NCA TBC Session 4 Jan 25 2017

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Advanced Team Based Care (TBC) Learning Collaborative

Welcome to Session 4January 25, 20173:00 - 4:30 EST

Developing core and extended team capabilities for implementing an advanced team based care model.

Introductions

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

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

Mentors , Coaching Faculty Deborah Ward, RN (1:6) Kasey Harding (1:7)

Evaluation Faculty Kathleen Thies, PhD, RN

Improvement Science Faculty Patti Feeney Mark Splaine, MD

*3 Practices Will Not Continue: Provider Turnover Participating Teams, Time Commitment

Mentor Name of FQHC State Coach Team Members Team

Kasey Avenal Community Health Center CA John Kalfayan

Frances Silva, Behavioral HealthVivian Stafford, Physician

Khuong Phui, Medical directorBetty Mora, MA

Christina Castaneda, Receptionist

1 BH, 1 Physician, 1 MA, 1 Medical Director, 1 Front Desk

Deb Carolina Family Health Centers , Inc. NC Mary Williams

Amparito Fiallo, MDAl Abaya, NP

Lisa Vinson, LPNBernadette Mangum, LPN

Cheyenne Robbins, Care CoordinatorBetty Lucas, Front Desk

Zenaida Aguilar, InterpreterRaquel Milbourne, CNA

Sandra Botello, Referral Specialist

1 MD, 1 NP, 2 LPN, 1 Care Coordinator, 1 Front Desk, 1 Interpretor, 1 CAN, 1

Referral Sepcialist

Deb Educational Health Center of Wyoming WY Pamela Oiler

Donna Romain, RNLaDonna Whittaker, Radiologic TechLiz Bravo-Alcon, Executive Assistant

Stephanie Schneider, MAPatrick Monahan, Clinical Manager

Marianne Ploucha, Business Office ManagerKimberly Broomfield, Faculty Physician

Jennifer Walsh, MAChristie Novy, MA

Evan Norby, Clinical Team LeadMonette McKee, RN

Thanh-Nga Nguyen, Faculty Pharm D.Pamela Oiler, Faculty LCSW

1 Provider, 2 RN, 1 Radiologic Technologist, 1 EMR Manager, 3 MA, 1

Clinical Manager, 1 Pharmacist, 1 LCSW


Kasey El Rio Santa Cruz AZ Josh Carzoli

Crystal Chavira, MAYomaira Preciado, RNJennifer Stivers, LPN

Rajiv Modak, PhysicianStephanie Pinedo, Reception

Linda Beauchesne, Medical Informatics SupervisorSonia Reidy, Physician

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

Deb Healthcare for the Homeless TX Carlie Brown

The core team: Henry Siem, MDLuis Huerta, MA

Krissy Joubert, MA – Intake/Registration Unfilled RN Position

Extended team: Cidney Aae, Case Manager

Joseph Benson, Community Health Worker

Need new team

Kasey Holyoke Health Center MAMegan T.

Wechsler, Rosie Romero

Core Team:Dr. Kefah Al-Ramahi, Internal Medicine, MD

Karen Horgan, RNNatalie Alicea, MA

Juan Acevedo-Behavioral Health Integration Program Manager

Mariluz Vargas, Front DeskExtended Team:

Dr. Alejandro Esparza, CMOMartha Fisk, Director of Quality and Compliance

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

Deb Johnson City Community Health Center TN Flo Weierbach

Martiza Ramirez, Front DeskRebecca Morrison, PNPAmy Mclaughlin, LCSW

Mae Crestinger, RNLaura Gentles Gonzales, Interpreter

1 Dfront Desk, 1 PNP, 1 LCSW, 1 RN, 1 Interpreter


Kasey Peach Tree Healthcare CA Ruben Ruiz

Core Team: Margarita Cuevas, MA

Rene Minnaar, NPJose Alvarado, MA

Kathleen Hawes, Site ManagerAlex Castro, Customer Service Specialist

Tang Yang, Operations SpecialistTameka Frank, Quality Coordinator

Hakeem Adeniyi, Chief Medical OfficerRuben Ruiz, Quality Coordinator

Sheila Arnold, Clinical Support Services ManagerOther Team Members in Monthly Meetings:Michelle Woodard, Director of Operations

Mary Renner, Director of HRDalip Rai, Data Analyst

1 Chief Quality Officer, 1 Quality Coordinator, 1 Director of

Operations, 1 Site Manager, 1 Director of HR, 1 NP, 3 MA, 1 Data Analyst, 1 Operations

