Transcript Presentation slides

Implementing quality improvement
in the ambulatory setting: Lessons and
cautions from the Pittsburgh Regional Health Initiative
B Block MD
Chief Learning and Medical
Informatics Officer
Practice Assessment
•
•
•
•
Productivity
Quality Metrics
Adaptive Reserve
PCMH-a
Productivity
CHARGEQTY
Doc A
Doc B
Doc C
Doc D
OFFICE VISITS
4,996
4,241
3,711
3,447
99213 - EST,LEVL III, OFFICE/OUTPT
2,596
VISIT 1,490
1,359
1,395
99214 - EST,LEVL IVOFFICE/OUTPT992
VISIT 2,141
1,263
812
99396 - PREVENTIVE VISIT,EST,40-64
505
167
364
452
99395 - PREVENTIVE VISIT,EST,18-39
172
57
84
219
G0439 - ANNUAL WELL VIS SUBSEQ98
(MDCR/MNG
51 CARE MDCR)
14
101
99212 - EST,LEVL II, OFFICE/OUTPT121
VISIT
29
196
37
G0438 - ANNUAL WELL VIS INITIAL (MDCR/MGN
123
52
CARE MDCR)
24
102
99397 - PREVENTIVE VISIT,EST,65 & 22
OVER
16
173
6
99203 - NEW,LEVL III, OFFICE/OUTPT41
VISIT
10
11
8
99385 - PREVENTIVE VISIT,NEW,18-39
42
2
10
26
99394 - PREVENTIVE VISIT,EST,12-1761
24
14
40
99243 - LEVEL III, OFFICE CONSULTATION
14
4
29
15
Doc E
3,404
1,207
1,367
293
89
121
15
49
25
49
34
22
50
Doc F
3,324
1,381
952
180
120
34
45
31
8
14
15
50
1
Doc G
3,208
854
1,703
151
22
66
200
51
56
7
4
5
29
Doc H
3,173
1,504
895
152
101
14
48
30
16
129
53
30
32
Mandated Quality Metrics
Medical Group Quality Metric Summary 10/13-9/14
Commercial
Practice
Measure
Num. Denom. Ratio Benchmark
SunnyView Colorectal Cancer Screeing
593
946
63%
57%
HbA1C Testing
205
230
89%
88%
Medical Attn for Nephropathy
200
230
87%
79%
Diabetes: Treatment of HTN
103
127
81%
81%
HbA1C <=9%
166
230
72%
65%
Med Adherence for Diabetes Meds
138
166
83%
79%
Med Adherence for HTN: RASA
358
470
76%
79%
Med Adherence fo Cholesterol: Statins 259
358
72%
72%
Avoidance of High Risk Meds in Elderly
32
544
6%
92%
Lewisburg Colorectal Cancer Screening
271
442
61%
57%
HbA1C Testing
62
68
91%
88%
Medical Attn for Nephropathy
57
68
84%
79%
Diabetes: Treatment of HTN
23
31
74%
81%
HbA1C<=9
54
68
79%
65%
Med Adherence for Diabetes Meds
27
32
84%
79%
Med Adherence For HTN: RASA
138
174
79%
79%
Med Adherence for Cholesterol: Statins 85
111
77%
72%
Avoidance of High Risk Meds in Elderly
12
241
5%
92%
Medicare
Medicaid
4 star Num. Denom. Ratio Num. Denom.
68%
143 227
63%
41
49
90%
103 108
95%
43
49
84%
102 113
90%
80%
79%
70
80
88%
81%
157 173
91%
76%
180 202
89%
92%
61 468
13%
68%
109 179
61%
15
20
75%
19
21
90%
17
20
85%
17
21
84%
22
35
64%
80%
79%
24
25
96%
81%
85
89
96%
76%
86
92
93%
92%
28 279
10%
Ratio
84%
88%
90%
81%
Adaptive Reserve
Practice A.
Practice B
Practice C
Practice D
Practice E
Practice F
Practice G
Ann Fam Med. 2010 May; 8Suppl 1: S9–S20.
PCMH-a
Assessment
PCMH-a Network
Practice Assessment
Quality
Continuous
Organized,
Engaged Improve Empanel
and TeamEvidenceLeadership
ment
ment Based Healing
Based Care
Strategy
Relationships
Practice
A
B
C
D
E
F
G
10.0
7.5
8.3
7.0
7.0
7.8
6.9
11.3
9.0
10.5
7.0
8.0
10.3
8.1
9.8
7.8
9.0
4.0
4.5
7.5
6.6
11.0
8.7
9.3
7.0
9.3
9.7
9.8
8.6
8.8
7.4
7.0
9.0
7.4
7.2
http://www.safetynetmedicalhome.org/resources-tools/assessment
PatientCentered
Interactions
7.7
7.3
9.3
4.5
6.8
6.2
7.0
Average
Enhanced
Care
PCMH-A
Access Coordination Score
(Pre)
10.5
9.5
11.3
7.0
9.8
9.8
8.7
9.7
7.2
9.0
7.0
8.2
8.7
8.6
Scale 1 to 12 higher is better
9.8
8.2
9.3
6.3
7.8
8.4
7.8
Using Data to Motivate and Engage
•
•
•
•
Practice Outputs
Patient Outcomes
Patients Lost to Care
Exploring the Causes
How Good is Your Diabetes Care?
