Transcript Slide 1
Developing Workflow Process Diagrams To Target Interventions
Moderator: Mindy Golatt, RN, MPH, Public Health Analyst, HRSA/HAB Presenters: Paul Cassidy, Program Director, GNBCHC Erika Harding, Health Administrator, CCHC Facilitator: Nanette Brey Magnani, NQC/HIVQUAL QM Consultant
Learning Outcomes
• • • Participants will be able to: Define the steps and symbols used in workflow process diagrams, Engage in discussion with grantees about their examples, and Begin to develop a workflow process diagram of their own work processes.
Agenda
QI Principles and Framework Workflow Diagrams The Basics Examples Try it out!
Post AGM Discuss and Revise with your Team.
Why Look at Processes?
Fundamental Concept of Improvement: “ Every system is perfectly designed to achieve exactly the results it achieves” Principles of Improvement:
– Understanding work in terms of processes and systems – Developing solutions by teams of providers and patients – Focusing on patient needs – Testing and measuring effects of changes
Review: QI Principle Most problems are found in processes
not in people.
Understanding Work in Terms of Processes and Systems
Benefits • Clearer understanding of the overall system and processes • • Target processes that need improvement Efficient allocation of staff and resources • Effective use of team’s input and creative problem solving • Better understanding of each other’s roles • Reduction in waste and time
What are your initial thoughts about this improvement system?
100 90 80 70 60 50 40 30 20 10 0 Jan-09 May Sep
Regional Quarterly Retention Rate
Dec Jan-10 May Sep Dec Jan-11 May Sep Dec
100 90 80 30 20 10 0 70 60 50 40
What are your initial thoughts about this improvement system?
Regional Quarterly Retention Rate
When do you develop your workflow diagram?
QI Project Steps Step 1: Review, Collect and Analyze Baseline Data Step 2: Develop a Project Team Work Plan Step 3: Investigate the Process/Problem Step 4. Plan and Test Changes – PDSA Cycles Step 5: Evaluate Results with Key Stakeholders Step 6: Systematize Change
QI Principle Most problems are found in processes not in people.
– A system is made up of processes – Processes comprise steps
Workflow Diagram Definition
A workflow diagram or flow chart is a picture of the steps of a process to: – Understand the process – Identify potential problem steps and reasons – Outline the ideal process steps – Enable communications with others
Creating a Process Diagram
1. Agree on use and level of detail 2. Define starting and ending points 3. Document each step 4. Follow each branch to the end 5. Review the chart . Flowcharts
Testing and Measuring a Workflow Process
1. Identify key problem steps.
2. Write key causes to each identified problem 3. Select interventions that address key cause.
4. Then test and measure new process.
5. Repeat as necessary.
6. Support new process – e.g. communication, new procedure guidelines.
Most Commonly Used Flowchart Symbols
Activity/step Connecting lines Begin/ Terminator Decision Flowcharts
VL Suppression
Grantee Examples
• Paul Cassidy – Greater New Bedford CHC, New Bedford, MA Gap in Care and Patient Transition to a different clinic • Erika Harding – Christian CHC, Chicago, IL
Greater New Bedford Community Health Center, MA
Performance Measure for VL Suppression
Percentage of HIV patients, regardless of age, with a viral load less than 200 copies/ml at last viral load test during the measurement year.
Measurement year 2011
Number of Patients = 320 Suppressed (Blue)= 236 Not Suppressed (Red)=84 Suppression Rate=73%
Baseline Data
Viral Load Suppression
84 236
Improvement Goal
To increase patients’ viral load suppression rate from 73% to 85% in six months.
Causal Analysis
Problem Steps with Workflow processes on two levels: •
Patient Level
Insufficient time for adherence education for patients not suppressed
Causal Analysis cont’d
Problem Steps with Workflow processes on two levels: •
Program Level
Weekly (3x/month) multi disciplinary team meetings for patient review had stopped meeting for 6 months due to • construction; thus a loss of focus on non suppressed patients Minimal input of multidisciplinary team members ideas into • tailored care plans for each non suppressed patient No feedback loop for reporting results of the interventions back to the team.
