Improving performance in practice
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Improving Performance in Practice :. From IPIP to GQI. Objectives. Provide an overview of IPIP methods and rationale as it moves statewide under the GQI/NCHQA Describe what we will do and what you will do Introduce the change model and change packages Introduce measurement.

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Improving performance in practice

Improving Performance in Practice:

From IPIP to GQI


Objectives

Objectives

  • Provide an overview of IPIP methods and rationale as it moves statewide under the GQI/NCHQA

  • Describe what we will do and what you will do

  • Introduce the change model and change packages

  • Introduce measurement


Adherence to quality indicators in the medical care setting

Adherence to Quality Indicators in the Medical Care Setting

  • Hypertension64.7

  • Depression57.7

  • Asthma53.5

  • Hyperlipidemia48.6

  • Diabetes45.4

Percentage of ConditionRecommended Care Received

McGlynn et al. NEJM 2003


Improving performance in practice

DiabetesRecommendations

Health Systems

Disease management Strongly Recommended

Case management Strongly Recommended

Self-Management Education

Community gathering placesRecommended

Home - type 1 diabetes Recommended


North carolina chronic disease management collaborative

North Carolina Chronic Disease Management Collaborative


Ipip a national initiative

IPIP: A National Initiative

American Board of Medical Specialties

American Academy of Family Physicians

American Academy of Pediatrics

American Board of Family Medicine

American Board of Pediatrics Plus

American College of Physicians

American Board of Internal Medicine

…funded by the Robert Wood Johnson Foundation


National ipip the vision

National IPIP: The Vision

Dramatic transformation of office care with improvement of chronic disease care

All Primary Care Disciplines—Family Medicine, Pediatrics, General Internal Medicine—across the whole state

New approach to CME and linkage to Maintenance of Certification Part IV

Started in two states (NC, CO) now spread to five more states (PA, MI, WA, WI, MN)


North carolina coalition

North Carolina Coalition

Physician Leadership (NCAFP, NCPS, and the NCACP)

Collaboration of NC AHEC and Community Care of North Carolina

With active involvement and support from

Medicaid

State Employees Health Plan

Blue Cross Blue Shield of NC

Health and Wellness Trust Fund

Division of Public Health

MRNC/CCME (QIO)

North Carolina Medical Society


Spreading statewide

Spreading Statewide

Focus is providing help for doctors to transform their practice by building systems to reach every patient, every time

Pilot: Eastern and Mountain, learn how to do it and spread it in each practice and across the state.

Governor’s Quality Initiative/North Carolina Health Quality Alliance


Ipip methods overview

IPIP Methods Overview

Focus on providing help for doctors to change their practices rapidly by using data to drive the change

Data Collection and Reporting

Rapid Cycle Process

Quality Improvement Consultants

Quarterly dinner meetings to share learnings

CME and MOC-IV credit


Learnings about process from the pilot wave

Learnings About Process From the Pilot Wave

Common measures of quality take time

Recruitment was not difficult

MD championship, CCNC/AHEC regional leadership critical

Regional strategy very successful

QICs immensely popular

Data systems are a large barrier, but can be overcome


Learnings can we improve care

Learnings:Can we improve care?


Diabetes quality improvement in wave 1 after 9 months n 12

Diabetes Quality Improvement in Wave 1 after 9 months (n=12)

%HbA1C <7 40 to 54%(40%)

%HbA1C >9 20 to 11%(15%)

%BP < 130/8035 to 47%(25%)

%LDL <100 36 to 50%(36%)

Smoking advice45 to 77%(80%)

Foot exam40 to 63%(80%)

Eye exam 24 to 35%(60%)

Nephropathy38 to 62%(80%)


Asthma quality improvement after 9 months n 5

Asthma Quality Improvement after 9 months (n=5)

Severity Classification68 to 80%

Controller Medication94 to 94%

Flu Shot38 to 67%


Ipip in north carolina

IPIP in North Carolina

Making it work for you!

Individualized office system assessments

Practice data collection with internal reporting to immediately impact care


What you can expect from ipip

What You Can Expect From IPIP

QIC to work with you on office systems changes

Help establishing database of your patient population

Tools and methods for changing your practice

Comparisons to other practices, with opportunity to learn from them

CME and MOC IV credit

Some financial support

Access to national leadership in quality improvement


What ipip expects from you

What IPIP Expects From You

Formation of a practice team to champion change, review and submit data

Implement registries, templates of care, practice protocols and support for self management

Frequent analysis and small changes in your practice, with tests of change

Participation in quarterly meetings to share your learning with other practices

Regular engagement with your QIC


Ipip reimbursement

IPIP Reimbursement

Initial $1000 after identification of clinical improvement team, attendance at kick-off meeting and beginning submission of baseline data

Second $1000 after submission of baseline and six months of data and participation in network activities.

Third $500 after 12 months of data and establishing a sustainable culture of quality improvement in your practice.

CME will be provided for ongoing activities


Ipip gqi nchqa vehicle for leadership in communities and across the state

IPIP/GQI/NCHQA: Vehicle for Leadershipin Communities and Across the State

One definition of quality across payors

One audit of quality per practice across all payers

Help us learn how to help other doctors transform their practice and respond to pay for performance initiatives

Developing permanent community based support for practice improvement


Questions

Questions?????

