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COMPASS. Using Data for Improvement Establishing the Current Condition and Identifying Opportunities for Improvement Robert Ferguson Program Manager. Purpose and Objectives. Purpose To describe how we collect, display, and use data ( not to show you our current outcomes or results)

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Using Data for Improvement

Establishing the Current Condition and Identifying Opportunities for Improvement

Robert Ferguson

Program Manager

Purpose and Objectives

  • Purpose

    • To describe how we collect, display, and use data (not to show you our current outcomes or results)

    • To elicit your feedback on how we can improve our data displays and your ideas and strategies for collecting, displaying, and responding to data

  • Learning Objectives

    • Describe COMPASS-PA’s framework for collecting and responding to data

    • Discuss five examples of how to collect and display data in COMPASS

Jewish Healthcare Foundation“A Think, Do, Train and Give Tank”

A public charity with two operating arms:

Pittsburgh Regional Health Initiative (PRHI)

Health Careers Futures (HCF)

Pittsburgh Regional Health Initiative

  • Pittsburgh Regional Health Initiative (PRHI)

    • A not-for-profit, regional, multi-stakeholder collaborative formed in 1997 by Karen Feinstein and Paul O’Neill

    • An initiative of a business group, the Allegheny Conference on Community Development

      PRHI’s message

      Dramatic quality improvement (approaching zero deficiencies) is the best cost-containment strategy for health care

PRHI’s Systems Vision

Data to Treat, Measure, Evaluate

Informed, Activated, Discerning Consumers, particularly at End-of-Life

Collaboration and Integration

Perfect PatientCare


for Collaboration

Across Care Settings

Medication Reconciliation

Screening and Tx

Essential Services System Requirements


Long Term Care



Emergency Services

Specialty Care

Primary Care

Care Mgt

Patient Engagement

Health IT

QI Training

Payment Incentives

Clinical Pharmacy

Behavioral Health

Implementation of Evidence-based Behavioral Healthcare in Primary Care


  • PCP Offices from 3 Groups:

  • Saint Vincent Healthcare Partners

  • Excela Health Medical Group

  • Premier Medical Associates

COMPASS Objectives

  • By 12/31/13, enroll 375 eligible patients per partner region

  • By 6/30/14, enroll 675 eligible patients per partner region

  • By 6/30/15:

    • Improve depression for 40% of patients

    • Improve A1c, LDL, BP control rates by 20%

    • Improve patient/provider satisfaction by 20%

    • Reduce ER visits by 20%

    • Reduce hospital admissions by 10%

PRHI’s Framework for Collecting and Responding to Data

Informed by Motivational Interviewing and PRHI’s Lean-based Perfecting Patient CareSM QI Methodology

The Lean Perspective

Problem Solving

(Continuous Improvement

& Learning)

The 4 P’S

of the

Toyota Way

People and Partners

(Respect, Challenge,

and Grow Them)

People and Partners

(Respect, Challenge,

and Grow Them)

Liker, Jeffrey K. The Toyota Way, New York: McGraw-Hill, 2004.

The Motivational Interviewing Perspective

A way of being with people which is…

  • Collaborative

  • Evocative

  • Respectful of autonomy


  • Obtain leadership’s support and direction

  • Identify the current condition and future state with those who do the work, using multiple data sources to make it meaningful and actionable:

    • Observations (“go and see”)

    • Process Mapping

    • EHR and AIMS CMTS data

    • HPIER’s Reports

  • Facilitated by PRHI coaches who are trained in Perfecting Patient Caresm, Motivational Interviewing, and COMPASS processes and skills

    • Their goal is to develop internal capacity for self-review, learning, improvement, and sustainability

Current Condition Observations

Process MappingVisualizing the Current and Future Condition

Well-functioning aspect of work



A3 Improvement Plan

Incremental Improvements Towards the Ideal





Each improvement moves the process closer to the ideal



Motivational Interviewing Observation Form to Elicit Feedback on Skill Development

Example 1: EHR Data at One Medical Group

Population Health Current Condition

January 2013

PHQ-9 Screening Current Condition, by Office

October 2013

44% PHQ-9 Completion

19% PHQ-9 > 9

67% Enrollment

Example 2: Displaying HPIER’s Reports, by Medical Group

COMPASS Patient EnrollmentBy Regional Partner

June 13, 2014

Initial Data CompletenessBy Medical Group

June 13, 2014

PHQ-9 Documentation

June 13, 2014

Depression Improvement:Baseline vs. Most Recent Score

June 13, 2014

Depression Remission:Among Those in COMPASS for > 119 Days

June 13, 2014

A1c Documentation

June 13, 2014

A1c Control Rate:Baseline vs. Most Recent Value

June 13, 2014

BP Documentation

June 13, 2014

BP Control Rate:Baseline vs. Most Recent Value

June 13, 2014

Hospital Admissions (Self-Reported)

June 13, 2014

Example 3: CMTS Data at One Medical Group


May 2014 CMTS Data

Last Follow-up PH-9<10


Initial Contact PH-9>9

Last Follow-up PH-9>9




No Follow-up PH-9

Entered in CMTS

Initial Contact PH-9<10



Last Follow-up PH-9<10


May 2014 CMTS Data

Last Follow-up A1c<8.0


Initial Contact A1c > 7.9

Last Follow-up A1c>7.9




No Follow-up A1c

Entered in CMTS

Last Follow-up A1c<8.0



Initial Contact A1c<8.0

Last Follow-up A1c>7.9



No Follow-up A1c


May 2014 CMTS Data

Last Follow-up SBP<140


Initial Contact SBP>139

Last Follow-up SBP>139




No Follow-up SBP

Entered in CMTS

Last Follow-up SBP<140


Initial Contact SBP<140


Last Follow-up SBP>139



No Follow-up SBP

Example 4: CMTS Data at Another Medical Group

March 2014

Example 5: CMTS Data of Follow-up Contacts

Follow-up Contacts and Active Caseload by Month and Care Manager

COMPASS-PA’s Next Steps

  • Analyze internal EHR data (PHQ-9, A1c, BP)

  • Continue to base the Steering Groups’ discussions around the data

  • Use AIMS’ CMTS Caseload Statistics and Caseload Summary for real-time data and monitoring

  • Continue to dig into the CMTS data

  • Continue to utilize Lean-based quality improvement methods at the front-line

  • Move meaningful, actionable data to where the work is occurring

Care of Mental, Physical, and Substance use Syndromes

The project described was supported by Grant Number 1C1CMS331048 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

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