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TRANSCRIPT
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Day 2
Data-Driven Population Health
Quality Improvement Summit
2
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Networking Breakfast
256
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Supporting Team-Based Care with Data Tools
Referral Management in DRVS
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Goal of Today’s Session
Referral module overview
Challenges of the referral process
Managing referrals– Goals and roles– Workflows and functionality
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Why is Referral Management So Important?
Improves provider communication and patient safety. Helps ensure patients complete the referrals recommended for them. Provides insight into
– Referral patterns– Specialist behavior
Patient Centered Medical Home Recognition– Care Coordination and Care Transitions (CC)
CC 01 B. Imaging Test Management CC 04 C. Referral Management CC 06 Frequently used specialists CC 11 Timeliness of referral response
3
The typical primary care provider coordinates with 229 physicians in 117 practices1. It’s hard to “close the loop”
1Pham, H. H., O’Malley, A. S., Bach, P. B., Saiontz-Martinez, C., & Schrag, D. (2009). Primary Care Physicians’ Links to Other Physicians through Medicare Patients: The Scope of Care Coordination. Annals of Internal Medicine, 150(4), 236–242.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3718023/
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How do we make it work?
4
Referral Management Module
An electronic tracking tool that provides clear actionable data to assist with the management of referrals.
Requires clear definitions and workflows.
The juggling act….
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Components of Referral Management in DRVS
Provides quick access to actionable referral lists• Requires appointment to be scheduled• Identify past due appointments requiring consult notes
Referral ReportsTrack and Monitor
Health• State - % open, completed, canceled, deleted• Time to complete a referral
Priority• Stat Open > 7 Days • Urgent Open >14 Days• Open – needs appointment • Open – needs follow up
Composition• Internal, Self-Scheduling, Type
Snapshot of referral management performanceDrill down capability to population of focus
DashboardKey Performance Metrics
MeasuresInsight, Priority & Composition
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Referrals Are Complicated!
6Azara Proprietary & Confidential
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How Can the Referral Module Help?
7Azara Proprietary & Confidential
• Monitor impact of changes made to workflow
• Workload distribution• Performance based on type, priority or
referred to location
• Prioritize work for each day by referrals that need the most attention
• Understand work load• Follow up on referrals that are pending a
consult note/results
MANAGEMENT REFERRAL COORDINATOR
• Identify open referrals• Identify referrals by specialist• Understand who you refer to most
often
• Stat and Urgent referral closure rate• Understand risk associated with
outstanding referrals – by priority and specialty type
PROVIDERS QUALITY & RISK
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Referral Workflow – Milestones
8
Ordered Date
Scheduled on Date
Appointment Date
Received Date
Completed Date
Date referral to specialist was placed.
Date coordinator entered an
appointment date for the referral.
Date consult note/result
received by practice.
Date provider reviewed
the consult note/result.
Date on which referralis scheduled or occurred.
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Referral Workflow Considerations
9
Provider Orders
Appointment to Specialist Gets Booked
Appointment Date
Recorded
Receiving the Consult
Note/Report
Report Reviewed by
Ordering Provider
• Indicates if stat/urgent/routine• If important/concerned creates
a ‘tickler’
• Who Books it? Patient or CHC.• What if it is urgent?• If appointment is not booked
before patient leaves, what is the follow up?
• If appointment is not booked before patient leaves, what is the follow up?
• Do you call patient to see if scheduled? How often?
• Do results come by paper/electronic or both?
• What happens after report is received?
• When does the provider sign off that it was reviewed?
• How and when is the result received?
• How does it get connected to the referral?
• What happens when a result is received but there is no order?
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Workflows and Approach
Workflows
External Referrals to a Specialist
Internal Referrals to a Provider/Specialist
Self-Scheduling Referrals
Diagnostic Imaging Orders
Consult note/result follow-up
Approach
Accountable start to finish– One person responsible to
schedule / follow up
Phase accountability– Role based assignments
Other
Referrals may require different workflows to assure they are ‘worked’ appropriately.
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Management
Organizing and coordinating the referral process
Define workflows – Define roles – Set clear expectations for users
Tools: – Dashboards, reports, and measure analyzer.
Understanding the referral environment Tracking and understanding how well the referral management process is working
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Referral Management Dashboard
12Azara Proprietary & Confidential
Priority Level of Referral Service
Referral Performance
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Referral Coordinator
Facilitate the referral process. Assure patients get recommended care.
Tools:– Registries to manage work queue.
Identify responsibility for referral. Make calls to patients or specialist. Follow up with provider when patient indicates they don’t want to purse specialist/referral
– Dashboard and Measures Prioritize work based on key indicators Awareness of team and individual performance Set goals for improvement.
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4 Referral Reports
Action-specific reports minimizes sorting and filtering.
14Azara Proprietary & Confidential
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3
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Report Details| The Basics
Manage referrals like a population for max efficiency.
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Report Details | Important Dates
Dates Identify patients that need action.
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Registry Details| Other
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Referral Measures in DRVS
Many measures available in DRVS for tracking overall referrals
Same functionality available for all other measures:
– Measure Analyzer Trendline– Center Benchmark Comparison– Location, Provider, etc. View– Provider Trendline– Patient Detail
18Azara Proprietary & Confidential
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Time Periods and Filtering
Time Period– Most measures and reports reflect referrals ordered in the time
period as the denominator/inclusion criteria– Choose your time period carefully so as to measure what is
important
Filters available– Location– Provider– Priority– Referral Owner– Referral Type– Internal Referral– Pt. Self Scheduling
Measures and reports only include referrals for patients who are ‘Active’ (not deceased or inactive in system) in the measurement period.
19Azara Proprietary & Confidential
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Referral Measures
Go to detail– Sort - referral provider, owner, internal/external, no appointment date
20Azara Proprietary & Confidential
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Quick easy access to reports, dashboards, measures with customized filter settings.
Unique to a specific user.
Set Up1. Select desired filters 2. Create Favorite3. Create unique name4. Set default Time Period
Save
Creating a ‘Favorite’ Referral Report|1
21Azara Proprietary & Confidential
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Creating a ‘Favorite’ Referral Report|2
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Creating a ‘Favorite’ Referral Report|3
23Azara Proprietary & Confidential
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Care Team
At the point of care, providers with teams using the Patient Visit Planning report can see Open Referrals without a consult note/results
Make data-informed decisions about patients:– Follow up to get consult note/results– Correct documentation if results actually exist in the EHR– Explore why patient has not followed up on referral. Opportunity to engage in shared
decision making and /or understand barriers such as social determinants of health.
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Integrated Referrals on PVP
25Azara Proprietary & Confidential
Open referral information can help guide actions and conversations during the visit.• Referral Type• Specialist / Location• Ordered Date• Appt Date
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Questions?
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Reflections from Day 1Pair up with someone, listen to and tell takeaways
from yesterdayReport out
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Data Driven Improvement
Presented by Abby ZitoOn Behalf of Yukon Kuskokwim Health Corporation Aniak, Emmonak, Hooper Bay, St. Mary’s, and
Toksook Bay Clinics
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285
Where We Started
We Knew:Low HTN Control Rates: 52.83%
5 Clinic
s 22 Remote Village
s
1093 HTN
Patients
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AIM Statement
Improve the percentage of patients diagnosed with HTN in Aniak whose
most recent BP was less than 140/90 by 7% within the next 6 months.
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YKHC HTN Improvement
Initial Rate: 41%
High Point: 64%
Sustained: 58%
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The Foundation for Improvement
Patient Engagement
Improvement
StaffEngagement
Data and Structured PI
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Staff Engagement
Ideas come from unexpected places
Multi-Disciplinary Team Don’t assume that all employees have the
same level of understanding
Staff EducationTraining and
Structure
Improvement Tools
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Staff Education Presentation
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Measuring Staff Engagement
Percentage of ALL staff trained in HTN basics
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Patient Engagement
What does BP mean and what is a good
BP?
BP Education
Initial VisitRegistry
Prioritized Recall
HTN Plan and Tracking
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Patient Education
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295
Measuring Patient Engagement
Informal measures: Anecdotal from providers
and patients
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Patient Tracking
Call Script
Initial HTN Education Visit
In-Appointment Follow-Up Scheduling
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297
System Wide Impact!
