URBAN HEALTH PLAN “OUR QUALITY JOURNEY”

1. URBAN HEALTH PLAN“OUR QUALITY JOURNEY” Paloma Hernandez Health Foundation of South Florida November 15, 2007

2. URBAN HEALTH PLANBRONX, NEW YORK • Founded in 1974 by Dr. Richard Izquierdo • El Nuevo San Juan Health Center • Bella Vista Health Center • Plaza del Castillo Health Center • 5 School Sites 4 Off Sites • 2 Administrative Sites • 2006 Volume: 150,000 • Users: 27,500 • 2007 Budget $ 29,000,000

3. Overview of Urban Health Plan • JCAHO accredited (2003, 2006) • Federally Qualified Community Health Center since 1999: FQHC Look alike since 1993 • Primary Care, 17 Sub-specialty, Ancillary, and Support Services • 325 staff members, 60 medical providers • Largest employer in our zip code • Expansion Plans-Queens, Main Site Expansion

10. Our Performance Improvement Journey • 1993 – Desire to move from QA to CQI • 1994/1995 – Compliance Project • 1999 – Became an FQHC • 2001 – Health Disparities Collaborative • 2003 – Masterminds (Internal Collabortives) First Attempt at EHR Implementation First JCAHO Survey • 2005 – Creation of our Quality Institute: Institute for the Advancement of Community Health • 2006 – Full successful EHR implementation • 2006 – JCAHO Re-Survey • 2007 – Corporate Dashboard • 2007 – Provider Compensation Program • 2008 – Service Excellence

11. Compliance Program(1993-Present) • Review of NYS Regulations • Development of Committee Infrastructure - Quality Council - Clinical Quality Sub council - Operations Sub council • Development of Reporting Tools-Logs • FOCUS: Data Collection

13. Participation in BPHC Asthma II Collaborative • NYC DOH Community Initiative Winding Down • Unacceptable Prevalence and Hospitalization Rates of Asthma • Inability to jumpstart our own Asthma Program in spite of funding • Exciting Venture for Staff – Reward • Federal Initiative • Desire to improve health outcomes

14. Bureau of Primary Health Care Asthma II Collaborative • Applied BPHC Health Disparities Collaborative Methodology 1. Learning Model 2. Chronic Care Model 3. Model for Improvement • Accomplished significant improvements across the six components of the Chronic Care Model • STAR TEAM

15. Impact of Learning Model • Provided structure • Provided a timeframe to complete work • Provided structured periodic review of work • Permitted interactions with other health centers outside of New York City • Permitted for an exchange of work while seeking a common solution

16. Chronic Care Model A population-based model that relies on knowing which patients have the illness, assuring that they receive evidence-based care and actively aiding them to participate in their own care Provided comprehensive framework from where to begin to our work Six components

17. Impact of Model for Improvement • Rapid PDSA • Helped develop specific and measurable goals • Integrated well into fast paced corporate culture • Allowed for testing in small increments • Dealt with resistance

18. Results of our Asthma Experience • Significant improvement in hospitalization rates in children as documented by the NYCDOHMH and United Hospital Fund • Increased user base • Awarded grants to impact asthma care in schools and homeless shelters by the United Way of NYC • Development of asthma health education program • Awarded USA EPA Exemplary Award for Asthma Management

19. Internal Spread of the Care Model • Wanted to spread success of Asthma to other areas • Attempted with preventive health in pediatrics and adults and struggled….. • Lacked knowledge (participating is not the same as running one independently) • Retained Consultant and envisioned a “Train the Trainer” Program • Secured funding from the United Hospital Fund • Began Planning in September 2002 • Kickoff of our Mastermind Program March 2003

20. Implementing an Internal Collaborative Strategy • Made a decision to use the Collaborative Model as a framework for our Quality Management Program • Masterminds: Train the Trainer Program as a means of achieving sustainability of this new initiative • Use of Care Model as a organizational framework for developing programs and carrying out business objectives

21. Urban Health Plan’s Dream • To redesign current departmental practice by implementing the methodology of the Breakthrough Series Model, Model for Improvement, and the Care Model in an interdisciplinary approach of train-the-trainer for all areas of our organization, clinical or non. • Focus on training five managers as Masterminds and five staff members as Team Leaders. • By January 2004 there will be ten managers trained in this methodology with the ability to train others. • Within three to five years this collaborative method of doing business will be integrated throughout the entire organization

22. Mastermind: Train the Trainer Program 1. Developed an AIM Statement 2. Developed a Population of Focus 3. Developed Outcome Measures 4. Selected Team of Masterminds 5. Selected Collaborative Teams 6. Selected Team Leaders 7. Kick off Teams

23. Masterminds • Five teams : Depression, Teen Obesity, Diabetes, External Referrals, A/P • One Spread Team: Asthma • Shared vision, people got excited, created critical mass • Built momentum • Replicated the models exactly a taught • Not everything works the way you want it to !!

