Practice-based Quality Improvement

Session 2

PCFDPNovember 12, 2010

Stephanie Berkson, MPA Sally Kraft, MD, MPH

Session Objectives

1. Understand the basic model of improvement: FOCUS PDCA

2. Be able to lead an improvement team through each step in FOCUS

3. Be able to write a specific AIM statement

Imperatives for Change

Unexplained Variation in Quality and CostsDartmouth Atlas for Health Care http://www.dartmouthatlas.org/

Medical errors

2000 IOM To Err is Human: 98,000 lives lost/year due to medical errors

High costs17% of GDP

2005 IOM Building a Better Delivery System: 30-40 cents of every health care dollar is spent on waste (overuse, underuse, misuse)

Imperatives for Change

Poor outcomes

US spends over twice as much per capita on health as compared to other industrialized nations but ranks last in number of preventable deaths

Disparities2002: Life expectancy at birth for a white male = 75 years, for a black male = 69 years. Even when correcting for education and income, African Americans have worse health outcomes compared to white Americans.

Uninsured15 % uninsured, 30% underinsured

Goals for Improving the US Healthcare System

The Triple Aim

1. Improve the patient care experience (quality of care, access, coordination)

2. Improve the health of the population

3. Lower costs without causing harm

Goals for Improving the Quality of Healthcare

STEEEP

Safety

Timeliness

Equity

Efficiency

Effectiveness

Patient- and family-centeredness

2001 IOM Crossing the Quality Chasm

Focus on Process Improvement

Exercise:

At each table, identify 3 health care processes that you do exactly the same every single time you perform the activity.

Improving Quality:Focus on Process

Example: Drawing blood cultures

Despite the fact that you are drawing blood cultures on different patients in different settings, you always draw cultures the same way.

Structure Process Outcome

Dimensions of CareStructure:

The capacity to provide care reflected in the quantity, type, and qualifications of individuals and facilities.

Good structure does not guarantee high quality

Examples: Physician certification, nurse-to-bed ratio

Process:

What is done when providing care. Appropriateness (doing the right thing) and skillfulness

Example: inserting a central line, screening all eligible patients for breast cancer

Outcome:

Effects of health care on a patient’s health status and satisfaction

Eliminating Central Line Infections in Michigan

Pronovost NEJM 2006; 355: 2725

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

% Pts w/ Up-to-Date A1C Testing

UW Health Pilot Sites Wave 1 MDs

Pilot Site Go-Live w/ Steps 1&2 Wave 1 MDs Go-

Live w/ Steps 1&2

Standard use of EHR Tools

Since Jan 2008, abandon-ment rate decreased from 13% to 1.3% !!

Dropping Press Ganey scores until Dec 2007, then high score of 100 in June 2008!

OA Monthly Abandonment Rate Comparison to all UWMF ACD Sites (Monthly Averages: Mar '07 - Aug '08)

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2.0%

4.0%

6.0%

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10.0%

12.0%

14.0%

Mar'07

Apr'07

May'07

Jun'07

Jul'07

Aug'07

Sep'07

Oct'07

Nov'07

Dec'07

Jan'08

Feb'08

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April'08

May'08

June'08

Jul'08

Aug'08

Month

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OA

UWMF Clinics

Phase IPhase II

Odana Atrium Press Ganey Scores (Based on Date of Service)

45

55

65

75

85

95

Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08

Ease o

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ett

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Cli

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Ph

on

e

Standardized Processes for Handling Phone Calls

Basic Model for Improvement

What are we trying to fix?

How will we know if we have improved?

What changes can we make that will lead to improvement?

Basic Model for Improvement What are we trying to fix?

FOCUS (Find a problem, Organize the improvement team, Clarify the current situation, Understand the causes of variation and poor

quality, Select solutions to test)

How will we know if we have improved?

DATA

What changes can we make that will lead to improvement?

PDCA(Plan-Do-Check-Act)

Find a Process to Improve

1. Review performance data

2. Ask your clinic team

3. Ask your patients

4. Evaluate your practice, the 5 P’s1. Know your purpose

2. Know your patients

3. Know your professionals

4. Know your processes

5. Know your patterns

Process Works well

Not a problem

Small problem

Real problem

Totally broken

Not applicable

to practice

Working on it

Source of patient

complaint

Pre-Visit

Patient calls; messaging, triage

Scheduling appointments; appointment availability

Standardized set of information gathered prior to new patient visit

Information provided for new patients to orient to practice

Core Ambulatory Practice Process AssessmentName:____________________________________ Date: ____________________

Rate each of the following practice support processes by placing a checkmark under the heading that most closely matches your understanding of the process for your clinic. Also mark it if the process is a source of patient complaints.

