Post on 04-Jan-2016
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
1
Michigan IPIP/PCMH
Preliminary Project Summation on the
Transformation of Primary Care Practice
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
2
Insert LongitudinalIPIP Project Development
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
3
Insert LongitudinalIPIP Project Implementation
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
4
IPIP Project: Start to Finish
Stats Jan 2009 June 2010
Number of Practices 18(Diabetic)
33(Diabetic + Asthma)
Number of Active Coaches 30 43Number of Physicians Involved 106 206Number of Patients Affected (Total Population) 148,080 276,499
Number of Practices with an EHR/EMR 10 23
Number of Practices with a Registry 8 24Number of Practices with PCMH /BCBSM Designation
12 27
Coach Time Estimated versus Coach Time Needed for project (hours per week)
4 10
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
5
Practice Enrollment
1 Based on data submission• Enrollment:– Wave 1 = Nov 2008 to Mar 2009 (17 practices)– Wave 2 = June 2009-Aug 2009 (8 practices)– Wave 3 = Sept 2009-Jan 2010 (4 practices)– Practices not reporting (4 practices)
• Engagement occurred within 3 months of starting
Practices Joining IPIP Project
2
1
5
8
1
0 0
1
5
2
1 1 1
0
1
0
1
2
3
4
5
6
7
8
9
Nu
mb
er o
f P
ract
ices
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
6
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
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Time Commitment & Coach Involvement
QIC Coach Time Tracking
010
2030
4050
6070
8090
100
Ho
urs
• Quality improvement tools & techniques knowledge possessed by all QI Coaches
• QI Coach involvement with practice underestimated
• 3-4xs more time needed with practices to assist in transformation than planned
• Engaged, strong facilitation skills & vigor lead to more transformation
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
8
Diabetic Measures: Start to Finish OUTCOME: More engagement , Closer to goal
DM Measures May-2010
0
10
20
30
40
50
60
70
80
90
100
Goal lower = better
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
9
Asthma Measures: Start to Finish
OUTCOME: More engagement, Closer to goal
Per
cent
Asthma Measures May-2010
0
20
40
60
80
100
Asth
ma
PctA
ctio
nP
lan
Asth
ma
PctA
llOrN
on
e
Asth
ma
PctA
sse
sse
d
Asth
ma
PctC
on
tro
ller
Asth
ma
PctE
DV
isit
Asth
ma
PctF
luV
acc
Asth
ma
PctH
osp
Asth
ma
PctS
mo
kC
ess
Asth
ma
PctT
ob
acco
Qu
ery
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
10
Diabetes Measures by Activity: Start to Finish
Count of DM patients 18-75 yo
-9-16
-18
-20
-22
-23
-27
-25
-23
-25
-24
-18
-18
-18
-18
-16
-4-2-10
100
200
300
400
500
Jun
-08
Jul-
08
Au
g-0
8
Se
p-0
8
Oct
-08
No
v-0
8
De
c-0
8
Jan
-09
Fe
b-0
9
Ma
r-0
9
Ap
r-0
9
Ma
y-0
9
Jun
-09
Jul-
09
Au
g-0
9
Se
p-0
9
Oct
-09
No
v-0
9
De
c-0
9
Jan
-10
Fe
b-1
0
Ma
r-1
0
Ap
r-1
0
Ma
y-1
0
Pct of DM patients with latest A1C >9
-9-16
-18
-20
-22
-23
-27
-25
-23
-25
-24
-18
-17
-18
-18
-16
-4-2-10
20
40
60
80
100
Jun
-08
Jul-
08
Aug
-08
Sep
-08
Oct
-08
No
v-08
De
c-08
Jan
-09
Fe
b-0
9
Mar
-09
Apr
-09
May
-09
Jun
-09
Jul-
09
Aug
-09
Sep
-09
Oct
-09
No
v-09
