Quality improvement project to improve providers' goal-setting activity for chronic disease self-management.

Background: Patient-centered medical home (PCMH) places patients at the center of care and actively considers patients' goals, preferences and skill levels in caring for their disease while developing a care plan. We implemented a quality improvement (QI) project to improve internal medicine resident goal-setting activity with patients for chronic disease self-management.

Methods: The plan-do-study-act (PDSA) model was used and a root cause analysis was conducted with internal medicine residents (n=20) and faculty (n=7) to identify barriers to patient goal setting. Two main causes were identified - lack of awareness and lack of knowledge about where and how to set patient goals in the electronic medical record (EMR). Reminders during daily morning huddles, discussions with faculty, educational video presentation and organizational policy change interventions were implemented in four serial PDSA cycles.

Results: The goal setting activity documentation rate by resident providers increased to 14% following inclusion of patient goal setting reminders during daily morning huddles. There was notable increase in the goal setting documentation rate to 29% following discussion in faculty meeting. The goal setting documentation rate remained the same (29%) despite educational video and policy change intervention. However, goal setting documentation rate increased to 33% by the end of the study.

Conclusion: Our QI project resulted in a measurable increase in the use of methods of healthcare delivery associated with improved outcomes. This model worked well in our setting, and sharing our success may benefit others seeking to achieve similar goals.