Integrating Primary Care Practices and Community-based Resources to Manage Obesity

Chapter 2: Building and Assessing the Clinic Foundation

As described in Chapter 1, the elements for organizational change include leadership, data, a planning process, and resources. This chapter is about gathering data and measuring your clinic's capacity for obesity screening, brief counseling, and referral to community resources.

As with choosing the design for your bridge, you should pick the most appropriate performance assessment method for your clinic. The construction workers for the bridge are your clinic staff, and they have technical roles to play in the evaluation and change process. Along with the Clinician Champion, staff may play very specific roles, including:

  • Front Office—Distribute Waiting Room Survey and enter data; present findings.
  • Referral Coordinator—Invite specific community resources to meet clinicians, create a method of communication between clinic and community resources.
  • Clinicians/Nursing—Establish and lead Plan Do Study Act (PDSA) cycles regarding increasing assessment of weight status, documentation of diet and exercise conversation with patient, and establishment of a referral process.
  • Medical Assistants—Create Community Resource Inventory and participate in PDSA cycles.

Below, we describe three process techniques to measure these clinic attributes and provide baseline data against which to benchmark your performance over time. These techniques include conducting one or more of the following:

  1. Chart reviews or audits.
  2. Observations of practice flow and organizational behaviors.
  3. Patient surveys.

Chart Reviews or Audits

The purpose of a chart review is to establish a baseline for measurement against implemented interventional changes in screening, counseling, and referrals for obesity. The U. S. Preventive Services Task Force recommends that all patients aged 6 or more be screened for Body Mass Index (BMI). Table 1 describes BMI and obesity status.

Table 1. BMI and obesity status in adults

BMI Obesity Status
<18.5 Underweight
18.5-24.9 Normal weight
25—29.9 Overweight
>30 Obese

BMI is a proxy for human body fat based on an individual's height and weight. BMI is an individual's body weight divided by the square of height and can be determined using online calculators or printed charts. The CDC provides an online tool for calculating BMI, BMI is not a perfect measure for all people, but it is the most efficient and effective means of screening.6

The chart review is designed as a quality improvement effort. By gathering data in the chart review you can determine how well you and your practice are performing (or not performing) certain tasks as reflected in the medical record.

Tool 2 provides a step-by-step guide to conducting a chart review, including forms, chart audit key terms, and instructions. Note that as electronic health record technology advances, it may be feasible to obtain data on the clinic's patient panel by running a query.


Findings from the Chart Audit in Our Intervention 

A total of 891 patient charts were reviewed in the pre-intervention audit using Tool 2. Ninety percent (799) were included in the analysis after meeting inclusion criteria for age, time in practice, etc. Half of the audited charts were female (n = 446). When race and ethnicity data was available, 86% of the sample was Caucasian and 64% was Non-Hispanic. A total of 930 charts were audited post intervention and 801 (86%) were included in the final analysis. Demographic characteristics were similar in pre- to post- patient samples.

The number of charts where BMI was not reported or calculable significantly decreased pre- to post- intervention (61% to 32%, p = 0.0205). The number of patients with any recorded BMI in the chart significantly increased (24% pre to 65% post, p = 0.0403) and the number of patients with no recorded height significantly decreased (67% pre to 35% post, p = 0.0068). There was no significant change in the number of patients with any recorded weight (96% pre and post, p = 0.8741) or the number of overweight and obese patients with BMI class noted in their chart.

Pre/Post Comparison of Chart Audit Data Across Our Six Intervention Clinics

Chart Audit Data Pre (N = 799) Post (N = 801) P value
Number of patients with any recorded BMI 195 (24%) 522 (65%) 0.0403
BMI not reported or calculable 484 (61%) 253 (32%) 0.0205
BMI reported in audit period per patient, mean (range) 0.5 (0 – 10) 1.0 (0 – 9) 0.0689
BMI class noted in chart      
  Overweight 44 (6%) 6 (1%) No convergence
  Obese 98 (12%) 93 (12%) 0.74
Number of documented discussions per patient      
  Weight, mean (range) 0.2 (0 – 8) 0.3 (0 – 5) 0.2199
  Diet, mean (range) 0.3 (0 – 6) 0.3(0 – 7) 0.9679
  Exercise, mean (range) 0.3 (0 – 6) 0.3 (0 – 5) 0.3602


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Observations of Practice Flow and Organizational Behaviors

Participant observation allows for someone to immerse themselves in the clinic with an eye toward viewing day-to-day activities, language, and workflow. The observer can also look at how interactions occur between different patients, staff members, and clinicians over the course of an intervention. Observation involves watching, listening, and recording

Tool 3 provides a form that may be used by the observer to conduct clinic observations. We provide prompting questions that might help guide the observer. It may be useful to have an outside observer (e.g., someone who does not work in the practice routinely) conduct the observation. Having a new set of eyes can provide a less biased perception of clinic activities. Consider asking community college nursing students, Cooperative Extension professionals, nurses from the hospital, or medical students. If clinic staff conduct the observations, it is important to be aware of how past experience may influence their perceptions.

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Patient Survey

It may also be helpful to conduct a patient survey to understand what they know about obesity, their general interest in change, and their knowledge of any community resources. An anonymous survey provides your patients an opportunity to share privately about potentially sensitive topics. If you choose to conduct a survey, you will want to determine:

  1. Who should complete the survey.
  2. When and how the survey will be distributed.
  3. When and how the survey will be collected.

Tool 4 provides a sample of the survey used in our intervention. You may modify this survey for use in your clinic. This survey collects data on:

  • Patient perceptions of their health status and current health behaviors.
  • Current patient efforts on health behavior change for diet and exercise.
  • Patient-identified community-based resources.
  • Patient perceptions of the role of clinicians in weight management.

We suggest collecting the survey from about 50 patients. Larger practices or those interested in a specific population may elect to sample a larger number of patients or those with specific characteristics. We sampled from parents of young adults (12-18 years of age) and adult patients (over 18 years) because this was our target population.

Front office staff is often used to distribute surveys when patients check in. The survey should be distributed to all consecutive patients that meet your target criteria. You may want to develop a script for distributing the survey, for example:

Front Desk: Our clinic is working to help our patients maintain or establish a healthy lifestyle. It would be helpful if you could complete this survey so we can better serve all our patients.

Patient: I'd be happy to help!

Front Desk: Thank you! Please return the completed survey to the medical assistant when you go back to the exam room or to the front desk before you leave today.


Findings from the Waiting Room Survey Results in Our Intervention 

Of the 384 patients completing our baseline patient survey, almost two-thirds (64%, n = 245) were overweight or obese (BMI > 25 kg/m2). The majority of overweight or obese respondents indicated they were currently working on or intended to start losing weight (71%), eating a healthy diet (92%), or engaging in regular exercise (90%).

Although 38% of the overweight or obese patients were "interested" or "very interested" in getting help from primary care to connect with weight management resources only 20% reported that they "frequently" or "very frequently" had conversations with their clinicians about weight-related health behavior change. Patients of all weight categories indicated that primary care played an important role in providing advice on the importance of healthy weight (40%), screening for weight status (34%), asking about interest in losing weight (34%), and assisting with weight loss plans (34%).

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Page last reviewed May 2014
Page originally created May 2014
Internet Citation: Chapter 2: Building and Assessing the Clinic Foundation. Content last reviewed May 2014. Agency for Healthcare Research and Quality, Rockville, MD.