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Medical Home Quality Improvement
A Facilitator’s Guide to Team Development and
Continuous Quality Improvement
Developed by
The University of Illinois at Chicago
Division of Specialized Care for Children
3135 Old Jacksonville Rd.
Springfield, IL. 62704-6488
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ACKNOWLEDGEMENT
This Guide was developed by the Medical Home Project staff at the University of Illinois, Division of Specialized Care for Children (DSCC), to provide insight and direction for those who are interested in serving as facilitators for Illinois Medical Home Quality Improvement teams and also for team members who are interested in learning more about the process of continuous quality improvement. As you review the following document, you will find references to the Center for Medical Home Improvement (CMHI), co-directed by Dr. Carl Cooley and Jeanne McAllister. The Center initiated The Rural Medical Home Improvement Project where the CMHI model was implemented with five primary care practice improvement teams: two in New Hampshire, two in Vermont and one in Maine. More information regarding the CMHI program and other Medical Home resources is available on their web site at: http://www.medicalhomeimprovement.org. The Medical Home Index and Medical Home Family Index are components of the CMHI Medical Home Improvement Took Kit that were created to aid primary care practices, programs and agencies in the measurement of medical homes for children with special health care needs and their families. They measure the tangible and observable care processes offered by the practice and experienced by families who access primary care for their children.
12.05.08
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Table of Contents Introduction to Facilitation 3
Establishing a Medical Home Quality Improvement Team 4
Preparing Team Members to Participate 5
More about the Role of the Facilitator 7
Coordinating Productive Meetings 9
The First Meeting: Preparation and Planning 10
Second Meeting – Sample Agenda 11
Determining an Improvement Starting Point 12
Third Meeting – Sample Agenda 13
Fourth Meeting – Sample Agenda 14
Subsequent Meetings – Sample Agendas 15
Tips for Successful Teams 16
Writing a Goal Statement 17
Tools: Decision Matrix 19
Force Field Analysis 20
Medical Home Value Compass 21
Plan Do Study Act (PDSA) Cycle 24
Keeping the Team on Track 26
Controlling Disruptive Meeting Behavior 28
Forms: Agenda Template 30
Meeting Minutes Template 31
Brainstorming Template 32
Goal Statement Template 33
Decision Matrix Template 34
Force Field Analysis Template 35
Medical Home Value Compass Template 36
PDSA Template 37
Parking Lot Template 38
The Process of Reaching Consensus 39
Facilitation Tips 40
Potential Funding Sources 41
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INTRODUCTION TO FACILITATION
The basics of facilitation are easily learned and provide a large measure of meeting improvement. It may help to understand the role and function of a group facilitator. The key role of the facilitator is to remain an objective observer of the team dynamics and to ensure that all team members actively participate in the decision making process. The primary function of the facilitator is to help the team as a whole identify and discuss areas of service delivery and maintain a momentum for change to improve care for children with special health needs. Guiding the discussion to a plan of action can be accomplished through the use of various tools and approaches that are outlined in this guide.
To effectively serve as a facilitator, you need to have some solid foundation from which to work, or else you'll feel like just another group leader or just another note taker. There are a few simple ways of doing this that seem to make a big difference in meeting productivity. While volumes have been written and graduate degrees offered on each of these topics, the basics of facilitation are easily learned and serve to enhance the structure and effectiveness of the meetings.
Whenever you can, you should prepare before the first meeting. When possible, talk with team members to identify areas of agreement and contention, working styles, and hidden agendas. Of course, if you are unable to do this prior to the first meeting you can always accomplish this at the first meeting. This will help you gain a sense of what to expect, as well as giving you an opportunity to let the team members know what to expect.
Make every effort to have the right people on the team. If you are discussing concerns about scheduling, ensure that at least one team member is a staff person who is responsible for doing the scheduling. This dramatically improves the likelihood that the issues are accurately defined and workable solutions are offered.
The first thing you should do with the team is gather ideas from them and write them down so that all team members can see them; use flip charts, chalk boards or whatever tools you have at your disposal. Ask people to state the problem and write down their proffered problem statements. Monitor the group responses to the ideas: sometimes one team member's way of stating the problem will resonate with the group, other times you will have to use voting or some other technique to prioritize the problems. At this and every other point, be explicit about getting the group to agree to the process. If you're going to vote, get consensus that voting is okay: otherwise find another way of coming to an agreement.
It is essential that the group understands that, while there may be many pressing problems, nothing will get done if they don't work on one problem at a time. They are only selecting the first one to work on, not the one and only one that they will ever get a chance to do anything about.
Once the team has agreed to work on a problem, use a similar process to get them to agree on an approach to solving the problem. As you gain experience and knowledge as a facilitator, you will have a number of tools in your toolbox that you can offer as problem solving approaches. Many such tools are included in this guide. It is always advantageous to see if there are ideas from within the group. They will have greater understanding and ownership of something they're familiar with, and the importance of buy-in cannot be over-emphasized.
As you will see, this guide outlines the basics for initiating team meetings, identifying problem areas and developing a consensus on potential solutions. A variety of tools are provided to help guide and focus efforts on following a process of problem solving that emphasizes continuous quality improvement.
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General Principles Forming a Team “Parents as Partners” Physician Liaison
Getting Started: Any practice that has established a medical home team and initiated quality improvement changes will tell you that working on medical home improvement processes takes time, but it is well worth the investment! General principles for Medical Home Quality Improvement Teams:
• Promise yourself the time and resources to do this right. Teams need the structure and
consistency of sixty-minute meetings, once a month. • Budget regular time for your team to meet and use the effective meeting strategies
provided in this guide. • Use the tools in this guide as a jumpstart for creativity; alter the tools as needed for the
practice environment and for “ownership”. • Utilize facilitators to provide support and assist teams with their quality improvement
efforts. A facilitator helps to keep the team on track and to get their work done.
• Don't do this alone. Developing a medical home requires a “core team” which should include, at a minimum-
a physician, at least two parents of CSHCN (Parent Partners), and a non-physician office staff member who can devote some time to care
coordination. Careful, initial thought about how to form the team will prove valuable to the teams success. Other practice staff should be added to the team as needed.
• Pursue funding for projects, if at all possible. It is particularly important to compensate the
time of “parent partners”, demonstrating their value and expertise. Compensation could be accomplished in a variety of ways: parent stipends, waived co-pays, gift cards, etc… Be creative! Information is provided in this guide on possible funding sources. Funding sources can empower the team and help them implement improvements and outreach efforts.
