Transcript Improving Health in Our Patients & Communities

Improving Performance
in Practice:
From IPIP to GQI
Objectives
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Provide an overview of IPIP methods
and rationale as it moves statewide
under the GQI/NCHQA
Describe what we will do and what you
will do
Introduce the change model and
change packages
Introduce measurement
Adherence to Quality Indicators
in the Medical Care Setting
Percentage of
Recommended Care
Received
Condition
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Hypertension
Depression
Asthma
Hyperlipidemia
Diabetes
64.7
57.7
53.5
48.6
45.4
McGlynn et al. NEJM 2003
Diabetes Recommendations
Health Systems
Disease management
Case management
Strongly Recommended
Strongly Recommended
Self-Management Education
Community gathering places
Home - type 1 diabetes
Recommended
Recommended
North Carolina Chronic Disease
Management Collaborative
IPIP: A National Initiative
American
American
American
American
American
Board of Medical Specialties
Academy of Family Physicians
Academy of Pediatrics
Board of Family Medicine
Board of Pediatrics
Plus
American College of Physicians
American Board of Internal Medicine
…funded by the Robert Wood Johnson
Foundation
National IPIP: The Vision
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Dramatic transformation of office care with
improvement of chronic disease care
All Primary Care Disciplines—Family
Medicine, Pediatrics, General Internal
Medicine—across the whole state
New approach to CME and linkage to
Maintenance of Certification Part IV
Started in two states (NC, CO) now spread
to five more states (PA, MI, WA, WI, MN)
North Carolina Coalition
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Physician Leadership (NCAFP, NCPS, and the NCACP)
Collaboration of NC AHEC and Community Care of
North Carolina
With active involvement and support from
 Medicaid
 State Employees Health Plan
 Blue Cross Blue Shield of NC
 Health and Wellness Trust Fund
 Division of Public Health
 MRNC/CCME (QIO)
 North Carolina Medical Society
Spreading Statewide
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Focus is providing help for doctors to
transform their practice by building
systems to reach every patient, every
time
Pilot: Eastern and Mountain, learn how to
do it and spread it in each practice and
across the state.
Governor’s Quality Initiative/North
Carolina Health Quality Alliance
IPIP Methods Overview
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Focus on providing help for doctors to change
their practices rapidly by using data to drive
the change
Data Collection and Reporting
Rapid Cycle Process
Quality Improvement Consultants
Quarterly dinner meetings to share learnings
CME and MOC-IV credit
Learnings About Process
From the Pilot Wave
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Common measures of quality take time
Recruitment was not difficult
MD championship, CCNC/AHEC regional
leadership critical
Regional strategy very successful
QICs immensely popular
Data systems are a large barrier, but can be
overcome
Learnings:
Can we improve care?
Diabetes Quality Improvement in
Wave 1 after 9 months (n=12)
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%HbA1C <7
%HbA1C >9
%BP < 130/80
%LDL <100
Smoking advice
Foot exam
Eye exam
Nephropathy
40
20
35
36
45
40
24
38
to 54%
to 11%
to 47%
to 50%
to 77%
to 63%
to 35%
to 62%
(40%)
(15%)
(25%)
(36%)
(80%)
(80%)
(60%)
(80%)
Asthma Quality Improvement
after 9 months (n=5)
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Severity Classification
Controller Medication
Flu Shot
68 to 80%
94 to 94%
38 to 67%
IPIP in North Carolina
Making it work for you!
Individualized office system
assessments
Practice data collection with internal
reporting to immediately impact
care
What You Can Expect From IPIP
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QIC to work with you on office systems changes
Help establishing database of your patient
population
Tools and methods for changing your practice
Comparisons to other practices, with opportunity
to learn from them
CME and MOC IV credit
Some financial support
Access to national leadership in quality
improvement
What IPIP Expects From You
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Formation of a practice team to champion
change, review and submit data
Implement registries, templates of care, practice
protocols and support for self management
Frequent analysis and small changes in your
practice, with tests of change
Participation in quarterly meetings to share your
learning with other practices
Regular engagement with your QIC
IPIP Reimbursement
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Initial $1000 after identification of clinical
improvement team, attendance at kick-off
meeting and beginning submission of baseline
data
Second $1000 after submission of baseline and
six months of data and participation in network
activities.
Third $500 after 12 months of data and
establishing a sustainable culture of quality
improvement in your practice.
