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Ambulatory 401:Building Improvement Teams in Primary Care
WREN ConferenceNovember 13, 2009
Dr. Sally KraftStephanie Berkson
Workshop Overview The Problem Context
– UW Health
The Solution– Physician-Manager Leadership teams– Ambulatory 401 Program– Key Concepts – Applied Learning
The Results Lessons Learned
The Problem
Quality problems are everywhere, affecting many patients. Between the health care we have and the care we could have lies not just a gap, but a chasm.
IOM Crossing the Quality Chasm 2001
Urgent Need to Improve Our US Health Care System
High costs Rising costs Disparities in care Rising rates of uninsured Medical errors Growing physician dissatisfaction Variable quality
Level
A “True North”
The experience of the patient and their loved ones
B Microsystems
Small units of care delivery
C Organizations
The systems that supports small units of delivery
D Environment
Policy, payment, regulation, accreditation: the factors that shape behavior, interests and opportunities
Berwick. Health Affairs 2002
Quality Improvement:Building High Performing Frontline Teams
The quality of the microsystem is its ability to achieve ever better care: safe, effective,patient-centered, timely, efficient, and equitable. The quality of an organization is its capacity to help microsystems do that. And the quality of the environment—finance, regulation, and professional education—is its ability to support organizations that can help microsystems to achieve those aims.
Berwick. Health Affairs 2002
Context: UW Health
University of Wisconsin Medical Foundation• UW School of Medicine and Public Health’s academic group practice plan
•1,090 physicians (~300 primary care physicians)
• Wisconsin’s largest multi-specialty medical group, one of the 10 largest medical groups in the nation
• 48 practice locations
• Epic electronic health record
• Experience with quality measurement, members of the WCHQ
• Experience with design and administration of P4P
UW Health Driving Forces Organization complexity
– Multiple management structures within the same organization
Physician dissatisfaction– Not empowered to improve own practice environment– Need for structures to support delivery of quality care
High Primary Care physician turnover– Recruitment difficulties
Culture shift to local problem solving– Desire to move away from top down solutions– Desire to engage physicians in improvement efforts– Desire to create local accountability
Variable quality across primary care settings
Current UW Health Performance in WCHQ
Size of the bubble is correlated to the number of eligible patients at each organization
13
UW Health Colorectal Cancer Screening Rates by Clinic
Size of the bubble is correlated to the number of eligible patients at each clinic
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Scre
enin
g Ra
te
UW Clinic
WCHQ Colorectal Cancer Screening Rates Measurement Period January - December 2008
UW Dane PCP (Clinics over 100 patients)
UW Overall Rate = 66.8%
UWHC Clinics UWMF Clinics
UW Health Colorectal CancerScreening Rates by Clinic
Failure to Build the System that makes it Inescapably Easy to do the Right Thing
The Solution
UW Health Strategy Establish new “lead physician” role at all clinics
– Pilot with Primary Care
Develop clinic leadership team– Partner lead physician with clinic manager
Promote key principles– Local ownership and accountability for clinical practice
within an academic context– Team based delivery of care
Enhance lines of communication– Within site, across sites, across organization
Provide new leadership teams with basic improvement knowledge and skills
Ambulatory 401 Program:Building Improvement Teams
Course Objectives Enhance and develop the physician-clinic manager leadership
team Learn to improve clinic processes & services delivered to patients Review, learn and apply performance improvement techniques Provide understanding of the UW Health structures and metrics
Physician leadand clinic manager build the leadershipteam
Build the clinic team,practice and learn performance improvement skills, solve clinic problems
Build a network of clinics to share learnings
Attendees Clinic manager and clinic physician leader
Time line: Four, 2.5 hour sessions over 6 months
Didactic training topics (including action learning during sessions): Organizational overview & strategic priorities Metrics used to monitor efficiency and quality of care Clinic improvement team approach to change Process improvement concepts, tools and techniques
Applied training: Each clinic team completed an improvement project Project results presented and shared
Ambulatory 401 Classes: 9 General Internal Medicine Clinics completed; May 2008 11 Family Medicine Clinics completed; January 2009 14 Family Medicine Clinics completed; June 2009 8 Pediatrics Clinics in progress
Ambulatory 401 Program Format
Ambulatory 401:Curriculum
Leadership skills– Overview of health care quality and the need to
improve– Model for organizational improvement– Understanding performance data– Team development– Effective meeting skills– System-based thinking
Performance improvement skills– FOCUS PDCA model
Ambulatory 401Why now?
The “good” old days Medical care was cheap Quality was not defined and
was not measured Physicians practiced
autonomously Insurance companies didn’t
exist Medical care was simple Medical care was an “art”
more than a science
Our current state Health care is expensive Quality is measured and
reported Physicians practice in large
groups, healthcare is integrated in systems
Insurance companies are powerful
Care is complicated Evidence and information are
plentiful
Kotter. Harvard Business Review 2007
Level
A “True North”
The experience of the patient and their loved ones
B Microsystems
Small units of care delivery
C Organizations
The systems that supports small units of delivery
D Environment
Policy, payment, regulation, accreditation: the factors that shape behavior, interests and
opportunities
Berwick. Health Affairs 2002
How do we get started?
Value-Added
An activity that changes the form, fit, or function of a product or service; something the customer would be willing to pay for.
Non Value-Added
Activities that do not add value to the final product or service for the customer. Given a choice, customer’s won’t pay for it.
Problem Identification What do we do that is valuable?
What do we do that isn’t valuable?