The Practice’s First Activity: Form a Team The team experience is one of the most positive aspects of the CMHI model. Sharing the challenges and the successes of building a medical home is an energizing process. Few practices have worked with a team approach involving “parents as partners”. A parent/provider team establishes the foundation of the medical home. All of the work that goes into building a medical home begins with these essential partnerships. A medical home cannot proceed without the innovations that are a result of each team member’s best ideas; these ideas inevitably foster even better ones over time. ▪ Identify a provider in the practice as someone with special interest in the primary care
needs of CSHCN, someone who wants to act as the liaison with the other physicians in the practice.
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Office Care Coordinator Parents Ground Rules Families as Partners
▪ Identify an office care coordinator or a non-physician staff person who may develop into the care coordination role (an office nurse, manager, social worker, experienced parent, or family support coordinator). This person will act as the liaison for the non-physician staff within the office setting.
▪ Invite at least two parent partners (parents of CSHCN) to join this team. If there is a
parent leadership group in your area, this is an ideal role for parents who have gone through some leadership and advocacy training. Many parents have a desire to help make things better for all children and families.
▪ Encourage all members of the team to work at active listening and respecting one
another’s point of view. Ground rules for the team should be established, documented and reviewed periodically (ground rule examples include: start on time, make no judgments, keep confidentiality among team members, ensure that all voices are equal, use humor, etc.)
Preparing Team Members to Participate The lists below are taken from the Institute for Family Centered Care publication titled Words of Advice: A Guidebook for Families Serving as Advisors (1997). This outlines the benefits to providers and to families when parents/caregivers of children with special health care needs serve as advisors. It can be used to elicit a discussion or an assessment of what each member brings to the team.
WHEN FAMILIES SERVE AS PARTNERS/ADVISORS Benefits for Families
• It improves services for children
• It provides opportunities to bring about meaningful changes
• It increases opportunities to share information with other parents
• It feels good to make a contribution
• It is satisfying to give back to the system
• It provides opportunities to network with other consumers and providers
• It expands knowledge and skills
Benefits for Providers
• It improves the planning process
• It helps to carry out the program’s mission
• It increases knowledge and skills
• It helps one to do their job better
• It brings fresh perspectives to problems
• It provides allies to advocate for better services for children and families
• It increases empathy and understanding
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Attitude Checklist Parent Preparation Practice Preparation Facilitator Preparation
Provider/Staff Attitude Checklist: Do I believe that parents bring unique expertise to our relationship?
Do I believe in the importance of family participation in decision making at the program and policy level?
Do I believe that parents’ perspectives and opinions are as important as professionals’?
Do I believe that families bring a critical element to the team that no one else can provide?
Do I consistently let others know that I value the insights of families?
Do I work to create an environment in which families feel supported and comfortable enough to speak freely?
Do I listen respectfully to the opinions of family members?
Do I believe that family members can look beyond their own child and family’s experiences?
Do I clearly state what is required and expected of families in their partnership roles?
Do I understand that a child’s illness or other family demands may require parents to take time off from partnership responsibilities?
Do I feel comfortable delegating responsibility to families?
Initial Preparation
The practice will identify the team members involved. The practice will briefly discuss the team structure and meeting schedule with the parent partners.
The practice will have at least 10 families complete the Family Index. It is important for
the families to remain anonymous to ensure they feel comfortable to honestly answer the questions. A return date and a stamped envelope should be provided to each family. Practices should expect about half of the indices to be returned.
The practice will complete the Medical Home Index. The Index should be completed
jointly with both medical and non-medical practice staff. The Medical Home Index and the Family Indices should be submitted at least four weeks prior to the initial meeting so that a summary analysis can be developed.
The facilitator will contact all team members to establish a first meeting date and time. The facilitator will establish an agenda for the first meeting and distribute it to the team
one week prior to the initial meeting.
The DSCC Family Liaison will contact and meet with the parent team members prior to the first meeting to further explain the parent role in the quality improvement process and serve as a support person for the team’s parent partners.
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Facilitator Role
More about the Role of the Facilitator A facilitator is someone who uses knowledge of group processes to formulate and deliver the needed structure for meeting interactions to be effective. The facilitator focuses on effective processes (meeting dynamics) allowing the participants to focus on the content or the substance of their work together.
Skills and Traits of Effective Facilitators:
Effective facilitators know the dynamics of group process and are skilled in using techniques for keeping the group task-focused, encouraging creative thinking, building consensus and keeping all group members involved. A critical skill is the ability to create and maintain a safe, open and supportive environment for all group members. Another is being able to recognize and deal with disruptive behaviors.
Skilled facilitators should always be "issue neutral" during a meeting. They should never advocate a point of view, regardless of their expertise and opinions on a given subject.
Listening and observation skills are essential for facilitators. They need to be listening and watching for nuance, content, body language and other feedback as well as anything else that impacts the group. They're always aware of a meeting on two levels simultaneously: content (what's being discussed or decided) and process (how the group is functioning).
The best facilitators blend assertiveness with tact and discipline with humor. They need to know how to effectively intervene when the meeting is veering off the subject or otherwise not moving toward accomplishing its purpose.
Communication Skills The facilitator primarily relies on listening and asking questions. Listening enables the facilitator to remember the content, relate the content to the discussion, capture its essence on the flip chart, note reactions of others to what is said, and make a judgment call about sticking with the topic or moving on to the next speaker or agenda item. By summarizing the speaker's point, or by recording the idea on the flip chart, the facilitator affirms to the speaker that he or she has been heard and understood.
Facilitators ask questions to control the process and to spark thinking. A question signals progress we are moving on with our agenda: "Shall we begin?" "What did you hope to walk away with by the end of the meeting?" Questions bring the discussion back on track: "Shall we add that topic to the agenda for next time?" "Do we need to make sure we cover the other items before we run out of time?" Or, "Do we need to decide this in order to decide that?" Questions can provide closure: "Is there anything else before we move on?" "What are our next steps?"
Questions also stimulate thinking, and rethinking. Statements can be perceived as challenges provoking a counter challenge or assertion of a superior idea. Questions, on the other hand, create a temporary vacuum and a time for reflection. The facilitator, by posing questions, eliminates much of the superfluous posturing and banter. Questions maintain an air of openness, an attitude of, "Let me hear more before I decide." Examples: "If you do this, what
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will happen?" "Could you describe the process of communication you currently use?" "If you could change one thing about the design, what would it be?" In other words, questions, rather than directives or advice, are the most potent way to encourage the group to focus on something, rethink a course of action, or evaluate options.