PATIENT REGISTERS MA TAKES VITALS PHYSICIAN EXAMINES PATIENT, REVIEWS RESULTS AND REGIMEN Order Blood work for next three month review
GNBCHC Workflow Process for Established Patients
<200 >200 Review Meds, barriers to barriers, pre-pack meds, deliver to house, review meds and fill pill box Determine next steps with patient ** RN Adherence Visit Multi Disciplinary Team Review Give lab orders, patient to Lab Lab Blood Draw Schedule next visit Lab Results sent to Physician Lab Results Sent to Data Entry. Blood work electronically entered into EHR Lab Results Sent to RN N No further Follow-up Concern with Results Y Call patient and make earlier visit than previously scheduled
Prepare Reports Identifying Patients Not Suppressed.
GNBCHC WEEKLY MULTI DISCIPLINARY MTGS .
RE- START WEEKLY MTGS-3/MONTH
•REVIEW PATIENTS •TAKE NOTES •DEVELOP CARE PLAN TEMPLATE •DEVELOP PATIENT SPECIFIC CARE PLANS •TEAM MAKES RECOMMENDATIONS •ASSIGNED STAFF PRESENT PLAN TO PATIENT FOR PATIENT INPUT •FOLLOW –UP ON RECCOMENDATIONS •INTERVENTION IS INDIVIDUALIZED
***
BARRIERS TO VIRAL LOAD SUPRESSION •SUBSTANCE ABUSE •HOMELESSNESS •NOT ATTENDING APPOINTMENTS •MENTAL HEALTH ISSUES •REFUSE MEDICATIONS
RN INTERVENTION
•DEVELOP AND IMPLEMENT CARE PLAN •FOLLOW -UP
SOCIAL WORK INTERVENTION
•FOLLOW-UP ON PLAN DATA ENTRY SCHEDULED TEAM MEETINGS REVIEW RESULTS OF INTERVENTIONS # OF PATIENTS WITH VL >200 REVIEWED # WITH TARGETED CARE PLANS PATIENT RESPONSE TO INTERVENTION
PEER NAVIGATOR INTERVENTION
•FOLLOW –UP ON PLAN
GNBCHC – Measurement
• Data Update
Christian CHC: Improvement Goals
To reduce the gap in care rate from 13% to 5%. (number of patients with a medical visit in the last 6 months of the measurement year) To ensure 170 patients or 69% of our HIV+ population at the Monterey Clinic are successfully transitioned to the Halsted Clinic.
Quality Improvement Team GROUP PHOTO HERE
26
Transition Care from Monterey to Halsted CCHC
Scheduler Patients notified Instructed to make appt at different site Patient Makes Appt.?
No Yes Receives reminder call from PHA – 1 day prior
Requires Follow-up
Repeat call from PHA No Appt Kept.
?
Yes Patient Registers 27
Data specialist initiates Patient Tracking Tool
Patient Follow-up
Import list of patients from CAREWare who’s last visit >45 days Note appt date in Patient Tracking Tool
Yes
Patient Has a Scheduled appt?
No
Refer names to Patient Health Advocate for follow-up Refer to Scheduler for appointment
Yes
Active, Continuing?
No
Document status in list and chart PHA meets monthly with QI Team for 28
Measurement Tracking Data
Yr Ending Rate Sept 2011 13% Nov 2011 16% Jan 2012 18% Mar 2012 7% Apr 2012 6% May 2012 8% 29
20% 16% 12% 8% 4% Sep-11
Measurement Data Start PSDA Cycle 1 Ends Cycle 3 Ends
Nov-11 Jan-12 Mar-12
Cycle 2 Ends
May-12 30
Task: Draw a Workflow Process Diagram
1. Select a process to improve. It can be just a few steps.
2. Agree on use and level of detail.
3. Define starting and ending points 4. Document each step. Use paper provided. 5. Follow each branch to the end 6. Review the chart. Flowcharts
Large Group DeBrief
What improvement processes did you choose?
Who will share your diagram?
What were some of your challenges?
What do you think are the benefits?
What can you do post AGM?
Flowcharts
Flowcharts
REMINDER This is a TEAM effort!
Contact Information
Paul Cassidy, Program Coordinator, Greater New Bedford Community Health Center, New Bedford, MA [email protected]
Erika Harding, MPH, Health Administrator, Christian Community Health Center, Chicago [email protected]
Flowcharts
Contact Information
Mindy Golatt, RN, MPH, Public Health Analyst, HRSA/HAB, Project Officer/Chicago, [email protected]
Nanette Brey Magnani, EdD, Quality Management Consultant, NQC/HIVQUAL, [email protected]
Flowcharts