Transcript IPIP Kick-Off! - East Carolina University

IPIP Kick-Off!
January 16, 2007
Monroe Center
Greenville, NC
Welcome
Thank you for contributing to IPIP
 Get to know the other teams
 Share senselessly and steal shamelessly
 Make us work for you tonight

Introductions

Steve Willis MD
 Executive

Director, Eastern AHEC
Chuck Willson MD
 Medical
Director of Community Care Plan of
Eastern Carolina (CCPEC)
Let us know…
Your Practice Name
 Are you measuring Diabetes or Asthma?
 What are you looking to get out of IPIP?

Improving Performance
in Practice
Warren P. Newton, MD, MPH
Greenville, NC
January 16, 2007
Objectives
1. Introduce briefly the Improving
Performance in Practice (IPIP) project,
and your role in it
2. Summarize IPIP methods and rationale
3. Describe how it will work– expectations,
timeline and reimbursement
IPIP: Why?
The Quality Chasm
About half the time, interventions
that we all agree should happen
don’t, no matter what the problem
or setting
IPIP: A National Initiative
American Board of Medical Specialties
American Academy of Family Physicians
American Academy of Pediatrics
American Board of Family Medicine
American Board of Pediatrics
Plus
American College of Physicians
American Board of Internal Medicine
…funded by the Robert Wood Johnson
Foundation and the CDC
IPIP: The Vision




Radical transformation of office care with
improvement of management of chronic disease
and access to 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
Pilot with Asthma and Diabetes in North Carolina
and Colorado
IPIP in North Carolina
Focus is providing help for doctors to
transform their practice
 Partnership of CCNC and AHEC; other
partners: NCAFP, NCPS, NC cACP and
NCMS, with NC Department of Public
Health, CCME (MRNC)
 Pilot: CCPEC/Eastern AHEC/Pitt Co HD
and Access II Care/MAHEC/Henderson
Co HD

IPIP Methods Overview
Focus is on providing help for doctors
change their practices rapidly
 Quality Improvement Coaches
 Data Collection and Reporting
 Learning Networks

What is the evidence?
Organized systems of care have resulted in
profound improvements
 Northern New England Cardiovascular Group
 End Stage Renal Disease Network
 Children’s Oncology Group
– Eight fold increase in survival for patients with ALL



Vermont Oxford Network (neonatology)
NHS primary care collaborative
Cystic Fibrosis Collaborative (ongoing)
Adequacy of Hemodialysis
Adequate Hemodialysis Dose, %
Hemodialysis Dose by Race
100
80
60
62
46
53
63
73
69
87
83
84
76
70
54
40
20
70
85
36
43
0
1993 1994 1995 1996 1997 1998 1999 2000
Sehgal A, JAMA 2003;289:1996-1000
Whites
Blacks
Asthma Management
Wroth TH, Boals JC NCMJ 2005;66(3):218-220
IPIP in North Carolina
How will it work for you?
IPIP Overall Goal
Dramatic and sustained
improvement in quality of care of
asthma and diabetes
IPIP will provide you with
QIC to work with you on all aspects of
practice redesign
 Help with setting up data systems
 Tools for changing your practice
 Comparisons to other practices, with
opportunity to learn from them
 CME and MOC IV credit
 Some financial support

What IPIP wants from you
Identification of a team from your practice
to champion change
 Participation in kick-off meeting
 Submission of baseline and regular data
 Frequent small changes in your practice,
with tests of change
 Participation in activities of learning
network

IPIP Timeline
12/06-2/07—develop data systems, kick off
meeting, submit baseline data
3/07-10/07—learning network phase 1
begins; submit regular data and record
changes in practice; participate in learning
network activities
10/07 onward—transition to phase 2, with
new focus of interest
IPIP Reimbursement



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.
CME will be provided for ongoing activities
IPIP
A Vehicle for Leadership

Help us learn how to help other
doctors across the state to
transform their practice and respond
to pay for performance initiatives

Pilot the Governor’s Quality Initiative

Help push reimbursement reform for
quality and the role of the medical
home
Ups and Downs of
Improvement
Darren DeWalt, MD
UNC General Internal
Medicine
Outline
Getting started
 Improving data management
 Involving the providers
 Using a registry to improve care
 Expanding the use of the registry