Median
Goal
0
10
20
30
40
50
60
70
13-Oct
13-Nov
13-Dec
14-Jan14-Feb14-M
ar14-Apr14-M
ay14-Jun14-Jul14-Aug14-Sep14-O
ct14-D
ecJan-15Feb-15M
ar-15Apr-15M
ay-15Jun-15Jul-15Aug-15Sep-15O
ct-15N
ov-15D
ec-15Jan-16Feb-16M
ar-1616-Apr16-M
ay16-Jun16-Jul16-Aug16-Sep16-O
ct16-N
ov16-D
ec17-Jan17-Feb17-M
ar17-AprM
ay-1717-Jun17-Jul17-Aug17-Sep17-O
ct17-N
ovD
ec-1718-Jan18-Feb
SRC Combined HTN Control RateRate of Control
Initial reporting on interventionsSwitch to ProbList
HTN workgroup
HTN Interventions
Focus on spreading changes
Initial Rate: 42.7%
High Point: 58.89%
Sustained: 56.85%
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Real Change Takes TIME
2017
2016
2015
2014
Low rates. Simply looking at data
Active data monitoring. Solidifying processes and
procedures.
Spreading tested changes.
Engaged our team. Began monitoring our data and
acting to improve.
2018
Moving onto remote villages.
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Thank you
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BreakTake 5
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Using Data to Transform Care DeliveryJane Taylor, Ed.D.April 2018
2
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ObjectivesState 3 types of measures for improvementCreate a family of measures for care deliveryApply run charts to analyze data
302
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The Model for Improvement: Aim
The Improvement Guide: A Practical Approach for Enhancing Organizational Performance (2009). Langely, et al. Jossey Bass.
303
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What does it mean to improve population health?Reducing or eliminating disparities60% of health is socially determinedWhat can we do?
• Improve social conditions, connections, and reduce isolation.
• Ask!• Ask: do you have resources to manage your health?
• How confident are you that you can manage most of your health?
• Know your community resources• Refer, follow up. Track!• Work with the community resources to see the gap and commit
to improving it.• Work with various ethnicities and community groups to
understand and support seeking and getting support304
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Tracking and Follow UpSet up field in electronic record for screening for social
conditionsSet up field for referralAnd follow upAnd, follow up with the person/patient
305
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UCL
LCL
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3
BaselinePercent
Screening for Social Conditions
306
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UCL
LCL
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1/1/
13
1/3/
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ImprovementPercent
Testing
Improved social condition screening
307
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UCL
LCL
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1/1/
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1/3/
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1/5/
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1/7/
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1/9/
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1/11
/13
1/13
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1/15
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1/17
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1/19
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1/21
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1/23
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1/25
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1/27
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1/29
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1/31
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2/2/
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2/4/
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2/6/
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2/8/
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2/10
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2/12
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2/14
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2/16
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2/20
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2/22
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2/24
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2/26
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2/28
/13
AchievementPercent
baseline
Specification (aim/goal/target)
Achieving new levels of performance in screening
308
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UCL
LCL
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1/1/
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1/9/
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1/11
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1/13
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1/15
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1/19
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1/21
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1/27
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1/29
/13
1/31
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2/2/
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2/8/
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2/10
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2/16
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2/20
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2/22
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SustainingPercent
baseline
Improvement period, no
Period of sustained performance
309
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UCL
LCL
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1/1/
131/
3/13
1/5/
131/
7/13
1/9/
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11/1
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13/1
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15/1
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17/1
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19/1
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21/1
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23/1
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25/1
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27/1
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29/1
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31/1
32/
2/13
2/4/
132/
6/13
2/8/
132/
10/1
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12/1
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14/1
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7/13
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7/31
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9/30
/13
Monitoring Percent
baseline
Improvement period, no control
Period of sustained performance, n=30
Transition to weeks, n=210
Transition to months, n=900+
310
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UCL
LCL
0%
10%
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30%
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100%
1/1/
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32/
2/13
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/13
Degradation Percent
Special cause variation, detected –direction is both positive and negative, but it is difficult to see
311
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UCL
LCL
50%
60%
70%
80%
90%
100%
2/9/
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13/1
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3/13
3/10
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3/17
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3/24
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3/31
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4/7/
134/
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31/1
39/
30/1
3
DegradationPercent
Special cause variation, detected –Cause for worry, investigation and maybe stratification of data by week or day for a more insightful picture
Special cause variation, detected –Cause for celebration and investigation to learn what caused momentary improvement
312
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UCL
LCL
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60%
70%
80%
90%
100%
2/9/
132/
10/1
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28/1
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3/13
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3/31
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4/7/
134/
14/1
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21/1
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28/1
35/
31/1
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30/1
37/
31/1
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31/1
39/
30/1
3
DegradationPercent
Special cause variation, detected –Cause for worry, investigation and maybe stratification of data by week or day for a more insightful picture
Special cause variation, detected –Cause for celebration and investigation to learn what caused momentary improvement
313
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Screening is just the beginningReferral – to whom?Follow up?Increasing confidence in patients around self
management supportUse chronic care model: plug and play chronic
conditions
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More thoughts on using data
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Data tells a story
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Baseline
Project starts
Implementation
New performanceHolding gains
Chart3
Sep-06Sep-06Sep-06Sep-06Sep-06
Oct-06Oct-06Oct-06Oct-06Oct-06
Nov-06Nov-06Nov-06Nov-06Nov-06
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Unreconciled Meds P-Chart P Statistic
Unreconciled Meds P-Chart CL
Unreconciled Meds P-Chart UCL
Y - Axis = LCL
Percent Target
Percent
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Hold Gains
&A
Hold Gains
Sep-06Sep-06Sep-06Sep-06Sep-06
Oct-06Oct-06Oct-06Oct-06Oct-06
Nov-06Nov-06Nov-06Nov-06Nov-06
Dec-06Dec-06Dec-06Dec-06Dec-06
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Dec-07Dec-07Dec-07Dec-07Dec-07
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&A
Page &P
Unreconciled Meds P-Chart P Statistic
Unreconciled Meds P-Chart CL
Unreconciled Meds P-Chart UCL
Y - Axis = LCL
Percent Target
Percent
Unreconciled Meds
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Unreconciled Meds
Unreconciled MedsY - Axis =Percent
P-Chart
SubgroupsP StatisticCLUCLLCLTargetNon-ConformingSample Size
Sep-02501020
Oct-0245920
Nov-0235720
Dec-0245920
Jan-0335720
Feb-0330620
Mar-0315320
Apr-0310220
May-0310220
Jun-0330620
Jul-0340820
Aug-0330620
Sep-0315320
Oct-0320420
Nov-0310220
Dec-0320420
Jan-0415320
Feb-0410220
Mar-0415320
Apr-0410220
May-0415320
Jun-0410220
Jul-045120
Aug-0410220
Unreconciled Meds
&A
Page &P
Unreconciled Meds P-Chart P Statistic
Unreconciled Meds P-Chart CL
Unreconciled Meds P-Chart UCL
Y - Axis = LCL
Percent Target
Percent
Unreconciled Meds
Sheet1
Sheet2
Sheet3
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Quantitative. Make it better?www.youtube.com
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http://www.youtube.com/
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Let’s watch and listen as data singshttps://www.youtube.com/watch?v=awUMW3AbPhQ
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https://www.youtube.com/watch?v=awUMW3AbPhQ
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Rules for Run ChartsA Shift:
6 or more
An astronomical data point
Too many or too few runs
A Trend:5 or more
Thank you to IHI for this slide presented at theOffice Practice Summit 04/07/13 PhoenixThe Data Guide. 2011. Provost and Murray Jossey-Bass.321
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CL 0.7212
0.000
0.100
0.200
0.300
0.400
0.500
0.600
0.700
0.800
0.900
1.000
Per
cent
age
com
plet
ed c
ompo
nent
s in
Wel
l Chi
ld A
sses
smen
t 5-
12
y.o.
a.
