29AMGA.ORG FEBRUARY 2019
Over the past three decades, Type 2 diabetes mellitus (DM2) has become a leading cause of death in indi- viduals 65 years and over. According to the Centers for Disease Control and Prevention (CDC), the diabetes epidemic affects more than 29 million Americans ( 9.3%),
with an additional 86 million Americans aged 20 years or older
If this statistic isn’t alarming enough, diabetes has an
annual price tag of $327 billion, which equates to one in seven
healthcare dollars spent on treating diabetes and its complications. 1 In 2017, the Optum/AMGA rankings, available through
our participation in Together 2 Goal®, demonstrated that our
medical group, Lehigh Valley Physicians Group (LVPG), was
performing subpar for diabetes management.
This disappointing recognition drove LVPG to establish a
system-wide goal around this chronic condition to influence
performance and improve clinical management. We committed to a combined measure that reflects uncontrolled
diabetes: the percent of our diabetic patients with a hemoglobin A1c (HbA1c) greater than Level 9 or not performed in the
past year. To realize this goal, LVPG created an improvement
team, and the DM2 care pathway work began.
LVPG is a nonprofit subsidiary medical group supported
by a large integrated healthcare network, Lehigh Valley
Health Network (LVHN), serving a geographically diverse
region in eastern Pennsylvania. Incorporated in 1993, our
multispecialty group comprises more than 1,500 physi-
cians and advanced practice clinicians (APCs). We deliver
comprehensive services in more than 250 practices, which
represent 60-plus medical specialties. We provide care to
over 2. 5 million lives scattered across rural, suburban, and
LVPG employs a standard triad leadership model in our
ambulatory practices. This triad comprises a physician leader,
an office manager, and a clinical coordinator (overseeing the
clinical staff and workflows). For documentation, we use
a vendor-based electronic medical record system that is
integrated across the continuum. Analytics employing clinical
and claims data are available, leveraged through multiple
accountable care arrangements.
In designing the ambulatory DM2 care pathway, we used the
A3 Thinking and Value Stream Mapping storyboard in conjunction with a rapid improvement event (RIE) to catalyze
our process, countermeasures, and standard work (Figure 1).
While standard RIEs last five days, our triad team performed
extensive current state analysis to allow for a modified two-day event. More than 30 key members of our health network
and medical group attended the RIE.
Rush A stepped wedge dissemination model to implement a diabetic pathway
By Jennifer Stephens, D.O., FACP; Janelle Sharma, CRMP, DNP; Brian
Shablin, M.D.; Kerri Vincent; Megan Boyer, R.N., B.S.N.; Hallie Melnick, R.N.,
B.S.N.; Magdalene Cruz-Rivera, R.N., B.S.N.; and Richard Mackenzie, M.D.