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A novel, multi-dimensional protocol named GENIE has been in use for intensive insulin therapy (IIT, target glucose

The Diabetes Clinic at VA Pittsburgh has been redesigned through an innovative systems-oriented approach to delivering integrated, multidisciplinary diabetes care founded on Principles of Perfecting Patient Care (PPCSM), which derive from Toyota Production Systems’ methods. The four elements of PPCSM (highly specified work content and sequence, unambiguous work flow connections, predefined pathways, and continuous process improvements based on scientific method) are incorporated into a model for delivering integrated multidisciplinary patient-centred care calibrated to each individual patient’s abilities, needs, preferences, and goals. The model, which we term the “Individualized Multidisciplinary Team-Care Model”, provides all the essential care elements in a multi-provider clinic visit comprising four sequential 15 min encounters with four providers possessing specific skills in DSME, MNT, BP and Lipid Management, and Glycaemic Management. Ongoing collaborative dialogue ensures that interventions are coordinated, calibrated to patient need and aligned with risk stratification. Documentation of all required care components is assured by templated component notes, which are assembled into a single, integrated, multiple-provider visit note in the electronic medical record. The clinic redesign has achieved unprecedented success, with 100 % documentation in all ADA specified process-of-care domains in diabetes care (HbA1c, LDL, blood pressure, annual creatinine and urinary microalbumin levels, annual foot and eye exams, and aspirin and statin use/contraindications/alternatives). It has also achieved significant improvements in HbA1c (decreased by 0.6 %), LDL ( 130 mmHg, or LDL >100 mg/dl there was documentation of action to intensify therapy, or the reason for inaction. The redesigned model can be adapted to a variety of needs, ranging from basic diabetes management, through more complicated management strategies, all the way up to the most advanced strategies for patients on insulin pumps. It delivers care that is both comprehensive and effective by combining the advantages of the established models (coordinated care emphasizing DSME and MNT of Group Visits and individualized attention in the Single Provider-Patient dyad) while eliminating their disadvantages (the impersonality of Group Visits and the fragmented inefficiencies of the Single Provider-Patient dyad).

Objective.To identify characteristics of encounters between healthcare workers (HCWs) and patients that correlated with hand hygiene adherence among HCWs.Design.Observational study.Setting.Intensive care unit in a Veterans Affairs hospital.Participants.HCWs.Results.There were 767 patient encounters observed (48.6% involved nurses, 20.6% involved physicians, and 30.8% involved other HCWs); 39.8% of encounters involved patients placed under contact precautions. HCW contact with either the patient or surfaces in the patient's environment occurred during all encounters; direct patient contact occurred during 439 encounters (57.4%), and contact with environmental surfaces occurred during 710 encounters (92.6%). The median duration of encounters was 2 minutes (range, 1 to ≤2 minutes, 51.1% after encounters of >3 to ≤5 minutes, and 64.9% after encounters of >5 minutes (P < .001 by the x2 for trend). In multivariate analyses, longer encounter duration, contact precautions status, patient contact, and nursing occupation were independently associated with adherence to hand hygiene recommendations.Conclusions.In this study, adherence to hand hygiene practices was lowest after brief patient encounters (ie

Objective.To measure the effectiveness of an industrial systems-engineering approach to a methicillin-resistantStaphylococcus aureus(MRSA) prevention program.Design.Before-after intervention studySetting.An intensive care unit (ICU) and a surgical unit that was not an ICU in the Pittsburgh Veterans Administration hospitalPatients.Allpatientsadmittedtothe study unitsIntervention.We implemented an MRSA infection control program that consisted of the following 4 elements: (1) the use of standard precautions for all patient contact, with emphasis on hand hygiene; (2) the use of contact precautions for interactions with patients known to be infected or colonized with MRSA; (3) the use of active surveillance cultures to identify patients who were asymptomatically colonized with MRSA; and (4) use of an industrial systems-engineering approach, the Toyota Production System, to facilitate consistent and reliable adherence to the infection control program.Results.The rate of healthcare-associated MRSA infection in the surgical unit decreased from 1.56 infections per 1,000 patient-days in the 2 years before the intervention to 0.63 infections per 1,000 patient-days in the 4 years after the intervention (a 60% reduction;P= .003). The rate of healthcare-associated MRSA infection in the ICU decreased from 5.45 infections per 1,000 patient-days in the 2 years before to the intervention to 1.35 infections per 1,000 patient-days in the 3 years after the intervention (a 75% reduction;P= .001). The combined estimate for reduction in the incidence of infection after the intervention in the 2 units was 68% (95% confidence interval, 50%-79%;P< .001).Conclusions.Sustained reduction in the incidence of MRSA infection is possible in a setting where this pathogen is endemic. An industrial systems-engineering approach can be adapted to facilitate consistent and reliable adherence to MRSA infection prevention practices in healthcare facilities.