11/1/11 - 12/1/13
Percentage of Completed Components for Wellness Assessment for School Age Children 5-12 years of
age
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Percentage of eligible children given flouridevarnish
323
CL 0.3918
UCL
0.6294
LCL
0.1542
0.000
0.100
0.200
0.300
0.400
0.500
0.600
0.700
0.800
0.900
6/1/12 - 11/1/13
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SummaryShow gap between what is possible and where you areUse data for drama!Show data and people ask questionsInterrogate the dataDrill downCompare with small multiplesEstablish if outcomes and processes are improvingSing
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Improving Patient Outcomes Through DataHow to Use Data to Transform Care Delivery
Alaska PCA Data SummitApril 10, 2018
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AgendaData Driven Care Delivery Tools
Implementation
Team-Based Care
Roles and Responsibilities
Results 2
1
2
4
3
5
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Pre-Visit Planning / Huddle Report
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Patient Visit Planning ReportMost EHRs have some kind of care gap, visit planning, or decision support tool, but few aggregate all the patients into a single list for easy huddling.
• Much more efficient for pre-planning work and making notes on one sheet
• More efficient as a huddle report to help focus only on the most important things/patients
• Our clients have said this works much better for them rather than having to go through each patient in the EHR
4
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What is a Visit Planning Report?
An efficient, electronic “to do” list of alerts and other data for patients with upcoming appointments.
• Does the work MAs/ LPNs currently do manually, using EHR data and electronic calculation of alerts
• Displays basic demographics, active diagnoses, relevant risk factors and social determinants of health (SDOH)
5
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Patient Visit Planning Report – Demo Sample
6
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7
Patient Visit Planning Report – Demo Sample
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Care Management Tools
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9
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Social Determinants of Health, Alerts, & Hospitalizations
The last five inpatient visits and/or emergency room visits that are available
from the claims data will be shown if Claims data has been integrated.
Alerts can be enabled/disabled & configured by the center- uses same rules as for PVP.
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Active Allergies & Medications
The last 10 active medications and date of
reconciliation
All Active Allergies and the last time they were
reviewed
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Implementation of the Visit Planning Report
12
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Visit Planning Report: Recommended Approach
What are your goals? Which are most important? How will you know you are improving?• Greater Patient Satisfaction• Greater Staff Satisfaction• More Efficiency - Automated Chart Audit• Improved Outcomes
Pilot with a few teams.
Measure progress and get
feedback.
Adjust process.
Expand to the rest of the teams.
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Choose 5 Evaluation Measures and Targets
14
Focus early on measures with potential to show improvement quickly –process measures (especially things that can be completed today, and are owned by MA/LPN.
Include measures with longer term improvement potential.Tie the measure selection to existing programs or grants.
Measure Baseline Dec
2017
Interim Target
Project Target
Cervical Cancer Screening (UDS) 62% 65% 68%Breast Cancer Screening (MU NQF) 59% 61% 64%Colon Cancer Screening (UDS) 34% 36% 39%Tobacco Screening and Cessation Intervention (UDS) 45% 55% 60%Pedi Weight Screening and Nutrition/Physical Activity Counseling (UDS) 29% 35% 38%Diabetes A1C Control >9 or Untested (UDS) 33% 31% 29%Depression Screening and Follow-Up (UDS) 28% 36% 48%
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Build a Scorecard with Targets
15
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16
Make a Workflow Map for All Evaluation Measures
Patient Arrives
Patient gets checked in.
MA/LPN Rooms Patient.
If Colonoscopy indicated, Provider
orders referral to GI: Colonoscopy.
For most patients, MA/LPN gives kit and
education. Then initiate referral.
Colon Screen
Complete
Colon screen needed
?
START
END
Patient returns kit to health
center for processing.
MA/LPN processes test and places POC
order, results (positive or negative) with date.
Paper/Fax Result Arrives
Result arrives by fax and attaches to chart. Gets labeled as colonoscopy.
Send to ordering provider’s inbox. Provider reviews the result. Communicate result to patient if abnormal. If normal, send result
to portal or a letter.
Patient needs colon screen. Note: For commercially insured patients,
recommend screening colonoscopy not FIT. Only if they refuse, then FIT.
MA/LPN task referral
coordinator to close referral.
If FIT is positive, notify provider, who notifies patient and places referral for
GI.
GI arranges colonoscopy.
Provider signs off on the referral
for tracking.
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Team-Based Care
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Care Team Members
Provider
MA/LPN
Patient
Front Desk
Care Manager
BH
Referral Clerks
Practice Manager
Nurse/RN
Health Educator
PharmacistComm Health
Workers
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Comprehensive Standing Actions for MA/LPNs
19
Usually standing orders are fragmented; leads to a lack of clarity. Need one comprehensive set which is part of the Policy and Procedures.Empower MA/LPNs to do support their provider by giving them the freedom and
trust to follow the protocol.Standing orders create the basis for use of the visit planning report as a foundation
for trust to delegate in team-based care.
Team-Based Care
Visit Planning Report
Standing Orders
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Sample Standing Actions
20
Category Alert Name Status Description MA/LPN RN Provider Action
Diabetes A1c Enable
Alert will trigger if A1c has not occurred in the last 90 days, or if the A1c value is >= 8. Alert only applies to patients >= 0 yrs old and = 0 yrs old and = 0 yrs old and = 100. Alert only applies to patients and = 0 yrs old and = 140 and numeric_2 value is >= 90. Alert only applies to patients and = 3 yrs old and
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Work with your team members or pick a buddy:
1. Review the list of standing actions.
2. For each:a) Would you choose to enable it?b) Which team member should take action?c) What is the action you want them to take?
Standing Actions Exercise
-
Configure and Then Validate Your Patient Visit Planning Report
22
Accurate data is critical to a successful roll-out, includes perception not just reality.The Basics:
• Are the correct patients listed? • Are the patients shown under the scheduled provider?
The Details:• Review 5-10 patients demographic data, visit reason, PCP,
Diagnoses, Risk Factors, and Alerts.If anything is incorrect, troubleshoot.
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Roles and Responsibilities
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MA/LPN
1. Run Azara PVP for scheduled patients daily. Print 2 copies for notes.
2. Identify missing data for diagnostic or lab tests. Look for scanned only results in Documents (especially Mammogram, Pap, Colonoscopy, A1c).
3. Screen, educate, order labs and diagnostics as supported by standing actions.
Care Manager/ BH/ Pharmacist/ Health Educators
1. CM run PVP and run one page report on high risk or newly assigned patients coming in. Evaluate patients’ cases and anticipate needs.
2. On the fly check-in with MA/LPN to communicate any recommendations, knowledge or concerns.
3. Which patients need to be seen face-to-face or receive additional education.
Clarify Roles and Responsibilities of Team
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Clarify Roles and Responsibilities ContinuedProvider
1. Delegate standing action tasks to appropriate support team members. Visit Planning Report provides technology foundation for trust.
2. Ensure huddles are happening. May take many forms but at the very least there should be some conversation with your MA/LPN about the plan for patients- a quick team meeting.
All1. Data Hygiene: Report data errors so they can be
addressed and fixed. Workflows and inputs change over time.
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Huddle (limit to 10 minutes)
26
1. Have a consistent time and stand for meeting. Any team member can initiate.
2. Must Discuss:a.Patients with special intervention needs b.Patients with risk factors and social determinants of
healthc. Any scheduling bottlenecks anticipated, and plans to
workaround
3. Organize for extra services if needed:a.Behavioral Health, Pharmacy, Enabling Servicesb.Diabetes, Asthma, Nutrition Education
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Pre-Visit Planning & Care Team Huddle Video
27
https://vimeo.com/227406460
https://vimeo.com/227406460
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Kick-off With Your Pilot Teams
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Vision and Team Building Session• Educate the pilot teams about the project the vision • for visit planning report, roles and responsibilities.
Hands-on training with Visit Planning report for MAs/LPNs• Train pilot staff who will be running the PVP or supporting the process.• Huddle prep with visit planning report for next time the team will be together seeing
patients.
Mock Huddles• Teams should have a mock huddle in front of the pilot group to practice using the PVP
to guide huddle.• Remind teams how to keep to agenda and stay efficient.
