reminded them where to go for their screening, but its easily identifiable appearance alerted all staff to help this particular patient find that particular waiting area. Another bump in the road smoothed out.
Everyone knows that remembering to refer every patient for every preventive screening every day, all the time, can be a huge challenge. While performing her chart audits, Chelsea noticed that physicians and MAs sometimes forgot to check on their diabetic patients’ retinal screening status. Knowing that visual cues are extremely helpful, little yellow chicks that soon perched vibrantly above each monitor – they couldn’t be ignored. The message below reminded staff to “CHICK to see if the patient is due for an eye exam!”
Not all of Chelsea’s great ideas have been wildly effective. Patients complained that retinal screenings were available only on weekdays, for example, so HealthPoint offered Saturday screenings for a few months. It was not a success; on average only three patients took advantage of the alternative screening opportunity.
Covering all the bases - daily
Still, Chelsea was ready for the next challenge, embracing every opportunity to implement an easy, reliable solution to keep the DR screening program running smoothly. She reviews all the reports from EyePACS daily, tracking follow-up for patients with abnormal exams while also keeping an eye on the quality of the retinal images as noted on the report. If she sees a trend toward “poor” retinal images for a particular photographer, Chelsea works with the Medical Assistant Supervisor, Keri Stephenson, to ensure the photographer receives another training session from the designated retinal iCam trainer, Jay Fernandez (MA2).
HealthPoint Auburn holds its photographers to high standards and creates fail safes to ensure they are performing at optimal capacity. But things can still go wrong. “Our camera might go down,” Chelsea said. “When that happens, we have workflows in place to ensure our diabetic patients are still referred to the ophthalmologist for their retinal screenings.”
Jay Fernandez, who has been with the retinal screening program since its inception, is now the photographer trainer and on-site administrator. He said, “I’m very proud of the partnership HealthPoint has with EyePACS to provide the Diabetic Retinopathy screening program together. As the main trainer, I have had the opportunity to train over 20 photographers through the past 5 years. We’ve seen significant growth in our productivity since we acquired the diabetic retinal camera. I love the fact that the patient can have an office visit and retinal exam on the same day here at HealthPoint. Patients are grateful that we relieve a lot of stress about possibly having to go elsewhere for further exams.”
Planning for future success
Chelsea added, “We inspire all MAs to become certified photographers. It’s a good challenge that moves them forward professionally, and the HealthPoint culture encourages employees to step up and accept new challenges. We make it a point to acknowledge and congratulate every retinal photographer newly certified by EyePACS.”
Today, HealthPoint Auburn Medical clinic ranks among the top ten most productive EyePACS screening programs in the nation. All creative solutions aside, another factor keeps HealthPoint driving toward success: Community Health Plan of Washington offers monetary incentives to its members who reach some fairly demanding goals. “We are proud of our partnership with HealthPoint and the success they have experienced through Community Health Plan of Washington’s Diabetic Retinal Care and training program,” says Victor Collymore, M.D., Chief Medical Officer of CHPW. “We have seen a continual increase in diabetic eye exams across the network in locations with a retinal camera since introducing the program in 2012.”
Asked how he feels about the DR screening program now, five years down the road, HealthPoint CEO Thomas Trompeter said, “We are really happy to make this service available to our patients. It is a major improvement in the quality of care that we provide. We can make a very important service more accessible and convenient for our patients, many of whom would probably not get this service if we weren’t providing it. This also helps us save money in our healthcare system, but most importantly we reduce the potential for the pain and misery caused by retinopathy.”