Practice Process Assessment: A Tool to Understand Your Processes

Full template is provided in your handouts

Global AimAfter assessing your practice and

reviewing performance data, identify what aspect of the practice you will improve.

Exercise: You are reviewing your practice assessment and organizational performance data on telephone performance at your clinic. Write a global aim statement using the template provided.

ProcessWorks Well

Not a problem

Small Problem

Real Problem

Totally Broken

NA to Practice or Does

Not ExistWorking

On It

Source of Patient

complaint

Between Visit Between VisitUsing My Chart and e-mail communication 1 11 11 7 0 11 1 3

Post-hospital, ER, Urgent Care discharge coordination (e.g. scheduling first medical appointment post hospital discharge)

4 10 20 5 0 2 0 0

RN telephone triage processes7 17 12 3 3 1 3 3

Message handling and timely telephone follow up (clinical and non-clinical)

2 17 17 2 0 3 1 0

*Monitoring and improving clinical processes and outcomes 0 6 16 9 0 3 6 2

Care management and coordination (e.g. preventive care reminders, using evidence based protocols, etc.)

0 5 21 10 1 2 5 1

20

Phone abandonment rates were higher than organizational goal (3 - 5%)

Average abandonment rates June 2007 to Dec 2007:

10% - Clinic4% - Organi-

zation

Low patient and provider satisfaction with Communications Center performance

OA Monthly Abandonment Rate Comparison to all UWMF Automatic Call Distribution (ACD) Sites

(Monthly Averages: Mar - Dec '07)

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

Mar '07 Apr '07 May '07 Jun '07 Jul '07 Aug '07 Sep '07 Oct '07 Nov '07 Dec '07

Month

Ab

an

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OA

UWMF Clinics

OA Monthly Call VolumesMar - Dec '07

12000

13000

14000

15000

16000

17000

18000

19000

Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07

Call Volume

Mo

nth

OA

Opened new OA neighborhood

Opened new OA neighborhood

Overall Theme “Global Aim Statement”

Create a project-wide aim or purpose statement that will help keep your focus clear and work productive

I/We aim to improve ________________________________________________________________ [NAME THE PROCESS]

In _______________________________________________________________________________

[CLINIC LOCATION IN WHICH THE PROCESS IS EMBEDDED] The process begins with: ____________________________________________________________

[NAME WHERE THE PROCESS BEGINS] The process ends with: ______________________________________________________________

[NAME WHERE THE PROCESS ENDS] By working on the process, we expect [LIST BENEFITS]: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ It is important we work on this now because [LIST IMPERATIVES]: ___________________________________________________________________________________ ___________________________________________________________________________________

Organize a Team

1. Include the people who do the work on the improvement team

2. Challenges in working with a team

3. Running effective team meetings

4. Stakeholders v. team members

Effective Meetings1. Running an effective meeting is a skill and

requires practice and hard work

2. Tips for success:• Prepare: create an agenda, state the objectives

for the meeting

• Make sure the right people are included

• Assign roles: Facilitator, Time keeper, Recorder

• Clearly state “next steps” and assign accountability

• Evaluate the meeting

Stakeholder Analysis

Used by the change team to create an enrollment and involvement strategy for each group

Analysis providesWho is affected

How they are affected

How critical they are in the process

Who should be contacted

24

Stakeholder Analysis

25

Clarify the Current SituationUnderstand the Causes of

Variation and Poor Performance

1. Work with the entire improvement team

2. Use brainstorming techniques to understand the current state and uncover reasons for defects

3. Collect data to improve your understanding of the current situation

4. Review the literature, identify best practices

Brainstorming

Cause & Effect DiagramWhat is it?

Identifies the “drivers” of the end product

Why would you use it?Shows all activities that contribute to the end

product

Places activities into “buckets” to help focus your improvement work

When would you use it? At the beginning, when you have an end

product you want to improve

Effect/Issue/Problem

Tools/Technology Organization

Environment

Project XXXXXX Cause and Effect DiagramA.K.A. Fishbone or Ishikawa Diagram

General Cause 1

Contributing Cause 2

Contributing Cause 1

Person

General Cause 2

Tasks

Causes EffectOther

30

Phone abandonment rates were higher than organizational goal (3 - 5%)

Average abandonment rates June 2007 to Dec 2007:

10% - Clinic4% - Organi-

zation

Low patient and provider satisfaction with Communications Center performance

OA Monthly Abandonment Rate Comparison to all UWMF Automatic Call Distribution (ACD) Sites