Specialist, 1 Clinical Support Services Manager

Deb Sumter Family Health Center SC Sandra Sturkie

Core Team:Linda Brice, Adult Health Clinical Manger

Dr. Etheridge, Adult Health MDPorcelyn Scarborough, MA

Ebony Singleton, Call Center/RegistrationSondra Richardson, Referrals Manager

Extended Team:Kitty Kulungowski, RN Behavioral Health

Wendy Bonds- Chapman, Case ManagementMary Byrd, Case Management

Tina Thompson, Behav Health RNJolie Costello, Dental Services CoordinatorJoyce Bair, Patient Financial Coordinator

Marti Martin, Clinical IT/EMRMelvina Chappell, Pharmacist

1 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


Deb Syracuse Community Health Center, Inc. NY Cathy Brigden

Dr. Roy Smith, Physician Ms. Zarina Smith, FNP

Ms. Stephanie Green, LPNMs. Rebecca Wright, RNMs. Shanieka Smith, MA

Ms. Tania Guntin-Bernal, MAMs. Tiffany Senke, MA

Ms. Stephanie Montgomery, Office ManagerMs. Verna Griffith Payne, RN

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

Kasey The Children’s Clinic CA Karla RodriguezDr. Shea Suskin, Provider

Joana Rios, MAElizabeth Castruita, LVN

Angela Moreno, Clinic Manager1 Provider, 1 MA, 1 Care Team Rep

Deb Tyler Family Circle of Care TX Sherri Gould

Carolyn Risinger, CMOLinda Isabell, COO

Nadra Miller, Lead LVNJuana Crespin, OARobin Hogue, PNP

Vanessa Vela, Process Improvement Manager

1 CMO, 1 COO, 1 LVN, 1 OA, 1 PNP, 1 Process Improvement Manager

Kasey Via Care Community Health Center CA Lourdes Olivares

Agustin Jaime Lara, CMOAnamaria Lopez-Chavelas, MSW

Ema Hernandez, LVNLaura Andrade, MA

Julio Arellano, EnrollerMaria Valdez, Director of Operations

Maricela Romero, MA/Front Desk leadVictoria Moreno, RN

1 FNP, 1 MA, 1 Outreach & Enrollment Specialist, 1 MSW, 1 Front Office Lead

MA

Objectives Session 4

Summarize Action Period 3 Milestones (6 weeks) Discuss physician challenges Learn how to standardize a process to achieve reliability Learn from Team Specific Aim and PDSAs presentations Provide path forward and resources for Action Period 4

Define Core and Extended Team

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 , Daily HuddlesMonthly ReportingShare Your Work – TBC Website (Moodle)

Developing Effective Meeting and Improvement SkillsImplementing Team Based Care – Small Tests of ChangeLearning from Each Other

Action Period 3

Core and Extended Team Improvements

TBC Webinars (1-6)

Effective Meetings and Daily Huddles

Readiness Survey

Role Activity and Cycle Time Data - deeper

Specific Aims• Defined by Fishbone• Defined by Data ,

Assessment• Defined by Current

State Process Map

PDSAs – tests of change

SDSAs – protocols, check lists , standing orders

Between Session Mentoring and Faculty SupportMoodle Resources and Discussion Board

7

Sept 21 Dec 14Jan 25

Mar 15 Apr 26 June 14Nov 2

Improvement Science Theory Bursts (10 min)Developing Capacity for Implementing Advanced TBC Model

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, bar graphs, sampling)

Session 4 : Jan 25o Standardizing (SDSAs) and Process Performance Over Time

Session 5 : March 15o Spreading Change

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

Improvement Ramp for Implementing TBC

1

Action Period 6

4-5

2-3

Team Based Care Learning Session 4January 25, 2017 Agenda (3:00-4:30)

3:00 5 min Welcome and IntroductionsImprovement Road Map

3:05 20 min Action Period 3 MilestonesChallenges and Exemplary TeamworkProvider Role Debrief (Sumter, Holyoke, The Children’s Clinic)

3:25 10 min Team Based Care PDSAsPeach Tree : MA Rooming Standards

3:35 15 min Standardizing and Process Performance Over Time

3:50 30 min Team Based Care PDSAs

El RIo : Well Child ScreeningVia Care : Scheduling Process

4:20 10 min Path Forward and Progress Check ListAction Period 3 Assignments

Action Period 3 Assignments

1. Meet weekly 45-60 min as a Core Team (discipline, rhythm, pace) 10 of 13 teams meeting 3-4 times monthly (Holiday challenges) 3 teams meeting fewer than 3 times monthly

2. Post Monthly Reports Jan 10th (9), Next Due Feb 14th

3. Implement Daily Huddles Work on improving (PDSAs) and standardizing (SDSAs)

4. Continue to Learn from Assessments Cycle Time (posted versions Spanish , Labs and Radiology steps added) Role Activity Analysis

3:05

Sept 16, 2015Lessons Learned PCMHSt Lukes Medical Group, Overland Park KansasDr Michael Munger

Define Core and Extended TeamStructure and Roles

Carolina Family Health Centers

Change Ideas for Access and Efficiency

Carolina Family Health Centers

Healthcare for Homeless

Provider Discussion Topic

Across the country, the biggest team based care challenge includes….

