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Team Based Care (TBC) Learning Collaborative

Session TwoNovember 2, 2016

3:35 - 4:30 EST

Developing a core team’s capabilities for implementing an advanced team based care model.

Introductions

TBC Collaborative Design, Facilitation, Faculty Ann Marie R Hess NP, MS

National Cooperative Agreement Anna Rogers, Director Reema Mistry, Program Coordinator

Mentors , Coaching Faculty Deborah Ward, RN (1:8) Kasey Harding (1:8)

3:35

Evaluation Faculty Kathleen Thies, PhD, RN

Improvement Science Faculty Patti Feeney Mark Splaine, MD

Name of FQHC Coach Team

Avenal Community Health Center John Kalfayan 1 BH, 1 Physician, 1 MA, 1 Medical Director, 1 Front Desk

Educational Health Center of Wyoming Brenda Burnett 1 Provider, 2 RN, 1 Radiologic Technologist, 1 EMR Manager, 1 MA, 1 Clinical Manager

El Rio Santa Cruz Josh Carzoli 1 MA, 1 RN, 1 BH, 1 Chief Clinical Officer, 1 LPN, 2 Physician, 1 Front Desk, 1 COO, 3 RN Clinic Manager, 1 IT

Holyoke Health Center Megan T. Wechsler, Rosie Romero

1 Director of Quality and Compliance, 1 Physician, 3 RN, 1 MA, 1 Front Desk

Peach Tree Healthcare Ruben Ruiz1 Chief Quality Officer, 1 Quality Coordinator, 1 Dir of

Operations, 1 Site Manager, 1 Dir of HR, 1 NP, 3 MA, 1 Data Analyst, 1 Ops Specialist, 1 Clinical Support Services Manager

Pecos Valley Medical Center L. David Young 2 RN, 1 NP, 1 MA

The Children’s Clinic Karla Rodriguez 1 Provider, 1 MA, 1 Care Team Rep

Via Care Community Health Center Kimberly McFerguson 1 FNP, 1 MA, 1 Outreach & Enrollment Specialist, 1 MSW, 1 Front Office Lead MA

Introductions

Introductions

Name of FQHC Coach Team

Carolina Family Health Centers , Inc. Chasity Godwin 1 MD, 1 NP, 2 LPN, 1 Care Coordinator, 1 Front Desk, 1 Interpreter,

1 CNA

Community Health Initiatives Zlata Vainstein 1 Medical Director, 1 Physician, 2 MA, 1 Front Desk

Daughters of Charity Grace Mena 1 Area Practice Manager, 1 MD, 3 FNP, 2 Care Coordinator, 4 MA

Healthcare for the Homeless Carlie Brown Need new team

Johnson City Community Health Center

Flo Weierbach 1 front Desk, 1 PNP, 1 LCSW, 1 RN, 1 Interpreter

Sumter Family Health Center Sandra Sturkie1 Director of Patient Services, 1 Clinical Manager, 1 BH Clinical

Manager, 1 BH RN, 1 Physician, 2 Case Managers, 1 MA, 1 Dental Services Coordinator, 1 Patient Financial Coordinator, 1 Clinical IT,

1 Pharmacist, 1 Call Center Rep, 1 Referrals Manager

Syracuse Community Health Center, Inc.

Cathy Brigden 1 Physician, 1 FNP, 1 LPN, 2 RN, 3 MA, 1 Office Manager

Tyler Family Circle of Care Sherri Gould 1 CMO, 1 COO, 1 LVN, 1 OA, 1 PNP, 1 Process Improvement Manager

Objectives Session 2 Summarize Action Period 1 Milestones (6 weeks) Provide concept overview Learn from team assignments

→ Adjusting Core and Extended Team Structure (Sumter)→ Practicing Effective Meeting Skills (Teams)→ Testing Daily Huddles (Carolina Family Health Center)→ Completing cycle time data collection (Johnson City Community Health Center)→ Completing role activity data collection (El Rio Santa Cruz| K Harding)

Learn new skills: Process Mapping and PDSA Methodology “Moodle” TBC Website Refresh Provide path forward and resources for Action Period 2