"Reframing" combines skill in communication with an ability to analyze what's happening on the spot. Reframing is a way to "launder language." The facilitator extracts inflammatory or negative impact from a statement, and crystallizes the legitimate underlying motivation for that statement. For example, a board member emphatically states, "There's no use in going forward with this planning process. What we need is a new executive director!" The facilitator quickly reframes the remark to highlight a valid concern: "You want to make sure staff can carry out the board's policy directives." Reframing a statement so the language is palatable to others does carry the risk of the speaker admonishing the facilitator for not summarizing the statement accurately, as originally stated. If that happens, the facilitator would have to rework the wording more to the speaker's liking. On the other hand, the speaker may be relieved to see that there is a more constructive way to present the concern and feel affirmed that someone has taken the concern seriously.
Facilitation can involve many different levels of knowledge and skill, can include work on all kinds of problems and challenges, can assist the group in fulfilling its desire, or can include pushing participants to new levels of understanding. Most importantly, however, facilitation includes both an ability to recognize when effective meeting processes are needed and an ability to provide those processes. Learning to work together does not necessarily come naturally. Nor is it always easy. The role of the facilitator is to help the participants learn how to work together by providing the structure (process) while they remain focused on the content. The role of the facilitator: 1) To support the team by:
▪ sharing the broad view ▪ encouraging innovation ▪ supporting the team process ▪ encouraging every team member to participate ▪ teaching meeting skills and processes ▪ helping with team members’ role development ▪ bringing in other “experts” as requested ▪ suggesting alternative methods and procedures ▪ remaining a neutral servant of the team ▪ coordinating pre- and post-meeting logistics
2) To act as a process observer by:
▪ offering parents and professionals feedback ▪ guiding team formation and progress ▪ empowering the team to facilitate itself in future
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7 Steps to a Good Meeting Meeting Tips
Coordinating Productive Meetings Seven Basic Steps for Conducting a Good Meeting
1. Clarify Objectives: What is it that you want to accomplish in the meeting? 2. Review Roles: Who will be the meeting’s timekeeper, recorder, and facilitator? Who will help all stick to the ground rules? 3. Review Agenda and Establish Time Allotments: Evaluate whether you have too much on the agenda for the meeting and if you
are giving agenda items enough time for meaningful discussion. 4. Work Through Agenda Items: Prioritize agenda items - Do the quick items first, but be sure they are quick, stick to your time allotments and renegotiate time priorities appropriately. 5. Review Meeting Decisions, Action Steps, and Responsibilities: Define who is responsible for each task and determine when tasks should be
completed. 6. Plan Next Agenda: Set next meeting time and date with new and/or carry-over agenda items. Be realistic with what you think you can accomplish in a meeting. 7. Evaluate the Meeting:
What did the team do well that it should continue doing? What could the team do differently to improve future meetings? Are ground rules being followed? Team meetings work best when all members:
Commit to the meeting time and process Clarify roles and responsibilities each time Begin and end meetings on time Listen to and respect perspectives
Do assigned “homework” Give honest feedback Evaluate and mark success Make the time enjoyable
The best results come from teams that meet regularly and frequently (e.g. once a month for sixty minutes). Assign roles of the meeting timekeeper and recorder. It is a good idea to alternate the people in these roles at each meeting so a healthy team atmosphere develops and all share the work responsibilities. The facilitator will be provided by DSCC. Keep in mind that the parents and providers are partners in this process. Each brings unique and necessary skills to this endeavor. No one person should dominate a meeting. Input and conversation should be encouraged from all team members while maintaining a commitment to staying on track. At the end of each meeting briefly evaluate how the team is doing and whether or not desired outcomes have been achieved.
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First Meeting
Note: The DSCC Family Liaison will be present to answer parent participants’ questions 30 minutes prior to the meeting time.
AGENDA (Sample)
I. Introductions - 5 minutes
II. Overview of the team purpose (include sample forms) - 10 minutes
III. Establish and clarify roles within the team - 5 minutes
The team will assign the following roles:
1. Time Keeper
2. Recorder- Take meeting minutes of the team’s discussion. (Facilitator will finalize the minutes and distribute prior to the next meeting)
3. Facilitator (DSCC)
IV. Establish ground rules - 5 minutes
Examples of ground rules:
1. Start on time 2. Make no judgments 3. Confidentiality 4. All voices are equal 5. Humor
V. Review/Discuss Medical Home Index & Family Index results from summary report - 30 minutes
1. Strengths
2. Improvement areas
3. Medical & Family Index correlations
4. Medical & Family Index discrepancies
VI. Establish date and time of next meeting - 5 minutes
Facilitator Tip: The facilitator assists the team in comparing the Provider and Family Medical Home Index results, using them to identify broad areas for medical home improvement. The facilitator can assist the team by identifying any differences in the provider and parent perspectives. Facilitators need to realize that although providers may already have ideas about the best “first focus” for the team, success will result from a whole team effort in defining where to start.
Quality Improvement Team’s Purpose
To achieve improvements that blends parent insight, professional knowledge, and care coordination to build primary care medical homes.
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Second Meeting
AGENDA (Sample)
I. Review previous meeting minutes - 10 minutes
II. Review agenda - 5 minutes
III. Team members report on status of action items* - 15 minutes
IV. Brainstorm areas for improvement - 25 minutes
V. Establish date and time of next meeting - 5 minutes
*Action Items
Action items are assignments/topics that members of the team are given. The agenda should list the assignment/topic and who is responsible for reporting on the agenda item. Example:
I. Review previous meeting minutes
II. Status report on team action items
▪ List of resources that provide respite – Joan Smith
▪ Information systems update – Randy Morris
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Brainstorm Prioritize
Determine Improvement Starting Point Where Are You Now?
Where Do You Want to Be? “Where do we begin?”
...and then further refine this by asking: "What are we trying to improve, and for whom?