De
c-09
Jan
-10
Fe
b-1
0
Mar
-10
Apr
-10
May
-10
Pct of DM patients on aspirin-5-1
1
-12
-12
-14
-14
-15
-15
-14
-15
-16
-14
-14
-12
-12
-11
-3-1-10
20
40
60
80
100
Jun
-08
Jul-
08
Au
g-0
8
Se
p-0
8
Oct
-08
No
v-0
8
De
c-0
8
Jan
-09
Fe
b-0
9
Ma
r-0
9
Ap
r-0
9
Ma
y-0
9
Jun
-09
Jul-
09
Au
g-0
9
Se
p-0
9
Oct
-09
No
v-0
9
De
c-0
9
Jan
-10
Fe
b-1
0
Ma
r-1
0
Ap
r-1
0
Ma
y-1
0Pct of DM patients with latest BP <=130/80
-9-16
-18
-20
-22
-23
-27
-25
-23
-25
-24
-18
-17
-18
-18
-16
-4-2-10
20
40
60
80
100
Jun
-08
Jul-
08
Aug
-08
Sep
-08
Oct
-08
No
v-08
De
c-08
Jan
-09
Fe
b-0
9
Mar
-09
Apr
-09
May
-09
Jun
-09
Jul-
09
Aug
-09
Sep
-09
Oct
-09
No
v-09
De
c-09
Jan
-10
Fe
b-1
0
Mar
-10
Apr
-10
May
-10
Pct of DM patients referred for eye exam
-2-3-4-7-9-10
-11
-11
-10
-17
-23
-17
-17
-17
-17
-16
-4-2-10
20
40
60
80
100
Jun
-08
Aug
-08
Oct
-08
De
c-0
8
Fe
b-0
9
Apr
-09
Jun
-09
Aug
-09
Oct
-09
De
c-0
9
Fe
b-1
0
Apr
-10
Pct of DM patients with foot exam
-8-15
-17
-19
-21
-22
-25
-24
-22
-24
-24
-18
-17
-17
-17
-16
-4-2-10
20
40
60
80
100
Jun
-08
Au
g-0
8
Oct
-08
De
c-0
8
Fe
b-0
9
Ap
r-0
9
Jun
-09
Au
g-0
9
Oct
-09
De
c-0
9
Fe
b-1
0
Ap
r-1
0Pct of DM pts 55-75 taking ACE/ARB
-2-7-7-7-7-7-8-5-3-1-10
20
40
60
80
100
Jun-
08Ju
l-08
Aug
-08
Sep
-08
Oct
-08
Nov
-08
Dec
-08
Jan-
09F
eb-0
9M
ar-0
9A
pr-0
9M
ay-0
9Ju
n-09
Jul-0
9A
ug-0
9S
ep-0
9O
ct-0
9N
ov-0
9D
ec-0
9Ja
n-10
Feb
-10
Mar
-10
Apr
-10
May
-10
Pct of DM pts prescibed a statin
-5-10
-9-12
-14
-13
-14
-14
-12
-14
-16
-14
-14
-12
-12
-11
-3-1-10
20
40
60
80
100
Jun
-08
Jul-
08
Au
g-0
8
Se
p-0
8
Oct
-08
No
v-0
8
De
c-0
8
Jan
-09
Fe
b-0
9
Ma
r-0
9
Ap
r-0
9
Ma
y-0
9
Jun
-09
Jul-
09
Au
g-0
9
Se
p-0
9
Oct
-09
No
v-0
9
De
c-0
9
Jan
-10
Fe
b-1
0
Ma
r-1
0
Ap
r-1
0
Ma
y-1
0
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
11
Asthma Measures by Activity: Start to Finish
Count of asthma patients 5-40 yo
-1-2-2-2-3-3-4-4-5-5-4-3-3-3-3-3-10-10100200300400500600700800
Jun-
08
Jul-0
8
Aug
-08
Sep
-08
Oct
-08
Nov
-08
Dec
-08
Jan-
09
Feb
-09
Mar
-09
Apr
-09
May
-09
Jun-
09
Jul-0
9
Aug
-09
Sep
-09
Oct
-09
Nov
-09
Dec
-09
Jan-
10
Feb
-10
Mar
-10
Apr
-10
May
-10
Pct of asthma patients with action plan-1-1-1-1-2-2-2-2-2-3-2-1-1-1-2-1-10-10
20
40
60
80
100
Jun
-08
Jul-
08
Au
g-0
8
Se
p-0
8
Oct
-08
No
v-0
8
De
c-0
8
Jan
-09
Fe
b-0
9
Ma
r-0
9
Ap
r-0
9
Ma
y-0
9
Jun
-09
Jul-
09
Au
g-0
9
Se
p-0
9
Oct
-09
No
v-0
9
De
c-0
9
Jan
-10
Fe
b-1
0
Ma
r-1
0
Ap
r-1
0
Ma
y-1
0
Pct of asthma patients with controller med
-1-2-2-2-3-3-3-3-3-3-2-1-1-1-1-10
20
40
60
80
100
Jun
-08
Jul-
08
Aug
-08
Sep
-08
Oct
-08
No
v-0
8
De
c-0
8
Jan
-09
Fe
b-0
9
Mar
-09
Apr
-09
May
-09
Jun
-09
Jul-
09
Aug
-09
Sep
-09
Oct
-09
No
v-0
9
De
c-0
9
Jan
-10
Fe
b-1
0
Mar
-10
Apr
-10
May
-10
Pct of asthma patients with control assessed
-1-2-2-2-3-3-3-3-3-3-2-1-1-1-2-1-10-10
20
40
60
80
100
Jun
-08
Jul-
08
Au
g-0
8
Se
p-0
8
Oct
-08
No
v-0
8
De
c-0
8
Jan
-09
Fe
b-0
9
Ma
r-0
9
Ap
r-0
9
Ma
y-0
9
Jun
-09
Jul-
09
Au
g-0
9
Se
p-0
9
Oct
-09
No
v-0
9
De
c-0
9
Jan
-10
Fe
b-1
0
Ma
r-1
0
Ap
r-1
0
Ma
y-1
0
Pct asthma pts with current flu vaccine
-1-2-2-2-3-2-2-2-2-3-2-1-1-1-2-1-10-10
20
40
60
80
100
Jun
-08
Jul-
08
Au
g-0
8
Se
p-0
8
Oct
-08
No
v-0
8
De
c-0