Agenda (3:00-4:30)

3:00 10 min Welcome and Introductions

3:10 35 min Action Period 1 MilestonesKey TBC Concepts Overview

Learn From Collaborative Teams

3:45 30 min Teach New Improvement Skills for Action Period 2Process MappingMethodology

4:15 7 min “Moodle” TBC Website : A Refresh

4:22 5 min Path Forward and Resources : Action Period 2 Assignments

4:27 3 min Evaluate Meeting and Wrap Up

Achieve multiple TBC specific aims

Standardize (SDSAs) roles and key processes (Playbook, Spread Plan)

Improve team and coach skills (improvement science, team work, coaching)

Move Practice Assessment Data toward Level A

Develop a post collaborative team action plan

TBC Learning Collaborative

90 minLearningSessions

Between Session Action Periods (6 weeks)Complete AssignmentsWeekly Team Meetings (5-6), Daily HuddlesMonthly Reporting

Implementation Tools and SkillsChange Concept ResourcesLearning From Each Other

Action Period One

Team Based Care Webinars (8)

Core and Extended Team Refinements

Effective Meetings and Daily Huddles

Team PracticeAssessment (LEAP)

Team Skills Data

Cycle Time Data Collection

Role Activity- Doing what now- Data collection

Global and Specific Aims

Fishbone : Defining Problem

Between Session Mentoring and Faculty Support

7

Sept 21 Nov 2 Dec 14 Jan 25 Mar 15 Apr 26 June 14

Improvement Ramp for Implementing TBC

Team CompositionEngage the teamWeekly meetings

1

Action Period 6

4-5

2-3

Improvement Science Theory Bursts (10 min)Developing Skills

Session 1 : Sept 21st o Running effective team meetings using toolso Developing and using a cause and effect diagram to inform PDSAso Writing a global and specific aim statement

Session 2 : Nov 2nd

o Developing a process map or current state workflow o Applying PDSA methodology for improvement

Session 3 : Dec 14o Using data for improvement (run charts, control charts)

Session 4 : Jan 25o Standardizing (SDSAs) and Reliability Science

Session 5 : March 15o Spreading Change

Session 6 : April 26o Gantt Charting : 3-6 month Core Team improvement plan

Team Skills Assessment Summary (N=68)Percentage Strongly Agree or Agree are Competent

Gathering an

d Using Data

Skills

Using Eff

ective

Mee

ting Skills

Implemen

ting Daily Huddles

Using Im

provement S

kills

Applying Tea

mwork Skills

020406080

10066

86 76 6891

Team Skills Self-Assessment Summary (N=68)Percentage Strongly Agree or Agree are Competent

% S

tron

gly

Agre

e or

Agr

ee

October 2016

How were some Coaches feeling Week One?

Mentors HelpingWeekly Coach : Mentor Group Meetings, Individual as Needed

Teaching skills, reviewing tools (more skill building needed from theory bursts, struggling with tools)

Addressing Online Learning Network Site (Moodle) challenges

Advising difficulties getting meetings off the ground (no time to meet), using roles (resistance)

Clarifying assignments, how to use assessment tools

Providing advice for managing : ‘turmoil’, ‘overwhelming assignments’, ‘team and leadership engagement issues’ , ‘team vs coach ownership’, ‘worried management will roadblock us’

Reminding : Start Where you Are, Use What you Have, Do What you Can….

Action Period 1 : 4 Mentor Sessions10 of 16 coaches attended 3 or 4

Individual as Needed

Transform your practice with team based care (webinar 1,2,3)

→ Define your Core and Extended Team Structure

→ Strategically redistribute work among team members (reduce waste, duplication, variation)

→ Create new responsibilities and provide training

→ Improve efficiencies (wait times, start times)

→ Standardize processes to reflect new model

Action Period 1 MILESTONES

Work on your Core (Pod) and Extended Team Structure ** (if needed)

6 Teams do not have significant work to do on Team Structure (session 1 polling) El Rio, Carolina Family Health Center, Peach Tree, Holyoke, Healthcare for Homeless, Sumter

4 Teams Working on Refining and Defining Structure-why am I on this team? , leader communication?-did not include RN or Front Desk-provider changes-RN and MA turnover (dilutes enthusiasm for change)-Dyad is “haphazard”-people on team do not consistently work together-not clear what is core and extended – need to define roles-team members work across multiple sites

1 Team part of a spread plan , implementing POD concept across clinic

** PCMH

Core (POD) and Extended Team StructureRefining and Defining

Sumter Family Health Center

How did you refine and why?