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Results
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Depression Screening and Follow up (NQF 0418)Q3 2015 to Q2 2017
34%
26%
62%68%
25%
71%76% 72%
0%
10%
20%
30%
40%
50%
60%
70%
80%
10 Centers One Center One Team
Depression Screening and Follow up
Q3 2015 Q2 2016 Q2 2017
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Child BMI Screening and Counseling (NQF 0024)Q3 2015 to Q2 2017
46%
63%
78%
87%
63%
83%87%
94%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
3 Centers One Center One Team
Child Weight Screening and Nutrition/ Physical Activity Advice
Q3 2015 Q2 2016 Q2 2017
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Colorectal Cancer Screening (NQF 0034)Q3 2015 to Q2 2017
36% 38% 38% 38%40%
45% 44% 45%38%
49%56% 54% 56%
80%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Centers 1-5 Centers 6-12 All Centers One Center One Team
Colorectal Cancer Screening
Q3 2015 Q2 2016 Q2 2017
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Wrap-Up and Questions
33
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Contact Information
Heather BuddVP of Clinical TransformationAzara [email protected]
mailto:[email protected]
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Alaska Primary Care Association Data Summit
Using Data Analytics to Improve Population Health: Make it Work!
Noelle Parker, Missouri Primary Care AssociationHeather Budd, Azara Healthcare
April 10, 2018
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Agenda
Introductions
MPCA Team and Approach
The History
Real Life Challenges and Success with Data
What’s Next?
Conclusions
2
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Missouri Primary Care Association530,000 Patients, 1.9M Encounters, 28 CHCs
Goals Own the statewide community health data infrastructure
to lead member CHCs into the future
Create statewide programs to improve quality and lower cost of care
Open new opportunities for membership programs
3
The Strategy: Be the Designer of Your Own Destiny
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Missouri Primary Care AssociationCenter for Health Care Quality Team
Center for Health Care Quality Leadership– Sam Joseph, Center for Health Care Quality Director– Heidy Robertson-Cooper, VP of Health Care Transformation
Practice Coaches– Noelle Parker, MBA, CMPE, PCMH-CCE– Angela Herman-Nestor, MPA, CPHQ, PCMH-CCE– Janice Pirner, LPN, CPHQ, CHEP, PCMH-CCE– Kathy Davenport, RN, CPHRM, PLNC, PCMH-CCE– Lindsay Haslag, RN, BSN– Machelle Dykstra, BSBA, CMPE, CPHQ
Data Team– Tim Wittman– Jess Willis– Josh Wood
4
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Drivers of Missouri’s Quality Journey
Understanding of impact of payment reform on health centers.
Importance of high-functioning Health Homes; “recognition” is not enough.
Data is essential.
Take advantage of transition.
Invest in relationships.
Chart a course to move forward successfully.
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Planning for Success
1. Plan your strategy first-a. What are your goals?b. What pieces do you need?
2. Data is key to successa. Need to have itb. Must know how to use it in practice to
get value
3. We are all CUSTOMERS in the processa. Internal and Externalb. Beyond the C Suite
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Trends Affecting Health Centers
Payer demand for quality and efficiency
New and developing payment models – ACOs, IPAs, others
Transparency/Public Reporting
Meaningful Use incentives and expectations
Patient Centered Health Home
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Data at Your Fingertips is Essential
External– Who needs/wants the data entrusted to you?
Funders Payers Patients Government Academic institutions/researchers
– Internal– Business Intelligence at all levels
Corporate/executive Mid-manager Providers and front-line staff
8
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The Missouri Primary Care Association Quality Improvement and Data Journey
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2006- The Vision
MPCA vision to aggregate and report clinical data following HRSA discontinuation of support for PECS
All health centers should have an EHR
Integration with state and local systems
Collaborative Reporting
Centralized data warehousing
Ability to respond to external data requests
Develop IT capacity
Health Information Exchange (HIE)
10
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2007
Missouri General Assembly Appropriation to create a data warehouse for FQHCs
Use of funds modified to assist FQHCs with acquiring Electronic Health Record systems
HIT Steering Committee formed
Initiate customized data warehouse
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2009
EHR acquisition mostly accomplished
Homegrown data warehouse stalled out
Azara engaged to implement SAAS data warehouse
12
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2010 ARRA HITECH + Congressional Mandate
Established Missouri Quality Improvement Network
– Bring Clinical, Quality, Finance, HIT, operations staff together
– Accurate, reliable & timely clinical quality measures reporting
– Organized statewide quality improvement program
– Accomplishment of Meaningful Use and related measures so FQHCs will receive full benefit of MU incentive payments.
13
MOQuIN
HCCNUDS
(HRSA)
MU(CMS) PCMH
CDC(DHSS)
PCHH(MHN)
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2010 ARRA HITECH + Congressional Mandate (Continued) Elected to outsource data warehouse, reporting
application – purchased Azara DRVS Initial mapping and data validation performed Originally connected to 13 different EHR systems,
now only 9 different EHRs
MPCA and FQHC’s able to utilize DRVS for federal and state reporting initiatives: Missouri Department of Health and Senior Services– Chronic Disease Collaborative (measures reporting
and T/TA)– Meaningful Use– UDS
14
MOQuIN
HCCNUDS
(HRSA)
MU(CMS) PCMH
CDC(DHSS)
PCHH(MHN)
EHR
EHR
EHR
EHREHR
EHR
EHR
Data Warehouse
NextGen eCW SuccessEHS Athena GE
Intergy MicroMD MediTab/IMS LSS/Meditech
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Data Flow Process
MPCA
FQHCs Azara data warehouse
Standard PCCs
MO HealthNet
CMS
EHR & PMS Connected to data warehouse (pulls data nightly)
FQHC has direct access to reporting tool to pull its own reports
List of PCHH Enrollees transferred to warehouse
MPCA has direct access to all reports
MPCA runs reports and sends them to each PCC
CMS reporting from MO HealthNet
PCC monthly uploads flat file to Azara warehouse
MPCA sends all reports to MO HealthNet for FQHCs & PCCs each month
Directly Connected PCCs
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MPCA’s Data Warehouse- DRVS
16
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Creation of Independent Practice Association
Clinically Integrated Network
DRVS Data System enabled expedited demonstration of Clinical Integration to comply with anti-trust laws
Group negotiation of rates with payers True Pay for Performance via Care Coordination fee
Shift toward HEDIS measures for Payer alignment Leverage MOQuIN and HCCN success
Quality thresholds = maintaining membership participation
Data integrity becomes even more important! CHCs have to communicate changes, to maintain the whole SYSTEM = maximum credit for everything you do
17
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2013 MissouriHealth+ Clinically Integrated Network
Evidence of clinical integration to enable MissouriHealth+ collective contract negotiation with Medicaid and other managed care plans
Monitoring of common clinical performance measures in MissouriHealth+ standards and contracts
Patient registries and visit planner support population health management
BUT
No claims information
No interactive capacity for care management tracking
Limited admission/discharge/transfer alerting
Different business drivers (transparency vs. proprietary)
18
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2012 – Second HCCN Grant & Health Home ACA HCCN 2nd Award
– Continued mapping and data validation 2 Health Centers not connected to DRVS Quality coaches using DRVS data to monitor and plan interventions Remapping – not a one and done
– Meaningful Use Continued to support CHC’s with attesting for Meaningful Use
– Quality Improvement Leverage DRVS to improve quality measures and patient outcomes
– MO Health Net Primary Care Health Home Launched Data system broadens to include non-FQHCs Creation of new measures (Care Coordination and SBIRT)
– Thinking about the future payment models Transitioning advocacy away from “direct” government funding to value-based payments
19
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Painful Realizations and Discoveries
EHR came before DRVS (insufficient planning)
DRVS came before financial incentive to use (MissouriHealth+)
Poor data quality and inconsistent data policies (document v self-report – eye exams)
Lack of discipline in EHR use (multiple data tables, multiple data entry points, descriptors open to any user to change)
Workflow deficiencies and inefficiencies
Communication and workflow gaps– Nurse knew there was a checkbox for a
follow-up service, but didn’t know she was supposed to check it
20
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2016 Third HCCN Grant
Health IT Implementation and Meaningful Use– Certified EHR Adoption and Implementation– Advance Meaningful Use