PTS SEEN
AT LEAST
ONCE IN
LAST 3
YEARS DIABETES
N
158
107
131
437
304
276
177
151
230
257
143
128
488
83
150
121
3341
SITE
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
MEAN
Network Diabetes Data Review
HbA1c
missing
10%
1%
8%
5%
7%
12%
15%
5%
9%
7%
11%
5%
15%
10%
5%
16%
9%
>8.5
11%
7%
11%
10%
12%
12%
16%
8%
8%
14%
9%
3%
18%
16%
11%
10%
12%
LDL
missing
12%
3%
12%
10%
13%
16%
16%
15%
11%
8%
17%
9%
20%
17%
11%
21%
13%
SBP
>130
10%
9%
13%
16%
12%
8%
19%
13%
8%
16%
11%
14%
15%
9%
15%
18%
13%
missing
-
>145
9%
4%
10%
11%
7%
22%
20%
3%
4%
6%
11%
13%
13%
21%
10%
9%
11%
Missing or SubOptimal
“It’s not
perfect,
but it is
very good.”
ANY
missing suboptimal lapsed >4 mos.
13%
25%
42%
3%
16%
10%
13%
29%
38%
11%
31%
40%
15%
25%
44%
18%
34%
47%
18%
38%
38%
15%
21%
37%
12%
17%
68%
10%
29%
22%
18%
25%
23%
10%
27%
25%
24%
32%
41%
18%
36%
31%
13%
29%
42%
25%
30%
47%
15%
28%
39%
Root Cause Analysis
Leadership Engagement
• Network Leader Responsibilities
• Practice Leader Responsibilities
• Practice Member Activation
PCMH-a Organizational Assessment:
Engaged Leadership
Practice Site Leadership
• Take on leadership roles within the group
practice, heading internal committees that
address critical issues.
• Develop consensus among providers in the group
about pre-visit work, triage, coverage, care
protocols, and customer service.
• Work with providers in other practices to share
better ways to improve patient care outcomes.
Practice-based Quality Leadership
•
•
•
•
•
•
Community Relations- work with marketing team to develop direction, review demographics,
patient surveys, and strategy. Outreach to community organizations, media, and employers.
Office Access and Scheduling- work with administration, practice manager and office staff to create
an access schedule to meet needs of patients. Develop scheduling templates and triage protocols
to better fit patients to time and resource constraints. Ensure balancing of workload among
providers.
Clinical Workflow- Review current workflows and adapt to improve efficiency. Identify
opportunities to standardize efficient workflows. Review documentation trouble spots and suggest
remedies.
Management- Provider Relations- Collect feedback from provider colleagues and represent those
points of view in discussions with management. Carry management perspectives to providers.
Work to find effective collaborations.
Care Team Training- Clarify staff roles, create performance metrics and training modules, provide
incentive and remediation options
Practice Sustainability- Align coding, charge capture, and health plan measures with clinical goals.
Move towards value based reimbursement and shared savings models.
Introducing a Quality Strategy
• Combating Hopelessness and Apathy with QI
• “Show Us the Work You Do”- Observation
• “Help Us Understand the Strengths and the
Trouble Spots” - Current and Target Condition
• Creating a Vision of the Ideal
• PDSA Cycles to Find the Right Solutions
“I’m doing everything I can to give
good care, but…”
Observation
No pre-visit
Pre-visit
test
review of
completion
testing
review
TARGET CONDITION
CURRENT
CONDITION
Test completion
review at
No care
team
huddle
huddle
No
Care team
performance
report
feedback
card
No
EHR
EHR
Reminders
reminders
No time for
wrap-up
Connections
Roles
Activities
Pathways
Patient in
a rush
No standing
Standing
orders
orders
Overdue
No test
follow-up
Follow-up
IDEAL CONDITION
http://www.safetynetmedicalhome.org/sites/default/files/Patient-Care-Reminders.pdf
Build QI Capabilities
Problems are solved one step at a
time – each attempt gets you closer
to success
IDEAL
Current
Condition
First Step in P-D-S-A
PLAN
 Identify an important
organizational concern
 Determine the processes
which affect that concern
 Explore problems in
those processes
 Find the cause of the problems
 Design the corrective actions
Try Out Corrective
Action
Design Corrective
Action and
Metrics
Improving Office Processes
• System Thinking
• Step-wise EHR Training in the Work Context
• Staff Communication Training
Opportunities to Clarify and
Support Medication Use
Clinical Pharmacist
Opportunities to Clarify and
Support Medication Use
Pre-Visit: Review the Health Management Plan
Step One: Open the patient’s HMP. Look in the To Do column of the HMP for medications with a red triangle.
