Building Sustainable

Quality Improvement

Systems in your Practice

February 10, 2015

We Want To Hear From You!

Type questions into the Questions Pane at any time

during this presentation

Patient-Centered Primary Care Institute

Online Modules

Webinars

Website

Learning Collaboratives

Trainings

TA Network

Oregon’s PCPCH Model is defined by six core attributes, each with specific standards and measures• Access to Care “Health care team, be there when we need you”• Accountability “Take responsibility for making sure we receive the best

possible health care”• Comprehensive Whole Person Care “Provide or help us get the health care,

information and services we need”• Continuity “Be our partner over time in caring for us”• Coordination and Integration “Help us navigate the health care system to get

the care we need in a safe and timely way” • Person and Family Centered Care “Recognize that we are the most important

part of the care team - and that we are ultimately responsible for our overall health and wellness”

Learn more: http://primarycarehome.oregon.gov

PCPCH Model of Care

Introduce Presenter

R.J. Gillespie, MD, MHPEMedical Director

Oregon Pediatric Improvement Partnership

Objectives

• Describe key factors in practice level sustainability and spread of QI efforts.

• Review concepts related to motivating change amongst members of a practice.

• Understand steps for creating a highly functioning quality improvement structure for your practice.

• Spotlight practices who have successfully built sustainable QI structures within the clinic.

ACCOUNTABILITY: Quality Improvement

Having a formal quality improvement (QI) program is an essential component of Patient-Centered Primary Care Homes.

• 2.D.1 - PCPCH uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience.

• 2.D.2 - PCPCH utilizes improvement teams that are multi-disciplinary and meet regularly to review timely, actionable, team-level data related to their chosen improvement project and documents their progress.

• 2.D.3 - PCPCH has a documented clinic-wide improvement strategy with performance goals derived from community, patient, family, caregiver, and other team feedback, publicly reported measures, and areas for clinical and operational improvement identified by the practice. The strategy includes a quality improvement methodology, multiple improvement related projects, and feedback loops for spread of best practice.

ACCOUNTABILITY: Patient and Family Involvement

PCPCH actively and formally involves patient and families in efforts to improve services.

• 2.C.1- PCPCH involves patients, caregivers, and patient-defined families as advisors on at least one quality or safety initiative per year.

• 2.C.2 - PCPCH has established a formal mechanism to integrate patient, caregiver, and patient-defined family advisors as key members of quality, safety, program development and/or educational improvement activities.

• 2.C.3 - Patient, caregiver, and patient-defined family advisors are integrated into the PCPCH and function in peer support or in training roles.

Understanding Practice Change

• Understanding clinic’s change culture and knowing how changes are made within the practice

• Communicating project goals, aim statements and measures to entire practice

• Successfully engaging / getting the backing of clinic leadership

• Communicating project goals, aim statements and measures to patients and families

Key thought: Understanding how the practice typically addresses change and decision-making will facilitate project spread.

Building Healthy QI Habits

• Developing QI skills as a practice (aim statements, PDSA cycles)

• Interpreting performance measures as a team (“sensemaking”)

• Engaging patients and families in QI efforts

Key thought: QI skills and knowledge can’t live in the brain of a single individual (or small group of individuals) if change is to be sustained.

Creating Durable Infrastructure for QI

• Creating a multi-disciplinary team for ongoing QI work

• Developing a clinic-wide strategic plan for QI• Creating systems for tracking performance

measures

Key thought: Ongoing sustainability requires a permanent infrastructure for QI.

INTENTIONALLY ENSURING CLINIC-LEVEL ENGAGEMENT

Understanding Practice Change

Food for Thought

• Given that medical home transformation is a flexible, long-term process…How can you build a project team in a way that creates new innovation at the same time that it

sustains your QI work?

Key Questions: Understanding Your Clinic’s Change Culture

• How are changes made in your practice?• Who holds decision-making authority in your

practice?• How can you engage other providers to

participate in changes made during the learning collaborative?

• What are the structural supports needed to maintain continued growth as a medical home?

Enabling and Sustaining Change:Who do you Need to Engage?

• Who will the change affect - directly and indirectly?• What are the drivers and barriers to change?• Who needs to be involved, consulted, informed?

– Remember that often means engaged participation of the non-provider office staff (can sink or float a project)

• To what extent will contextual and cultural factors such as team dynamics or differences in approach between departments affect the success of change?

• How can I develop a shared vision?

Leadership Driving Improvement

• Who are the key leaders that are needed to achieve this development in practice and where are they positioned?

• Does this leadership reflect the range of stakeholders?

• How can the vision be shared to inspire and engage leadership at all levels?