“Brainstorm” as a team: Supplied with a flip chart, tape, magic markers and stickers for voting, use the following strategies to focus on an improvement area and to come up with a team consensus for a first mini-improvement project. Brainstorming is the process of offering for consideration any creative idea that comes to mind (without any judgment attached to it). Use a flip chart to write down the ideas that members of the team feel might be addressed. All members of the team should be encouraged to participate in this process – perhaps go around the table and take turns providing one suggestion at a time. Once all ideas are written down, some ideas may address the same theme. Spend some time refining, categorizing and clarifying the ideas, but avoid jumping to solutions at this point. Prioritize; rank top choices to gain consensus on where to begin Rank – Selecting After brainstorming ideas of what the team would like to accomplish, it is time for the team to prioritize objectives. A logical order of priorities may be apparent, but it is a good idea for the team to rank which objectives needs to be worked on first, second, and third. Plan to focus on 2 or 3 objectives at first then revise if necessary. It is important that all team members develop together their sense of what the team hopes to accomplish within their specified timeframe. Each team member should be working toward this goal.
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Third Meeting
AGENDA (Sample)
I. Review previous meeting minutes - 10 minutes
II. Review agenda - 5 minutes
III. Team members report on status of action items - 10 minutes
IV. Refine and clarify the ideas from previous brainstorming - 20 minutes
V. Prioritize/Rank ideas - 10 minutes
VI. Establish date and time of next meeting - 5 minutes
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Fourth Meeting
AGENDA (Sample)
I. Review previous meeting minutes (5 minutes)
II. Review agenda (5 minutes)
III. Team members report on status of action items (10 minutes)
IV. Discuss ranked ideas (30 minutes)
a. Utilize tools to assist with refining improvement decisions (eg. Force Field Analysis, Decision Matrix, etc…)
V. Evaluate the meeting (5 minutes)
VI. Establish date and time of next meeting (5 minutes)
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Subsequent Meetings
AGENDA (Sample)
I. Review previous meeting minutes (5 minutes)
II. Review agenda (5 minutes)
III. Team members report on status of action items (10 minutes)
IV. Brainstorm implementation strategies for the selected plan of improvement (30 minutes )
V. Evaluate the meeting (5 minutes)
VI. Establish date and time of next meeting (5 minutes)
AGENDA (Sample)
I. Review previous meeting minutes (5 minutes)
II. Review agenda (5 minutes)
III. Team members report on status of action items (15 minutes)
a. Roles and responsibilities
b. Time frames
IV. Determine strategy for implementation (25 minutes)
V. Evaluate the meeting (5 minutes)
VI. Establish date and time of next meeting (5 minutes)
AGENDA (Sample)
I. Review previous meeting minutes (5 minutes)
II. Review agenda (5 minutes)
III. Team members report on status of action items (10 minutes)
IV. Identify barriers that occur during implementation (15 minutes)
V. Team feedback regarding barriers and problem solving (15 minutes)
VI. Evaluate the meeting (5 minutes)
VII. Establish date and time of next meeting (5 minutes)
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AGENDA (Sample)
I. Review previous meeting minutes (5 minutes)
II. Review agenda (5 minutes)
III. Team members report on status of action items (10 minutes)
IV. Review team feedback re: barriers and problem solving (10 minutes)
V. Modify plan for improvement based on problem solving (20 minutes)
VI. Evaluate the meeting (5 minutes)
VII. Establish date and time of next meeting (5 minutes)
Tips for Successful Teams:
▪ When a plan for improvement has been met, the team returns to the initial priority list to discuss and identify the next project.
▪ Meetings should follow the standard agenda process, outlined in this guide, to develop a plan of improvement for subsequent goals.
▪ Meeting agendas should be modified to meet the team’s needs. If the team decides to work on more than one improvement plan at a time, agendas should be modified to address the team’s multiple plans.
▪ Every meeting agenda should include the team Ground Rules to ensure that all team members can and will continuously see and abide by them.
▪ All team members should be encouraged to participate at every meeting. Everyone’s perspective should be acknowledged and respected.
▪ Invite guest speakers and/or guest team members to add dimension and other perspectives to the team’s work.
▪ Routinely evaluate the team’s progress – “Are we accomplishing what we set out to achieve?” Ask how progress can be measured… and then measure for it.
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TEAM TOOLS
Writing a Goal Statement Samples
Write a GOAL Statement: A goal statement articulates in 1 or 2 sentences what the team is trying to improve and for whom. This is based upon the practice assessment and improvement prioritization process that you already completed. This may not be as easy as it sounds, but doing this process well the first time around will keep a team on track. It will help to know what the focus should be, re-orient members when they get off track and facilitate the development of simple measurements to determine if a change is indeed an improvement.
Sample GOAL Statements An opportunity exists to improve the:
• Improve communication between MD and parents of children with chronic conditions at the office visit.
• Improve the identification of children and families with special health care needs.
• Identify any specific needs as they pertain to health care visits.
• Develop solutions to meet the identified needs.
• Improve the coordination of inpatient care between the tertiary medical center and the primary care practice.
• Improve the identification of CSHCN and the intake of family priorities to increase communication and planning.
Once the goal is clarified, “methods” to address them through an initial pilot project can be determined. Avoid jumping to the first solution offered. Allow time to explore more than one solution. The process will help to form the team and demonstrate what members have to offer. Completing a decision matrix or a force field analysis are two quality improvement strategies that help a team pick their best improvement approach. These techniques analyze options and highlight the best first approach to achieve your goal.
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SAMPLE GOAL STATEMENT
An Opportunity exists to improve the:
Identification of children with special health care needs served at the practice
(Name process or area to work on)
Beginning with: polling each of the providers in the practice, running an IS report by
diagnosis, identifying at least 50 children with special health care needs by staff recall (beginning boundary or starting point)
And Ending with: reviewing every chart by March 15 (ending boundary or finish point)
This effort should improve: scheduling of extended office visits for CSHCN, care
coordination and referral follow-up efforts, and improve continuity of care (key quality characteristic of area working on)
For the: practice staff and families/children (child/family, staff, others)
This process is important to work on now because: (1)no current system of
identifying children with special health needs; (2) will improve scheduling for families
and for providers; (3) will establish a framework for addressing continuity of care issues
identified by the QI team; and (4) will establish acknowledgement of the special needs
of CSHCN. (what it will improve and for whom)
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Decision Matrix Purpose: To develop, display and rate practice change options against several benchmark criteria. As everyone knows, declaring a specific goal is one thing, but doing it is something else. The Decision Matrix and the Force Field Analysis (below) help to illuminate the pros and cons of improvement activities that the team has identified to address their goal. Steps: Rank change ideas for each criteria on a scale of 1-5 (5= totally meets criteria). Multiply each number cumulatively across. Sample Decision Matrix:
The matrix listed below includes ideas from a brainstorming session, the ideas address the goal to “improve the identification of children and families with special health care needs.” According to this team’s established criteria, #4 “billing data reviewed”, holds the highest probability for success. The decision matrix requires teams to think about the tasks associated with a given objective before the work begins. This facilitates a process that gives prior thought as to what might be involved in accomplishing a particular objective. As a result of the decision matrix, teams may want to revise their objectives or tasks; or they may decide that a lower scoring “change idea” might still be preferable.