24. Impact of the Mastermind Program on the Health Center • Received full Board Attention • Became incorporated into fundraising plan • Care Model became the Performance Improvement methodology used in the organization • Increased funding for health education programs • Strategic community partnerships • Creative development of educational materials • Increase in asthmatic patients at center • Development of clinical registries • Improved ability to measure outcomes • Integration of clustered visits • IMPROVED STAFF MORALE • Improved staff retention

25. How We Made It Happen FINANCIAL AND HUMAN RESOURCE STRATEGY…. • Secured funding for Consultant • HRSA support for Registry Coordinator • Fundraising Strategy that worked • Use of Student Internships • Improved use of Medical Assistants • Strategic Community Partnerships ORGANIZATIONAL COMMITMENT….. • Committed Board and Senior Leadership • Organizational Alignment • Commitment of Time and Resources • Full integration into QM Plan

26. Urban Health PlanQuality Management Program • Program focuses on both clinical and non clinical areas • Monitors clinical and administrative performance indicators through committee structures • Designed to meet community needs through prioritization of topics by medical and administrative leadership • Incorporates Care Model as framework for all improvement • Incorporates Rapid PDSAs as the tool to test changes and make improvements • Makes use of performance improvement teams and focused performance improvement projects

27. Evolving Organizational Health Care Delivery System • Establishment of the Learning Center for Professional Development • Ongoing training on models, especially PDSAs • Adoption of Collaborative model as QM methodology throughout the organization • Development of Health Education Department • Establishment of a QM Department with a Director who is knowledgeable on collaboratives • Registry Coordinator • Ongoing organization wide focused PI projects

28. Mastermind Experience • Asthma Team • 5 Internal Collaborative Teams - Diabetes - External Referrals - Teen Obesity - Finance - Depression • Pediatric and Adult Prevention • Cancer Screening • Type 2 Diabetes Prevention • HIV Healthy Behaviors • 4 new teams ( kick off 6/07) - Diabetes II - Geriatric Program Development - Cycle Time - Teen Pregnancy Prevention Program Development 8 Masterminds trained to date

29. The Birth of Institute for the Advancement of Community Health • IHI Presentation with the Mayo Clinic • During that conference between our CMO and a Mastermind the Institute for the Advancement of Community Health was born • Very apropos…”poor man’s IHI” • Why IACH ???

30. Mission of IACH To improve the health status of underserved communities by developing and disseminating innovative best practices. Activities: 1. Support Teams 2. Oversee QM Plan and all PI work 3. Developed Risk Management and Safety Committee and oversee activity 4. Staff of 4.5 FTE 5. Will develop Utilization management component

31. The Joint Commission Experiences Performance Improvement Function 2003 • Presented on External Referrals and Diabetes • Surveyors Response • Write up on QM Process • Invited to sit on Ambulatory Advisory Committee 2006 • Presented on further progress with External Referrals and Failure Mode Effect Analysis • Surveyors Response • Write up on Joint Commission Preparation Process and use of process as handout at conferences

32. Spread of PI Work to Risk Management and Safety • Evolution of Risk Management and Safety Committee • Use of Unexpected Event Reporting • Promotion of an “accountable yet blame free” culture • Identification of trends to assess areas needing improvement

33. Unexpected Events

34. Needlesticks Recommendation:Needle-less Retractable Syringes

35. Electronic Health Record Implementation • Failed Implementation • Second implementation-March 2006 • Fully implemented at all sites and all providers-September 2006 • EHR is not a registry • Incorporated measures into EHR system • Reporting Challenges…however possibilities are endless !!!!! • Provider Compensation Program

36. Development of a Corporate Dashboard • January 2006 began an attempt to develop an organization wide dashboard • Integrate financial, operational, organizational, access, and clinical indicators • Goal to begin on Corporate level and slowly develop site/departmental dashboards • December 2006 first comprehensive draft completed • Evolving now to Spider Chart-easier to visualize and analyze

38. SPIDER DASHBOARD

39. Visual Evolution of our Data • Logs – Data Collection • Run Charts – Data Analysis and • Control Graphs – Data Variation • Corporate Dashboard - • Spider Charts

44. SPIDER DASHBOARD

45. Current Focus • Improve efficiencies (cycle time, next 3rd available appt, redesign, open access) • Align Incentive Programs • Service Excellence • Studies have shown that patients who are satisfied with their care have better health outcomes • Different view of Competitors • Patient Satisfaction vs. patient loyalty • Disney Book

46. Next Steps • Continue to work on EHR reporting • Integrate all database functions into EHR • Enhance Spider Graphs • Spread Spider Graphs to other areas • Communicate information throughout organization in order to improve staff’s knowledge base of organizational performance and effectiveness • By doing this…continuous performance improvement can occur at every corner of the organization

47. How Can It Happen For YOU !! • The tools are available • Believe that this work will transform your organization in ways you could never imagine • You must be passionate • You must be willing to start and not look back but give it all you’ve got • It demands true leadership and a lot of hard work • But your organization will be that much stronger for it • At the end, it is up to you to make it happen

48. Biggest Lessons Learned • Rome wasn’t built in a day ! • Every journey begins with a single step !! • The process must begin in order for it to happen !!! • Change is non negotiable…it happens everyday, whether we choose it or not !!!! • Our adaptation to change, however, is up to us !!!!! • We chose to change and today we are working on becoming the very best for making that decision !!!!!!

49. Contact Information Paloma Hernandez President/Chief Executive Officer Urban Health Plan, Inc. 1065 Southern Boulevard Bronx, New York 10459 718 991-4833 paloma.hernandez@urbanhealthplan.org