Ambulatory 401:Building Improvement Teams in Primary Care

WREN ConferenceNovember 13, 2009

Dr. Sally KraftStephanie Berkson

Workshop Overview The Problem Context

– UW Health

The Solution– Physician-Manager Leadership teams– Ambulatory 401 Program– Key Concepts – Applied Learning

The Results Lessons Learned

The Problem

Quality problems are everywhere, affecting many patients. Between the health care we have and the care we could have lies not just a gap, but a chasm.

IOM Crossing the Quality Chasm 2001

Urgent Need to Improve Our US Health Care System

High costs Rising costs Disparities in care Rising rates of uninsured Medical errors Growing physician dissatisfaction Variable quality

Level

A “True North”

The experience of the patient and their loved ones

B Microsystems

Small units of care delivery

C Organizations

The systems that supports small units of delivery

D Environment

Policy, payment, regulation, accreditation: the factors that shape behavior, interests and opportunities

Berwick. Health Affairs 2002

Quality Improvement:Building High Performing Frontline Teams

The quality of the microsystem is its ability to achieve ever better care: safe, effective,patient-centered, timely, efficient, and equitable. The quality of an organization is its capacity to help microsystems do that. And the quality of the environment—finance, regulation, and professional education—is its ability to support organizations that can help microsystems to achieve those aims.

Berwick. Health Affairs 2002

Context: UW Health

University of Wisconsin Medical Foundation• UW School of Medicine and Public Health’s academic group practice plan

•1,090 physicians (~300 primary care physicians)

• Wisconsin’s largest multi-specialty medical group, one of the 10 largest medical groups in the nation

• 48 practice locations

• Epic electronic health record

• Experience with quality measurement, members of the WCHQ

• Experience with design and administration of P4P

UW Health Driving Forces Organization complexity

– Multiple management structures within the same organization

Physician dissatisfaction– Not empowered to improve own practice environment– Need for structures to support delivery of quality care

High Primary Care physician turnover– Recruitment difficulties

Culture shift to local problem solving– Desire to move away from top down solutions– Desire to engage physicians in improvement efforts– Desire to create local accountability

Variable quality across primary care settings

Current UW Health Performance in WCHQ

Size of the bubble is correlated to the number of eligible patients at each organization

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UW Health Colorectal Cancer Screening Rates by Clinic

Size of the bubble is correlated to the number of eligible patients at each clinic

0%

10%

20%

30%

40%

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60%

70%

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90%

100%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Scre

enin

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UW Clinic

WCHQ Colorectal Cancer Screening Rates Measurement Period January - December 2008

UW Dane PCP (Clinics over 100 patients)

UW Overall Rate = 66.8%

UWHC Clinics UWMF Clinics

UW Health Colorectal CancerScreening Rates by Clinic

Failure to Build the System that makes it Inescapably Easy to do the Right Thing

The Solution

UW Health Strategy Establish new “lead physician” role at all clinics

– Pilot with Primary Care

Develop clinic leadership team– Partner lead physician with clinic manager

Promote key principles– Local ownership and accountability for clinical practice

within an academic context– Team based delivery of care

Enhance lines of communication– Within site, across sites, across organization

Provide new leadership teams with basic improvement knowledge and skills

Ambulatory 401 Program:Building Improvement Teams

Course Objectives Enhance and develop the physician-clinic manager leadership

team Learn to improve clinic processes & services delivered to patients Review, learn and apply performance improvement techniques Provide understanding of the UW Health structures and metrics

Physician leadand clinic manager build the leadershipteam

Build the clinic team,practice and learn performance improvement skills, solve clinic problems

Build a network of clinics to share learnings

Attendees Clinic manager and clinic physician leader

Time line: Four, 2.5 hour sessions over 6 months

Didactic training topics (including action learning during sessions): Organizational overview & strategic priorities Metrics used to monitor efficiency and quality of care Clinic improvement team approach to change Process improvement concepts, tools and techniques

Applied training: Each clinic team completed an improvement project Project results presented and shared

Ambulatory 401 Classes: 9 General Internal Medicine Clinics completed; May 2008 11 Family Medicine Clinics completed; January 2009 14 Family Medicine Clinics completed; June 2009 8 Pediatrics Clinics in progress

Ambulatory 401 Program Format

Ambulatory 401:Curriculum

Leadership skills– Overview of health care quality and the need to

improve– Model for organizational improvement– Understanding performance data– Team development– Effective meeting skills– System-based thinking

Performance improvement skills– FOCUS PDCA model

Ambulatory 401Why now?

The “good” old days Medical care was cheap Quality was not defined and

was not measured Physicians practiced

autonomously Insurance companies didn’t

exist Medical care was simple Medical care was an “art”

more than a science

Our current state Health care is expensive Quality is measured and

reported Physicians practice in large

groups, healthcare is integrated in systems

Insurance companies are powerful

Care is complicated Evidence and information are

plentiful

Kotter. Harvard Business Review 2007

Level

A “True North”

The experience of the patient and their loved ones

B Microsystems

Small units of care delivery

C Organizations

The systems that supports small units of delivery

D Environment

Policy, payment, regulation, accreditation: the factors that shape behavior, interests and

opportunities

Berwick. Health Affairs 2002

How do we get started?

Value-Added

An activity that changes the form, fit, or function of a product or service; something the customer would be willing to pay for.

Non Value-Added

Activities that do not add value to the final product or service for the customer. Given a choice, customer’s won’t pay for it.

Problem Identification What do we do that is valuable?

What do we do that isn’t valuable?