UNC General Internal Medicine Practice
circa 1999

75 resident and faculty physicians

½ day per week to 5 days per week

Individual care often good, but uncoordinated

Limited access to providers

Limited diabetes education/other illness selfmanagement support

Patient barriers often not addressed because of
limited time, skills, resources
Getting Started

Interest in improving chronic illness care

Improve access to self-management education

Reduce variation in practice

Ensure adherence to guidelines
Data Entry

All manual entry in beginning

Slow transition to connect with health
system information technology
Randomized Controlled Trials
Planned care versus Usual care

Diabetes
 Lower
A1C
 Lower BP
 More prescribing of aspirin
*Rothman et al. American Journal of Medicine 2005, 118:276-284.
**DeWalt et al. BMC Health Services Research 2006, 6(1):30
Problem of Scale-Up

Diabetes trial had 230 patients

We care for ~1600 patients with diabetes

Needed to engage all staff of clinic
Needed Innovations

Decision support (case management not
available on scale-up)

Automation of guidelines (ordering needed
tests)
Managing Information at the Visit

Patient profile—all the information needed
for a given patient
 Useful

for the nurse or other care assistant
Decision support tool for clinicians
 Addresses
specific concerns the physician
should address
Patient Profile
Patient Profile
Patient Profile
Patient Profile
Patient Profile
Decision Support
Jul-05
Jun-05
May-05
Apr-05
Mar-05
Feb-05
Jan-05
Dec-04
Start
Automated
Nov-04
Oct-04
80
Sep-04
% Cholesterol checked last 15 months
Cholesterol Checks
90
Stop
Automated
70
LDL
60
total chol
Goal
50
40
n0
Fe 5
b0
M 5
ar
-0
Ap 5
r-0
M 5
ay
-0
Ju 5
n05
Ju
l-0
Au 5
g0
Se 5
p0
O 5
ct
-0
No 5
v0
De 5
c0
Ja 5
n0
Fe 6
b0
M 6
ar
-0
Ap 6
rM 06
ay
-0
Ju 6
n0
Ju 6
l-0
Au 6
g0
Se 6
p0
O 6
ct
-0
No 6
v06
Ja
% Total Cholesterol Tested
Percent of patients with Total Cholesterol Tested Yearly
100
90
80
70
60
50
40
Re-implement
30 automated
Front desk
fidelity
20
10
0
Month
Front Desk Process
List of patients with diabetes
 Whether or not labs need to be drawn


I had patients that needed labs that were
not getting triaged appropriately

Looked at front desk logs
Front Desk Logs
About 60 patients with diabetes/week
 30 needed a lab drawn


Only 15 had it drawn (50%)
Pizza for 90% Fidelity
25/33 = 75% No pizza
 34/36 = 94% PIZZA

n0
Fe 5
b0
M 5
ar
-0
Ap 5
r-0
M 5
ay
-0
Ju 5
n05
Ju
l-0
Au 5
g0
Se 5
p0
O 5
ct
-0
No 5
v0
De 5
c0
Ja 5
n0
Fe 6
b0
M 6
ar
-0
Ap 6
rM 06
ay
-0
Ju 6
n0
Ju 6
l-0
Au 6
g0
Se 6
p0
O 6
ct
-0
No 6
v06
Ja
% Total Cholesterol Tested
Percent of patients with Total Cholesterol Tested Yearly
100
90
80
70
60
50
40
Re-implement
30 automated
Front desk
fidelity
20
10
0
Month
Continue to Evolve
Monthly review of run charts and PDSAs
 Quarterly “all-hands” meeting
 Working on several different projects
(diabetes, advanced access,
anticoagulation, chronic pain
management, colon cancer screening)
 Giving out awards to clinicians…

Summary
Improvement work different from research
 Need to engage all members of staff
 When results slow, examine parts of the
process
 We continue to make changes and to take
on new projects
 Improvement isn’t about arriving, it is
about changing and optimizing

What Now?

Improving total cholesterol measurement,
but how do we get LDL measurement up?
Another Example If Needed
Measurement and
Improvement
Darren DeWalt, MD
UNC General Internal
Medicine
IPIP Measures
Starting with diabetes and asthma
 Avoid creating new measures, adopt
nationally endorsed measures
 Use national goals when available
 IPIP charter expects that practices will
reach all goals within 3 years
 Close gap between performance and goal
by 33% per year.