Key Steps in Leadership Driving Change

• Senior leadership (clinical and administrative) must play an active and visible role

• Change should be conducted by a multidisciplinary team

• Leadership needs to create a sense of urgency and dissatisfaction with the status quo

Engaging Others

• Leadership is needed at all levels to drive forward continuous improvement. Leadership involves:– inspiring, enabling and transforming others– facilitating and supporting change– developing staff – and acting as a role model for others

Lessons from the National Center for Medical Home Improvement (CMHI)

• Evaluated practices that improved on their “medical homeness” AND sustained their improvements

• Lessons from these sustained innovators:“If you do nothing else…”– Identify your population of CSHCN– Gain family participation/feedback– Develop the capacity for practice-based care

coordination and the use of care plansAdapted from Cooley, W.C. (2012, June). Care coordination – Assuring a family-centered approach [PowerPoint Slides].

Maxims of Patient-Centered Care

The needs of the patient come first

Nothing about me without me

Every patient is the only patient

From: D. Berwick. What ‘Patient-Centered’ Should Mean: Confessions of an Extremist. Health Affairs, 28, no.4 (2009): w555-565.

Steps For Adding Parents (Patients) To Your Team

1. Embracing the idea of a parent partner2. Discussing characteristics, traits, and qualities3. Successfully selecting a parent partner4. Inviting and compensating a parent partner5. Replacing a parent partner (when necessary)

Adapted from “Parent Partners, Creative Forces on Medical Home Improvement Teams”, Ann Donoghue Dillon, 2003, Center for Medical Home Improvement

Embracing the Idea

• Discuss the concept in depth– Include all stakeholders on current team– Be sure to include key thought leaders and decision

makers at your practice– It is best not to debate the concept AFTER bringing a

parent into the mix• Start this journey committed to the concept

– There may be barriers experienced and refinements needed- committing to work through this experience is key to achieving success and realizing the value

Discussing Traits and Qualities

See section III (page 9) of the guide for more details

• Determine what collection of characteristics meets your needs

• Key traits include: – Has the time to commit (access to childcare, etc.)– Confident, and able to speak up in group settings– Fit with group dynamic- humor!– Experience with local resources and multiple

specialists• Parents of CYSHN have an extremely valuable perspective

when it comes to medical homes for children• Multiple partners with different experiences provide for an

even more rich parent perspective

Selecting a Parent Partner

• Ask clinicians and staff in your practice to suggest parents that fit your list of traits

• Consider alternate recruiting strategies– Signs in waiting room, newsletter, etc.

• Conduct meetings and interviews to explore interest and fit

Inviting and Compensating

• Be detailed in laying out the time commitment and stipend – Parents as consultants typically receive $12-$25 per hour

for their time and effort• Be strategic in the presentation of background

information and onboarding/orientation information– Include information about:

• Relevant clinic processes (QI Committee process/policies etc)• Medical Home concept in general• Specific projects in which they will be participating

• Consider connecting to Parent Partners in other practices, or other parent to parent resources

Replacing Parent Partners (As Needed)

• It would be to your benefit to plan for turnover from the outset– Document the results of completing the steps the

first time• A statement about the value of this effort to your practice• A list of characteristics and traits• A plan for recruitment• A generic/boilerplate contract specifying commitment and

compensation• Cataloguing of orientation materials

• Consider keeping a list of parents that you identify as potential future participants

SPREADING QI SKILLS THROUGHOUT THE PRACTICE

Building Healthy QI Habits

Simple Steps to Implement as a Practice Team

• Working on team identity and function• Finding ways to share project information, goals, aim

statements with others– What are the avenues for sharing information with other

providers and staff? Are there standing meetings that you need to get yourself on the agenda for?

• Publicizing project data with other staff members, providers– How is performance data shared with others in the

practice?

Conducting Pilots in a Way that Engages Different Types of Adopters in Your Clinic

• Small tests of change are critical before wide-spread clinic level changes are conducted

• Pilots should test:– Different processesAND– Can engage different providers and stakeholders in testing

out the change• By being part of the test, can become an advocate for the change

• Intentionally recruit internal “thought leaders” in the pilot testing

• Intentionally recruit people that approach project differently in the practice

Factors Supporting Sustained Change

• A culture of openness and transparency• Staff at all levels involved• A system for communication of good practice

development projects• Clear organizational goals in respect of quality• Coordination of activity across projects• National and local initiatives within a coherent

operational plan• A financial infrastructure to support development of

practice and associated education

FINE-TUNING QUALITY IMPROVEMENT EFFORTS FOR YOUR CLINIC

Creating Durable Infrastructure for QI

QI versus QA

• Generally speaking, QA is about measuring performance against certain standards and ensuring care matches the standard of care– Academic detailing and decision support to encourage appropriate

care based on guidelines would be examples– Also figuring out when care isn’t given at the level it should be…is it

an individual problem or a system problem?– In this way, QA can inform QI

• Quality improvement is about taking a proactive approach to improving the processes and systems– Motivated by a desire to continuously improve processes to perform

at the highest level possible– Takes a broader look at the systems that impact care and how to

improve them

What a QI Committee Should Do

• Medical home “transformation” is about broad systems change. Assessing and improving the practice based on recognized medical home definitions require QI.

• Interpreting policy / health reform changes and how that will impact the clinic also informs QI.

