B Block MD Chief Learning and Medical Informatics Officer

1. Implementing quality improvement in the ambulatory setting: Lessons and cautions from the Pittsburgh Regional Health Initiative B Block MD Chief Learning and Medical Informatics Officer

2. Practice Assessment • Productivity • Quality Metrics • Adaptive Reserve • PCMH-a

3. Productivity

4. Mandated Quality Metrics

5. Adaptive Reserve Practice A. Practice B Practice C Practice D Practice E Practice F Practice G Ann Fam Med. 2010 May; 8Suppl 1: S9–S20.

6. PCMH-a Network Assessment PCMH-a Practice Assessment Scale 1 to 12 higher is better http://www.safetynetmedicalhome.org/resources-tools/assessment

7. Using Data to Motivate and Engage • Practice Outputs • Patient Outcomes • Patients Lost to Care • Exploring the Causes

8. How Good is Your Diabetes Care? “It’s notperfect,but it is very good.” Network Diabetes Data Review

9. Root Cause Analysis

10. Leadership Engagement • Network Leader Responsibilities • Practice Leader Responsibilities • Practice Member Activation

11. PCMH-a Organizational Assessment: Engaged Leadership

12. Practice Site Leadership • Take on leadership roles within the group practice, heading internal committees that address critical issues. • Develop consensus among providers in the group about pre-visit work, triage, coverage, care protocols, and customer service. • Work with providers in other practices to share better ways to improve patient care outcomes.

13. Practice-based Quality Leadership • Community Relations- work with marketing team to develop direction, review demographics, patient surveys, and strategy. Outreach to community organizations, media, and employers. • Office Access and Scheduling- work with administration, practice manager and office staff to create an access schedule to meet needs of patients. Develop scheduling templates and triage protocols to better fit patients to time and resource constraints. Ensure balancing of workload among providers. • Clinical Workflow- Review current workflows and adapt to improve efficiency. Identify opportunities to standardize efficient workflows. Review documentation trouble spots and suggest remedies. • Management- Provider Relations- Collect feedback from provider colleagues and represent those points of view in discussions with management. Carry management perspectives to providers. Work to find effective collaborations. • Care Team Training- Clarify staff roles, create performance metrics and training modules, provide incentive and remediation options • Practice Sustainability- Align coding, charge capture, and health plan measures with clinical goals. Move towards value based reimbursement and shared savings models.

14. Introducing a Quality Strategy • Combating Hopelessness and Apathy with QI • “Show Us the Work You Do”- Observation • “Help Us Understand the Strengths and the Trouble Spots” - Current and Target Condition • Creating a Vision of the Ideal • PDSA Cycles to Find the Right Solutions

15. “I’m doing everything I can to give good care, but…”

16. Observation

17. CURRENT CONDITION TARGET CONDITION No pre-visit review of testing No performance feedback No Follow-up No EHR reminders No time for wrap-up No care team huddle No standing orders Patient in a rush Connections Roles Activities Pathways Test completion review at huddle Care team report card Pre-visit test completion review EHR Reminders Standing orders Overdue test follow-up

18. IDEAL CONDITION http://www.safetynetmedicalhome.org/sites/default/files/Patient-Care-Reminders.pdf

19. Build QI Capabilities

20. Problems are solved one step at a time – each attempt gets you closer to success PDSA PDSA IDEAL PDSA Current Condition

21. First Step in P-D-S-A PLAN • Identify an important organizational concern • Determine the processes which affect that concern • Explore problems in those processes • Find the cause of the problems • Design the corrective actions Design CorrectiveAction and Metrics Try Out CorrectiveAction

22. Improving Office Processes • System Thinking • Step-wise EHR Training in the Work Context • Staff Communication Training

23. Opportunities to Clarify and Support Medication Use Clinical Pharmacist

24. Opportunities to Clarify and Support Medication Use

25. Pre-Visit: Review the Health Management Plan Step One: Open the patient’s HMP. Look in the To Do column of the HMP for medications with a red triangle. If the patient is not doing well, check the other important as well. Right-click the medication and select “Renew with Changes.” Step Two: In the “Medication Details” window that appears, scrolldown to the “Order and Renewal History” section. Row #1 shows the most recent Rx for the medication. ACTION ITEM: If there is a date in the column labeled DNFB in Row #1, the patient may not have picked up their most recent prescription. Contact the patient to clarify the situation. Document the outcome in the Pre-visit Planning section of the encounter note. Step Three: Click on the “Fill History” button. Compare the Fill date to the date in the Renewal History. ACTION ITEM: If the Fill Date is earlier than the Renewal date, then it is likely that the patient did not get the latest refill. Contact the patient to clarify the situation. Document the outcome in the Pre-visit Planning section of the encounter note. Sometimes the Fill History fails to show a completed refill. This can happen if the information is out of date, or if the patient paid cash rather than using their insurance coverage. Use the patient and the Pharmacist to clarify the situation. If the patient really did stop a critical medicine unexpectedly, then the provider needs to be notified.

26. Compare the Fill and Renewal Dates Prescribed in Dec. 2014 but not filled since June 2014 Discuss with the patient to clarify

27. Clarifying Medication Use • Hello Mrs. Vetri. We were preparing for your visit with us on Tuesday next week. Is 1:15 still a good time for you? • I noticed, in our records, that a prescription we wrote for you last month hasn’t been picked up yet at the pharmacy. Is that correct? It was for lisinopril. • Since our records can sometimes be wrong, I wanted to check that out with you. Did you run into any problems with the prescription? • What would you like to do about the prescription? Patient was having cough and stopped her lisinopril a month ago.

28. Patient Engagement • Preparing the Patient for Self-Care • Clinical Assistant Training Program • Expanding the Visit Wrap-up • Staff Communication Training

29. Health Happens In-Between Doctor’s Visits

30. Exit Phase

31. Wrap-Up: Support, Clarify, and Activate

32. Patient “Education” 1975 Fear of Consequences AuthoritativeAdvice Health

33. Improving care OUTCOMES requires more than GOOD ADVICE and a stern warning Patient Engagement 2015

34. Patient Self-Care Support

35. Beyond Office Care • Systematic Case Review • Limitations in Primary Care Resources • Volume to Value for Whom? • Wellness-Aligned Outcomes

36. Systematic Case Review In the COMPASS initiative, the psychiatrist and medical consultant met weekly with care managers to offer recommendations for the care of patients with poor progress. But We Learned that Elegant Office Care is Not Enough

37. Limitations of Primary Care Settings • Poor communication and alignment with hospital care providers, nursing home, personal care, rehab and hospice programs • Poor connections to behavioral health services and social service agencies • Inadequate clerical and coordination support • No outreach workers, peer community health workers, behavioral health consultants

38. Volume to Value…for Whom? Mandated clinical quality measures merely assess documentation of physician activities or compliance with physician recommendations rather than actual impact on personal wellbeing. http://www.samhsa.gov/wellness-initiative/eight-dimensions-wellness

39. Wellness-Aligned Outcomes

40. Questions? B Block MD Chief Learning and Medical Informatics Officer bblock@prhi.org