Provider ‘challenges’ related to letting go of tasks that others can perform within their level of licensure and training.

They worry about things getting done and whether another care team member is trained to do the job.

Standards often do not exist, and when they do exist they are not reliable.

Everyone’s plate is full.

Physician Panel

Dr Etheridge Sumter Family Health Center

Dr Keefah Al-ramahi Holyoke Health Center

Dr Suskin The Children's Clinic

How have you been addressing physician role challenges while implementing team based care?

3:10

Physicians act as the team leader, but not as the sole provider– Helps formulate care plans and initiate therapy for complex patients– Supports and encourages team members to practice at their capacity– Utilizes the work of team members to provide comprehensive care and management for our

patients– We have to learn to give up the “hero doctor” role and rely on the team to help manage and

educate patients• Accept specialty training of others working within their credentials to improve patient care

– Need to create protocols and standing orders that help facilitate team-based care rather than hinder their efforts

– Use targeted registries to formulate new care approaches and determine how to best utilize care staff to meet these goals

– Encourage the educational and motivational growth of team members to further enhance the team-based care offerings

– Utilize the efforts of the team to ease the work burden of all members when we all “row together”

Dr Etheridge : Sumter Family Health Center

Questions forPhysician Panel?

3:10 - 3:25

“Development of meaningful care teams implies major changes in the ways individuals and groups within practices

view their roles, and the ways they work together”.

It requires ongoing and relentless dedication to continuous improvement that will challenge “change fatigue” of even the

most robust practice.


5. Write specific aim(s) statements , using data and knowledge of problem Continue Assessments (role activity, cycle time, other) Complete Fishbone diagrams and process mapping

6. Implement PDSAs (small, measurable, rapid) Share your work by uploading TBC website, discussion board Use brainstorming and benchmarking to inform changes

Specific Aims, PDSAs, Measures

Session 3 PresentationsSession 4 PresentationsSession 5 Presentations

Name of FQHC Process Team Specific Aims PDSAs Measures

1 Avenal Community Health Center Team huddles and Role efficiency

Increase efficiency across roles (role activity data). Team based care huddles have been standardized across all sites

at the agencyHuddle PDSAs and standardizing . Working on PDSA for

Team based care role optimization . Role Activity Assessment of Efficiencies

2 Carolina Family Health Centers , Inc. Visit Efficiency (All Roles)

Decrease total cycle time from 78 minutes to 60 minutes by Dec 15th 2016. Improve provider schedules that

impact workflows of the POD. Test daily huddle checklist and standardize. Test pre visit

planning tool. Cycle time

3 Educational Health Center of WyomingLab Result Notification Process

Med Refill Process (MD, MA Roles)

Increase patient notification of labs. Reduce time it takes to process medication refills.

Lab result notification protocol. Medication refill protocol and process

Timely Lab Notification?, Med Refill Completed?

4 El Rio Santa CruzWell Child Screening Process (MD and MA

roles)We aim to improve 24 month well child screenings by 10%

by Dec 31 2016Optimize front desk role identifying opportunity to provide

well child while in for acute if gap. Pre visit Protocal MA. Well Child Screening

5 Healthcare for the Homeless Referral Process (CM, CHW, MD, MA Roles) Reduce referral process inconsistencies and ineficiencies Test new referral process to 'in clinic' case managers and

community health workers Standard referral process implemented

6 Holyoke Health Center Visit Efficiency (All Roles)

Decrease double documentation by 100% (eliminate paper). Decrease wait times and free up more MA time. Eliminate paper patient processing sheets and utilize EMR. Cycle Time

7 Johnson City Community Health Center Visit Efficiency (All Roles) Reduce cycle time (average 78 min) Customize tools (english and spanish). Fishbone to define

problems for PDSAs Cycle Time

8 Peach Tree Healthcare Visit Efficiency and Access (All Roles)

Decrease no shows. Increase amount of appontment slots. Decrease overall cycle time and waiting room time by

standarding MA rooming process (fishbone)

Test new scheduling template for open access to open appointment slots for same day? Standardize daily huddles

(re evaluating).