Data Quality and Reporting– Data Quality– Health Center and Site Level Data Reports– Health Data Integration (oral health, behavioral health)
Health Information Exchange
Population Health Management
Quality Improvement– Clinical– Operational– Advance PCMH Status
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Quality Journey Overview
For the past several years, MPCA and its Members have Invested Heavily in the Following Areas:
PCMH: Recognition, Practice Transformation, and Quality Coaching
Behavioral Health and Primary Care Integration
Data: EHR Adoption, Validating Data, Building a Data Warehouse, Utilizing a Reporting Tool (DRVS), and Using Data to Drive Quality
Managed Care: Capturing the Market
Reimbursement Models: Section 2703
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2007 State Appropriation- Home-grown failed
2010 HCCN Grant - Azara DRVS
2012 HCCN Grant- Data Quality and Mapping Expansion
2013 MissouriHealth+ Formed- IPA and Clinically Integrated Network
2016 HCCN Grant- Building on the Foundation
Timeline Recap
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MPCA Partnerships: Associations, Networks and Academics
Missouri Regional Extension Center– Training and Technical Assistance Funding – ONC
MO HealthNet – Missouri Medicaid Department of Health and Senior Services Primaris NACHC
– Million Hearts Hiding in Plain Sight (HIPS) (measures developed)– Improving Data Integrity, Access and Analysis (measures selected)
St. Louis Integrated Health Network St. Louis Regional Health Commission
– Clinical Quality Measures Incentive Distribution Basis for Gateway to Better Health Medicaid Waiver University of Missouri-St. Louis (HRSA Workforce grant) Washington University (Gestational diabetes study)
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Own Your Data…Own Your Future
Stage 1Stage 2
Stage 3Adoption
Quality of data equals quality of care
Quality Improvement
ACO / PCMH/IPA
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Making a Difference in Quality Using Data
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MPCA Practice Coaches: Expectations and Activities
PCHHs (Primary Care Health Homes)
Assistance with addressing high utilizers (MO HealthNet #1 priority)
Assistance with DRVS reporting, maintaining data mapping/connectivity, and use of DRVS functionality
Assistance with improving achievement of PCHH performance measures
Assistance with identification and resolution of Quality/workflow issues
Practice Transformation and PCMH 2014 standards/reapplication
HCCN Grant
Assistance with improving achievement of HCCN performance measures
Assistance with DRVS reporting, maintaining data mapping/connectivity, and use of DRVS functionality
Assistance with identification and resolution of Quality/workflow issues
NCQA PCMH recognition application assistance for those without recognition
Practice Transformation and PCMH 2014 standards/reapplication
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Capitalizing on all sources of Data –Work Smarter not Harder
Being a good consumer of available data– How can different types work together– Not always available in one system– What was the intent? What are limitations? Not
trying to make it do something it was not designed to do
Claims based data
Ultimate goal quadruple aim– Clinical information for Outcomes– Revenue Cycle and Claims data for Cost and
utilization– Satisfaction (both patients AND staff)
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What Happens Without a Plan?Made Without Pattern or Sewing Expertise
Judges Panel Says:
- Lack of detailed plan (misaligned pieces)- Lack of expertise (fabric choice, puckered sewing)- Poor presentation (not pressed)
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Bridging the Quality Chasm
IT, EHR, & Quality Operations & Clinical LeadershipAccurate Data for
Reporting
Getting Performance Data to Reflect Quality of Care Delivered to Maximize Reward
Better Quality & Experience,
Lower Cost
Data at Point of Care for
coordination and QI
Maximize credit and $
for work
Document to reflect quality
of care
Continuous quality
improvement
Standardize key workflows
Set up and maintain systems
Follow key standards and offer feedback
RESULTSSYSTEMS
CARE
30
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Understanding the Impact of Documentation on Data Prove you did the work: no money for mission alone No Margin- No Mission
– Rogue workflows are quick to develop– If it’s not structured- it didn’t happen– Connect the dots:
Workflow to Reports– Does data accurately– reflect practice?
Usable Data is your End Product– Everyone is a customer:
External agencies Internal consumers Patients
Have the right people on the team reviewing the data- it’s not one and done 31
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Cervical Cancer Screening Workflow Map
Patient Arrives
Visit
Front Desk Checks in Patient
MA/LPN Rooms Patient
MA/LPN performs vital signs, and
record history in vitals (LMP) and last
Pap date.
MA/LPN preps for
procedure
Provider places order: Pap =30 for HPV every 5
years.
Pap Complete
MA/LPN packages specimen with the requisition to be
sent to lab.
Paper/ fax
result Arrives
Result to provider, signs off, gives to
MA/LPN, who enters data into Health
Maintenance.
If Pap done elsewhere, Provider or RN fills out “Last Pap” request result.
Provider performs
Pap.
MA/LPN runs visit planning report
for all patients to determine need
for Pap. If needed, not planned, and
feasible, fit Pap in.
If Pap can’t be done today, encourage a patient schedule f/u
visit in the near future.
END
START
Results come as HL7 & and auto
complete.
Referral coordinator request result, and send to MR to be
scanned.
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Missouri’s Strategic Initiatives and the Importance of Measure Alignment
DiabetesA1c
BP / LDL Control
HypertensionBP / LDL Control
ObesityChild/Adolescent Weight Screening,
Activity & Nutrition AdviceAdult Weight Screening
& Follow up
Cancer Screening
Cervical, Breast, Colon
Sweet Spot
33
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Measure Matrix- Leverage Alignment and Use National Standards
34
Measure Name UDS 2015 HCCN
MPCA Clinical Quality Award
2015Health Home
PC SPA
Chronic Disease
Collab. CDC HEDIS MU CQMDM A1c Control X X X X X XDM A1c Uncontrolled X X X X X X XCervical Cancer Screening X X X X XChildhood Immunizations X X X X XHTN BP Control X X X X X X XChild Weight Screening and Counseling X X X X X XColorectal Cancer Screening X X X X XDepression Screening and Follow-up X X X XDM A1c Testing X X XAdult Weight Screening and Follow-up X X X X XAsthma Pharmacological Therapy X X X X XCAD Lipid Therapy X X XIVD Use of Aspirin X X X XNew HIV Cases and Follow-Up XPrenatal Trimester of Entry to Care X XPostnatal Birthweight XChild Dental Sealants XTobacco Assessment and Cessation Advice X X XBreast Cancer Screening X XDM Nephropathy Screening X X XChlamydia Screening X XInfant Well Child Visit 15 mos X XWell Child Visits 3-6 yrs X XAdolescent Well Care XDM BP Control X X X XDM LDL Control X X X XDM Eye Exam X X XDM Foot Exam X X XAdult LDL Control XCare Coordination XSBIRT (Screening &Follow-Up: Alcohol /Drug) XFlu Immunization XPneumoccal Immunization X
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Missouri Quality Information Network (MOQuIN) & Health Center Controlled Network (HCCN) Measures
Measure UDS Definition MOQuIN
BASELINE
MOQUIN
Y1 GOAL
MOQuIN
Y2 GOAL
MOQuIN
Y3 GOAL
Healthy People 2020
BASELINE
Healthy People 2020GOAL
PAP
% women 24-64 with Pap test within measurement year or two years prior, or 4 years prior if >30 years old w/ HPV test 29% 40% 50% 65% 84.5% 93%
IZ
% of children fully immunized by their 3rdbirthday using AAP/CDC Standards 12% 30% 60% 68% 68% 80%
DM% DM Pts. 18-75 with A1c
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Measure UDS Definition MOQuINBASELINE(TY July 2016)
MoQuINPerformance
TY January 2018 Current
Performance
Direction FromLast MOQuIN
Healthy People 2020GOAL
Diabetes A1c >9 or Untested % DM Pts. 18-75 with A1c >9 or Untested 33.5% 32.9% 32.4% 16.2%
Childhood Immunizations
% of children fully immunized by their 2nd birthday using AAP/CDC Standards 20.3% 21.6% 22.0% 80.0%
Cervical Cancer Screening *Previously
Pap Only
Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: Women age 21-64 who had cervical cytology performed every 3 years OR Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years *48.4% 51.0% 52.2 93.0%
Hypertension BP Control % HTN Pts. 18-85 with BP
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Establish On-going CollaborationAmong Practices to Drive Stateside Quality Improvement
MOQuIN Bi-Monthly Meetings– IT / EHR, Quality, Clinical, Support Staff, Ops, Billing, & Leadership
Discussion topics:– Strategic planning for QI PDSAs– HCCN Grant progress updates and measure review– Best Practice Spotlight Sharing– DRVS Updates– Grantor Program requirements and updates
37
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Keeping Focused on Data: HCCN Default Scorecard for Missouri User’s
An early MOQuIN / HCCN scorecard:
38
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How to Evaluate Your Performance Data Tools
The Measure Analyzer offers numerous ways to dig into data:
root cause analysis identification of best practices to be spread
evaluation of a PDSA cycle
Enables you to investigate what makes your practice’s performance number what it is.