(Monthly Averages: Mar - Dec '07)

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

Mar '07 Apr '07 May '07 Jun '07 Jul '07 Aug '07 Sep '07 Oct '07 Nov '07 Dec '07

Month

Ab

an

do

nm

en

t R

ate

OA

UWMF Clinics

OA Monthly Call VolumesMar - Dec '07

12000

13000

14000

15000

16000

17000

18000

19000

Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07

Call Volume

Mo

nth

OA

Opened new OA neighborhood

Opened new OA neighborhood

Create a Cause and EffectDiagram to Explain this Poor Performance

Data Collection to Clarify and Understand the Problem

1. External sources of data are typically not appropriate or readily available

2. Internally collected data is ideal for improvement work

• Qualitative data

• Quantitative data

3. Data needs to be valid, feasible, and consistent

Exercise: create a data collection sheet to identify the causes of the high phone abandonment rate at the clinic

Non-Clinical Data Collected Validation

368 372300

379

31

442

281

37 26

43

7

9

78

166

0

100

200

300

400

500

600

Tu

esd

ay

We

dn

esd

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Th

urs

da

y

Frid

ay

Sa

turd

ay

Mo

nd

ay

Tu

esd

ay

Day

# o

f C

alls

Not Recorded

Total "Tallied" Calls

1

Overall Abandonment Rate Summary

9%10%

6% 7%

3%

17%

11%10%

0%2%4%6%8%

10%12%14%16%18%

Tues

day

1/22

Wed

nesd

ay1/

23

Thur

sday

1/24

Frid

ay 1

/25

Satu

rday

1/26

Mon

day

1/28

Tues

day

1/29

Ove

rall

4

Symp-tomatic

Other Refills Labs/Results

Gen Info Appt Sched Referral Re-lated

FYI NH/

Hospice

0

20

40

60

80

100

120

140

160

180

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

154 151

123

71

5751

34

20

OA Clinical Call Types (3/28 - 3/31, 77% total calls captured)

Call Types

# O

f C

alls

% C

on

trib

utio

n

175; 5%51; 1%

3520; 94%

Overall Call Summary

Sched II Calls

Repeat Sched II Calls

All Other Calls

Process Map Basics

DefinitionIllustration of steps in a process using symbols and arrows

PurposeUnderstand existing processes Identify non-value added steps Clarify complex processesIdentify improvement opportunitiesGenerate alignment and agreementTrain new staff

Patient Arrives at Clinic

Patient checks in at Registration

Patient checks out at Reception

Provider consults with Patient

Patient checks in at Reception

Patient Leaves Clinic

Anyone calls Odana Atrium

OA Telephone Call Routing Process Map

Is call Clinical (CL) or Non-Clinical (NCL)?

Caller enters CL Queue

Caller enters NCL Queue

Receptionist answers call

Can Receptionist resolve call?

Call is resolved

Is call Clinical?

Is call for specific

provider?

NCLCL

No

No

Yes

CL Staff (MA) answers call

Call is transferred to CL Queue

Yes

Can CL Staff resolve call?

Is provider in?Call routed and

resolved by provider

Yes

Yes

Message left for Provider Call Back

No

Call routed/xferred as needed

No

Call is resolved

Call is transferred to Care Manager

(RN)

No

Yes

Can Care Manager (RN) resolve call?

Call is resolved Yes

No

Call routed to DOD or provider as

needed

Call routed to Dr’s Hotline

Is call from patient or Health Care

Representative?

Health Care Representative

Patient

Select Solutions to Test 1. Select one specific solution to test that:

• addresses a cause of the problem• is within the scope of control of your team• has key stakeholders’ support

2. Develop a SMART aim statementSpecific

Measurable

Agreed upon and actionable

Relevant

Time-bound

I/We will achieve improvement in

[Process]

by (increasing/decreasing/improving)

[Key aspect(s) of process performance]

by [Amount]

within [Time Frame]

focusing on

[Actions and strategies for change]

SMART AIM Statement

GoalReduce clinic telephone abandonment rate

to 3% or below by August 2008

Defined Project MetricsQuantitative – Abandonment rate (AR), call volumes

Qualitative – Patient and provider satisfaction with access to reaching clinic by phone

OA Abandonment Rate Goal

QI foundation: Plan-Do-Check-Act

We’ll focus on applying the PDCA process in Session 3.

Skills we will practice at the Jan session:

1. Developing and implementing an action plan

2. Collecting improvement data; measuring processes and outcomes

3. Assessing strategies for sustaining improvements