Cross‐fertilizing Our Team’s Knowledge and Ability to Improve Quality through the PPRNet Model

1. Cross‐fertilizing Our Team’s Knowledge and Ability to Improve Quality through the PPRNet Model A PPRNet Powered Patient-Centered Family Medicine Home Tim Tobolic MD Byron Center Family Medicine ttobolic@bfmpc.com Auigust 22, 2014

2. PPRNET History • Solo > Small group (5 FP, 30+ staff) > paper chart • 1999 New EMR designed Office > PPART • c. 2004 PPRNET • 4/2009 “Sold out” - “captured” - “sold again”. • Raised in captivity - “Epic” diet • Secretly making plans to escape

3. “It is not necessary to change. Survival is not mandatory.” ...W. Edwards Deming

4. PPRNET History • 9/2010 “Escaped” captivity > solo > paper chart • 12/2010 Chose PPART because of PPRNET • 2012 PCMH Designation

5. PPRNet Early days • Champion in our office manager - embraced PPRNet Model. • Participation agreed on by Drs, but lackluster participation • PPRNET Quality Improvement Team, Project leaders. Office projects focused on HTN, DM, Aspirin, Mammograms • Invited PH - a mistake since they stole Office Manager but better for her. • Newsletter, QI and Patient satisfaction info for large group. • Steve Proposal for “distribution of wealth” (Steve = Obama visionary)

6. Fertilizing BCFM with PPRNet - TRIP Model • Prioritize Performance • Involve All Staff • Delivery System Redesign • Patient Activation • Population-based Medicine • EMR Tools

7. Byron Center Family MedicineStrategic Plan MISSION To provide a innovative patient centered family medicine home that exceeds patient expectations and improves the quality of life of our patients and the community. Strategic Plan Incorporates PPRNet model and strategies

8. Health Maintenance • In “Cross Fertilzing” Terms - HM = the ultimate fertilizer spreader. • PPRNet gave meaning to Health Maintenance • “Get the Red Out” • “Need to look at date” • Constant updating, tweaking, rule making. • Helps with Independent / Team thinking. • Chronic Disease (Cross Ferilization) relationships are better understood! • 11 months is the new 12 • 5 months is the new 6 • Patient Activation @ POC Staff Educate patients on the what and why of HM needs in real time.

9. EMR / HM Tools Multiple simple embedded QT to help push and pull information and identify needed HM PPRNet Site visits & Best Practices Here for acute problem, check on HM needed Push Result it to HM <<CKD Tool>>

10. EMR Tools • Multiple simple QT reminders embedded in Progress Note, PC-Refill,PC-Problem, Lab Result Templates “Hi Mr Jones, Rx called in, only gave 30 day supply until you get Bp and A1c checked.” Calling for Refill Open related Lab HM, OV, Lab Needed? Get it done !

11. TRIP - PROJECTS We should work on our process, not the outcome of our processes. ...W. Edwards Deming

12. C-TRIPColorectal Screening • Our First experience with TRIP Project • Multifaceted - PPRNet TRIP Model • Focus on Preventive Screening • Staff Involved • Engaging patients • Meaningful use of PPART • Practical use of HM, Dot Codes • Cross Fertilize team ability and knowledge -put us ahead of the curve on quality incentives for payors

13. C-TRIPColorectal Screening Results of project Power of the Chart 2007 2008 2009

14. MS-TRIPMedication Safety • Bring in ALL medications to each visit. • Keep medication in original labeled bottle • Dispose of outdated, not used meds. • Bring All meds to consultants, hospitals, ER, UC

15. MS-TRIPMedication Safe Sack Project

16. CKD-TRIPChronic Kidney Disease • Evaluation group • Knowledge base and knowledge need - higher • Understand CKD relationships to medication • Understand CKD relationship to other chronic disease, labs - HTN, Lipids, CBC, GFR, ACE/ARB, NSAIDS • “CKD Tool” - complicated but so far very helpful - (thanks Cara Litvin) • Higher level of patient ed. - NKDEP information • One of our payors just introduced CKD as a quality measure - fertilizer is working !

17. PPRNet TRIP Projects • COLORECTAL • MEDICATION SAFETY • CKD • Requests for Project Support • AAFP TOBACCO • AAFP IMMUNIZATION • STAY INVOLVED • YES DEMANDING BUT NEVER LET UP • CROSS FERTILIZE EDUCATION • We don’t have time to do it all • The Professors from MUSC

18. PPRNet TRIP ProjectsBenefits • Focus on important Quality Initiatives - Preventive care & Chronic disease management. • Staff - Not researchers or statisticians but better idea about research, process. evidence-based care. • Skills transferable (cross-fertilize) other projects and office processes • PPRNET Projects cross fertilizes many PCMH domains and many payor quality initiatives + incentives • Staff better understand the multiple links between chronic diseases -eg: Working on DM “cross-fertilizes quality improvement in HTN, CV disease, Immunizations, Lipids.

19. PPRNet TRIP ProjectsBenefits • Staff develop desire and refine their ability to provide care that improves quality of life for our patients

20. PPRNet in Community

21. KNOWLEDGE It is not enough to do your best; you must know what to do, and then do your best. ...W. Edwards Deming

22. TRIP Projects = Value • Involvement Investment in PPRNET projects • Site Visits • Individual and Team project focused training • HM tools - enhancements • PPRNetWebinars • “Best Practices” discussed

23. PPRNET Meetings = Value Involvement in PPRNET Meetings • Educational • Networking with “experts” • Carry back (“fertilize”) other team members • HM tools - enhancements • Realize they are not alone !