Look at the underside of the fabric and see how well it’s sewn.
39
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Data- Driven Process Improvement: Center Comparative Analytics Break into bite size chunks; focus on one measure at a time
• Order of measures: Pap first in MO because it needed most work• Determine how many PDSA cycles per measure
Double-click anywhere in
the bar to drill down.
Cervical Cancer Screening
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Individual Center Comparative Analytics
Cervical Cancer Screening
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Focus on the tail to
identify rogue
workflows and training
issues.
Provider Performance Variation- Chart view
• Provider performance variation can be a factor of practice preference, staff differences, equipment, or other.
42
Focus on the high performers with
significant denominators to
harvest best practices.
-
43
Provider Performance Variation- Table view
• Sort by denominator (Qualifying Patients) to identify true high and low performers.• Scroll bar on right allows you to view all providers.
-
Single Provider Trend and Comparison
Dr. Cheri Harlow• Investigate trends.• Look for focused training opportunities and low-hanging fruit.• Drill down to the patient detail list for more information.
-
Patient Detail- Click Detail list on Menu for list of patients in the measure
• Sort by Numerator to identify out of compliance patients• Export to PDF or Excel. Create an outreach list for staff to contact as appropriate.
-
HCCN PDSA Cycle Planning Form (sample)Baseline data is from DRVS reporting
PapWomen 24-64 w/ Pap within, or two years prior to the measurement year
Baseline Center Baseline: 23%
MOQuIN Baseline: 29%
Cycle 1 Center PDSA Intervention 1
PDSAIntervention / Goal Ensure accurate data entry for externally completed Pap Smears. Evaluate workflow and re-train based on new standard. Center Goal: 36% MOQuIN Goal: 40%
Risk #1 May not currently have enough staff allocated for audits (to see if standard is being followed).
Risk Management Strategy #1
Get buy-in from leadership to utilize a certain amount of clinical staff time to do observation audits, and use DRVS data to carefully track, and identify additional training needs.
Risk #2 Patients may not be willing to sign HIPAA release form for health center to receive results from external provider.
Risk Management Strategy #2
Re-educate health center staff on successful approaches to this conversation with patients. Identify someone else who can help (manager, etc.).
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29%
36% 37% 37%45% 44%
93%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal
%
HP 2020
Year 1 Goal- 40%
Baseline- 29%
Year 2 Goal-50%
Year 3 Goal-65%
15% Overall
Improvement
47
Cervical Cancer Screening at Missouri CHCs
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Cervical Cancer Screening Lessons Learned
Many practices in MO do not perform Paps in-house, and depend on receiving external information that a Pap was completed to document it.
– Often Pap results are not entered as structured data (only scanned in) - needs process and staff for entry
Evolving workflows led to some data not being captured though screen done
Lack of Practice understanding the impact of documentation behavior on ultimate performance numbers
Without workflow and subsequent process changes, practices would not be getting credit for all their work
48
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A1c >9 PDSA Improvement Story
MOQuIN CHC teams were asked to identify a PDSA intervention to address the DM A1c >9 measure, which had plateaued.
One practice used the measure analyzer to determine their greatest opportunity was to address their “Untested.” They used the DRVS Diabetes Registry Report to outreach to patients who needed to be tested.
With just this relatively small changein practice, their A1c >9 %
(which includes the untested),decreased from 36% to 22% in two months: 14% improvement!
49
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DRVS Diabetes Registry- Sorting for “Untested”
50
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Results- “You are IN”
If you build it they will come… to you to ask you for data!
Missouri Primary Care Association
Results Formed MOQuIN & initiated MO Diabetes Care Program 60% reduction of out of control / untested A1cs 25% increase in A1cs under control 34% increase in LDL s under control
Awarded HCCN Grant in 2012
MPCA administered MO Medicaid Health Home Program (2703b SPA Waiver) $60 PMPM to health centers for Care Management $3 PMPM to PCA for infrastructure 15% increase in cervical cancer screening rates
Formed 23 CHC IPA using DRVS Infrastructure as basis to demonstrate clinical integration
-
Missouri PCA Practice Coaches Lessons Learned
Transition from PCMH recognition and transformation to QI, data, workflow support, etc. is not always smooth
Changed role expectations– Consistent access to data– Opportunities with State Medicaid, IPA
Practice Coaches can play a significant role in cross-pollination of best practices
Having the data (while it can be work to get there) is powerful and opens many doors
52
-
The Next Chapter: Changing Landscape = Changing Motivation and Rewards
-
Moving Forward: Quality Journey 2016 and Beyond
Understanding key trends affecting CHCs and impact of health reform and payment reform on health centers
Importance of high-functioning Health Homes; Care teams and real Transformation
Data is essential to improve quality and drive reimbursement
Demonstrate Value by managing Cost, improving Quality, taking and managing Risk, and Scale
Implementing strategies to take advantage of transition/change
Constant Performance Improvement
Adding additional competencies at MPCA and CHCs
Chart a course to move forward successfully: Continue to Own our Future!
-
New $ as a result of data
Leveraging DRVS– Expansion of DRVS functionality for care
coordination– Quality Improvement – New Measures– Expansion of Registries– Operational Measures– Transition of Care Registry/measures
Now vision has expanded beyond – more money for health centers
– Primary Care Health Home/Medical Home– State Health Department Chronic Disease
Collaborative – NIMBLE with ease, avoid pain of getting from each
EHR– Reduces need for CHC resources
-
MPCA & DRVS
CoordinateRisk, Cost & Quality
Health InfoExchange
Imm.Registry
Health Plans
HospitalADT
SyndromicSurveillance
CHC PracticeData
56
Harnessing Data Beyond CHCs
-
Payers are Driving PCMH Recognition, Performance and Practice Transformation
Centers for Medicare and Medicaid
Health Resources and Services Administration: Bureau of Primary Health Care (HRSA-BPHC)
Insurers-Private and Public
Foundations
Payers want value: – better outcomes with cost savings
-
What is the latest?
Using Azara Risk Algorithm across all MPCA CHCs
Chronic Pain Management Project and subsequent Controlled Substance Module
Capture of Social Determinants of Health and use with health home patients to address needs
Integration of HIE data including transitions of care
Use of payer enrollment data to do member matching
Community Health Workers using Data to Improve Population Health
58
-
Factors Impacting the Future
High Expectations – Triple Aim– Better Care, Lower Costs, Happier Patients
Intense and Increasing Scrutiny
Public Reporting
Transparency
Accountability to Deliver
Uncertain Public Funding
Shifts in Policy and Funding to 3rd Party Payers
Varying Reimbursement Models (VBC)
-
Motivation for Engagement with DataAcross the All Key Areas
– MO HealthNet– PCMH support– UDS Clinical Quality Improvement Incentives– MPCA Clinical Quality Awards– MissouriHealth+
60
ALIG
NM
ENT
-
Wrap-Up and Questions
61
-
Contact Information
Noelle Parker, MBA, CMPE, PCMH-CCE Missouri Quality Improvement Network Manager
Missouri Primary Care Association
Heather Budd
VP of Clinical Transformation
Azara Healthcare
-
InfomercialAbby (cancer), ANTHC (HPV)
388
-
Gap Analysis: Using your dataJane Taylor, Ed.D.April 2018
389
-
ObjectivePractice using flow charts to understand current
processes and to identify areas to improveUse subgrouping data to better understand gapAnalyze run chart data for non-random signals
390
-
391
Process Mapping
-
Learning Objectives
1. Understand that process mapping provides a visual aid that describes a process as it is currently.
2. May be used to redesign or streamline a process.
3. Recognize that process mapping can identify gaps, missing steps, problem area looking for waste. In particular they expose needless complexity, rework and delays
392
-
Process Mapping
Visual aidHow processes as they are todayProvides the “big picture” and maybe used
to show detail process flowSeveral types of flow charts (process,
value stream)Common understandingIdentifies gaps, strengths and areas for
improvement 393
-
Process MappingObserve Document norms Ask, what happens nextDisplay it in a graph
394
-
Looking closer at the steps:1. Pick a process that is critical to success, is time
consuming, and error prone2. What is the goal?3. Assemble a team4. Map out the flow as it is currently first in a block
diagram then in more detail under each basic step5. What happens in each step and by whom?6. Use arrows to show the flow of each step7. Review
395
-
Start with Sticky Notes
396
-
397
High Level Process Map
Activity Box
-
High Level Process Map
398
DecisionActivity Box
-
Small process changes lead to bigger gains Mapping out high level processesDocument the current then future processes Identify transition steps that need to occur Acknowledge roles, use verbs and present tense
399
-
400
-
AssignmentSelect a process to mapGreat a high level block diagramWork upstream for highest leverage
• Create detailed flow chart of current process.• Use all the shapes, including the delay shape
401
-
The Next Steps1. Gaps? Missing steps? Problem areas? 2. Brainstorm solutions3. What is the goal we set?4. Evaluate the ideas 5. Pick one or two to start 6. Did change occur? Was it an improvement?