Decision Matrix Sample: Goal: Improve the identification of children & families with special health care needs.
CRITERIA Practice Change Ideas/Goal Cost Ease Benefit Reliability Total 1.Make list from memory 5 2 2 2 40 2.Review all charts 1 1 5 5 25 3. Receptionist asks each family at phone call 4 4 2 3 96 4. Billing data reviewed 3 3 3 4 108 5. Questionnaire to all patients 2 2 3 2 24 6. Data from referral site 3 3 2 4 72
Rank change ideas for each criteria on a scale of 1-5 (5= totally meets criteria).
▪ Fill in the team’s objective on the line after the word “GOAL”.
▪ Under the column entitled “Practice Change Ideas”, make a list of specific strategies that might accomplish the objective.
▪ Using a scale from 1-5 (5= totally meets criteria, easily accomplished, very doable), rate each task by using criteria chosen by the team (for example the criteria might be cost, ease, benefit and reliability for a given change idea).
▪ Multiply the scores across to find the total for each change. The higher score change ideas are those which best meet the team’s criteria and hold the best chance for success.
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Force Field Analysis
Another tool is the force field analysis. Consider each objective and related tasks by examining “driving forces” and “restraining forces.” The driving forces are the factors that will tip the environment toward the change; the restraining factors are the barriers. Analysis of both shows what to capitalize upon (drivers) and what to be aware of and reduce if possible (restrainers) (see example below) Both decision analysis and force field analysis exercises give teams work to do together early on and a method by which they can learn more about their medical home environment; they will clarify assumptions, weaknesses and strengths.
Force Field Analysis Sample
GOAL: Identify population of CSHCN, establish their needs.
+ DRIVING FORCES + - RESTRAINING FORCES -
Need to know population Share information Need to improve care CSHCN Need to improve continuity Need to improve access Pressure from insurers
C URRE NT S T A T E
Competing priorities Overextended staff Lack of resources/software Time for data entry Money Need for staff education
P R A C T I C E C H A N G E
Force Field Analysis: Complete
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DEVELOP MEASUREMENTS Medical Home Value Compass Example Family Feed-back Feed-Back
Evaluating Practice Improvements What is it you are trying to improve and for whom? Learn from the consumers of health care, in this case the children with special health care needs and their families, and use these lessons to develop the team’s improvements. Plot out anticipated outcome areas around the Medical Home Value Compass (below). Use those areas to determine how to measure an improvement at each compass point: Impact on child/family, outcome objectives, satisfaction and cost arenas.
What are you improving and for whom at each point on the compass? A Simple Improvement Example: Your team is addressing low family satisfaction with the timing of visit follow-up. An assessment of the root cause of the problem leads you to the fact that patient charts do not accurately document the current PCP. As a result, charts end up in a stack on the wrong provider’s desk after appointments until he/she discovers the error and routes the chart correctly. As an improvement effort you collect baseline data, pulling thirty charts to check for accurate PCP names. When families’ check-in for their appointment you have scripted for the front desk staff, “Is your child’s primary care provider listed accurately on your child’s chart?” If it is incorrect, you immediately change the PCP name on the chart. After three months of this improvement activity you pull thirty charts active in the last three months, check for PCP names, and measure the improvement for accuracy. You also inquire of those selected families if follow-up is going smoothly for them and use existing patient satisfaction measures to assess overall increased satisfaction. Feed-back, Feed-forward, Feed-back: You are looking for ways to learn from families about their experience of care; their feedback guides any changes contemplated. The evaluation of change efforts and pertinent lessons learned are “fed forward” into the next improvement effort; feedback from that activity is also collected and used accordingly in a continual improvement cycle. Family feedback can be obtained in numerous ways from a broad population sample as in a survey or a representative sample such as ten to twelve family members in a focus group. Either way, you learn about family needs and use this data for improvements. For example, data from family surveys at each of the original CMHI medical homes were
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Feed-Forward Improvement Outcomes
collected and analyzed as a whole across five practices. Data were also analyzed comparing each site’s data to the whole sample. Using the CMHI Family Survey, practices could see what their own families said and how their needs compared to families across the other four practices. This process serves as a powerful and much needed reinforcement for what the office is doing and what it could improve. This feedback drives improvements. Small group feedback happens within the practice in formats such as focus groups, family advisory boards, suggestion boxes or mini-surveys completed at the time of the visit (pre and post) for instant feed forward (into the visit) and feedback (following the visit). Medical Home Value Compass The anticipated outcomes of strong medical homes were plotted earlier on a clinical value compass. The compass leads a team to identify improvement outcomes related to the: • Impact on the child/family, • Outcome Objectives, • Satisfaction in comparison to expectation • Care costs/reduced costs (resulting from care and interventions). Each point on the “compass” offers the substance for a matching measurement. A goal may focus on the child/patient, the family, or the practice/providers. Each goal has the potential to improve the impact on the child/family, objectives, satisfaction and cost outcomes. A team should consider what outcomes might result at each of these points related to their chosen goal. Plotting these points assists the team to develop a measure for each outcome at all four points on the compass. Rather than describing each component consider the example on the next page showing a clinical value compass that analyzes the potential outcomes for enhanced communication with the primary care provider. The improvement addressed in GOAL #1 relates to family survey data which showed that of 83 family respondents, 40% reported that they never or rarely had clear written information about their child’s condition provided to them.
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Medical Home Value Compass (Example) Medical Home Improvement Goal: To improve communication between MD and parents of children with chronic conditions at the office visit.
Enhanced communication; reduced parental worry
Improved care Parental satisfaction coordination & clinical course Staff time on phone
Parent lost work time Unnecessary office/ER visits
PLAN: Create a family friendly parent journal/record of the office visit (i.e. a medical care plan)
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CREATING A PILOT PROJECT (PDSA CYCLE) PDSA Cycle
Plan-Do-Study-Act Cycle When the team has clearly identified a quality improvement goal and discussed the various options for meeting the goal, including discussion of the benefits and limitations for each of the identified options, the next step is to develop a Plan-Do-Study-Act (PDSA) cycle to test the options for success. The PDSA cycle has two parts. Answering the questions below will help you get started:
1. What are we trying to accomplish? What is your goal and how will you measure it - for example, "We want patients to experience a 25% shorter wait time before their appointment than they do now".
