pfcc. breakout 1. helga avila. use of lean tools to advance pfcc
DESCRIPTION
TRANSCRIPT
Use of Lean Tools to
Advance PFCC
Quality Forum Presentation
By Helga Avila
Manager Process Improvement
February 27, 2013
MoH KRA 3
• Implement an integrated model of primary and community care to more effectively meet the needs of British Columbians, especially frail seniors and patients with chronic and mental health and substance use conditions.
VIHA Guiding Principles
• Comprehensive Services Across the Care Continuum
• Person/Patient Focus • Geographic Coverage and Population Served • Standardized Care Delivery through Inter-
Professional Teams • Quality Improvement
VIHA Guiding Principles
• Information Systems • Organizational Culture and
Leadership • Physician Integration • Governance Structure • Financial Management
Complexity of Need Triangle
Source: Kaiser and MOHS HCC Care Management Strategy
Level 1 Well Population
No Risk but may have socioeconomic risk factors
Level 2 Supported Self Care & Management
Low Risk
Level 3 Chronic Disease
Management Care High Risk
Level 4 Complex Care
High Risk Complex
Complexity of N
eed
Individual Based
Population Based
↓ Disability & Complication
Maintain Health & ↓ incidence of
disease
Support respectful end
of life
Stay Healthy
Goals of Care
Nuka System - summary
Cultural Foundations
We
Are our own healing
Move as a people/tribe
where they we want to go
Know our identity/
uniqueness
Are the pure descendents
Walk along side and allow
choice
Healing the spirit world
wide is about relationship
Source: Southcentral Foundation Nuka Model
• 1999 –redefined Vision, Mission, Key Points, Operational Principles – Mission: Working together with the Native Community to
achieve wellness through health and related services
– Vision: A Native Community that enjoys physical, mental, emotional and spiritual wellness
• Since –continual principle driven design
Organization
Source: Southcentral Foundation Nuka Model
Cornerstones • Value working together with the individual, the family, and the
community. • Honor the dignity of every individual. • Journey to wellness being traveled in shared responsibility
and partnership with those for whom we provide services.
Shared Responsibility
• Strive to provide the best services for the Native Community. • Employ fully qualified staff in all positions and we commit
ourselves to recruiting and training Native staff to meet this need.
• Structure our organization to optimize the skills and contributions of our staff.
Commitment to Quality
• Value the family as the heart of the Native Community. • Work to promote wellness that goes beyond absence of
illness and prevention of disease. • Encourage physical, mental, social, spiritual and economic
wellness
Family Wellness
Source: Southcentral Foundation Nuka Model
Decision Making Model
100 Patient/Family
“Control”
The “System” 0
Low
Acuity High
1. Control - who makes the final decision influencing outcome? 2. Influences - family, friends, co-workers, religion, values, money 3. Real opportunity to influence health costs/outcomes – influence
on the choices made - behavioural change 4. Current model - tests, diagnosis, treatment (meds or procedures)
Source: Southcentral Foundation Nuka Model
• If the goal is population health over time • The major variables we can affect relate to
chronic conditions, habits, choices, optimizing impact of treatments
• Then…the backbone MUST be effective, longitudinal, personal coaching, teaching, supporting, coordinating relationship
• Office visits, procedures, hospitalization become episodes of care only
Rethinking the basic platform
Source: Southcentral Foundation Nuka Model
Evidence-Based Health System
Consultants
Hospital Services
Social Services
Individual/Family
Medical Home/Care Team
Community Resources
Public Health
Note: The “Medical Home” is likely not the “primary care” that we currently have. Source: Southcentral Foundation Nuka Model