If the patient is not doing well, check the other important as well. Right-click the medication and select
“Renew with Changes.”
Step Two: In the “Medication Details” window that appears, scroll down to the “Order and Renewal History”
section. Row #1 shows the most recent Rx for the medication.
ACTION ITEM: If there is a date in the column labeled DNFB in Row #1, the patient may not have picked up
their most recent prescription. Contact the patient to clarify the situation. Document the outcome in the Previsit Planning section of the encounter note.
Step Three: Click on the “Fill History” button. Compare the Fill date to the date in the Renewal History.
ACTION ITEM: If the Fill Date is earlier than the Renewal date, then it is likely that the patient did not get the
latest refill. Contact the patient to clarify the situation. Document the outcome in the Pre-visit Planning
section of the encounter note.
Sometimes the Fill History fails to show a completed refill. This can happen if the information is out of date, or
if the patient paid cash rather than using their insurance coverage. Use the patient and the Pharmacist to
clarify the situation.
If the patient really did stop a critical medicine unexpectedly, then the provider needs to be notified.
Compare the Fill and Renewal Dates
Prescribed in Dec. 2014 but
not filled since June 2014
Discuss with the patient to clarify
Clarifying Medication Use
• Hello Mrs. Vetri. We were preparing for your visit
with us on Tuesday next week. Is 1:15 still a good
time for you?
• I noticed, in our records, that a prescription we wrote
for you last month hasn’t been picked up yet at the
pharmacy. Is that correct? It was for lisinopril.
• Since our records can sometimes be wrong, I wanted
to check that out with you. Did you run into any
problems with the prescription?
• What would you like to do about the prescription?
Patient was having cough and stopped her lisinopril a month ago.
Patient Engagement
•
•
•
•
Preparing the Patient for Self-Care
Clinical Assistant Training Program
Expanding the Visit Wrap-up
Staff Communication Training
Exit Phase
Wrap-Up:
Support, Clarify,
and Activate
Patient “Education” 1975
Authoritative
Advice
Fear of
Consequences
Health
Patient Engagement 2015
Improving care
OUTCOMES
requires more than
GOOD ADVICE and
a stern warning
Patient
Self-Care
Support
Beyond Office Care
•
•
•
•
Systematic Case Review
Limitations in Primary Care Resources
Volume to Value for Whom?
Wellness-Aligned Outcomes
Systematic Case Review
PHQ-9
HbA1c
Systolic BP
LDL
Contacts
Other
Pt ID
First Latest First Latest First Latest First Latest
Med
Recon
Hosp/Ed
Maint
Plan
Consult
No. of Wks
Date
Sessions in Tx
First
Latest
Next
2/20/15
2/27/15
5/8/15
N
2/24/15
2
1
12/23/14 2/27/15 6/12/15
Y
12/20/14
4
9
2/24/15
12
37
2/3/15
19
41
4256
5
5
14
14
130
130
48
48
7389
8
3
6.9
6.9
150
130
42
42
1256
11
13
5.1
5.7
143
150
UNK
UNK
6/10/14
2/27/15
4/2/15
6794
9
1
8.5
8
112
114
168
159
5/14/14
2/27/15
UNK
5467
13
17
11.2
6.4
132
165
90
143
10/4/13
2/26/15 3/20/15
8880
13
12
9.1
10.5
102
100
123
UNK
1/23/14
2/26/15 4/13/15
Y
1/12/2015
12/3/13
Y
11/5/14
N
1/27/15
19
73
Y
1/6/15
17
57
But We Learned that Elegant Office Care is Not Enough
In the COMPASS initiative, the psychiatrist and
medical consultant met weekly with care managers
to offer recommendations for the care of patients
with poor progress.
Limitations of Primary Care Settings
• Poor communication and alignment with hospital
care providers, nursing home, personal care,
rehab and hospice programs
• Poor connections to behavioral health services
and social service agencies
• Inadequate clerical and coordination support
• No outreach workers, peer community health
workers, behavioral health consultants
Volume to Value…for Whom?
Mandated clinical
quality measures
merely assess
documentation of
physician activities or
compliance with
physician
recommendations
rather than actual
impact on personal
wellbeing.
http://www.samhsa.gov/wellness-initiative/eight-dimensions-wellness
Wellness-Aligned Outcomes
Program
Outputs
Outcomes
DIMENSION
inputs
short-term
medium-term
long-term
Integrated
Health Care
services
symptom,
sign, or risk
reduction
patient
goals-driven
functional
improvement
improved
problem solving
and social
participation
Measure
Tools
#contacts,
#assessments,
#patients, #
medications, etc.
PHQ-9<5,
HbA1c<8.5,
BP< 145mm,
etc.
work education,
caretaking,
self-care, etc.
Life Skills
Inventory, Social
Connectedness
Survey, etc.
Emotional:
coping effectively with
life, and creating
satisfying relationships
MORS, ROSI, STORI,
RSA, RAS, etc.
Questions?
B Block MD
Chief Learning and Medical
Informatics Officer
[email protected]