Michigan IPIP/PCMH

CJ Systems: JNG 8.25.2010

Working Together for a Healthier Michigan

1

Michigan IPIP/PCMH

Preliminary Project Summation on the

Transformation of Primary Care Practice



2

Insert LongitudinalIPIP Project Development



3

Insert LongitudinalIPIP Project Implementation



4

IPIP Project: Start to Finish

Stats Jan 2009 June 2010

Number of Practices 18(Diabetic)

33(Diabetic + Asthma)

Number of Active Coaches 30 43Number of Physicians Involved 106 206Number of Patients Affected (Total Population) 148,080 276,499

Number of Practices with an EHR/EMR 10 23

Number of Practices with a Registry 8 24Number of Practices with PCMH /BCBSM Designation

12 27

Coach Time Estimated versus Coach Time Needed for project (hours per week)

4 10



5

Practice Enrollment

1 Based on data submission• Enrollment:– Wave 1 = Nov 2008 to Mar 2009 (17 practices)– Wave 2 = June 2009-Aug 2009 (8 practices)– Wave 3 = Sept 2009-Jan 2010 (4 practices)– Practices not reporting (4 practices)

• Engagement occurred within 3 months of starting

Practices Joining IPIP Project

2

1

5

8

1

0 0

1

5

2

1 1 1

0

1

0

1

2

3

4

5

6

7

8

9

Nu

mb

er o

f P

ract

ices



6



7

Time Commitment & Coach Involvement

QIC Coach Time Tracking

010

2030

4050

6070

8090

100

Ho

urs

• Quality improvement tools & techniques knowledge possessed by all QI Coaches

• QI Coach involvement with practice underestimated

• 3-4xs more time needed with practices to assist in transformation than planned

• Engaged, strong facilitation skills & vigor lead to more transformation



8

Diabetic Measures: Start to Finish OUTCOME: More engagement , Closer to goal

DM Measures May-2010

0

10

20

30

40

50

60

70

80

90

100

Goal lower = better



9

Asthma Measures: Start to Finish

OUTCOME: More engagement, Closer to goal

Per

cent

Asthma Measures May-2010

0

20

40

60

80

100

Asth

ma

PctA

ctio

nP

lan

Asth

ma

PctA

llOrN

on

e

Asth

ma

PctA

sse

sse

d

Asth

ma

PctC

on

tro

ller

Asth

ma

PctE

DV

isit

Asth

ma

PctF

luV

acc

Asth

ma

PctH

osp

Asth

ma

PctS

mo

kC

ess

Asth

ma

PctT

ob

acco

Qu

ery



10

Diabetes Measures by Activity: Start to Finish

Count of DM patients 18-75 yo

-9-16

-18

-20

-22

-23

-27

-25

-23

-25

-24

-18

-18

-18

-18

-16

-4-2-10

100

200

300

400

500

Jun

-08

Jul-

08

Au

g-0

8

Se

p-0

8

Oct

-08

No

v-0

8

De

c-0

8

Jan

-09

Fe

b-0

9

Ma

r-0

9

Ap

r-0

9

Ma

y-0

9

Jun

-09

Jul-

09

Au

g-0

9

Se

p-0

9

Oct

-09

No

v-0

9

De

c-0

9

Jan

-10

Fe

b-1

0

Ma

r-1

0

Ap

r-1

0

Ma

y-1

0

Pct of DM patients with latest A1C >9

-9-16

-18

-20

-22

-23

-27

-25

-23

-25

-24

-18

-17

-18

-18

-16