402
-
Identify Potential Solutions
403
-
Change Concepts“A change concept is a general notion or approach
found to be useful in the development of specific ideas of change that result in improvement”
Existing concepts of change that can be combined with the knowledge gathered already about a specific change you want to develop.
404
-
Change Concepts Addressing Waste
1. Standardize the environment2. Drive work away from the constraint*3. Find and remove bottlenecks*4. Move process steps closer together5. Eliminate unnecessary process steps*6. Use technology7. Synchronize, patients, providers and
information* 405
-
Change Concepts
406
-
Drive the work away from the constraint/constrictionDisruptions and distractionsWork someone else can performWaiting: for x-rays, reports, etc. or for patients to
get roomedSearching for suppliesGetting off-track
407
-
Find and Remove BottlenecksPeople and flowFacility and space/roomPaperworkRe-workEquipment/Supplies
408
-
Eliminate Unnecessary Processes StepsChecking another’s workMultiple sign-offsMaking multiple copies RedundanciesPatient path
409
-
Synchronize Patients, Providers, and InformationUse huddles Start 1st appointment on timeCheck charts in advance Standard checklists for suppliesThe system set up is such that the patient is
ready before the provider walks inUse technology prompts to anticipate needs
410
-
Remember to Observe “Through the Patient’s Eyes”
• Patient’s time with staff• Facility barriers • Equipment inadequacies• Paperwork• Duplication of work• Question the processes• Handoffs that may reduce continuity • Where do the waits occur?
411
-
ResultsEliminates errors & gaps in careIncreased efficiency Minimizes wasteAllows for substitution of processes that add
value More time for the productive patient interactions
412
-
Group Activity
Process Mapping
413
-
The Model for Improvement: Aim
The Improvement Guide: A Practical Approach for Enhancing Organizational Performance (2009). Langely, et al. Jossey Bass.
414
-
Rules for Run ChartsA Shift:
6 or more
An astronomical data point
Too many or too few runs
A Trend:5 or more
Thank you to IHI for this slide presented at theOffice Practice Summit 04/07/13 PhoenixThe Data Guide. 2011. Provost and Murray Jossey-Bass.415
-
416
0
10
20
30
40
50
60
70
Per
cent
age
Jan-15 - Apr-17
Percentage of Patients, not of color whose blood pressure at the most recent visit is adequately controlled during the measurement
period
-
417
0
10
20
30
40
50
60
70
perc
enta
ge o
f per
sons
of c
olor
Jan-15 - Apr-17
Percentage persons of color whose blood pressure at the most recent visit is adequately controlled during the measurement period
-
How to Create a Baseline and Monitor Changes
0102030405060708090
100
0
20
40
60
80
100
120
Extended baseline median
Extend the median into the future –visualize improvement
Interventions began
Changedpayment
Baseline Median 80
Introduced protocol
418
-
Using Run Charts to Measure Improvement
How is the process performing?Are we improving?Are we holding the
gains?
0
10
20
30
40
50
60
70
80
90
100
Baseline
419
-
Subgrouping Data, Small Multiples
420
-
IHS – Performance of 38 sites for Each Key Measure
421
-
422
-
423
Remember, get your data by month if you want to use it for improvement.Use the run rules to analyze it.If you detect non-random signals: investigate. If you detect random signals: improve!
-
424
Process mapping to identify gaps
-
BreakTake 5
425
-
426
What can you do by next Tuesday? Without harming the hair of a patient! Don Berwick, MD Senior Fellow, IHI
Jane Taylor, Ed.D.April 2018
-
ObjectiveDesign practical tests of change that will result in
learning and improvementProduce an aim statement for improvementDevelop an action plan for making improvement
427
-
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Act Plan
Study Do
From:: Associates in Process Improvement
428
-
Use the PDSA Cycle for :
Testing or adapting a change idea Implementing a change Spreading the changes to the rest of
your system
429
-
Why Test?•Increase the belief that the change will
result in improvement•Predict how much improvement can be
expected from the change•Learn how to adapt the change to
conditions in the local environment•Evaluate costs and side-effects of the
change•Minimize resistance upon implementation 430
-
Repeated Use of the PDSA Cycle
Hunches Theories Ideas
Changes That Result in Improvement
A PS D
A PS D
Very Small Scale Test
Follow-up Tests
Wide-Scale Tests of Change
Implementation of Change
431
-
Aim: Improve primary care appointment availability through reducing and standardizing appointment types
Reduction of appointment types will increase appointment availability
Improved access
A PS D
A PS D
Cycle 1: Define a small number of appointment types
Cycle 2:
Cycle 3:
Cycle 4: Standardize appointment types
Cycle 5: Staff education in new standards
Compare requests to the types for one week
Test the types with 1-3 physicians
432
-
Tips for Testing Changes•Plan multiple cycles for a test of a change•Think a couple of cycles ahead•Scale down size of test (# of patients,
location)•Test with volunteers•Do not try to get buy-in, consensus, etc.•Be innovative to make test feasible•Collect useful data during each test•Test over a wide range of conditions
433
-
Testing on a Small Scale•Have others that have some knowledge
about the change review and comment on its feasibility
•Test the change on the members of the team that helped develop it before introducing the change to others
•Incorporate redundancy in the test by making the change side-by-side with the existing system
434
-
Testing on a Small Scale•Conduct the test in one facility or
office in the organization, or with one patient
•Conduct the test over a short time period
•Test the change on a small group of volunteers
•Develop a plan to simulate the change in some way 435
-
The PDSA Cycle
Act
• What changesare to be made?
• Next cycle?