2. How will we know that a change is an improvement? Thinking through some of the process and consequences can help here - for example, "Our patients currently wait an average of 20 minutes before they are brought to the exam room; reducing this to 15 minutes should be an improvement unless they end up waiting even longer once in the exam room or we miss something important because we're hurrying too much".
3. What change can we make that will result in the improvement? Looking at current processes is usually helpful - for example, "Checking the forms, questionnaires, and insurance documentation for each patient takes a long time. Often the MA is waiting while this is done; so, perhaps we could have the patient being readied by the MA in the exam room while receptionist checks over the forms and documentation".
Use the answers to these three questions to enter the PDSA cycle:
Plan - Decide upon a relatively small and well-defined change in the way you do something that you think will move you toward the desired improvement (something you can accomplish in a day or two).
Do- Implement your plan for a short period of time (Think days, not weeks or months!).
Study - While implementing the change, measure the impact of the change and monitor for unexpected consequences. Review with the rest of the team all ideas for an improved implementation or revised strategy.
Act - Decide what to do next - o You might want to make the change permanent (and look for additional
ways to improve in the future), OR o You might want to revise or modify the change slightly because it didn't
work like you planned, OR o You might want to try another approach altogether because your change
didn't work at all.
The PDSA cycle is meant to be used repeatedly and continuously to result in ongoing quality improvement.
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MODEL FOR IMPROVEMENT: P-D-S-A (Sample)
Date: March 12th Cycle:_1___ Objective for this PDSA Cycle: Identify CSHCN within the practice PLAN QUESTIONS:
How many CSHCN are cared for in the practice? How will they be identified? What will this information tell us? How can we use this information to improve care?
PREDICTIONS:
All staff will participate in identifying CSHCN seen in the office on 1 day. Everyone will be able to identify CSHCN. There will be more children identified than are currently known. This will help to get the staff to buy into the process. PLAN FOR CHANGE OR TEST (WHO, WHAT, WHEN, WHERE):
Everyone will review the Visit List and/or see families - identified CSHCN will be added to a list. (As a 2nd step - will list the child's name and diagnosis) PLAN FOR COLLECTION OF DATA (WHO, WHAT, WHEN, WHERE):
Plan to develop a list of CSHCN beginning with all seen on the 1 pilot date - Lists will be generated by the front office staff, nurses and MDs. Plan to implement the week of April 1. Responsible staff: All office staff
DO: CARRY OUT THE CHANGE OR TEST; COLLECT DATA AND BEGIN ANALYSIS.
STUDY: COMPLETE ANALYSIS OF DATA; SUMMARIZE WHAT WAS LEARNED. ACT: ARE WE READY TO MAKE A CHANGE? PLAN FOR THE NEXT CYCLE.
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Keeping the Team on Track Keeping the team on track starts with good preparation and includes the use of appropriate process intervention. Process intervention is an interruption of the meeting process and conversation, by the facilitator, in order to refocus the participants and/or to rebalance group interactions. Most interventions can link back to the posted ground rules or group norms. As a guideline, always start with the lowest level of intervention, which is the least obvious and least threatening to the individual or group. As facilitator, your goal is to support the participants in achieving their desired outcomes by staying on track and balancing participation with results, so interventions must be supportive. Several tools and techniques can be used to get the team back on track and the meeting progressing as planned. The Parking Lot The Parking Lot is a place to record ideas, questions, or future agenda items. This approach is especially useful in deferring a conversation to another time, without losing track of the current agenda. At the same time, it ensures that the item will be addressed in the future. Suggest the use of a Parking Lot to capture items that need to be pursued, but are not the focal points for this meeting. Hang a flipchart sheet on the wall and label it “parking lot.” Whenever a member brings up a question or discussion topic that is not part of the group’s agenda, simply “park” the question/comment in the lot. Return to the parking lot at the end of the meeting and either address items that were not addressed during the meeting (if there is time) or put them on the agenda for the next meeting. Decision Making by Consensus
Consensus is the cooperative development of a decision that is acceptable enough so that all members of the group agree to support the decision. Consensus means that each and every person involved in decisionmaking has veto power. If participants are reassured nothing can go forward without their approval, they tend to relax, contributing more to the content and worrying less about procedural matters.
Consensus does not mean there is an absence of conflict. It does mean there is a commitment of time and energy to work through the conflict. Consensus requires taking all concerns into consideration and attempting to find the most universal decision possible. Groups able to make decisions by consensus usually demonstrate:
Unity of purpose, a basic agreement shared by all in the group regarding goals and purpose of the group
Commitment to the group, a belief that the group needs have priority over individual needs
Recognition that all team members have equal status and importance within the group Recognition that process is as important as outcome Underlying attitudes of cooperation, support, trust, respect, and good communication Understanding and tolerance of differences, acceptance of conflicting views Willingness and capability to devote time to the process
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Factors working against consensus include: competition, individualism, passivity and solution-orientation.
There are many techniques to facilitating consensus:
Frame the dilemma so participants see the big picture and recognize their interdependence: What decision do we need to make and why do we need to make it?"
Remove insecurity and make sure all participants have the same key information and have the opportunity to discuss that information together.
Build little agreements along the way: "So we agree that this is a good way to state the problem we are trying to solve." Or, "At least you do all agree that something has to be done, that change is desirable ."
Motivate creativity by asking "Isn't there anything else you can suggest?" and then allow for a long pause to encourage thoughtful suggestion.
Summarize and delineate: "This is what we agree on, and this is still in question. What are the specific causes for concern?" Or, "How can we get the benefit from doing this, but not the detriment?"
Refer to the mission and purpose of the group for guidance: "If we do this, are we in line with what we are all about?"
Finally, ask: "What will happen if we can't all agree?" Or, "Do you really need to make a decision on this issue?"
Voting and consensus are the "how" of decisionmaking. Decisions, themselves, seem to come in three shapes:
1. Some decisions have to be answered "yes" or "no." Either we close the theater for inclement weather, or we go on with the show. The outcomes are mutually exclusive and a choice is imperative for the good of the organization.
2. Other decisions require finding a solution to a problem. "How shall we solve for X?" "What shall we do about lack of attendance at our performances?" Or, reframing the problem in the affirmative: "How can we ensure record attendance?"