• Building the clinic’s Adaptive Reserve should be a primary goal of the QI committee.– Other providers / office staff should be competent in QI– “Sensemaking” is an adaptive reserve skill that needs to be

fostered

Adaptive Reserve

• What’s predictive of medical home transformation is the characteristics of the practice themselves…specifically adaptive reserve

• The ability of a practice to be resilient, to bend, and thrive survive under force. Facilitates adaptation during times of dramatic change.

What is Sensemaking?

• “Sensemaking is the process through which the fluid, multilayered world is given order, within which people can orient themselves, find purpose, and take effective action. Organizations don’t discover sense, they create it.” --Don Berwick

• When it comes to quality measures, sensemaking is the process of creating a story about data to give that data meaning within a clinical context.

• Once you can give the data meaning within a practice, an action plan becomes a simple next step.

QI Committee Structure

• Multidisciplinary team is needed– Nursing staff, front office, operations, parent, tech staff, etc.– Only way to ensure that clinical processes are improved

broadly• Need to determine clear accountabilities for tasks of the

committee, meeting schedule, leadership, etc.• Consider how to insert the committee into the existing

governance structure• Parent Advisory Committee should be considered - some

materials from QI Committee should be vetted through a parent group

Engaging Families and/or Youth

• In working with practices, this is difficult but meaningful in many ways

• Some ideas for how to engage families:– Recruiting families for QI teams or standing clinic committees– Focus Groups

• Recruit a group of parents to discuss specific topics• Example: focus group to review service needs for CYSHCN

– Parent Advisory Group• Can also be subject-specific, or have the agenda driven by the parents

– Survey patients and families about their experience of care• Formal surveys• Shorter surveys of topics of interest

Strategic Planning

• Strategic plans for practices often consider elements of running the business of the practice

• QI Strategic Plan considers the changes in clinical services or operations that need to be made– If a practice has a lot of projects going on…how do they

connect to each other and inform the direction that the clinic wants to take?

– What are the goals of the clinic related to improvement?

Strategic Planning

• Consider a framework for deciding topic areas for QI– SWOT analysis…what are the strengths of your clinic’s

quality, weaknesses, opportunities (projects you can join), or threats (for example, if we don’t have a medical home certification, will that impact our contracting?)

– GNOME analysis…Goals, Needs, Objectives, Methods, Evaluation. Often anchored to the values of your practice’s providers.

Template for Strategic Plan Components

Tracking Clinical Measures

• External sources– Q corp, Health Plans

• Internal sources– What matters to your practice clinically?

Standardized measures or something else?– What capacity does your practice have for tracking

measures? Within practice management?• How do you identify what EMR fields need to be

completed by providers to get good data?

Jenny Hoelter, MDPediatrician

Child Health Associates of Salem

Guest Presenter

Medical Home Steering Committee

Goals

• A formal mechanism to integrate patients and families as key advisors of quality, safety, program development or educational improvement activities

• Development of a clinic-wide improvement strategy with goals derived from quality measures, patient feedback, multiple projects and feedback loops

• Mechanism for dissemination of team-based innovation and QI projects

Committee Structure

• Meets quarterly at 12:30-1:45– At Salem Hospital meeting rooms

• Lunch is served• Agenda:

– Clinic updates– Review of ongoing projects – Review new QI data (CAHPS)– Team reports– New business

The Committee

• Representatives from all CHAOS departments– Upstairs: Billing, medical records, scheduling– Downstairs: MA and RN staff, providers, interpreters,

reception

• 5 parent partners• Representatives from each of 4 clinical teams

– MA or RN

Parent Partners

• Currently 5 Moms• Range of ages (toddler to teen)• CYSCHN and typically developing children• Range of “outside” experience

– Autism Medical Home Learning Collaborative– RN involved with QI projects at Salem Hospital– Community outreach programs with the YMCA– Foster and education systems

• Recruitment– Clinicians nominated parents– Facebook

• Compensation: $25/meeting (Gift Card)

Light Bulb Moments

• Advanced Check in for CYSCHN and new patients• Transition to adult health care providers—

approach with families/teens• Portal feedback• Screening for barriers to medical care

Challenges

• Team building• Airing our dirty laundry in “public” can be

uncomfortable• Feedback from parents that can be difficult to

hear• Teaching and encouraging widespread use of QI

tools• Access to data• Collaborative “sense-making”

Possible New Directions

• Subcommittees to work on issues between meetings

• Team building• Enhanced data reporting (More numbers!! More

graphs!!)• Clearer goals and more well-defined projects

What Questions Do You Have?

Type questions into the Questions Pane at any time

during this presentation

Resources

• Link to general QI tools:– https://projects.oregon-pip.org/resources/cme-

resources/quality-improvement• Center for Medical Home Improvement (resources

for QI, also recruiting parents)– http://www.medicalhomeimprovement.org/knowledge/p

ractices.html

THANK YOU! Please complete the post-webinar survey