Collect cycle time for 2 days during the 1st week of each month.

Open Appts.

9 Sumter Family Health Center Visit Effiiency Pre Visit Planning (Reception)

Increase percentage of patients that are Pre Registered (pre visit planning) from 26% to 29% by Dec 31st.

Test standard for what to cover in the pre registration phone calls. Dedicated staff assignment- additional.

Cycle Time Pre Visit Planning and Pre Registration

completions

10 Syracuse Community Health Center, Inc.Med Refill Process Lab Follow Up Process

(MD, RN Roles)Reduce provider inbox med refills and lab follow ups. RN role defined and dedicated to this task. RN tally types of

follow up done.Cycle Time Inbox

messages

11 The Children’s Clinic Colorectal Cancer Screening (MD,MA roles)

Increase the number of screenings ordered by (Dr Suskin) from x to 80% for eligible patients. Increase patient

compliance with screening. Improve pre appointment chart review process.

Test process that reduces workflow barriers Pilot a chart review tool Screeening Rates

12 Tyler Family Circle of Care Access (All Roles) No Show decrease from 21% to 20% Reminder phone calls . Access scheduling. No Show Rates

13 Via Care Community Health Center Visit Efficiency (All Roles)

Reduce # of 'erroneous scheduling' issues from 6 per week to 0 per week. Test new patient appt scheduling Cycle Time Scheduling Issues

http://online.ideasontario.ca/wp-content/uploads/2015/10/Slide1.png

Increase to 80% Colorectal Cancer Screening

Accuracy of Documentation

MD Ordering Process

Patient Compliance with Screening

Chart Review Tool – pre visit planning

One Physician

The Childrens Clinic

http://online.ideasontario.ca/wp-content/uploads/2015/10/Slide1.png

Cycle Time

Provider SchedulingImpact on AM PM start times

Daily Huddles

Pre Visit Planning

Rooming Standards

Use The Tools : PDSA Worksheet


7. Complete readiness survey ( N=49), post data on TBD WebsitePurpose : To assess whether an organization is ready and committed to the implementation of a specific change, from the perspective of care team members.

7. Review or refresh change concepts and change ideas Webinars 1-4

#1 Building a Primary Care Team#2 Enhancing the Role of the Medical Assistant#3 The Emerging Role of Nurses in Primary Care#4 Data Driven Dashboards to Support Team Based Care#5 Team Approach to Prevention and Chronic Illness Management#6 Complex Care Management in Primary Care#7 Achieving Full Integration of Behavioral Health and Primary Care#8 Dissolving the Walls: Clinic Community Connections

Key Challenges and Opportunities Action Period 3 (Mid Point)

Provider worries about ‘letting go of tasks’ to others Coach turnover and core team turnover – getting them up to

speed Keeping meetings focused

trying to work on too many things at once some meetings turn into gripe sessions

Documenting what we are doing to share with others in practice, and share on TBC Moodle site (data walls, staff meetings)

Measuring PDSAs – seeing change, seeing rapid results When does the ‘ah ha’ moment come? Hard to keep the same passion for change as when we started

Everyone learning new skills together, at different levels

Peach Tree Healthcare

Medical Assistant Rooming Process Established Patient

3:25

Peach Tree : Medical Assistant Rooming Process Established Patient

Peach Tree

Standardizing and Process Reliability

While most of your cycles will involve PLANS for tests of change, your last few cycles should involve STANDARDIZING your changes to make them the new “usual way we do things”…

3:40-3:55

Process performance tends to degrade no matter what, even if a standard is defined,explained to everyone, posted and regularly audited.

This is not because of a lack of discipline. Any organized process naturally tends to decline to a chaotic state if we leave it alone.

Standards are what we strive for…..

http://www.slideshare.net/AMEConnect/retire-the-pdca-wedge

A Single Standardized Process within the acceptable science is superior to allowing

multiple processes …..

because it allows for competency and training new employees

How can we use data to understand process performance over time?

24 month well child screenings

43

El Rio Community Health Center

• Pediatric team looking to improve team based care• Started with approach to 24 month old screening (CBC,

Lead, MCHAT) and reducing duplication of work• Specific Aim “We aim to improve 24 month well child

screenings by 10% by 12/31/2016.• Team Leader (Dr. Modak) met with site prescribers.

Additionally worked with Jennifer and Crystal around protocol for process.