3. A third type of decision is even more open-ended. "Which way shall we go?" Or, "What goal shall we attain?"
Try out different ways of framing the decision using the above three formats. The way in which the decision is framed sets the stage for the solutions generated.
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Controlling Disruptive Meeting Behavior
Some adults who are otherwise mature and competent people will behave just the opposite in meetings. It doesn't take much to derail a meeting. Sometimes the process is at fault; more often than not, disruptive people bring meetings to a grinding halt. Use the 3D strategy to get the meeting and the team members back on track: depersonalize, detach, and defuse.
1. Step one is to depersonlize. Realize that people come with their own emotional baggage and agendas.
2. Step two is to detach. That means that you don't engage the ego. Don't let your emotions get out of control. Ask questions to gain understanding. Don't get defensive.
3. The last step is to defuse the negative energy. And one of the best defusers is humor. Take a light, playful approach. If you get tense, the negative energy will increase.
Managing Resistance To get a handle on disruptive meeting behavior, begin to recognize the signs of resistance. Are they side-talking, reading the paper, challenging you, or having difficulty understanding directions. Do they sit with closed body language? If you have ever felt like you were working too hard to get a response, chances are you were dealing with resistance. Once you recognize resistance, figure out where it is coming from.
Reasons for resistance fall into three categories: How To, Chance To, Want To.
Is the reason for resistance that they don't know how? Then provide clearer instructions on how you want them to participate.
Is it that they don't have a chance to? Let's say you asked team members to turn to a partner and discuss a point you just made and some people do not respond. Maybe they can't find a partner. When this is the case, provide an opportunity.
The last reason for resistance is a lack of motivation. You ask for a volunteer and nobody moves. Perhaps they don't see the benefit. Make it fun, offer a prize. Your job is to help them see the value.
To break resistance, use a pattern interrupt. In other words, do something different. Shake them up. Pick up the pace. Tell a story. Get them involved. Children at play are not resistant. Have fun. But most of all, break your own resistance. Are you doing anything that is contributing to their resistance.? Are you too rigid? Are you following a script that just isn't working? Are you reacting to a difficult person instead of responding to the situation?
Cast of Characters Who is the personality that can really push your buttons? Is it the know-it-all or the whining complainer who finds fault with everything? To stay cool and in control, begin by recognizing which type of person will set you off. By recognizing this person, you will strengthen your ability to handle him or her.
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Here are a few difficult personalities and how to handle them:
Eager Beaver - This person is always the first to participate and is eager to help. This makes it difficult for others to respond. Acknowledge their contributions and suggest that others participate.
Nay-Sayer - Very resistant and negative about you, the subject matter, and doesn't want to be there. Begin to acknowledge his/her concerns. Deal with the problem immediately. Paraphrase your understanding of the issues. Ask the group to problem solve or offer to discuss the concerns later.
Complainer/Whiner - Finds fault with everything. Likes to whine but has no solutions. He/she is not necessarily negative about the subject matter, but likes to complain. He/she will respond with "Yes, but" to your solutions. Don't go there. This is a no win. Instead, ask team members for alternatives. Stay focused and move on.
Expert - Challenges you; argues with others. This may truly be a person with expertise who wants recognition. Acknowledge comments without getting defensive. (Remember depersonalize, detach, defuse.) Ask the group for other opinions. One of the best strategies is to play to his/her expertise. Invite and recognize the expert's comments. Soon you will have an ally instead of an enemy.
Rambler - This is a storyteller. You ask for the time; you get the history of watch-making. To manage the rambler, cut in, summarize the comments and ask for other opinions. Don't let them drone on.
Poor Loser - These people will not admit a mistake. They don't have the ego strength. Do not back them into a corner. Instead, agree to disagree. Let them save face.
Dominator - Wants to control. He/she may not be an expert but can intimidate a group by monopolizing the conversation or activity. Don't let dominators take over. Ask for other responses. Use humor. Jokingly say, "Someone other than Jerry." If that doesn't work, call a break and speak to the person privately.
Side conversations - Two or more people engage in private conversations during the meeting. Make eye contact with the talkers and stop speaking until they look up. You can also confront them directly and ask them to hold their conversation until later. Or try the walk technique. Walk toward them, stand in front of them, and keep talking. They will get the message.
Hecklers - Do not play their game. Try to ignore them and continue the meeting. If they are not getting a response from you, they may give up. A clever retort will only challenge the heckler to come back at you one more time. Instead, walk over to him and put your hand on his shoulder and keep on talking to the group. Do not show any hostility or use put downs. Another technique is to ask the difficult person to identify himself and his company. This often works because the heckler wants anonymity.
Remember that the disruptive behavior is a symptom of an unmet need. When you can give them what they need, the behavior will disappear. Since this is not always possible, you still have a choice of how to deal with it. You can stay in control or let it control you. Your best strategy is a sense of humor. In most cases, it is not about you. The next time you encounter disruptive behavior, take a 3D view: depersonalize, detach, and defuse!
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AGENDA TEMPLATE
Core Team Meeting: Date/Time __________________ Place ____________________ Roles:
Practice liaison _____________________________
Timekeeper _______________________________
Recorder ___________________________________
Facilitator __________________________________
Set Agenda, Review, & Work Through Action Items (__________Budgeted Time) (1)___________________________________________________________ (2)_____________________________________________________________________ (3)_____________________________________________________________________ (4)____________________________________________________________________ (5)_____________________________________________________________________ (6)_____________________________________________________________________ Summarize Meeting, Clarify Next Agenda (day and time) (__________ Time)
Other Business (__________ Time)
_______________________________________________________________________
_______________________________________________________________________
Evaluate the Meeting (what worked, what you would do differently) (__________ Time)
_______________________________________________________________________
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MEETING MINUTES TEMPLATE
Name of Group __________________________ Date/ Time ___________________ Place_______________________________ Facilitator_______________________ Attendees:__________________________________________________________
Agenda Item Discussion Recommendations/Follow-Up
Notes:________________________________________________________________________________________________
______________________________________________________________________________________________________
Next meeting date/time:_______________________________________
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BRAINSTORMING TEMPLATE Quietly write down change ideas; then offer one idea at a time, going around in a circle (make no comments on ideas). Team members may “Pass” when they have nothing new to offer or the team has exhausted all possibilities.