  • We need your advice, understanding and help

  • If we haven’t addressed what’s on your mind, TELL US PLEASE!


Changing office systems

Changing Office Systems

Model for Improvement: How to Change

Change Packages: What to Change


Improving performance in practice

Chronic Care Model

Community

Health System

Health Care Organization

Resources and Policies

Practice Level

ClinicalInformationSystems

Self-Management Support

DeliverySystem

Design

Decision

Support

Prepared,

Proactive

Practice Team

Informed,

Activated

Patient

Productive

Interactions

Improved Outcomes


Improving performance in practice

Model forImprovement

Act

Plan

Study

Do

What are we trying to

accomplish?

How will we know that a

change is an improvement?

What change can we make that

will result in improvement?

  • Workflow Analysis

  • Brainstorming

  • Nominal Ranking

  • Try again?

  • Change it?

  • Dump it?

  • Small tests of change

  • 2 pts. 1 doc

  • Quick tests with feedback

  • Data pulls

  • Check sheets

  • feedback


Change model key elements

Change Model: Key Elements

  • PDSAs are a generalized approach, but personalized for your practice

  • Pilot and Spread

  • Emphasize Learnings

  • Rapid small cycles!


Improving performance in practice

Repeated Use ofthe Cycle

Changes

That Result

in

Improvement

A P

S D

DATA

D S

P A

A P

S D

A P

S D

Hunches

Theories

Ideas


What is a change package

What is a Change Package?

  • A change package is an evidence-based set of changes that are critical to the improvement of an identified care process.

    • Ed Wagner MD

      Improving Chronic Illness Care. org


Ipip change package organization

IPIP Change Package Organization

  • High-leverage Changes

  • Detailed Changes

  • Change Tools


Ipip change package

IPIP Change Package

  • High-leverage Changes (12-18 months)

    • Step One: Implement Electronic Database – clinical information systems

    • Step Two: Use Template for Planned Care – delivery system design

    • Step Three: Use Protocols – decision support

    • Step Four: Adopt Self-management Support Strategies


Improving performance in practice

P

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S

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Changes in Parallel

Self-

Mgmt

Support

Delivery

System

Design

Decision Support

Clinical

Information

Systems

Community Resources

Organization

Strategies for Each Component of the Care Model

= Initial work in IPIP

= Areas to work after initial work is complete


Detailed changes registry

Detailed Changes: Registry

  • Select and install a registry tool

  • Determine staff workflow to support registry use

  • Populate registry with patient data

  • Routinely maintain registry data

  • Use registry to manage patient care and support population management

Step One: Implement an electronic database:


Detailed changes ehr

Detailed Changes: EHR

Step One: Implement and Electronic Database:

  • Learn capability of EHR for registry functions (identifying patients, flowsheets or disease templates and data reporting)

  • Improve use of EHR to support registry function

  • Routinely maintain correct use of EHR

  • Use EHR as registry to manage patient care and support population management


Detailed changes templates

Detailed Changes: Templates

  • Select template tool from registry/EHR or use a flow sheet

  • Determine staff workflow to support use of template

  • Use template with all patients

  • Ensure registry updated each time template used

  • Monitor use of template

Step Two: Use a template for guided care:


Detailed changes protocols

Detailed Changes: Protocols

  • Select and customize evidence-based protocols to office

  • Determine staff workflow to support protocols, including standing orders

  • Use protocols with all patients

  • Monitor use of protocols

Step Three: Implement Protocols


Self management support step four

Self-management SupportStep Four:

  • Obtain patient education materials (e.g., asthma action plans)

  • Determine staff workflow to support SMS

  • Provide training to staff in SMS techniques

  • Set patient goals collaboratively

  • Document and monitor patient progress toward goals

  • Link with community resources (schools, service organizations)


Monitoring the process

Monitoring the Process

  • Critical step in high-leverage changes

  • Different than measurement data

  • To inform Improvement Team

  • Goal is 90% reliable processes

  • Requires work and planning

  • Can decrease frequency when process is at 90%


Ipip change package tools

IPIP Change Package Tools

It’s not the tools, it’s the process…in your setting with your staff and your patients

  • Housed on IPIP Extranet

  • Organized by Change

  • Adding Tools from Practices


In summary change package

In Summary: Change Package

  • Includes details about making changes, measures, assessment scales and tools

  • A resource for practices and QICs

  • Offers guidance and resources

  • Remember: Teams testing these changes in a small, rapid-cycle style, will help adapt them to your individual practice and adopt strategies throughout your entire office.


Improving performance in practice

Questions?