Blue Pod(Core Teams)

Dr. Etheridge

Jackie, MA

MA

Dr. Brant

Joe, MA

Porcelyn, MA

Richie Hall, NP

Vicky, LPN

MA

Team RN – LindaTeam Scheduler – PendingCare Coordinator – Pending (referrals, med records, health coaching)

• Melvina Pharmacist

• JolieDental Liaison

• KittyBH Liaison

• Mary• WendyCase Management

Extended Care Team

Team Based Care Model (webinar 1)

All Teams Have Met

12 Teams 3-6 Meetings4 Teams 1-2 Meetings

Mondays 12:15Tuesdays 9:00Wednesdays 3:00Thursdays 1:00Friday 1:00

30, 45, 60 minutesSome Cancel, Some Always Meet (shorter)

*leadership support for team meetings

Schedule your Weekly Meetings and Practice Skills using Tools

Challenging

Getting meetings off the ground is a struggle, plus new staff and changes

Frustrating process using tools, agendas too structured, need discussion time

Team members hesitating and resisting to take lead, and other roles.

Cancelling meeting due to different schedules . Team at different sites, no common time Transitioning from coach as Lead Focusing on what is in the core team’s control

vs focusing on management issues Finishing notes after meeting too much Cannot shut down clinic Using improvement skills ** Leader support for meeting time

Going Well Using a lead rotation schedule, same lead multiple

meetings, coach help us practice all roles Frank and honest dialogue is happening Group norms are being created and adhered to (e.g.

getting off topic, equal voice, don’t cancel meeting) People are making this meeting a priority over other

commitments, want to stay on track Sharing roles and meeting together has helped us

become a more cohesive team. Agenda’s created at the end of every meeting, notes

typed in the meeting from flipcharts Managers join meetings as show of support Team meets without coach, but coaches role

invaluable stepping in to help us Admin helping with meeting scheduling Schedulers protecting provider time for meeting

– TBC fits our Transformation ‘project’

** PCMH

Building a team….

Healthcare for Homeless

Recording

Sumter

2 Recorders Key Discussion Notes (blue) Action Items (red)

Running Effective Team Meetings

What is working well or not working well for your team?

Action Period 1 MILESTONES

Try Daily Huddles to improve efficiency **

4 Teams ( 2) POD Huddles working well: Plan the Day,

Improve Efficiencies, Standardizing (1) Tried and did not work, worked on reducing

anxiety and back on track Requested standard tools (posted Moodle)

** PCMH

Team Role Analysis :At least 2 hours/6 hour day of staff time can be spent identifying patients due for screenings and immunization.Could a huddle streamline these efforts, save time?

Huddle ExperienceCarolina Family Health Center

When do you huddle and who attends? How long have you been testing huddles?

How are huddles going? Overall going well Took some time to get into a good routine and iron out the logistics In the process of modifying a huddle template to use daily to log our efforts Tool will help standardize our huddles:

• Everyone on the team knows the expectations • We have a record of the discussion

Huddle ExperienceCarolina Family Health Center

What do we talk about?

1. What patients are scheduled today and how many appt slots are available for each provider?

2. Are there outstanding orders or referrals on each patient?3. Does the patient have any recent hospital visits? If so, obtain the records.4. Discuss patient specific needs : Interpreter? More time during visit needed?5. Discuss staffing for the day and go over roles for the day.

