Current Performance of a Process

Promote screening and early detection of metabolic syndrome in patients with schizophrenia

Strategies to Sustain

Dr Poornima, Dr Lee YW, Ms Vicki Lee, Dept of Community Psychiatry, Institute of Mental Health

Results

Mission Statement To improve complete screening for metabolic syndrome in all patients in Annual Review Clinic for with a diagnosis of schizophrenia without pre-existing diagnosis of Diabetes, Hypertension or Hyperlipidaemia managed by Community Psychiatric Department at Community Wellness Clinic, Queenstown IMH over the next 6 months (Oct 2015 to Apr 2016) from 3 per cent to 50 per cent

Evidence for a Problem worth solving Metabolic syndrome affects 20-25% of the world's population • Associated with ↑ risk of complications like stroke, heart disease • Twofold increase in likelihood of death • Patients with schizophrenia are found to have ↑ insulin resistance, impaired glucose tolerance and ↑ intra-abdominal fat vs. controls (Papanastasiou 2012), associated with ↑ risk of diabetes mellitus by 2-3 times independent of anti-psychotic drug use (de-Hert 2009) • Anti-psychotic medications contribute to ↑ risk of metabolic syndrome.

Team Members

Flow Chart of Process

Cause and Effect Diagram

Pareto Chart

Implementation and Problems Faced

Name Designation Department Leader Dr Poornima Gangaram Consultant Community Psychiatry Members Ms. Reena Poo Case Manager

Nurul Shireen Executive (CWCQ) Operations Ms. Vicki Lee Senior Staff Nurse Community Psychiatry Mr. Chee Kok Seng Senior Pharmacist Community Psychiatry Ms. Lalitha Health Care Assistant IMH Dr. Lee Yu Wei Medical Officer Community Psychiatry

Sponsor Dr Lee Cheng VCMB Community Psychiatry Facilitator Susan Lim Associate Director Operations

40.0

70.0

90.0100.0

0

20

40

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02468

101214161820

Difficult to identifypopulation who

needs sreening forMS.

Short consultationand documentation

time

No way of ensuringbloods tests are

completed

No f/u on patientswho default bloodtest appointment

Perc

enta

ge

Num

ber

of V

ote

Main Concerns

Reasons For Incomplete Screening

CAUSE / PROBLEM (refer to Pareto

Chart)

INTERVENTION PDSA cycles

1. Waist circumference done only at ARC

Doctors to write WC on appointment card for patients meeting inclusion criteria.

PDSA 1a. Doctors in CWCQ informed to write WC on the card. No difference at all.

Waist circumference to be done on most visits and to be done following Blood pressure measurement

PDSA 1b – 15 Feb 2016 PSAs not expected to measure WC on busy days since WC does not change and it is recorded every 6 months; good if staff could record WC when BP is taken (as a CPIP intervention) Study – on sample size-significant improvement in waist circumference measurement leading to improvement in measuring all four parameters.

Creating a visual prompt explaining ill-effects of MS – to improve screening for Blood tests.

PDSA 2a – 8 Mar 2016 Further RCA was done as there is no improvement. Patients have long TCU timeframe. When patients come for blood tests, if blood test has been ordered, intervention is not working.

Education and informing doctors within CWCQ to pay attention to visual prompts.

PDSA 2b – 10 Apr 2016 To wait ≥ a month to assess effectiveness of intervention (bearing in mind long TCU timeframe); to capture ordered blood tests Improvement is in progress-Sustainable in the long run

2. Difficult to identify patients

- Obtain list of patients with inclusion criteria from ARC register by contacting IPACE coordinator-Ms. Esther. - Tidy up patient list - Get hold of future appt/date/time to target patients eligible for metabolic syndrome

PDSA 3a. Contacted IPACE coordinator by phone and email (31 Aug 2014) Conclusion: Retain patient list, need to tidy up PDSA 3b. Nurse/PSA to look through electronic case notes for all patients in the list. Conclusion: Nurses not required to input manually for all patients (exclusion criteria)

3. Short consultation and documentation time with Doctors

To work on the patients meeting the inclusion criteria from the list. PSA will usually call patients 3-5 days in advance Please refer to the intervention steps detailed in previous slides.

PDSA 4a. Nurse/ PSA delegated to call patient from list at least 3 days in advance from 7th October 2015 – Problem: Not in chronological order; causing delays in calls Conclusion: To arrange patient list in chronological order by appt date

4. Between 25% -40% of patients were not contactable

Nurse/PSA leave a note for doctors in case notes for (i) Educating patients (ii) Ensuring blood tests are ordered for the next appointment

PDSA 4b – 19 Jan 2016 onwards Nurse to leave a note for doctor to request blood tests for next appointment. Conclusion: To continue to document in case notes and to monitor if doctor has taken action

Phase 1 CPIP

Phase 2 CPIP

Cost Savings Prevention of diabetes or delaying the onset of diabetes/hypertension/hyperlipidaemia and associated complications • Reduces medical/insurance costs • Economical savings for institution/government

• Nurse/PSA to continue working on patient master list • Nurse/PSA will book appointments in SAP for next due date to ensure the parameters will done on a yearly basis • List to be updated on a monthly basis

Baseline data

Overcrowding at parameters counter

One-man show

Chart1

All 3%

BP-96%

FBG-33%

FL-37%

WC-14%

No of pts completed screening tests for Metabolic syndrome

Percentage of patients meeting our inclusion criteria completed screening tests for Metabolic syndrome

0.03

0.96

0.34

0.27

0.14

Sheet1

Screeening tools for Metabolic syndromeNo of pts completed screening tests for Metabolic syndrome

All 3%3%

BP-96%96%

FBG-33%34%

FL-37%27%

WC-14%14%

To resize chart data range, drag lower right corner of range.

All

Chart1

Difficult to identify population who needs sreening for MS.Difficult to identify population who needs sreening for MS.

Short consultation and documentation timeShort consultation and documentation time

No way of ensuring bloods tests are completedNo way of ensuring bloods tests are completed

No f/u on patients who default blood test appointmentNo f/u on patients who default blood test appointment

Vote

Cum %

Main Concerns

Number of Vote

Percentage

Reasons For Incomplete Screening

16

40

12

70

8

90

4

100

Data

VotePercentageCum %

Difficult to identify population who needs sreening for MS.1640.040.0

Short consultation and documentation time1230.070.0

No way of ensuring bloods tests are completed820.090.0

No f/u on patients who default blood test appointment410.0100.0

40100

Sheet2

Sheet3

Chart1

All 63%

B.P 100%

FB-75%

WC-77%

No of pts completed screening tests for Metabolic syndrome

Percentage of patients meeting our inclusion criteria completed screening tests for Metabolic syndrome

0.63

1

0.75

0.87

Sheet1

Screeening tools for Metabolic syndromeNo of pts completed screening tests for Metabolic syndrome

All 63%63%

B.P 100%100%

FB-75%75%

WC-77%87%

To resize chart data range, drag lower right corner of range.

All

Slide Number 1