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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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Compass
COMPASS

Using Data for Improvement

Establishing the Current Condition and Identifying Opportunities for Improvement

Robert Ferguson

Program Manager


Purpose and objectives
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
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

  • 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
PRHI’s Systems Vision

Data to Treat, Measure, Evaluate

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

Collaboration and Integration

Perfect PatientCare

Rewards

for Collaboration

Across Care Settings

Medication Reconciliation

Screening and Tx

Essential Services System Requirements

Hospice/Palliative

Long Term Care

Rehab

Hospital

Emergency Services

Specialty Care

Primary Care

Care Mgt

Patient Engagement

Health IT

QI Training

Payment Incentives

Clinical Pharmacy

Behavioral Health



Compass

  • 31 COMPASS-PA Primary Care

  • PCP Offices from 3 Groups:

  • Saint Vincent Healthcare Partners

  • Excela Health Medical Group

  • Premier Medical Associates


Compass objectives
COMPASS Objectives Primary Care

  • 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
PRHI’s Framework for Collecting and Responding to Data Primary Care

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


The lean perspective
The Lean Perspective Primary Care

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
The Motivational Interviewing Perspective Primary Care

A way of being with people which is…

  • Collaborative

  • Evocative

  • Respectful of autonomy


Method
Method Primary Care

  • 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



Process mapping visualizing the current and future condition
Process Mapping Primary CareVisualizing the Current and Future Condition

Well-functioning aspect of work

Improvement

Opportunity


A3 improvement plan
A3 Improvement Plan Primary Care


Incremental improvements towards the ideal
Incremental Improvements Primary CareTowards the Ideal

Target

Condition

PDSA/A3

PDSA/A3

Each improvement moves the process closer to the ideal

Current

Condition



Example 1 ehr data at one medical group
Example 1: EHR Data at One Medical Group Feedback on Skill Development


Population health current condition
Population Health Current Feedback on Skill DevelopmentCondition

January 2013


Phq 9 screening current condition by office
PHQ-9 Screening Current Condition, by Office Feedback on Skill Development

October 2013

44% PHQ-9 Completion

19% PHQ-9 > 9

67% Enrollment



Compass patient enrollment by regional partner
COMPASS Patient Enrollment Feedback on Skill DevelopmentBy Regional Partner

June 13, 2014


Initial data completeness by medical group
Initial Data Completeness Feedback on Skill DevelopmentBy Medical Group

June 13, 2014


Phq 9 documentation
PHQ-9 Documentation Feedback on Skill Development

June 13, 2014


Depression improvement baseline vs most recent score
Depression Improvement: Feedback on Skill DevelopmentBaseline vs. Most Recent Score

June 13, 2014


Depression remission among those in compass for 119 days
Depression Remission: Feedback on Skill DevelopmentAmong Those in COMPASS for > 119 Days

June 13, 2014


A1c documentation
A1c Documentation Feedback on Skill Development

June 13, 2014


A1c control rate baseline vs most recent value
A1c Control Rate: Feedback on Skill DevelopmentBaseline vs. Most Recent Value

June 13, 2014


Bp documentation
BP Documentation Feedback on Skill Development

June 13, 2014


Bp control rate baseline vs most recent value
BP Control Rate: Feedback on Skill DevelopmentBaseline vs. Most Recent Value

June 13, 2014


Hospital admissions self reported
Hospital Admissions (Self-Reported) Feedback on Skill Development

June 13, 2014


Example 3 cmts data at one medical group
Example 3: CMTS Data at One Medical Group Feedback on Skill Development


Compass

COMPASS PHQ-9 Feedback on Skill Development

May 2014 CMTS Data

Last Follow-up PH-9<10

28%

Initial Contact PH-9>9

Last Follow-up PH-9>9

41%

99%

32%

No Follow-up PH-9

Entered in CMTS

Initial Contact PH-9<10

1%

100%

Last Follow-up PH-9<10


Compass

COMPASS A1c Feedback on Skill Development

May 2014 CMTS Data

Last Follow-up A1c<8.0

12%

Initial Contact A1c > 7.9

Last Follow-up A1c>7.9

41%

49%

47%

No Follow-up A1c

Entered in CMTS

Last Follow-up A1c<8.0

43%

30%

Initial Contact A1c<8.0

Last Follow-up A1c>7.9

10%

48%

No Follow-up A1c


Compass

COMPASS SBP Feedback on Skill Development

May 2014 CMTS Data

Last Follow-up SBP<140

23%

Initial Contact SBP>139

Last Follow-up SBP>139

15%

37%

62%

No Follow-up SBP

Entered in CMTS

Last Follow-up SBP<140

48%

Initial Contact SBP<140

17%

Last Follow-up SBP>139

60%

36%

No Follow-up SBP


Example 4 cmts data at another medical group
Example 4: CMTS Data at Another Medical Group Feedback on Skill Development


Compass

March 2014 Feedback on Skill Development


Example 5 cmts data of follow up contacts
Example 5: CMTS Data of Follow-up Contacts Feedback on Skill Development



Compass pa s next steps
COMPASS-PA’s Next Steps Manager

  • 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
Care of Mental, Physical, and Substance use Syndromes Manager

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.