CME will be provided for ongoing activities
IPIP/GQI/NCHQA:
Vehicle for Leadership
in Communities and Across the State
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One definition of quality across payors
One audit of quality per practice
across all payers
Help us learn how to help other
doctors transform their practice and
respond to pay for performance
initiatives
Developing permanent community
based support for practice
improvement
Questions?????
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We need your advice,
understanding and help
If we haven’t addressed what’s on
your mind, TELL US PLEASE!
Changing Office Systems
Model for Improvement: How to
Change
Change Packages: What to Change
Chronic Care Model
Community
Health System
Health Care Organization
Resources and
Policies
Practice Level
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
•Try again?
•Change it?
•Dump it?
•Data pulls
•Check sheets
•feedback
Act
Plan
Study
Do
•Workflow
Analysis
•Brainstorming
•Nominal
Ranking
•Small tests
of change
•2 pts. 1 doc
•Quick tests
with feedback
Change Model: Key Elements
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PDSAs are a generalized approach, but
personalized for your practice
Pilot and Spread
Emphasize Learnings
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Rapid small cycles!
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Repeated Use of the Cycle
A P
S D
Hunches
Theories
Ideas
A P
S D
Changes
That Result
in
Improvement
What is a Change Package?
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A change package is an evidence-based
set of changes that are critical to the
improvement of an identified care
process.
Ed Wagner MD
Improving Chronic Illness Care. org
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IPIP Change Package
Organization
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High-leverage Changes
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Detailed Changes
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Change Tools
IPIP Change Package
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High-leverage Changes (12-18 months)
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Step One: Implement Electronic Database –
clinical information systems
Step Two: Use Template for Planned Care –
delivery system design
Step Three: Use Protocols – decision support
Step Four: Adopt Self-management Support
Strategies
Changes in Parallel
SelfMgmt
Support
Delivery
System
Design
Decision
Clinical
Community
Support Information Resources
Systems
Organization
Strategies for Each Component of the Care Model
= Initial work in IPIP
= Areas to work after initial work is complete
Detailed Changes: Registry
Step One: Implement an electronic database:
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Select and install a registry tool
Determine staff workflow to support registry
use
Populate registry with patient data
Routinely maintain registry data
Use registry to manage patient care and
support population management
Detailed Changes: EHR
Step One: Implement and Electronic Database:
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Learn capability of EHR for registry functions
(identifying patients, flowsheets or disease
templates and data reporting)
Improve use of EHR to support registry
function
Routinely maintain correct use of EHR
Use EHR as registry to manage patient care
and support population management
Detailed Changes: Templates
Step Two: Use a template for guided care:
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Select template tool from registry/EHR or use
a flow sheet
Determine staff workflow to support use of
template
Use template with all patients
Ensure registry updated each time template
used
Monitor use of template
Detailed Changes: Protocols
Step Three: Implement Protocols
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Select and customize evidence-based
protocols to office
Determine staff workflow to support
protocols, including standing orders
Use protocols with all patients
Monitor use of protocols
Self-management Support
Step Four:
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Obtain patient education materials
(e.g., asthma action plans)
Determine staff workflow to support
SMS
Provide training to staff in SMS
techniques
Set patient goals collaboratively
Document and monitor patient progress
toward goals
Link with community resources
(schools, service organizations)
Monitoring the Process
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Critical step in high-leverage changes
Different than measurement data
To inform Improvement Team
Goal is 90% reliable processes
Requires work and planning
Can decrease frequency when process
is at 90%
IPIP Change Package Tools
It’s not the tools, it’s the process…in your
setting with your staff and your patients
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Housed on IPIP Extranet
Organized by Change
Adding Tools from Practices
In Summary: Change Package
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Includes details about making changes,
measures, assessment scales and tools
A resource for practices and QICs
Offers guidance and resources
Remember: Teams testing these changes in a
small, rapid-cycle style, will help adapt them to
your individual practice and adopt strategies
throughout your entire office.
Questions?
Measurement
Practical Examples
Key Points for PDSA Cycles
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Do cycles on smallest scale possible
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Think baby steps
“Failed” cycles are learning when small
(trial and learning)
Pilot, then spread
Example 1: A Children’s Clinic
 Aim:
Improve asthma outcomes (reduce
ED and hospital visits by 50% and
improve patient well-being) by:
improving
care process in office
improving
patient self-management skills
 First
step: Identify asthma patients (so
they can assess symptoms and improve
management)
Improve Severity Classification: Cycle One
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Plan
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Do
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Computer run of all asthma diagnoses
Study
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Find and label charts of all asthma patients
Theory: we can feasibly label charts of all asthmatics
N = 3500
Too many patients to label
Act
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New cycle: focus on sickest patients
Improve Severity Classification: Cycle Two
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Plan
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Do
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Asthmatics seen in ED and in practice in last 2 months
identified by computer
Asthma patients identified as they come into office
Study
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Start with sicker patients
Theory: we can feasibly label charts of our sickest
asthmatics (seen in ED or practice recently)
N= 75, easy to accomplish
Act
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Begin labeling these charts
Example 3:
Nurse-directed services:
Improving the prompts
Interventions June 2006
Developed prompting
for nursing staff
Poorly accepted by
providers and
nurses.