Lean Thinking (from Toyota improvement model): Seeing and eliminating waste, i.e. eliminating anything that doesn’t add value to the process
Keep Eliminate
Value Stream Map
A tool to identify non-value added steps in a process. This can be a good starting point to identify problems and their causes.
Steps:1. Define start and end points of the process2. Identify all current steps in the process, with
stakeholders3. Identify non-value steps (waiting, variation, rework)4. Validate current state process5. Create ideal value stream map (only value added
steps)
25
BrainstormingA group exercise designed to generate lots of ideas. This should be fun! Get everyone involved. Encourage
creativity. Get excited!
Steps: Review the topic with the whole group Give people time to think silently about the topic Each person writes down an idea on a card—one
idea per card (or write down all ideas on a flip chart) Post the cards or flip chart papers on the wall Continue until all ideas have been recorded
Affinity Diagram
A tool to group large numbers of ideas into clusters so that patterns and categories can be identified
Steps:
1. Ideas from your brainstorming session are posted on cards on the walls
2. Silently members of the group move the cards into distinct areas on the wall. Cards can be moved multiple time, from cluster to cluster
3. After the cards have been grouped silently, the entire team identifies “headers” for each cluster
Affinity Diagram
Beginning of Amb 401,Assess your current clinic
What do youwant in your clinic?
Multiple small improvement projects,each one building from the earlierproject.
Clinic leaders keep the improvement
efforts moving forward toward the goal
Ambulatory 401
Physician leadand clinic manager build the leadershipteam.
Build the clinic team,solve problems
Build a network of clinics to share learnings
Creating the vision(brainstorming),Assessing our starting point(SWOT analysis)
Cause and effect(root cause analysis)Small tests of change(PDCA)
Shareour learnings
The Results
Ambulatory 101/401 History
2007 UWMF Ops Committee endorsed primary care clinic physician-manager leadership teams
Jan – May 2008
First Ambulatory 101 course taught to physician leaders-managers at GIM clinics (9 clinics)
Sept 2008 – Jan 2009
First ‘wave’ of DFM clinic leaders complete Ambulatory 401 (11 clinics)
Feb-June 2009 Second ‘wave’ of DFM clinic leaders complete Ambulatory 401 (14 clinics)
In Progress Pediatrics clinic leaders participating in Ambulatory 401 (8 clinics)
Results: Teams Made Improvements!
January 2009 Family Medicine class– 11 improvement projects completed
– 10 with data documenting improvements in care
June 2009 Family Medicine class
– 10 improvement projects completed
– 9 with data documenting improvements in care
Improving INR Result Times, Sun Prairie Clinic
Change Leader: Cindy Haase, Clinic Manager
Team Members: David Quoeff, MD, Joan Premo, RN, TL
Aim Statement:
We will improve timely communication of INR results to the patient with a goal of contacting the patient with the results within 4 hours or less from the time the lab results are reported for 95% of patients getting INR labs by Jan 1, 2009 focusing on:
1. Developing and implementing a protocol for RN’s to communicate med changes to patients
2. IS changing Epic workflow: All INR results going into both MD and RN Results pools
Patients Contacted w/ INR Results in 4 hrs
47%
90% 99%
0%
20%
40%
60%
80%
100%
Nov 08 J an 09 Feb 09
Initial Findings:
From 47% to 90% contacted w/in 4 hrs
Follow-up Findings:
99% contacted w/in 4 hrs
Project Example
Results: Participants Found Program Valuable
88% of GIM respondents agreed that the information was helpful to their role as a clinic leader
95% of Family Medicine respondents agreed that participation has or will lead to improvements in their clinic
95% of Family Medicine respondents agreed that improvement tools presented were useful
Results: Participants Found Program Valuable
We have had QI improvement projects all along...but I learned new techniques to discover how to evaluate the current process and then to move on to designing a new process. I think we are set and will continue using the skills/methods we have learned and apply them to future problem areas in the clinic. In this way it has been helpful.
- Spring 2009 Ambulatory 401 Participant
Lessons Learned
Lessons Learned Selecting the right person is key Site participation in selection of the individual is important Video conferencing can work for some aspects but not ideal
particularly for project sharing Teams presentations are critical –teams learn quickly from
each other ---networking is enhanced Structured presentations allow for focus on work
accomplished Time and existing work loads are an issue Flexibility required –never ending conflicts for time Provides a strong foundation for all other improvement
activities Must be viewed as a long term investment –impact on
patient satisfaction, MD satisfaction, manager satisfaction, staff / MD retention, practice efficiency , communication, ownership
Opportunities Bring in the Patient. Identify strategies to bring patient input into
improvement work.
Anyone can be a Champion. Everyone within the clinic has the potential to be a change leader; champions do not have to be limited to physicians and clinic leadership.
Share Improvements. Maximize e-communication tools to share improvement work. Organize improvement projects by topic i.e. results reporting, access, care management.
Improve Together. Clinics with similar challenges and priorities could work together to develop improved processes.
Research. Critical evaluation to understand why improvement interventions succeed or fail across a range of care settings.
Challenges
Disseminating innovations and improvements
Sustaining improvements
Aligning “top down” and “bottom up” priorities
The Need to Improve….
Very seldom, under existing conditions, does a patient receive the best care
which is possible to give with the present state of medicine.
The Need to Improve is Historical
Very seldom, under existing conditions, does a patient receive the best care
which is possible to give with the present state of medicine.
The Flexner Report 1910
Very seldom, under existing conditions, does a patient receive the best care which is possible to give with
the present state of medicine.
The time to improve is now.