Lean Thinking (from Toyota improvement model): Seeing and eliminating waste, i.e. eliminating anything that doesn’t add value to the process

Keep Eliminate

Value Stream Map

A tool to identify non-value added steps in a process. This can be a good starting point to identify problems and their causes.

Steps:1. Define start and end points of the process2. Identify all current steps in the process, with

stakeholders3. Identify non-value steps (waiting, variation, rework)4. Validate current state process5. Create ideal value stream map (only value added

steps)

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BrainstormingA group exercise designed to generate lots of ideas. This should be fun! Get everyone involved. Encourage

creativity. Get excited!

Steps: Review the topic with the whole group Give people time to think silently about the topic Each person writes down an idea on a card—one

idea per card (or write down all ideas on a flip chart) Post the cards or flip chart papers on the wall Continue until all ideas have been recorded

Affinity Diagram

A tool to group large numbers of ideas into clusters so that patterns and categories can be identified

Steps:

1. Ideas from your brainstorming session are posted on cards on the walls

2. Silently members of the group move the cards into distinct areas on the wall. Cards can be moved multiple time, from cluster to cluster

3. After the cards have been grouped silently, the entire team identifies “headers” for each cluster

Affinity Diagram

Beginning of Amb 401,Assess your current clinic

What do youwant in your clinic?

Multiple small improvement projects,each one building from the earlierproject.

Clinic leaders keep the improvement

efforts moving forward toward the goal

Ambulatory 401

Physician leadand clinic manager build the leadershipteam.

Build the clinic team,solve problems

Build a network of clinics to share learnings

Creating the vision(brainstorming),Assessing our starting point(SWOT analysis)

Cause and effect(root cause analysis)Small tests of change(PDCA)

Shareour learnings

The Results

Ambulatory 101/401 History

2007 UWMF Ops Committee endorsed primary care clinic physician-manager leadership teams

Jan – May 2008

First Ambulatory 101 course taught to physician leaders-managers at GIM clinics (9 clinics)

Sept 2008 – Jan 2009

First ‘wave’ of DFM clinic leaders complete Ambulatory 401 (11 clinics)

Feb-June 2009 Second ‘wave’ of DFM clinic leaders complete Ambulatory 401 (14 clinics)

In Progress Pediatrics clinic leaders participating in Ambulatory 401 (8 clinics)

Results: Teams Made Improvements!

January 2009 Family Medicine class– 11 improvement projects completed

– 10 with data documenting improvements in care

June 2009 Family Medicine class

– 10 improvement projects completed

– 9 with data documenting improvements in care

Improving INR Result Times, Sun Prairie Clinic

Change Leader: Cindy Haase, Clinic Manager

Team Members: David Quoeff, MD, Joan Premo, RN, TL

Aim Statement:

We will improve timely communication of INR results to the patient with a goal of contacting the patient with the results within 4 hours or less from the time the lab results are reported for 95% of patients getting INR labs by Jan 1, 2009 focusing on:

1. Developing and implementing a protocol for RN’s to communicate med changes to patients

2. IS changing Epic workflow: All INR results going into both MD and RN Results pools

Patients Contacted w/ INR Results in 4 hrs

47%

90% 99%

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Nov 08 J an 09 Feb 09

Initial Findings:

From 47% to 90% contacted w/in 4 hrs

Follow-up Findings:

99% contacted w/in 4 hrs

Project Example

Results: Participants Found Program Valuable

88% of GIM respondents agreed that the information was helpful to their role as a clinic leader

95% of Family Medicine respondents agreed that participation has or will lead to improvements in their clinic

95% of Family Medicine respondents agreed that improvement tools presented were useful

Results: Participants Found Program Valuable

We have had QI improvement projects all along...but I learned new techniques to discover how to evaluate the current process and then to move on to designing a new process. I think we are set and will continue using the skills/methods we have learned and apply them to future problem areas in the clinic. In this way it has been helpful.

- Spring 2009 Ambulatory 401 Participant

Lessons Learned

Lessons Learned Selecting the right person is key Site participation in selection of the individual is important Video conferencing can work for some aspects but not ideal

particularly for project sharing Teams presentations are critical –teams learn quickly from

each other ---networking is enhanced Structured presentations allow for focus on work

accomplished Time and existing work loads are an issue Flexibility required –never ending conflicts for time Provides a strong foundation for all other improvement

activities Must be viewed as a long term investment –impact on

patient satisfaction, MD satisfaction, manager satisfaction, staff / MD retention, practice efficiency , communication, ownership

Opportunities Bring in the Patient. Identify strategies to bring patient input into

improvement work.

Anyone can be a Champion. Everyone within the clinic has the potential to be a change leader; champions do not have to be limited to physicians and clinic leadership.

Share Improvements. Maximize e-communication tools to share improvement work. Organize improvement projects by topic i.e. results reporting, access, care management.

Improve Together. Clinics with similar challenges and priorities could work together to develop improved processes.

Research. Critical evaluation to understand why improvement interventions succeed or fail across a range of care settings.

Challenges

Disseminating innovations and improvements

Sustaining improvements

Aligning “top down” and “bottom up” priorities

The Need to Improve….

Very seldom, under existing conditions, does a patient receive the best care

which is possible to give with the present state of medicine.

The Need to Improve is Historical

Very seldom, under existing conditions, does a patient receive the best care

which is possible to give with the present state of medicine.

The Flexner Report 1910

Very seldom, under existing conditions, does a patient receive the best care which is possible to give with

the present state of medicine.

The time to improve is now.