-4-2-10

20

40

60

80

100

Jun

-08

Jul-

08

Aug

-08

Sep

-08

Oct

-08

No

v-08

De

c-08

Jan

-09

Fe

b-0

9

Mar

-09

Apr

-09

May

-09

Jun

-09

Jul-

09

Aug

-09

Sep

-09

Oct

-09

No

v-09

De

c-09

Jan

-10

Fe

b-1

0

Mar

-10

Apr

-10

May

-10

Pct of DM patients on aspirin-5-1

1

-12

-12

-14

-14

-15

-15

-14

-15

-16

-14

-14

-12

-12

-11

-3-1-10

20

40

60

80

100

Jun

-08

Jul-

08

Au

g-0

8

Se

p-0

8

Oct

-08

No

v-0

8

De

c-0

8

Jan

-09

Fe

b-0

9

Ma

r-0

9

Ap

r-0

9

Ma

y-0

9

Jun

-09

Jul-

09

Au

g-0

9

Se

p-0

9

Oct

-09

No

v-0

9

De

c-0

9

Jan

-10

Fe

b-1

0

Ma

r-1

0

Ap

r-1

0

Ma

y-1

0Pct of DM patients with latest BP <=130/80

-9-16

-18

-20

-22

-23

-27

-25

-23

-25

-24

-18

-17

-18

-18

-16

-4-2-10

20

40

60

80

100

Jun

-08

Jul-

08

Aug

-08

Sep

-08

Oct

-08

No

v-08

De

c-08

Jan

-09

Fe

b-0

9

Mar

-09

Apr

-09

May

-09

Jun

-09

Jul-

09

Aug

-09

Sep

-09

Oct

-09

No

v-09

De

c-09

Jan

-10

Fe

b-1

0

Mar

-10

Apr

-10

May

-10

Pct of DM patients referred for eye exam

-2-3-4-7-9-10

-11

-11

-10

-17

-23

-17

-17

-17

-17

-16

-4-2-10

20

40

60

80

100

Jun

-08

Aug

-08

Oct

-08

De

c-0

8

Fe

b-0

9

Apr

-09

Jun

-09

Aug

-09

Oct

-09

De

c-0

9

Fe

b-1

0

Apr

-10

Pct of DM patients with foot exam

-8-15

-17

-19

-21

-22

-25

-24

-22

-24

-24

-18

-17

-17

-17

-16

-4-2-10

20

40

60

80

100

Jun

-08

Au

g-0

8

Oct

-08

De

c-0

8

Fe

b-0

9

Ap

r-0

9

Jun

-09

Au

g-0

9

Oct

-09

De

c-0

9

Fe

b-1

0

Ap

r-1

0Pct of DM pts 55-75 taking ACE/ARB

-2-7-7-7-7-7-8-5-3-1-10

20

40

60

80

100

Jun-

08Ju

l-08

Aug

-08

Sep

-08

Oct

-08

Nov

-08

Dec

-08

Jan-

09F

eb-0

9M

ar-0

9A

pr-0

9M

ay-0

9Ju

n-09

Jul-0

9A

ug-0

9S

ep-0

9O

ct-0

9N

ov-0

9D

ec-0

9Ja

n-10

Feb

-10

Mar

-10

Apr

-10

May

-10

Pct of DM pts prescibed a statin

-5-10

-9-12

-14

-13

-14

-14

-12

-14

-16

-14

-14

-12

-12

-11

-3-1-10

20

40

60

80

100

Jun

-08

Jul-

08

Au

g-0

8

Se

p-0

8

Oct

-08

No

v-0

8

De

c-0

8

Jan

-09

Fe

b-0

9

Ma

r-0

9

Ap

r-0

9

Ma

y-0

9

Jun

-09

Jul-

09

Au

g-0

9

Se

p-0

9

Oct

-09

No

v-0

9

De

c-0

9

Jan

-10

Fe

b-1

0

Ma

r-1

0

Ap

r-1

0

Ma

y-1

0



11

Asthma Measures by Activity: Start to Finish

Count of asthma patients 5-40 yo

-1-2-2-2-3-3-4-4-5-5-4-3-3-3-3-3-10-10100200300400500600700800

Jun-

08

Jul-0

8

Aug

-08

Sep

-08

Oct

-08

Nov

-08

Dec

-08

Jan-

09

Feb

-09

Mar

-09

Apr

-09

May

-09

Jun-

09

Jul-0

9

Aug

-09

Sep

-09

Oct

-09

Nov

-09

Dec

-09

Jan-

10

Feb

-10

Mar

-10

Apr

-10

May

-10