• Defining the purpose – relationship over time • Understanding complexity science -principles • Moving from product to service as the
fundamental base of entire system • Optimized primary care with redefined entire
system on that ‘new’ backbone/platform • Customer driven design –reallocation of power
and control at every level • Optimizing messy human relationships
The SCF Nuka Model
Source: Southcentral Foundation Nuka Model
Parallel Work Flow Redesign
Integrated Care Team
Medication refill
Chronic disease Monitoring
Management of study / test results Info
Undiagnosed or Changing new
Consumer concern
Preventive med Intervention
In clinic Point of care
testing
Chronic Disease Compliance
Barriers
Acute Mental Health
Concern
Customer
Customer
Customer
Customer
Customer
Customer
Customer
Customer
Customer
Customer
Customer
Customer
Behavioural Health
Consultant
Certified Medical
Assistant Clinical
Pharmacist PCP
Provider Dietician Case Manager
Source: Southcentral Foundation Nuka Model
Voice of the Customer – ‘Deep listening
• Multiple geographic advisory councils • Focus Groups • Comment cards • Customer Satisfaction surveys • SCF internet • Annual Gathering • Individual in depth interviews
•Elder Council •Listening Conference •Governing board •Staff Interactions •Service agreements •Individual complaints •Relatives and friends of staff •Customer Service staff
Source: Southcentral Foundation Nuka Model
Current State Mapping
• Integrated Health Network • Adult Mental Health • Child Youth & family • Senior’s Health • Diabetes Education • Heart Health
Time consuming finding communication pathLack of details
Hospital
Paris
Oceanside Health Centre – Home & Community Care - Current State Detailed Map – April 26, 2012 – FINAL Version
C
Hospital Liaison/EST or Acute
determine if client known to HCC
Client Known? Fax Referral to Dr. Fax?Hospital Liaison/
EST or AcuteFax/Phone/Email
YesYes
External ReferralClient Update
form Paris
- St Hoes- RJH
Home Support?
Discuss Service- Resume - Change
Yes YesPhone
Case Manager- HNC
- OT?PT
Does not always receive notifications
May not get picked up if directed to a ClinicianC
Note Pads
Admin Determines who to forward fax
to
GPCommunity
Family
Central IntakePhone or Fax
Paris
Eligibility Screen(High Level)
BC Resident0 MVA, 3RD PartyCanadian Citizen
Criteria Met? Determine PriorityYesLogs in Paris/
Opens Encounter in Cerner
Cerner
No
Complete Home Support Details
FormEnter into Paris
Client Update form Paris
- St Hoes- RJH
Inform Admin Photocopy
Change in Service Hours
Home Support Procura
End
Distributes Fax
Open Intake Assessment
Paris
Yes
No
Clinician Assesses Over Phone/
Decides Discipline & Urgency
Logs Referral to Appropriate Discipline
Paris
Send to Geographic Team
Fax Collateral Info to Geographic
Team
Paris
Admin Receives & Disseminates to
Appropriate Discipline
Admin Prints Outstanding Call
List
Creates New or Adds to Existing
Chart
Paris DocumentsFaxed Collateral
Blank DocumentsLabels (Paris)
Kardex
Case Management?
Nursing?
Social Work
Admin Places in Basket on Desk
No
No
No
Does not refer to Home Support
Why?C
Admin Delivers Paper Info into
Route Box
Route RN Checks Box in am and pm
(8am – 2-4pm)Yes Filter Updates
Yes Sort New Referrals into OT and PT
If an Update Uses Rolodex to Determine Therapist
Records Name on Update Paper
Admin Delivers to Therapist MailboxStamp & Date
Sort into Geographic
Region
Access Paris to Allocate via Geographic
Region
OT(Rehab)/PT
Home Support
No
Check Off Names from Outstanding
Referral ListDocument in Paris
Paris
Allocate Charts for HCN
Case Management? Yes
Place Charts on Shelf & Signed
Out by Appropriate Clinician
No
Admin Delivers to Baskets on Wall Outside Office
Client Known?Close Encounter
(Cerner)Close Paris
End
Create Master File
Log Referral(Central Intake)
Fax paperwork to Geographic Office
File Paper in Existing File
Provide info via phone
A
Update?
New Referral?
Changes to Service?
HSDFHome
Support Details Form
No
No
No
Human Resources (Staff)
New Referral?
OT/PT ActionUpdates?