Asthma Measures
Measure
Goal
Endorsements
Symptom assessment
>90%
NQF, PC, BPHC
Severity Classification
>90%
CCNC
>90%
AQA, NQF, CCNC
Influenza vaccination
>90%
AQA, NQF, CCNC
Smoking counseling
>90%
AQA, NQF
Assessment
Anti-inflammatory
Persistent asthma on anti-inflammatory
Prevention
Composite Measure
Receive all 3 key strategies for asthma care
(classification, anti-inflammatory, vaccination)
>75%
Utilization
ED visit
<0.3%
Hospitalization
<0.1%
Diabetes Measures
Measure
Goal
Endorsements
A1C
AQA, NCQA, NQF, CCNC
A1C documented
>90%
Most recent A1C level greater than 9.0%
<20%1 AQA, NCQA, NQF
Most recent A1C level less than 7.0%
>40%1 NCQA
Blood Pressure
BP documented in the last year <140/90
>65%1 AQA, NCQA, NQF
BP documented in the last year <130/80
>35%
NCQA
Cholesterol
At least one LDL
>85%1 AQA, NCQA, NQF, CCNC
LDL Control <130 mg/dl
>63%1 NCQA, NQF
LDL Control <100 mg/dl
>36%1 NCQA, NQF
Diabetes Measures Cont’d
Measure
Goal
Endorsements
>60%1
AQA, NCQA, NQF, CCNC
>80%1
NCQA, NQF, CCNC
>80%1
NCQA, NQF
Influenza vaccination
>60%
AQA, NCQA, NQF, CCNC
Smoking counseling
>80%1
AQA, NCQA, NQF, CCNC
Eye Exam
Received a dilated eye exam
Foot Exam
Foot exam
Nephropathy
Tested for nephropathy or already
under treatment
Prevention
Using Data for Improvement

Choose evidence-based process or
outcome measures for goals

Create meaningful measures as needed
for smaller PDSA cycles (lab order
example)

To improve, measurement does not need
to be perfect (small samples ok)
Measurement for Improvement

IS:
 Designed
to help your team and other teams learn
 Like a growth curve: it’s not where you are, but where
you are going

IS NOT:
 Designed
for criticism or punishment
 Supposed to end (it should be sustainable)
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What changes can we make that
will result in improvement?
Act
Plan
Study
Do
From: Associates in
Process Improvement
Model for Improvement
AIM:
What are we trying to
accomplish?
MEASURES:
How will we know that the
change is an improvement?
IDEAS:
What changes can we make that
will result in an improvement?
Key Points for PDSA Cycles

Often the “study” is specific to the PDSA
 Usually
not one of core measures
 Usually ends with PDSA cycle
 Often qualitative

Do cycles on smallest scale possible
 Think
baby steps
 “Failed” cycles are learning when small (trial
and learning)
Example: Lumberton 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 rate severity and improve
management)
Improve Severity Classification: Cycle One

Plan
 Find
and label charts of all asthma patients
 Theory: we can feasibly label charts of all
asthmatics

Do
 Computer

run of all asthma diagnoses
Study
N
= 3500
 Too many patients to label

Act
 New
cycle: focus on sickest patients
Improve Severity Classification: Cycle Two
•
Plan
Start with sicker patients
 Theory: we can feasibly label charts of our sickest
asthmatics (seen in ED or practice recently)

•
Do
Asthmatics seen in ED and in practice in last 2 months
identified by computer
 Asthma patients identified as they come into office

•
Study

•
N= 75, easy to accomplish
Act

Begin labeling these charts
Tests of Change
Changes that
result in
improvement
Ideas
Resources (Learn QI and Get Ideas)

Quality Improvement Consultant (QIC)

Extranet

Improvement network--sharing of ideas
What Now?

Where will you begin your improvement?

What global measure will you start with?

What can you do this week? (PDSA)

What measure will you use in the PDSA?
Report Out

Teams report their results of the exercise
Wrap UP!

The 1st Stipend Payment
 Please
turn in your signed Letter of Intent tonight.
 Payment will be sent to you from NC Academy of
Family Physicians once requirements are met

Conference Calls
 Please
return your survey tonight
 Once compiled, a day and time will be emailed to you
for our first conference call.

Thank you for coming tonight -- We are looking
forward to working with you and your practice!
Contact Information
Bobbie Bonnet RN, BSN
Quality Improvement Consultant
Eastern AHEC
(919) [email protected]
Ann Lefebvre MSW, CPHQ
Project Director
(919) 833-2110
[email protected]