Carolina Family Health

Action Period One Milestones

Collect Cycle Time Data using patient tool** (15 patients randomly)

9 Teams Completed or in process of completing cycle time data collection

When tools have incomplete data, add more patients Varied the days and times Customizing (e.g. added labs, referral steps) Want to do it again – verify results

3 Teams analyzing the data Example 19 patients : average 57 min Finding Quick Hits: Educate the Scheduler

2 teams Developed and implemented a Spanish tool

** PCMH

Cycle Time Data Collection

Johnson City Community Health Center

Time 1 October 26, 2016 30

total time in office

check in time

waiting room time

time with the nurse

exam room wait

time

time with provider

check out time

0

20

40

60

80

100

120

140

160

180

Cycle Time: Johnson City CHC

Mean Minimum Maximum

How did we collect our data? How many patients, how selected,

when collected? What appointment type was used? Any challenges?

What did our data show, and what did we learn? Average time and breakdowns , any

surprises? Min and max time insights? English vs Spanish?

What else are we curious about?• Can interruptions be reduced during

exam room time with patient?• Are rooming standards reliable?• Do we start on time 8am, 1pm?

What opportunities for improvement are we identifying?

Action Period 1 Milestones Complete Role Activity Assessment and Tracking Tools **

5 Teams Assessed Role Activity in the Past : HC for Homeless, EHC of Wyoming, Daughter of Charity, Sumter, Peach Tree

10 Teams Completed or in the process of completing Role Optimization Assessment and Role Activity Tracking Working on compiling the data Completing assignment timely and appropriately has been challenging (tried more days, less time tracking) Modified tools to shorten (easier to complete) and aligned with their unique tasks plus new ones Repeating the data collection, did not think data was accurate or did not meet our needs Very surprised by the number and type of tasks that they ‘were not doing’ Finding significant duplication of efforts supporting assumptions about working in silos (e.g. RN and NP Asked staff outside their team to complete role activity to learn more Everyone coming up with ideas for roles, want radical changes now Struggling with ‘the point’ of assessment roles and activity current state MAs do not want MORE work

** PCMH

Role Activity Tracking

El Rio Santa Cruz

How did they collect the data?

How did they display the data?

What did the data show ?

What are the next steps?

Preliminary Report

What did the data show and what are we learning?

Uses Registry Data to Close Care Gaps

Scheduling

Communication

Normal Results

Triage Porta

l

Messages

Identifies and Flags

Due for Screening

and Immunizations

Provides Education

And Support

Provides Health

Coaching

Follow Up

No Shows

Please share your work TBC Online Learning Network (Moodle)

Who is doing what now? Is there duplication of effort? Are core processes standardized? Are there protocols and standing orders? What is the miscellaneous work?

How is our time spent? Is there a more efficient way to do things? Is there anything we should stop doing, start doing (always did it that way, did not know another way)

“Using role and cycle time data to fishbone or brainstorm reasons why there are workflow ‘redundancies’ and unequal distribution of work across team members.

• Data shows lots of duplicative efforts during patient visits

• Core team wants to improve ‘everything at once’

Quick Hit: • Educate call center on appointment scheduling issues

causing bottleneck.

Lengthy Appointments

People Equipment

Materials Process

Clinical staff inconsistent Support staff not trained

No one responsible for patient flow Patients arrive with more needs than originally stated

Providers are lateSupport staff unprepared for patient visits

Equipment broken

Not enough computers

Equipment missing

Inventory low

Missing exam room supplies

Charts are missing

Information, e.g. test results missing

No standard registration process

MA does paper flow and patient flow

Variation in rooming process

Check out process delays

Poor communication between all staff on patient status

Fishbone (Cause and Effect) of Lengthy Appointments

Rio Monthly Report

Using Role Activity Data

Using Role Activity Data

If there are No Standards for Roles that are ‘doing the same activity’, or currentstandards are inconsistently followed – this is waste and inefficient

For example : Data for Closing Gaps in Care Using Registry Data• MA 6% of time• LPN 33% of time

Leveraging Waste Elimination and Standardization Creates Capacity

Capacity for Role Optimization

Nurses in Primary Care Webinar 3

Primary Care Team Guide Assessment Data (n=16 Teams)

Level A Level B Level C Level D0

2

4

6

8

10

Medical Assistant (MA)

Level A Level B Level C Level D01234567

Registered Nurse (RN)