Faxes from Dr’s
Lab Results
Home Support Info/Client Info/Client Charts
Nursing via paperC
i.e.: Do not resuscitate
Palliative BenefitsPharmacy
BPMHMed Hx
No
No
No
No
Review/Validate/PrioritizeYes
Yes
Yes
ReviewCommunicate to
Dr(fax or phone)
Prioritize by Urgency
Review
Action Dr. Orders
Action
Action Dr. Orders
Action
Entered into Procura
ProcuraCharting/
Scheduling
Primary Clinician(MRC)
Internal Referrals
Determine Need for Other Service
Log New Referral In Paris
Existing? Yes Revise Care Plan
No
Create New Care Plan
Document In Procura
(Scheduling Components)
ProcuraDated Note
PrintCare PlanInfo SummaryDOT & ListRespite Info Sheet
Documents place in Home By
Community Health Workers
Action
HCW come into office 60-70 per
day
ProcuraDated Note
Home Support?
CompleteHSDFAllergy
Delegation of Task
Forward to Admin (if Urgent – Verbal)
Enter Details into Procura
Forward to Home Support
ProcuraDated Note
Yes
Complete Client Update Form
ProcuraDated Note
Copy Relevant Info from Chart to
New Clinician Chart
Create File Forward to Case Management
No
HS
CM
HS
CM
Case Manager
Home Support
Nursing
OT/PT/SW
Ambulatory Clinic
Contact Client to Schedule Visit Determine Need
Workflow Sheet
Clipboard
Home Visit Determine Other Services Required
Schedule Next Visit
Review Inbox on Wall
Pull Referrals for Area
Screen & Determine Priority
Window
Valid OT/PT Referral?
Contact Client to Determine and/or
Arrange Visit(phone)
Change in Paris to Appropriate
Clinician OT or PT
No
Yes
Place in Appropriate Priority Slot
Financials require 2 visits
Home Visit(1 – 1.5 Hr)
Complete Home Assessment
Take Actions from Visit
SSRI (Paris)
Funding LettersMedical
EquipmentJustification
ReportsPre-
Discharge
FileUpdate CareplansUpdate Progress
Notes Complete Flow
Sheets
Update Paris
ParisSSRI
FinancialHome
Support Service Audit
Document Scheduled Next
VisitWorkflow/Chart/
Kardex
OT/PT record next visit on day
planners (paper)
V
V
View Schedule via Computer
Pull Charts for Clients to be Seen
Gather Supplies & Set Up Room
See Clients in Clinic Clean Equipment
Charting & Referrals (External
or Internal)
Retrieve Basket – Prioritize Issues
for Action
Schedule Home Visits
New? Quick Response Person (QRP)
Brain Injury ClientPriority 1/2
New?Case Management
Other Priorities
Create Chart
Gather Info for Visit
Red BookFile
Resource Info
Home Visit w Laptop
Use Smart Form (CM Only)2-3 Hr visitRAI to Paris
Complete Paperwork
Review Voicemail and Action V
HSCLReferral from
CLBL 19+
Central Intake(Nanaimo)
Create Chart Mail to Parksville
Received by Community Nurse
Schedule Appointment
(Self Managed)Visit Assessment Create Care PlanDetermine Needs
simple vs. complex
Provide Education i.e Diabetes
Test Blood SugarYearly Visit to test
MS Word
Create Referrals to Other Services
Paris
Update Activity in Paris
Update CLBCPhone (Complex) or Fax (Simple)
Ongoing Monitoring
Darcie Wolfe – Home & Community CareElaine Collison-Baker – Home & Community CareKatherine Zimmer – Home & Community CareDonna Hay – Home & Community CareDeb Bonora – Home & Community CareTerrie Wright – OHC Project TeamParker Gauld – VIHA Process Improvement
Julia Wilson – Home & Community CareAna Maria Gidofalvi – Home & Community CareBarb Duncan – Home & Community CareCathie Beddoes – Home & Community CareCathleen Hansen – Home & Community CareAlisha Pauling – Home & Community CareShirley Quesnel – Home & Community Care
Patient Journey Mapping
• Patients and Caregivers • Complex • Multi-diagnosis
Future State Mapping
• Registering and Intake • Assessing • Initiating • Optimizing • Transitioning
Thank-you! Helga Avila, Manager Process Improvement
Vancouver Island Health Authority