8
Jan
-09
Fe
b-0
9
Ma
r-0
9
Ap
r-0
9
Ma
y-0
9
Jun
-09
Jul-
09
Au
g-0
9
Se
p-0
9
Oct
-09
No
v-0
9
De
c-0
9
Jan
-10
Fe
b-1
0
Ma
r-1
0
Ap
r-1
0
Ma
y-1
0
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
12
Overall Team Assessment Ratings by Report Period
0 2 4 6 8 10 12 14 16
Nov-08
Dec-08
Jan-09
Feb-09
Rep
ort
Per
iod
Number of Teams
0.5-1
1.5-2
Engagement Ratings by Report Period
0 2 4 6 8 10 12 14 16
Nov-08
Dec-08
Jan-09
Feb-09
Rep
ort
Per
iod
Number of Teams
0
0.5-1
1.5-2
Leadership Ratings by Report Period
0 2 4 6 8 10 12 14 16
Nov-08
Dec-08
Jan-09
Feb-09
Rep
ort
Per
iod
Number of Teams
0
0.5-1
1.5-2
Registry Ratings by Report Period
0 2 4 6 8 10 12 14 16
Nov-08
Dec-08
Jan-09
Feb-09
Rep
ort
Per
iod
Number of Teams
0
1.5-2
2.5-3
3.5-4
Template for Planned Care Ratings by Report Period
0 2 4 6 8 10 12 14 16
Nov-08
Dec-08
Jan-09
Feb-09
Rep
ort
Per
iod
Number of Teams
0
0.5-1
2.5-3
3.5-4
Diabetes Protocol Ratings by Report Period
0 2 4 6 8 10 12 14 16
Nov-08
Dec-08
Jan-09
Feb-09
Rep
ort
Per
iod
Number of Teams
0
0.5-1
2.5-3
3.5-4
Asthma Protocol Ratings by Report Period
0 0.2 0.4 0.6 0.8 1
1
Rep
ort
Per
iod
Number of Teams
Series1
Self Mgmt Support Ratings by Report Period
0 2 4 6 8 10 12 14 16
Nov-08
Dec-08
Jan-09
Feb-09
Rep
ort
Per
iod
Number of Teams
0
0.5-1
IPIP
Rep
ort
ing
Cri
teri
a:N
ov
2008
- F
eb 2
009
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
13
IPIP
Rep
ort
ing
Cri
teri
a:
Feb
- M
ay 2
010
Overall Team Assessment Ratings by Report Period
0 5 10 15 20 25 30 35 40
Feb-10
Mar-10
Apr-10
May-10
Re
po
rt P
eri
od
Number of Teams
0.5-11.5-22.5-33.5-44.5-5
Engagement Ratings by Report Period
0 5 10 15 20 25 30 35 40
Feb-10
Mar-10
Apr-10
May-10
Re
po
rt P
eri
od
Number of Teams
00.5-11.5-22.5-3
Leadership Ratings by Report Period
0 5 10 15 20 25 30 35 40
Feb-10
Mar-10
Apr-10
May-10
Re
po
rt P
eri
od
Number of Teams
00.5-11.5-22.5-3
Registry Ratings by Report Period
0 5 10 15 20 25 30 35 40
Feb-10
Mar-10
Apr-10
May-10
Re
po
rt P
eri
od
Number of Teams
00.5-11.5-22.5-33.5-44.5-5
Template for Planned Care Ratings by Report Period
0 5 10 15 20 25 30 35 40
Feb-10
Mar-10
Apr-10
May-10
Re
po
rt P
eri
od
Number of Teams
00.5-11.5-22.5-33.5-44.5-5
Diabetes Protocol Ratings by Report Period
0 5 10 15 20 25 30 35
Feb-10
Mar-10
Apr-10
May-10
Re
po
rt P
eri
od
Number of Teams
00.5-11.5-22.5-33.5-44.5-5
Asthma Protocol Ratings by Report Period
0 0.5 1 1.5 2 2.5
Feb-10
Mar-10
Apr-10
May-10
Re
po
rt P
eri
od
Number of Teams
00.5-1
Self Mgmt Support Ratings by Report Period
0 5 10 15 20 25 30 35 40
Feb-10
Mar-10
Apr-10
May-10
Re
po
rt P
eri
od
Number of Teams
00.5-11.5-22.5-33.5-44.5-5
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
14
Implementation of Electronic System(s)
EHR Registry
Access/Excel 1 4
AllScripts 4 1
Ariphron 0 6
Care Tracker 1 0
Centricity 4 0
Cielo 0 2
CDEMS 0 1
eClinicals 1 1
EPIC 2 0
Kryptic 0 4
Misys 2 0
NextGen 5 0
Other 2 0
Synamed 1 0
WellCentive 0 5
Total 23 24
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
15
Learning Collaborative
Date of LC FocusAttendance / Occurrences
February 2009Introduction to PCMH, CCM & the need for change
142
July 2009