Level A Level B Level C Level D02468

Medication Management

Level A Level B Level C Level D02468

10

Planned Care

Level A Level B Level C Level D02468

10

Population Management

Level D: Just Getting StartedLevel C: Early Stages of ChangeLevel B: Implemented Basic ChangesLevel A: Achieved Most or All of the Important Change Required

Individual Team Data

Role Assessment of ‘the work’: Webinars 1-8

Improvement Ramp for Implementing TBC

Process Mapping Current State

1

Action Period 6

4-5

2-3

Capacity for Role Optimization

MA RoleWebinar 2

Benchmarking

Primary Care

MAPre Visit Planning

Workflow

Process Starts: Reviewing Next Day Schedule and Chart

Process Ends :Team Huddle

Hess.CPM.2010

How the Fishbone Helps Plan PDSA Cycles

50

Brainstorming Change Ideas for PDSAs Take a minute or so for silent thinking Be creative Record ideas from ALL participants WITHOUT judgment Clarify as needed and No discussion. Build on other’s ideas Combine similar ideas Vote on idea(s) you want to try Test change ideas using PDSA cycles

Benchmarking to Identify Change Ideas Using Best Practices

51

Literature Search , Conferences

Internal Within Your Team or Practice Across Organization

External ImprovingPrimaryCare.org PCMH “Moodle” TBC Website REFRESH

Dartmouth Microsystem Improvement Curriculum (DMIC)

NCA Online Learning Network Find material for download, TBC webinars, and team folders for sharing your work...

Improvingprimarycare.org

Discussion Board Ask questions or make requests of teams, faculty….

Action Period Milestones6 Teams General Focus of Global Aims

o Team Based Careo PCMH o New Mission Statement

General Focus Specific Aims “sub-aims” of Global Aim

o Reduce Waste, Reduce Cycle Time, Reduce Wait for Provider, Close Care Gaps

o What Patients Love and Drives Them Nutso Other : ‘education’ and ‘communication’ -

(what do you want to achieve by this – that might be the aim)

Create a therapeutic alliance with each individual patient that promotes comprehensive care for every member of the community with efforts to proactively promote health and wellness while treating disease

Reduce cycle time for a 15 min appointment from 45 min to 25 min by Dec 15 PDSA 1: daily huddles for better

communication to avoid duplication of effort PDSA 2: start time 8 am and 1pm PDSA 3: rooming protocols PDSA 4 : redesign check out process

Action Period 2 Assignments

1. Meet weekly (30-60 min) as a Core Team Practice effective meeting skills and use tools with

coaching support

2. Continue Daily Huddles or Start Daily Huddles Work on standardizing (PDSAs, SDSAs) Align Huddle intervention with a specific aim

3. Continue to work on using tools, practice skills: Core and Extended Team Structure Role Optimization Assessment and Role Tracking Cycle Time Fishbone – define problems discovered by data or

other sources Specific Aim Statement(s) Aligned with Global Aims

Complete Readiness Survey

1. Access the ORIC Tool on the NCA Moodle Website

2. Follow the link and complete the form

3. Alternatively, scan and upload on the NCA Moodle Website: Post and Access Assignments Here >> Health Center Reports

Action Period 2 Assignments

4. Complete Readiness Survey

5. Develop a process map of a workflow you want to improve

6. Plan your tests of change

7. Do some PDSA cycles to achieve your specific aim

8. Upload monthly progress report to inform Session 3 Planning

Action Period 2 AssignmentsMentoring and Faculty Support

Continue Weekly Mentor meetings for 2 groups of Coaches Individual coaching support as needed Teach improvement skills, how to use tools – helping teams learn

Analyze and post Readiness Survey data

Improve everyone’s experience using the Online Learning Network

Prepare for Session 3 : Identify | support teams for sharing their improvement work

Looking Ahead Session 3

Has your POD and Extended Team model evolved?What have you continued to learn from all assessments, other data?How are your meetings and huddles going?How are you defining problems using a fishbone diagram?How are you doing with specific aims and PDSAs? Aligned with Global aim?What TBC change ideas are you testing? (guidelines, tools, protocols, role descriptions, processes)

NewLearning about data sampling, run charts and control chartsUpdate from CHCI : MA Training Program

Thank You All

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