24. Cross Fertilizing = Cross Training “Quality is everyone's responsibility.” ...W. Edwards Deming

25. OLD Staff = MA + Front Desk + Billing + Chart people + Office Mgr. • Greet Patient • Bp, Ht, Wt. - occasionally • Put patient in room • Call in Refills • Answered Problem Calls • Give Labs to Doctor • Made Next Appointment • Arranged Referrals • Billed

26. OLD Office VisitPre-PPRNet • “Why are you here” - “Let me put you in a room and doctor will go over everything.” • “I don’t know, you’ll have to ask the doctor” • “The Doctor will tell you what you need.” • “You better talk to the doctor, he will order the colonoscopy if he thinks you need it” • Patient: “Who’s that person working at the front desk” • “The doctor will be in to tell you why you need those tests”

27. NEW(PPRNet Powered) Staff = Team Office Visits • Greet / Triage • BP, Ht, Wt, BMI - every time • Review Medications • Review Medication Safety • Review all meds each visit • Recommend meds - eg. Aspirin Use • Better Knowledge of drugs & interactions. Health Maintenance • Understand / Explain /Discuss needed HM • Better Understanding HM time tables • Patient Education • Prevention / Chronic Disease Guidelines

28. NEW(PPRNet Powered) Staff = Team Standing Orders • Order needed labs • Order and Do Immunization • Order preventive: Colorectal screen / Pap / Mammogram • POC Testing - A1c, Spirometry System Redesign • Order Previsit labs • Reminder calls (Human vs Electronic) • Follow up No Shows • Cross Trained Phone Calls • Now More Comprehensive • Order needed screening • Lab Result Discussion and follow up ordered EMR • Deal with Interface • Order Entry • Data Entry, Tracking • Previsit Planning • Labs, Paperwork • TCV Visit • WebView (anticipated)

29. New(PPRNet Powered) Office VisitWhen I walk into exam room • “Yes I know I need a colonoscopy, Mary already ordered it.” • “Jackie already took my urine to check my kidneys” • “They wouldn’t give me any more medication till I came in to get my blood pressure (or my A1c, or my lipids, etc) checked.” • “Nikki caught me and told me I need to be back here in October for my labs and she scheduled a diabetic eye exam and a colonoscopy“ • “I know, I was already told I need to bring in all my medications at the next visit.” • “I almost forgot my visit till Shannon called to remind me.” • “I’ll just talk to Shannon - “When I Check out” - “When I call in next time” - “If I Need anything” • “Don’t worry Doc, They will let me know when I need ........” • New Office Visit - a different level of patient understanding, empowerment, expectations, complexity and time.

30. Staff (on PPRNet) has Evolved • Intense • Involved • Aggressive • Empowered • Persistent • Comprehensive • LOOK AT THE BIG PICTURE! • Confident and Convincing. • Knowledgable • More Accurate! • Better Communicators • Caring • Patient Experience • PPRNET and PCMH savy • Better “Team” Culture • Better at creative thinking • Better and more comfortable patient educators • Better at getting needed data. • Attitude of Excellence • Show Passion for what they do

31. REWARD “Defects are not free. Somebody makes them, and gets paid for making them.” ...W. Edwards Deming “Show Me the Money!”

32. PPRNet = PCMH = P4P • PPRNet Model made PCMH process easier • PPRNet Background reduced learning curve

33. Share the WealthOrnstein Effect • Staff play significant role in meeting quality guidelines. • PPRNET education has been significant part of that . I could never do it alone. • Team Knowledge + Patient Activation + Quality Improvement = Enhanced Incentive Payments with several payors. • Staff should share in those enhanced payments • Approx 15-20% of income in 2013 estimated to be incentives. • PPRNet “Best Practice” is worth something!

34. WEPWage Enhancement Program OLD METHOD • Come to work, put individual patient in room, answer physician messages, do refills, go home, get paid. • “Bonus” based on personal characteristics and individual performance. NEW METHOD • Value in independent thinkers who are team players, innovation, understanding of data, registries, quality parameters, patient education, recommended prevention & community based care. • “Wage” based on outcome, team activity, quality incentives.

35. Review Work in PCMH and PPRNet environment Educational - review PCMH & PPRNet elements Review accomplishments & set goals Team based & Individual Employee Incentive Review

36. Priority HealthExample of Cross Fertilizing Incentives - Motivations One of larger payors • Incentives • Disease Management • Preventive Health • Infrastructure • Info Shared with staff • Received Quality Award

37. PPRNet Motivation “Best Practice” / “High Performance” Awards - OF COURSE

38. PPRNet = Why It Works • Goals - clarify, focus, prioritize • Intensity • Continue to improve Skill • Continue to Improve the Processes • Consistency in process • Every Encounter, Every Time = Opportunity • Teamwork - Challenging / Rewarding • Develop a better understanding of the knowledge we gain • Yes its hard, time-consuming, but rewarding

39. “The job can't be finished only improved to please the customer.” ...W. Edwards Deming