Repeat of February 2009 to bring second wave of practices on board
42
September 2009Diabetes, Asthmas & Self Management efforts
156
March 2010
Practices sharing to build community amongst IPIP team, seeing some best practice examples
118
Monthly Practice LC Call-ins (March 2009 – June 2010)
Webex conducted 3rd Wednesday & 4th Thursday of the month
Average 10 practices per call
Monthly QICs meetings (June 2008 – June 2010)
First Monday of month at AIAG offices & via webex
Average 34 coaches per meeting
Individual JIT & Assistance
Weekly handled based on needs of practice or
coach
2 incidences per week
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
16
Lessons Learned: People & Culture
• Engage everyone!
• Get physician buy-in/engagement early
• Make the “Big Picture” visible:– Understanding the process– Understanding how their actions
impact others– Different views = valuable
• Transformation takes longer than you think
• “Coaching” is critical
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
17
Lessons Learned: Process Change
• Improving the process improves the patient care
• Think simple, be creative & resourceful• Standardizing the work improves the
outcomes• Elimination of waste:
– Unnecessary steps– Redundant actions– Duplication of documentation– Identification of inefficiencies– Accuracy of data/information– Lack of accountability
• Success breeds more success• Important to understand what you “want
to improve” to avoid frustration
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
18
Lessons Learned: Outcomes
• Realization that current way is not necessarily the best way
• Registry allows for more “active” care of the patient population
• Be specific on what you measure!• Measures & tracking drive the
improvements• Consistency in direction & efforts• Tailoring tools to the user works
best!• Coaching time needed for practice
assistance was underestimated• Automation of metrics facilitated
transformation
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
19
Skill/ToolNumber of Coaches
Possessing Skill
Value Stream Mapping 42
Lean Manufacturing Principles
42
Process Flow Mapping 47
PDSA/PDCA 42
Kaizen 37
DMAIC 42
Structured Problem Solving 47
5-S 40
Root Cause Analysis 48
5 Whys 44
Fish Bone 47
Data Collection 48
Error Proofing 42
Team Building 45
Standardized Work 40
Visual Controls 41
Facilitation/Coaching 47
Good Problem Definition/Scoping (Defining Boundaries)
46
Educational Presentation Experience
47
Other 24
QI C
oac
h S
kills
Inve
nto
ry
Su
mm
ary
CJ Systems: JNG 8.25.2010
Working Together for a Healthier Michigan
20
Things to Change & Keep
CHANGE• Plan more time for
transformation• Make website/library
easier to use• Plan LCs by region &
practice size• Better funding• Create a database for
reporting/tracking• Upgrade Coach
Handbook for easier use (make on-line?)
• Practice tool box/ guideline
• Stronger link between coach & practice
• Change Management training
KEEP• Coach actively
present within practice
• Energetic leadership for driving the program/process
• Engaged leadership for the program/process
• National IPIP reporting system
• Learning Collaboratives
• Access to coaches • TQM & PDSA• Process mapping