Since July of last year, Shifali Arora, MD, an assistant professor of medicine and the vice chief of clinical operations in the Division of Gastroenterology and Hepatology, has been working on a VCAG (Value Care Action Group) project to improve the efficiency of inpatient endoscopy. To date, the project has yielded several valuable tools that are working to improve the colonoscopy prep order sets in Epic, communication among care teams, and patient education.
“One of the main modifiable reasons we have to push a patient’s procedure to the next day is poor colonoscopy prep,” Arora explained. “We’ve been considering some of the issues that can contribute to, or impact, a poor prep. Although there are many variables we can’t control, there are several things we can adjust to improve the patient experience.”
Order Set in Epic
An order set is a systematic way to order all of the necessary components associated with effective clinical care, for taking care of a patient. Order sets have been shown to improve outcomes and adherence to evidence-based guidelines, along with enhancing both patient care and the provider experience.
Arora partnered with Caroline Barrett, MD, a gastroenterology fellow, to review the current prep order set and create an optimized version. Key stakeholders reviewed the draft order set and provided feedback. This version is being piloted with two medicine services. Every two weeks, when new residents come on service, they are sent an email on how to access the orders and are given a specific order combination to use when they are helping a patient prepare for their colonoscopy. So far, they have been able to get feedback from residents and made modifications.
“We have seen improvements in the preps,” Arora added. “We are planning on retrospectively reviewing cases to gather data on the quality of preps. We have seen that when the older Epic order set is used, anecdotally the preps have not been as clear. We think this is because the volume of prep recommended is lower than what we use in the outpatient setting.”
Checklists for Team Communication
Another aim of the project is to bolster team communication via improved pre- and post-procedure checklists. The checklists are meant to help clinicians assess and follow care guidelines that are appropriate for each patient. For instance, the checklists are used to notify the team when to stop and start a blood thinner, and when to order a prep, medication, or lab work.
Sonia Abichandani, MD, and Joshua Hudson, MD, MSc, two gastroenterology fellows, have worked on this and created two new checklist templates, one used prior to the procedure and one that provides post-procedure guidance. Now, Arora and the team are trying to come up with the process to standardize use of the new checklists, and then get buy-in from the fellows and the fellowship director to make sure that it meets the needs of the consult services.
The third aim of the project focuses on patient education. The goal was to create an educational tool to help guide patients through their prep.
Rachel Swier, a fourth-year medical student, visited Arora’s clinic and spoke with patients who had undergone colonoscopies. Patients were asked to evaluate their current outpatient preparation instructions to determine what information they would have liked to know but did not, and what information was not as clear as it could have been.
After collecting patient feedback, Arora’s team created their own educational booklet, complete with photos of what patients should expect, more detailed descriptions, and words that are easier for patients to understand. They have also created a Spanish version of their booklet.
“We were just able to get permission and a budget to get it printed,” said Arora. “Our goal is that our educational booklet will be more widely distributed and can be given to any patient that is having an inpatient colonoscopy. We are using them on a few floors right now to get feedback from the nurses and fellows who are speaking to patients.”
About Value-Care Action Group
VCAG encourages the review of current practices, looking for improvements for high-value outcomes in healthcare. High-value is defined by the quality of patient-centered care achieved per unit of cost, derived from measuring health outcomes against the cost of delivering the outcomes. Ron Falk, MD, chair of the department of medicine, created the Value-Care Action Group (VCAG) in 2016 and appointed value-care champions in each medicine division. VCAG projects have included the outpatient diuresis clinic, the inpatient diabetes management service and a patient education initiative that has improved care for cancer patients while reducing unnecessary visits to the ED. New VCAG awardees and projects for FY-2022 were recently announced. Scott Keller is the director of business development keeping the team focused on value-oriented care models. Darren DeWalt, MD, serves as medical director for the team and helps define the projects. John Vargas is the project manager.