1. _______________________________________
2. _______________________________________
3. _______________________________________
4. _______________________________________
5. _______________________________________
6. _______________________________________
7. _______________________________________
8. _______________________________________
9. _______________________________________
10. _______________________________________
11. _______________________________________
12. _______________________________________
13. _______________________________________
14. _______________________________________
15. _______________________________________
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SAMPLE AIM STATEMENT
An Opportunity exists to improve:
(Name process or area to work on)
Beginning with:
(beginning boundary or starting point)
And Ending with:
(ending boundary or finish point)
This effort should improve:
(key quality characteristic of area working on)
For the: (child/family, customers or staff)
This process is important to work on now because:
(what it will improve and for whom)
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DECISION MATRIX
GOAL:
CRITERIA Practice Change Ideas/Goal Cost Ease Benefit Reliability Total
Using a scale of 1-5 (5= totally meets criteria), rank change ideas for each criteria. Purpose: To develop, display and rate your practice change options against several benchmark criteria (you select). Steps: Rank change ideas on a scale of 1-5 (5= totally meets criteria) for each benchmark criteria. For each idea/goal, multiply the scores for each criteria to achieve the total score. (Example: Cost=3; Ease=4; Benefit=2;Reliability=2; multiply 3 x 4 x 2 x 2 = 48 Total) The change ideas with the highest total score are the goals that best meet the team’s selected criteria and hold the best chance for success.
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FORCE FIELD ANALYSIS
Goal: _____________________________________________ _____________________
_______________________________________________________
+ DRIVING FORCES +
(factors that will tip the environment toward change) - RESTRAINING FORCES -
(factors that will impede efforts for change)
C U R R E N T S T A T E
P R A C T I C E
C H A N G E
Force Field Analysis Worksheet
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MEDICAL HOME VALUE COMPASS
Plot out anticipated outcome areas around the Medical Home value compass (below). Use those areas to determine how to measure an improvement at each compass point: impact on child/family, outcome
objectives, satisfaction and cost arenas.
What are you improving (and for whom) at each point on the compass?
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PDSA MODEL FOR IMPROVEMENT
DATE: CYCLE #:
Objective for this PDSA Cycle:
PLAN: Describe the change you are testing and state the question you want this test to answer:
What do you predict the result will be?
What measure will you use to learn if this test is successful or has promise?
PLAN FOR CHANGE OR TEST (Who, What, When, Where):
DATA COLLECTION PLAN (Who, What, When, Where):
DO: (Report what happened after you carried out the test. Describe observations, findings, problems encountered, special circumstances.)
STUDY: (Compare results from this completed test to your predicitions. What did you learn? Any surprises?) ACT: (Modifications or refinements for the next cycle; what will you do next?)
Act Plan
Study Do
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Parking Lot
“Park” questions or discussion topics that are brought up but not part of the group’s agenda here in the Parking Lot. Return to the parking lot at the end of the meeting and either address items that were not addressed during the meeting, if there is time, or put them on the agenda for the next meeting.
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THE PROCESS OF REACHING CONSENSUS
1) Item on the agenda (advanced circulation if possible)
2) Proponent introduces item, giving background, rationale, benefits and drawbacks
3) Clarification of the proposal itself (keep working on problem definition)
4) Open up discussion on the proposal
a) keep discussion on course (to the subject matter)
b) keep public record (flip chart)
c) clarify, summarize, record new issues
5) If there are unresolved concerns, list them one at a time -- the person who objects should be the one to
talk through those unresolved concerns (use silence as a strategy)
6) Test for consensus again
Responses
Agree in Principle: with minor revisions, with reservations
No Agreement: opportunity to persuade, agree to disagree
Blocking: When one or more (usually two) individuals oppose an otherwise agreed upon decision that
has been developed through the consensus process outlined above. Blocking is not disagreement --
disagreement has been expressed throughout the consensus process. This disagreement strengthens
the decision. Blocking comes after the synthesizing of differing views, and is a momentous
undertaking.
Advantages of consensus
quality of the decision
commitment to implementation
fostering values and skills we preach but forget to practice
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Facilitation Tips
Before the meeting During the meeting After the meeting
▪ Make sure everyone knows the date, time & location of the meeting. Send out the agenda in advance so that team members can request additions.
▪ Sending out the previous meeting’s minutes along with the next meetings agenda is helpful for team members to prepare for the meeting.
▪ Start on time.
▪ Understand the goals of the meeting.
▪ Assess the meeting room and make any needed adjustments.
▪ Keep the team on the agenda and moving forward.
Don’t let the group get immersed into details that are not the real issues, e.g. “What color the resource folders will be?” Assign a team member or request a volunteer bring a couple sample folders to the next meeting and the team can vote on the color.
▪ Don’t forget the ground rules.
▪ Don't use your position as facilitator to impose your personal ideas and opinions on the group.
▪ Involve everyone in the meeting, both the controlling domineering people and the shy ones.
▪ Be attentive to people who are speaking--look at them, lean forward, smile, and nod. Make eye contact with people who may need encouragement to speak.
▪ Be an active listener; restate comments to ensure everyone understands the speaker’s point. Ask for clarification.
▪ Make sure decisions are made democratically.
▪ Bring closure to discussions before moving to the next agenda item.
▪ Be flexible. Sometimes issues occur that alter the agenda.
▪ Make sure the minutes designate who is responsible for assignments/actions and that person will report on the assignment/action at the next meeting.
▪ Summarize the meeting: what has been accomplished or agreed upon and what is left to be resolved.
▪ Take time to reflect on the meeting and thank members for their input.
▪ Set the time, date and location of the next meeting.
▪ End the meeting on time.
▪ Complete and distribute the minutes as soon as possible so that the information is fresh in your mind.
▪ Get ready for the next meeting.
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Potential Funding Sources Each May-July, pediatricians can apply for CATCH Planning Grants to support their practice quality improvement efforts. You can obtain more information about CATCH Planning Funds by contacting the Illinois Chapter of the American Academy of Pediatrics. CATCH Planning Funds
Division of Community-based Initiatives
American Academy of Pediatrics
141 Northwest Point Blvd.
Elk Grove Village, IL 60007
1-800-433-9016 ext. 7632
email: [email protected]
web site: http://www.aap.org/visit/catchhome.htm
Visit the web site of the American Academy of Pediatrics, National Center of Medical Home Initiatives for Children with Special Needs, for more information about medical home and potential funding opportunities.
The National Center of Medical Home Initiatives
141 Northwest Point Blvd.
Elk Grove Village, IL 60007
ph: (847) 434-4000
fax: (847) 228-7035
email: [email protected]
Web site: http://www.medicalhomeinfo.org/grant/index.html
08.23.06
