NIATx tools translate to primary care settings, increase referrals for specialty care

NIATx users have found that the NIATx model works with any aim in any organization looking to improve its systems, no matter who the customer or the type of service provided.

That’s proving to be true for Dr. Yao Liu, Assistant Professor, Department of Ophthalmology and Visual Sciences and Director of the UW Teleophthalmology Program at the University of Wisconsin School of Medicine and Public Health. “We’re using the NIATx model to implement best practices and innovative solutions to increase the use of teleophthalmology for diabetic eye screening.”

Dr. Liu attended the Spring 2017 NIATx Change Leader Academy to build her knowledge of the NIATx model.

Change Project Goal: Increase diabetic eye screening in a rural health system

Dr. Liu selected a specific healthcare system for her NIATx change project: The Mile Bluff Medical Center in Mauston, Wisconsin, which serves a rural population covering six counties. “We see a high incidence of diabetes among rural patients, who tend to have more chronic conditions and less access to care,” says Dr. Liu.

Diabetic eye disease is the leading cause of blindness among working-age adults. Anyone with diabetes is at risk, and that risk increases over time. The American Diabetes Association recommends yearly diabetic eye screening. An eye doctor can perform this screening, but it can also be completed through an eye photo test (i.e. teleophthalmology). Currently, only 50 percent of Americans with diabetes are getting their eye screening exams.

Dr. Liu’s change project is working to increase referrals from the Mile Bluff Medical Center primary care clinics for diabetic eye photo tests. Patients seeing their primary care doctors can have the eye photo taken in the primary care clinic. The images are then sent to eye specialists at UW Health in Madison to determine who may need further eye care.

The overall goal of the change project is to increase the referrals for eye photo screening to 300 per year, or 25 per month. 

Meetings Secure Buy-in  

Dr. Liu recruited volunteer providers and staff from the primary care clinics; 20 responded and agreed to attend a series of three meetings designed to engage the primary care clinical staff and leadership. These carefully planned meetings followed an established agenda, with a designated leader and specific time limits outlined for each agenda item. Dr. Liu also enlisted the help of a professional facilitator, Deanne Boss MS, from the Wisconsin Research and Education Network. “Having a third-party facilitator lead the meetings helped ensure that everyone felt ownership of the outcome of the meetings,” says Dr. Liu.

Clinic leaders showed their buy-in for the project by blocking off the clinic schedule during each hour-long meeting so that there was no competition with patient appointments and ensured excellent meeting participation. Agendas were emailed in advance of the meetings so attendees knew what to expect at each meeting.

At the first meeting, the group brainstormed and prioritized challenges to eye screening; the following meetings focused on opportunities and strategies to increase screening.

See the NIATx Resource Center:

Forms and Templates

Sample Agenda for First Change Team Meeting

NIATx Tools Lead to Decisions and Action Steps 

Dr. Liu credits two of the essential NIATx tools, the Nominal Group Technique and flowcharting, with helping their  group develop ideas for PDSA Change Cycles.

“Both tools helped make everyone’s voice heard,” says Dr. Liu. “As a result, every meeting generated a decision and an actionable item. Participants felt a real sense of accomplishment and participation.”

Initial results

The project is on track to meet the goal of 300 eye photo referrals in one year.

“While 300 seemed like a big number, I translated this into more doable terms by asking all primary care providers to refer one or two patients per month,” explains Dr. Liu. “With just the engagement from our planning meetings, we’ve already seen a four-fold increase in referrals.”

In fact, as of the second quarter of 2017, the number of monthly tele-ophthalmology referrals have already more than doubled over the previous year.

The group will continue to meet via monthly teleconference, to review results of PDSA cycles.

Once the change project goal is met, Dr. Liu plans to create new clinical champions at each Outreach clinic for the eye photo screening, so that these leaders can continue and are recognized for the good work they are doing. She’s also working on creating a statewide teleophthalmology network to increase access to diabetic eye screening.    

Dr. Liu’s experience demonstrates using the NIATx model for integrating other preventive services into primary care settings.

“The NIATx model was critical for our successful engagement of busy clinic providers and staff in process change,” she said.