44

El Rio Community Health Center

46

24 Month Well Visit MA Pre Visit Protocol Open intake for well visit, 6 point check

Verify vaccines and order per standing orders

Vital patient including weight, length, head circumference, temperature, pulse, respirations, and vision screening

Hand MCHAT to parent and explain why screening is being performed

Enter vitals into EHR including screening intake summary (second hand smoke exposure)

Order CBC and lead labs (under routine health code) and place on patient's door

Print anticipatory guidance/growth charts and place on patients door along with ROAR book

Collect MCHAT from parent, enter in EHR. If patient fails, place MCHAT on provider's computer

Clock patient in ready for provider

47

History of FQHC’s in United States (cont.)

Sep-All Other Clinics

Oct-All Other Clinics

Nov-All Other Clinics

Dec-All Other Clinics

Jan-All Other Clinics

Sep-Southwest Pediatrics

Oct-Southwest Pediatrics

Nov-Southwest Pediatrics

Dec-Southwest Pediatrics

Jan-Southwest Pediatrics

0%

20%

40%

60%

80%

100%

120%

40%

61%

54%48%

60%

81%77%

84%

100%93%

44%

63%

54%49%

62%

81% 77% 81%

100%

93%

16% 17% 16% 15%

26%

89%

77%

97% 95% 93%

24-Month Well Child Visits - SW Pediatrics vs. All Other ClinicsOct-Dec 2016

CBC Pct Lead Pct MCHAT Pct

All Other Clinics

Southwest Pediatrics

PSDA #1 Improving New Patient Flow

Identification of Gap

Began with huddles dailyTeam Collaborative Meetings

WeeklyShared findings from huddlesSelected top area of concern

identified by the staff Developed a PSDA: To Improve

New Patient Flow

Planning During TCM Meeting

A site was selected to pilot (only one) A timeframe was selected: 2 weeks Lead members to launch this were identified:

1 clinic supervisor 1 Enroller to help with front desk reminders 1 MA to help reminder the team daily CMO reminded daily in huddles

A base measurement was made- 6 new patients were incorrectly scheduled

New patients scheduled randomly with standing patients, leaving no extra time for new patient registration paperwork.

Impacts of incorrect scheduling were identified Delay in patient check-in Backed up front desk flow Resulted in low patient satisfaction Caused MAs and other staff to run late and stay after their daily

shift

Implementation

CMO reviewed with team in daily huddle Clinic Supervisor provided daily verbal reminders

Helped place scheduling note in the EHR MA lead emailed reminders to front desk staff Enroller posted this new pilot step by step on a

print out for visual reminder next to front desk computers

Directive provided: NEW PATIENTS WERE ONLY TO BE SCHEUDLED DAILY DURING THE FIRST HOUR OF OPENING THE CLINIC AND FIRST HOUR AFTER LUNCH.

End result

At the end of two weeks Only 1 patient had been found to be scheduled out of

order Staff was happy that they did not have to stay late on

any given day Clinic flow ran smoother- which was motivating TCM team was happy with a quick victory Increased buy in from staff for this project

Organizations can mitigate team based care implementation and role optimization challenges

through small-scale testing, training, observation,

and collecting data on workflows and outcomes to demonstrate effectiveness and performance

of a standard process over time.

*IHI 2016 Team Based Care Collaborative


1. Meet weekly as a Core Team , continue defining Use Effective Meeting and Improvement Skills Focus on PDSAs using Fishbone(s), Current State Process Map(s) Use the improvement RAMP to stay on track, organize and communicate

2. Achieve 1 Specific Aim, multiple PDSAs

3. Implement SDSAs Standardize Daily Huddles Other processes redesigned, protocols,

checklists, EHR Decision Support


4. Post your draft or final visuals of Core and Extended Team Include any role definition documents Discuss with leaders, implications practice strategy

5. Submit Feb 14th Monthly Report (Coaches) Include well written Specific Aim Statements and Measures Post PDSA worksheet(s)

6. Complete Readiness Survey by Feb 8th , data will be posted on TBC Moodle Site

7. Review Webinars 1-6

8. Complete Progress Check List (Coaches)

7. Review Webinars 1-4

#1 Building a Primary Care Team#2 Enhancing the Role of the Medical Assistant#3 The Emerging Role of Nurses in Primary Care#4 Data Driven Dashboards to Support Team Based Care#5 Team Approach to Prevention and Chronic Illness Management#6 Complex Care Management in Primary Care#7 Achieving Full Integration of Behavioral Health and Primary Care#8 Dissolving the Walls: Clinic Community Connections

Webinar 5:

Progress Check List

Are you achieving most or all of the important changes required?

Peach Tree Healthcare

Improvingprimarycare.org

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

Thank You All

Survey Post Session

Thank you for your participation today and feedback : Session Evaluation

NCA TBC Session 4 Jan 25 2017

Healthcare

Transcript of NCA TBC Session 4 Jan 25 2017