Pct of asthma patients with action plan-1-1-1-1-2-2-2-2-2-3-2-1-1-1-2-1-10-10

20

40

60

80

100

Jun

-08

Jul-

08

Au

g-0

8

Se

p-0

8

Oct

-08

No

v-0

8

De

c-0

8

Jan

-09

Fe

b-0

9

Ma

r-0

9

Ap

r-0

9

Ma

y-0

9

Jun

-09

Jul-

09

Au

g-0

9

Se

p-0

9

Oct

-09

No

v-0

9

De

c-0

9

Jan

-10

Fe

b-1

0

Ma

r-1

0

Ap

r-1

0

Ma

y-1

0

Pct of asthma patients with controller med

-1-2-2-2-3-3-3-3-3-3-2-1-1-1-1-10

20

40

60

80

100

Jun

-08

Jul-

08

Aug

-08

Sep

-08

Oct

-08

No

v-0

8

De

c-0

8

Jan

-09

Fe

b-0

9

Mar

-09

Apr

-09

May

-09

Jun

-09

Jul-

09

Aug

-09

Sep

-09

Oct

-09

No

v-0

9

De

c-0

9

Jan

-10

Fe

b-1

0

Mar

-10

Apr

-10

May

-10

Pct of asthma patients with control assessed

-1-2-2-2-3-3-3-3-3-3-2-1-1-1-2-1-10-10

20

40

60

80

100

Jun

-08

Jul-

08

Au

g-0

8

Se

p-0

8

Oct

-08

No

v-0

8

De

c-0

8

Jan

-09

Fe

b-0

9

Ma

r-0

9

Ap

r-0

9

Ma

y-0

9

Jun

-09

Jul-

09

Au

g-0

9

Se

p-0

9

Oct

-09

No

v-0

9

De

c-0

9

Jan

-10

Fe

b-1

0

Ma

r-1

0

Ap

r-1

0

Ma

y-1

0

Pct asthma pts with current flu vaccine

-1-2-2-2-3-2-2-2-2-3-2-1-1-1-2-1-10-10

20

40

60

80

100

Jun

-08

Jul-

08

Au

g-0

8

Se

p-0

8

Oct

-08

No

v-0

8

De

c-0

8

Jan

-09

Fe

b-0

9

Ma

r-0

9

Ap

r-0

9

Ma

y-0

9

Jun

-09

Jul-

09

Au

g-0

9

Se

p-0

9

Oct

-09

No

v-0

9

De

c-0

9

Jan

-10

Fe

b-1

0

Ma

r-1

0

Ap

r-1

0

Ma

y-1

0



12

Overall Team Assessment Ratings by Report Period

0 2 4 6 8 10 12 14 16

Nov-08

Dec-08

Jan-09

Feb-09

Rep

ort

Per

iod

Number of Teams

0.5-1

1.5-2

Engagement Ratings by Report Period

0 2 4 6 8 10 12 14 16

Nov-08

Dec-08

Jan-09

Feb-09

Rep

ort

Per

iod

Number of Teams

0

0.5-1

1.5-2

Leadership Ratings by Report Period

0 2 4 6 8 10 12 14 16

Nov-08

Dec-08

Jan-09

Feb-09

Rep

ort

Per

iod

Number of Teams

0

0.5-1

1.5-2

Registry Ratings by Report Period

0 2 4 6 8 10 12 14 16

Nov-08

Dec-08

Jan-09

Feb-09

Rep

ort

Per

iod

Number of Teams

0

1.5-2

2.5-3

3.5-4

Template for Planned Care Ratings by Report Period

0 2 4 6 8 10 12 14 16

Nov-08

Dec-08

Jan-09

Feb-09

Rep

ort

Per

iod

Number of Teams

0

0.5-1

2.5-3

3.5-4

Diabetes Protocol Ratings by Report Period

0 2 4 6 8 10 12 14 16

Nov-08

Dec-08

Jan-09

Feb-09

Rep

ort

Per

iod

Number of Teams

0

0.5-1

2.5-3

3.5-4

Asthma Protocol Ratings by Report Period

0 0.2 0.4 0.6 0.8 1

1

Rep

ort

Per

iod

Number of Teams

Series1

Self Mgmt Support Ratings by Report Period

0 2 4 6 8 10 12 14 16

Nov-08

Dec-08

Jan-09

Feb-09

Rep

ort

Per

iod

Number of Teams

0

0.5-1

IPIP

Rep

ort

ing

Cri

teri

a:N

ov

2008

- F

eb 2

009



13

IPIP

Rep

ort

ing

Cri

teri

a:

Feb

- M

ay 2

010

Overall Team Assessment Ratings by Report Period

0 5 10 15 20 25 30 35 40

Feb-10

Mar-10

Apr-10

May-10

Re

po

rt P

eri

od

Number of Teams

0.5-11.5-22.5-33.5-44.5-5

Engagement Ratings by Report Period

0 5 10 15 20 25 30 35 40

Feb-10

Mar-10

Apr-10

May-10

Re

po

rt P

eri

od

Number of Teams

00.5-11.5-22.5-3

Leadership Ratings by Report Period

0 5 10 15 20 25 30 35 40

Feb-10

Mar-10

Apr-10

May-10

Re

po

rt P

eri

od

Number of Teams

00.5-11.5-22.5-3

Registry Ratings by Report Period

0 5 10 15 20 25 30 35 40

Feb-10

Mar-10

Apr-10

May-10

Re

po

rt P

eri

od

Number of Teams

00.5-11.5-22.5-33.5-44.5-5

Template for Planned Care Ratings by Report Period

0 5 10 15 20 25 30 35 40

Feb-10

Mar-10

Apr-10

May-10

Re

po

rt P

eri

od

Number of Teams

00.5-11.5-22.5-33.5-44.5-5

Diabetes Protocol Ratings by Report Period

0 5 10 15 20 25 30 35

Feb-10

Mar-10

Apr-10

May-10

Re

po

rt P

eri

od

Number of Teams

00.5-11.5-22.5-33.5-44.5-5

Asthma Protocol Ratings by Report Period

0 0.5 1 1.5 2 2.5

Feb-10

Mar-10

Apr-10

May-10

Re

po

rt P

eri

od

Number of Teams

00.5-1

Self Mgmt Support Ratings by Report Period

0 5 10 15 20 25 30 35 40

Feb-10

Mar-10

Apr-10

May-10

Re

po

rt P

eri

od

Number of Teams

00.5-11.5-22.5-33.5-44.5-5



14

Implementation of Electronic System(s)

EHR Registry

Access/Excel 1 4

AllScripts 4 1

Ariphron 0 6

Care Tracker 1 0

Centricity 4 0

Cielo 0 2

CDEMS 0 1

eClinicals 1 1

EPIC 2 0

Kryptic 0 4

Misys 2 0

NextGen 5 0

Other 2 0

Synamed 1 0

WellCentive 0 5

Total 23 24



15

Learning Collaborative

Date of LC FocusAttendance / Occurrences

February 2009Introduction to PCMH, CCM & the need for change

142

July 2009

Repeat of February 2009 to bring second wave of practices on board

42

September 2009Diabetes, Asthmas & Self Management efforts

156

March 2010

Practices sharing to build community amongst IPIP team, seeing some best practice examples

118

Monthly Practice LC Call-ins (March 2009 – June 2010)

Webex conducted 3rd Wednesday & 4th Thursday of the month

Average 10 practices per call

Monthly QICs meetings (June 2008 – June 2010)

First Monday of month at AIAG offices & via webex

Average 34 coaches per meeting

Individual JIT & Assistance

Weekly handled based on needs of practice or

coach

2 incidences per week



16

Lessons Learned: People & Culture

• Engage everyone!

• Get physician buy-in/engagement early

• Make the “Big Picture” visible:– Understanding the process– Understanding how their actions

impact others– Different views = valuable

• Transformation takes longer than you think

• “Coaching” is critical



17

Lessons Learned: Process Change

• Improving the process improves the patient care

• Think simple, be creative & resourceful• Standardizing the work improves the

outcomes• Elimination of waste:

– Unnecessary steps– Redundant actions– Duplication of documentation– Identification of inefficiencies– Accuracy of data/information– Lack of accountability

• Success breeds more success• Important to understand what you “want

to improve” to avoid frustration



18

Lessons Learned: Outcomes

• Realization that current way is not necessarily the best way

• Registry allows for more “active” care of the patient population

• Be specific on what you measure!• Measures & tracking drive the

improvements• Consistency in direction & efforts• Tailoring tools to the user works

best!• Coaching time needed for practice

assistance was underestimated• Automation of metrics facilitated

transformation



19

Skill/ToolNumber of Coaches

Possessing Skill

Value Stream Mapping 42

Lean Manufacturing Principles

42

Process Flow Mapping 47

PDSA/PDCA 42

Kaizen 37

DMAIC 42

Structured Problem Solving 47

5-S 40

Root Cause Analysis 48

5 Whys 44

Fish Bone 47

Data Collection 48

Error Proofing 42

Team Building 45

Standardized Work 40

Visual Controls 41

Facilitation/Coaching 47

Good Problem Definition/Scoping (Defining Boundaries)

46

Educational Presentation Experience

47

Other 24

QI C

oac

h S

kills

Inve

nto

ry

Su

mm

ary



20

Things to Change & Keep

CHANGE• Plan more time for

transformation• Make website/library

easier to use• Plan LCs by region &

practice size• Better funding• Create a database for

reporting/tracking• Upgrade Coach

Handbook for easier use (make on-line?)

• Practice tool box/ guideline

• Stronger link between coach & practice

• Change Management training

KEEP• Coach actively

present within practice

• Energetic leadership for driving the program/process

• Engaged leadership for the program/process

• National IPIP reporting system

• Learning Collaboratives

• Access to coaches • TQM & PDSA• Process mapping

Documents

Michigan IPIP/PCMH