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Day 2

Data-Driven Population Health

Quality Improvement Summit

2

Networking Breakfast

256

Supporting Team-Based Care with Data Tools

Referral Management in DRVS

Goal of Today’s Session

Referral module overview

Challenges of the referral process

Managing referrals– Goals and roles– Workflows and functionality

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/

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….

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

Referrals Are Complicated!

6Azara Proprietary & Confidential

How Can the Referral Module Help?


• 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

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.

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?

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.

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

11

Referral Management Dashboard


Priority Level of Referral Service

Referral Performance

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.

13

4 Referral Reports

Action-specific reports minimizes sorting and filtering.


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Report Details| The Basics

Manage referrals like a population for max efficiency.

Report Details | Important Dates

Dates Identify patients that need action.

Registry Details| Other

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


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.


Referral Measures

Go to detail– Sort - referral provider, owner, internal/external, no appointment date


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




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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.

24

Integrated Referrals on PVP


Open referral information can help guide actions and conversations during the visit.• Referral Type• Specialist / Location• Ordered Date• Appt Date

Questions?

Reflections from Day 1Pair up with someone, listen to and tell takeaways

from yesterdayReport out

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284

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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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

292

Measuring Staff Engagement

Percentage of ALL staff trained in HTN basics

293

Patient Engagement

What does BP mean and what is a good

BP?

BP Education

Initial VisitRegistry

Prioritized Recall

HTN Plan and Tracking

294

Patient Education

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

297

System Wide Impact!

Median

Goal

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ar14-Apr14-M

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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%

298

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.

299

Thank you

BreakTake 5

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Using Data to Transform Care DeliveryJane Taylor, Ed.D.April 2018

2

ObjectivesState 3 types of measures for improvementCreate a family of measures for care deliveryApply run charts to analyze data

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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.

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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

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

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BaselinePercent

Screening for Social Conditions

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ImprovementPercent

Testing

Improved social condition screening

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AchievementPercent

baseline

Specification (aim/goal/target)

Achieving new levels of performance in screening

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SustainingPercent

baseline

Improvement period, no

Period of sustained performance

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Monitoring Percent

baseline

Improvement period, no control

Period of sustained performance, n=30

Transition to weeks, n=210

Transition to months, n=900+

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Degradation Percent

Special cause variation, detected –direction is both positive and negative, but it is difficult to see

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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

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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

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

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

Dec-06Dec-06Dec-06Dec-06Dec-06

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Apr-07Apr-07Apr-07Apr-07Apr-07

May-07May-07May-07May-07May-07

Jun-07Jun-07Jun-07Jun-07Jun-07

Jul-07Jul-07Jul-07Jul-07Jul-07

Aug-07Aug-07Aug-07Aug-07Aug-07













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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&A

Hold Gains

























&A

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Percent

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P-Chart

SubgroupsP StatisticCLUCLLCLTargetNon-ConformingSample Size

Sep-02501020

Oct-0245920

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Dec-0245920

Jan-0335720

Feb-0330620

Mar-0315320

Apr-0310220

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Jun-0330620

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Unreconciled Meds

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Unreconciled Meds

Sheet1

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Sheet3

Quantitative. Make it better?www.youtube.com

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http://www.youtube.com/

Let’s watch and listen as data singshttps://www.youtube.com/watch?v=awUMW3AbPhQ

320

https://www.youtube.com/watch?v=awUMW3AbPhQ

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

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ompo

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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

Percentage of eligible children given flouridevarnish

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CL 0.3918

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0.6294

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6/1/12 - 11/1/13

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

325

Improving Patient Outcomes Through DataHow to Use Data to Transform Care Delivery

Alaska PCA Data SummitApril 10, 2018

AgendaData Driven Care Delivery Tools

Implementation

Team-Based Care

Roles and Responsibilities

Results 2

1

2

4

3

5

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

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)

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Patient Visit Planning Report – Demo Sample

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Patient Visit Planning Report – Demo Sample

Care Management Tools

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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.

Active Allergies & Medications

The last 10 active medications and date of

reconciliation

All Active Allergies and the last time they were

reviewed

Implementation of the Visit Planning Report

12

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.

Choose 5 Evaluation Measures and Targets

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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%

Build a Scorecard with Targets

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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.

Team-Based Care

17

Care Team Members

Provider

MA/LPN

Patient

Front Desk

Care Manager

BH

Referral Clerks

Practice Manager

Nurse/RN

Health Educator

PharmacistComm Health

Workers

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

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

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.

Roles and Responsibilities

23

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

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.

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

Pre-Visit Planning & Care Team Huddle Video

27

https://vimeo.com/227406460

https://vimeo.com/227406460

Kick-off With Your Pilot Teams

28

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.

Results

29

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

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

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

Wrap-Up and Questions

33

Contact Information

Heather BuddVP of Clinical TransformationAzara [email protected]

mailto:[email protected]

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

Agenda

Introductions

MPCA Team and Approach

The History

Real Life Challenges and Success with Data

What’s Next?

Conclusions

2

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

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

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.

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

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

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

The Missouri Primary Care Association Quality Improvement and Data Journey

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

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

11

2009

EHR acquisition mostly accomplished

Homegrown data warehouse stalled out

Azara engaged to implement SAAS data warehouse

12

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)

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

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

MPCA’s Data Warehouse- DRVS

16

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

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

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

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

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

21

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

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

23

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)

Own Your Data…Own Your Future

Stage 1Stage 2

Stage 3Adoption

Quality of data equals quality of care

Quality Improvement

ACO / PCMH/IPA

Making a Difference in Quality Using Data

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

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)

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)

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

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

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.

32

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

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

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

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

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

Keeping Focused on Data: HCCN Default Scorecard for Missouri User’s

An early MOQuIN / HCCN scorecard:

38

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

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

Individual Center Comparative Analytics

Cervical Cancer Screening

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.).

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

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

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

DRVS Diabetes Registry- Sorting for “Untested”

50

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

[email protected]

Heather Budd

VP of Clinical Transformation

Azara Healthcare

[email protected]

mailto:[email protected]:[email protected]

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

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

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



spread 1,2,3 to all areas 6/29


"secretaries for check out/central check in 9/22 &28

Appt-out


hours: minutes


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



spread 1,2,3 to all areas 6/29


"secretaries for check out/central check in 9/22 &28

Appt-out


hours: minutes


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