Lacked consensus.
Weak follow-up and
reporting.
Process to Engage Nurses
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Solidified divisional support for utilization
of the intervention
Developed educational session with nurses
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Meeting introduction by medical director
Revisited intent of the yellow sheets
Reiterated the role of the nurse as an integral
member of our team
Reviewed evidence behind our recommendations
Listened to nurses’ concerns
Developed rapid means of feedback
Items to be Included in Nurse
Assessment
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Assess as indicated on the prompt
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Depression screening
Smoking assessment and intervention
Eye referrals
Monofilament testing
Pneumococcal vaccination
Intervention
Feedback and
change in clinical
focus led to
significant revision of
the yellow sheets
Simple Procedure for Tracking
Daily Progress
Effective Team Care
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Population Based Care
Treatment Planning
More Effective Consultations
Evidence Based Clinical Management
Self Management Support
More Effective Consultations
Sustained Follow-Up
Successful Management of
Diabetes
Intensive Therapy - Team Approach
• 2 oral meds or one oral plus insulin
• 3 or more daily injections of insulin
• 4 or more clinic visits per year
Successful Management of
Diabetes
Intensive Drug Therapy-Team Approach
• Better Population Monitoring
• Direct contact with Nurse Manager
• Collaborative care with Physician Extenders
• Close follow-up
Annette - Diabetes Educator
Maintain patient Database
Active Case Management
Coordinate referrals
Provide glucometer and glucometer supplies
Determine glucometer competency
Basic Diabetes Education (see education sheet)
Close follow-up
Tracy - Dietitian
Diet information
Exercise Information
Education reinforcement
Regular Follow-up
Social Worker
Transportation issues
Financial issues
CMC-Biddle Point
Family Practice
Comprehensive
Diabetes Management
Approach
Stacy -PharmD
Intensive Management
Medication counseling
Insulin teaching
Education reinforcement
Refer as needed
Pharmacy Departments
Patient assistance program
Mailbox program
Year One
Baseline
A1c<7: 36%
A1c>8: 43%
Insulin Tx: 16%
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Year One
A1c<7: 35%
A1c>8: 39%
Insulin Tx: 23%
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Example 2: Diabetes
Improvement—GIM at UNC
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Just working harder doesn’t lead to better outcomes
Doctors in the system don’t follow algorithms or
policies very well
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Other members of the health care team are better
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Just making a policy doesn’t mean the process gets done
Status of Lipid Management
September 2004
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55% of patients had total cholesterol
tested annually
Approximately 68% were prescribed
statins
Average total cholesterol = 185 mg/dl
Average LDL = 99 mg/dl
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% Total Cholesterol Tested
Percent of Patients with Total Cholesterol Tested Yearly
100
Start
Automated
80
60
Stop
Automated
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40
0
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% Total Cholesterol Tested
Percent of Patients with Total Cholesterol Tested Yearly
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Automated
80
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Automated
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Stop
Automated
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% Total Cholesterol Tested
Percent of Patients with Total Cholesterol Tested Yearly
100
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Automated
80
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Automated
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Stop
Automated
20
Front Desk Process
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List of patients with diabetes
Whether or not labs need to be
drawn
Patients that needed labs that
were not getting triaged
appropriately
Looked at front desk logs
Plan/Do
Study
Front Desk Logs
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About 60 patients with diabetes/week
Study
30 needed a lab drawn
Only 15 had it drawn (50%)
Act-Plan
Pizza for 90% Fidelity
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25/33 = 75% No pizza
34/36 = 94% PIZZA
Study
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% Total Cholesterol Tested
Percent of Patients with Total Cholesterol Tested Yearly
100
Start
Automated
80
Re-Start
Automated
60
Stop
Automated
Front desk
fidelity
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200
Jul-05
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Results (mg/dl)
Average Lipid Results
Total Chol
LDL
175
150
125
100
75