Measurement

Measurement

Practical Examples


Key points for pdsa cycles

Key Points for PDSA Cycles

  • Do cycles on smallest scale possible

    • Think baby steps

    • “Failed” cycles are learning when small (trial and learning)

  • Pilot, then spread


Example 1 a children s clinic

Example 1: A Children’s Clinic

  • Aim: Improve asthma outcomes (reduce ED and hospital visits by 50% and improve patient well-being) by:

    • improving care process in office

    • improving patient self-management skills

  • First step: Identify asthma patients (so they can assess symptoms and improve management)


Improve severity classification c ycle one

Improve Severity Classification: Cycle One

  • Plan

    • Find and label charts of all asthma patients

    • Theory: we can feasibly label charts of all asthmatics

  • Do

    • Computer run of all asthma diagnoses

  • Study

    • N = 3500

    • Too many patients to label

  • Act

    • New cycle: focus on sickest patients


Improving performance in practice

Improve Severity Classification: Cycle Two

  • Plan

    • Start with sicker patients

    • Theory: we can feasibly label charts of our sickest asthmatics (seen in ED or practice recently)

  • Do

    • Asthmatics seen in ED and in practice in last 2 months identified by computer

    • Asthma patients identified as they come into office

  • Study

    • N= 75, easy to accomplish

  • Act

    • Begin labeling these charts


Example 3 nurse directed services improving the prompts

Example 3:Nurse-directed services: Improving the prompts


Interventions june 2006

Interventions June 2006

Developed prompting for nursing staff

Poorly accepted by providers and nurses.

Lacked consensus.

Weak follow-up and reporting.


Process to engage nurses

Process to Engage Nurses

  • Solidified divisional support for utilizationof the intervention

  • Developed educational session with nurses

    • Meeting introduction by medical director

    • Revisited intent of the yellow sheets

    • Reiterated the role of the nurse as an integral member of our team

    • Reviewed evidence behind our recommendations

    • Listened to nurses’ concerns

  • Developed rapid means of feedback


Items to be included in nurse assessment

Items to be Included in Nurse Assessment

  • Assess as indicated on the prompt

    • Depression screening

    • Smoking assessment and intervention

    • Eye referrals

    • Monofilament testing

    • Pneumococcal vaccination


Intervention

Intervention

Feedback and change in clinical focus led to significant revision of the yellow sheets


Simple procedure for tracking daily progress

Simple Procedure for Tracking Daily Progress


Effective team care

Effective Team Care

  • Population Based Care

  • Treatment Planning

  • More Effective Consultations

  • Evidence Based Clinical Management

  • Self Management Support

  • More Effective Consultations

  • Sustained Follow-Up


Successful management of diabetes intensive therapy team approach

Successful Management of DiabetesIntensive Therapy - Team Approach

  • 2 oral meds or one oral plus insulin

  • 3 or more daily injections of insulin

  • 4 or more clinic visits per year


Successful management of diabetes intensive drug therapy team approach

Successful Management of DiabetesIntensive Drug Therapy-Team Approach

  • Better Population Monitoring

  • Direct contact with Nurse Manager

  • Collaborative care with Physician Extenders

  • Close follow-up


Improving performance in practice

Annette - Diabetes Educator

Maintain patient Database

Active Case Management

Coordinate referrals

Provide glucometer and glucometer supplies

Determine glucometer competency

Basic Diabetes Education (see education sheet)

Close follow-up

Tracy - Dietitian

Diet information

Exercise Information

Education reinforcement

Regular Follow-up

CMC-Biddle Point

Family Practice

Comprehensive

Diabetes Management

Approach

Stacy -PharmD

Intensive Management

Medication counseling

Insulin teaching

Education reinforcement

Refer as needed

Social Worker

Transportation issues

Financial issues

Pharmacy Departments

Patient assistance program

Mailbox program


Year one

Baseline

A1c<7: 36%

A1c>8: 43%

Insulin Tx: 16%

Year One

A1c<7: 35%

A1c>8: 39%

Insulin Tx: 23%

Year One


Example 2 diabetes improvement gim at unc

Example 2: Diabetes Improvement—GIM at UNC

  • Just working harder doesn’t lead to better outcomes

  • Doctors in the system don’t follow algorithms or policies very well

  • Other members of the health care team are better

  • Just making a policy doesn’t mean the process gets done


Status of lipid management september 2004

Status of Lipid Management September 2004

  • 55% of patients had total cholesterol tested annually

  • Approximately 68% were prescribed statins

  • Average total cholesterol = 185 mg/dl

  • Average LDL = 99 mg/dl


Improving performance in practice

Start

Automated

Stop

Automated


Improving performance in practice

Start

Automated

Re-Start

Automated

Stop

Automated

Stop

Automated


Improving performance in practice

Start

Automated

Re-Start

Automated

Stop

Automated

Stop

Automated


Front desk process

Front Desk Process

  • List of patients with diabetes

  • Whether or not labs need to be drawn

  • Patients that needed labs that were not getting triaged appropriately

  • Looked at front desk logs

Plan/Do

Study


Front desk logs

Front Desk Logs

  • About 60 patients with diabetes/week

  • 30 needed a lab drawn

  • Only 15 had it drawn (50%)

Study


Pizza for 90 fidelity

Pizza for 90% Fidelity

Act-Plan

  • 25/33 = 75% No pizza

  • 34/36 = 94% PIZZA

Study


Improving performance in practice

Start

Automated

Re-Start

Automated

Stop

Automated

Stop

Automated

Front desk fidelity


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