Plan
• Objective• Questions and
predictions (why)• Plan to carry out
the cycle (who,what, where, when)
Study• Complete the
analysis of the data• Compare data to
predictions• Summarize what
was learned
Do• Carry out the plan• Document problems
and unexpectedobservations
• Begin analysisof the data 436
-
Form for planning a PDSA cycle
437
-
CORNELL INTERNAL MEDICINE ASSOCIATESPatient FLOW TIME (Attendings)
0:000:140:280:430:571:121:261:401:552:092:24
avg flow time per date
hour
s: m
inut
es
Appt-out 1:07 1:03 0:30 1:04 0:23 0:31 0:24 0:26 0:52 0:50 0:34 0:25 0:37 0:39 0:44 0:44 0:41 1:04
5/8 5/13 5/15 5/18 6/3 6/5 6/11 6/15 6/16 6/30 7/2 7/8 7/10 7/14 7/15 7/17 7/21 9/28test #1 starts ded. Registrar 6/2
test #3 starts-synchronize 6/3
test #2 starts-"huddles" 6/4
spread 1,2,3 to
#6,7,9,10 Template change; backlog;same day appts; PCP match 7/1
" secretaries for check out/central check in 9/22 &28
438
Chart2
5/8
5/11
5/13
5/14
5/15
5/18
6/2
6/3
6/4
6/5
6/8
6/11
6/12
6/15
6/16
6/29
6/30
7/1
7/2
7/7
7/8
7/9
7/10
7/13
7/14
7/15
7/16
7/17
7/20
7/21
9/22
9/28
test #1 starts ded. Registrar 6/2
test #3 starts-synchronize 6/3
test #2 starts-"huddles" 6/4
spread 1,2,3 to all areas 6/29
#6,7,9,10 Template change; backlog;same day appts; PCP match 7/1
"secretaries for check out/central check in 9/22 &28
Appt-out
avg flow time per date
hours: minutes
CORNELL INTERNAL MEDICINE ASSOCIATESPatient FLOW TIME (Attendings)
0.0469907407
0.0925925926
0.04375
0.0365530303
0.0210648148
0.0447420635
0.0277777778
0.0165674603
0.0341540404
0.0216435185
0.0355324074
0.0169753086
0.0215277778
0.0185185185
0.0364583333
0.0192708333
0.0349206349
0.0290123457
0.023828125
0.0361111111
0.0175347222
0.0269265233
0.0263310185
0.0238514957
0.0277083333
0.0308114035
0.0235243056
0.0305555556
0.03046875
0.0286111111
0.0317956349
0.0445
0000
all charts
all charts
5/8
5/11
5/13
5/14
5/15
5/18
6/2
6/3
6/4
6/5
6/8
6/11
6/12
6/15
6/16
6/29
6/30
7/1
7/2
7/7
7/8
7/9
7/10
7/13
7/14
7/15
7/16
7/17
7/20
7/21
9/22
9/28
test #1 starts ded. Registrar 6/2
test #3 starts-synchronize 6/3
test #2 starts-"huddles" 6/4
spread 1,2,3 to all areas 6/29
#6,7,9,10 Template change; backlog;same day appts; PCP match 7/1
"secretaries for check out/central check in 9/22 &28
Appt-out
avg flow time per date
hours: minutes
CORNELL INTERNAL MEDICINE ASSOCIATESPatient FLOW TIME (Attendings)
0.0469907407
0.0925925926
0.04375
0.0365530303
0.0210648148
0.0447420635
0.0277777778
0.0165674603
0.0341540404
0.0216435185
0.0355324074
0.0169753086
0.0215277778
0.0185185185
0.0364583333
0.0192708333
0.0349206349
0.0290123457
0.023828125
0.0361111111
0.0175347222
0.0269265233
0.0263310185
0.0238514957
0.0277083333
0.0308114035
0.0235243056
0.0305555556
0.03046875
0.0286111111
0.0317956349
0.0445
multiples
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
FLOW TIME
patients observed
hours:minutes
CORNELL INTERNAL MEDICINE ASSOCIATESPatient FLOW TIME (residents)
0.03125
0.0881944444
0.1118055556
0.1159722222
0.0513888889
0.0131944444
0.0194444444
0.0694444444
0.0729166667
0.0729166667
0.0625
0.0291666667
0.0541666667
0.1145833333
0.0715277778
0.0423611111
0.1090277778
0.0465277778
0.0548611111
0.0868055556
0.0534722222
0.0875
0.0381944444
0.0590277778
0.0416666667
0.0902777778
0.0659722222
0.0520833333
0.0243055556
0.0138888889
0.0347222222
0.0590277778
0.08125
0.0326388889
0.0416666667
0.0361111111
0.0444444444
0.0763888889
0.0673611111
0.1041666667
0.0840277778
0.05
0.1118055556
0.06875
0.0625
0.0291666667
0.0513888889
0.0409722222
0.0638888889
0
pt. flow
3579635796
3579735797
3580035800
3580135801
3580235802
3580335803
3580435804
3580735807
3580835808
3580935809
3581035810
3581135811
3581435814
3581535815
3581635816
3581735817
3581835818
3582135821
3582235822
3582335823
3582435824
3582535825
3582835828
3582935829
3583035830
3583135831
3583235832
3583535835
3583635836
3583735837
3583835838
3583935839
3584235842
3584335843
3584435844
3584535845
3584635846
3584935849
3585035850
3585135851
3585235852
3585335853
3585635856
3585735857
3585835858
3585935859
3586035860
3586335863
3586435864
3586535865
3586635866
3586735867
3587035870
3587135871
3587235872
3587335873
3587435874
3587735877
3587835878
3587935879
3588035880
3588135881
3588435884
3588535885
3588635886
3588735887
3588835888
3589135891
3589235892
3589335893
3589435894
3589535895
3589835898
3589935899
3590035900
3590135901
3590235902
3590535905
3590635906
3590735907
3590835908
3590935909
3591235912
3591335913
3591435914
3591535915
3591635916
3591935919
3592035920
3592135921
3592235922
3592335923
3592635926
3592735927
3592835928
3592935929
3593035930
3593335933
3593435934
3593535935
3593635936
3593735937
3594035940
3594135941
3594235942
3594335943
3594435944
3594735947
3594835948
3594935949
3595035950
3595135951
3595435954
3595535955
3595635956
3595735957
3595835958
3596135961
3596235962
3596335963
3596435964
3596535965
3596835968
3596935969
3597035970
3597135971
3597235972
3597535975
3597635976
3597735977
3597835978
3597935979
3598235982
3598335983
3598435984
3598535985
3598635986
3598935989
3599035990
3599135991
3599235992
3599335993
3599635996
3599735997
3599835998
3599935999
3600036000
3600336003
3600436004
3600536005
3600636006
3600736007
3601036010
3601136011
3601236012
3601336013
3601436014
3601736017
3601836018
3601936019
3602036020
3602136021
3602436024
3602536025
3602636026
3602736027
3602836028
3603136031
3603236032
3603336033
3603436034
3603536035
3603836038
3603936039
3604036040
3604136041
3604236042
3604536045
3604636046
3604736047
3604836048
3604936049
3605236052
3605336053
3605436054
3605536055
3605636056
# APPTS
New
DATES OBSERVED
# appointment requests/day
CORNELL INTERNAL MEDICINE ASSOCIATESDemand for Appointments 1998
0
0
148
22
310
41
286
47
307
32
295
38
343
53
368
53
373
51
380
35
280
29
265
33
4
0
407
43
334
53
290
34
263
38
304
27
335
40
327
45
260
31
266
33
352
56
315
42
305
37
337
50
289
27
310
42
350
44
345
41
276
48
244
33
0
0
328
54
295
40
282
51
223
32
320
45
351
25
309
43
268
41
270
36
325
49
268
44
303
38
290
41
245
30
356
56
278
58
352
42
300
35
290
33
308
58
272
46
364
43
292
28
265
36
291
47
292
39
263
35
280
44
255
23
352
53
295
43
280
38
288
39
288
39
284
38
262
37
306
48
300
38
174
15
260
43
260
35
265
27
215
48
223
29
374
71
359
50
298
41
300
31
295
32
299
32
221
34
333
47
291
41
233
27
318
47
259
30
338
40
240
29
221
22
297
40
247
36
234
37
327
51
265
26
367
51
249
42
386
47
330
36
220
24
1
2
334
40
312
44
320
44
231
39
324
53
311
44
290
38
296
33
352
36
386
60
293
44
438
35
299
44
267
24
388
51
336
40
371
39
247
35
308
28
353
62
378
32
351
38
255
39
218
27
318
44
312
30
328
46
302
32
4
1
444
54
332
32
330
39
318
31
270
37
298
48
281
40
329
43
288
40
318
35
313
38
258
39
279
35
227
31
230
32
279
40
273
37
296
48
283
42
263
37
315
39
274
41
321
51
254
49
214
48
285
51
331
42
323
43
286
32
235
33
243
48
272
38
275
43
230
30
250
26
291
50
253
40
313
50
216
33
217
29
293
39
199
34
306
39
224
35
247
17
0
0
295
38
352
39
330
40
271
21
328
50
291
46
307
42
333
40
297
27
98 DEMAND
3543235432
3543335433
3543635436
3543735437
3543835438
3543935439
3544035440
3544335443
3544435444
3544535445
3544635446
3544735447
3545135451
3545235452
3545335453
3545435454
3545735457
3545835458
3545935459
3546035460
3546135461
3546435464
3546535465
3546635466
3546735467
3546835468
3547135471
3547235472
3547335473
3547435474
3547535475
3547935479
3548035480
3548135481
3548235482
3548535485
3548635486
3548735487
3548835488
3548935489
3549235492
3549335493
3549435494
3549535495
3549635496
3549935499
3550035500
3550135501
3550235502
3550335503
3550635506
3550735507
3550835508
3550935509
3551035510
3551335513
3551435514
3551535515
3551635516
3551735517
3552035520
3552135521
3552235522
3552335523
3552435524
355273