Need for Quality, Introduction to Quality Improvement and PCMH

1. Need for Quality, Introduction to Quality Improvement and PCMH Thanks to Migrant Clinics Network , Institute for Health Care Improvement, Marc Williams- Intermountain Healthcare & Mike Hindmarsh MacColl Institute for Health Care Innovation Institute For Healthcare Improvement Paul Bray, MA, LMFT Assistant Research Professor, Dept. of Family Medicine, ECU Work e-mail pbray@pcmh.com

2. Why are we discussing improving quality in health care? • It is the center of discussion with health care reform:All reform emphasis quality • It’s on your certification exams: Specialty board certification & JCAHO (Joint Commission on Accreditation of Health Care Organizations) accreditation • It can increase your pay: Incentive pay, managed care pay, patient centered medical home and Pay for performance • It can keep you competitive: Learn about quality improvement because it is a world wide movement • Most important, for your patients: Learn about the methods to help your patients

3. Do we have a quality Problem in US health care? Consensus: We do not have a problem we have a CRISIS! The IOM Quality Report- To Err Is Human: Building a Safer Health System

4. To Err is Human Medical Injuries IOM November 1999 Report • 44,000-98,000 deaths per year through medical errors • More people die from medical • errors than from breast cancer or • AIDS or motor vehicle accidents • 100,000 deaths per year from procedures/surgery complications, exceeding motor vchicle deaths • Direct health care costs $9-15 • billion/year • It’s a conservative estimate!!

5. March 1, 2001 “Between the health care we have and the care we could have lies not just a gap, but a chasm.” The IOM Quality Report- Update 2001

6. How Good Are We? • Only 50% of Americans receive recommended preventive care • Patients with acute illness • 70% received recommended treatments • 30% received contraindicated treatments • Patients with chronic illness • 60% received recommended treatments • 20% received contraindicated treatments Schuster et al. How good is the quality of healthcare in the United States? Milbank Quarterly 76:517-63, 1998

7. The toll on patients is high: US DataSource: Elizabeth McGlynn, et al. “The Quality of Health Care Delivered to Adults in the US.” NEJM 2003; 348:2635-45 CONDITION SHORTFALL IN CARE AVOIDABLE TOLL Diabetes Hypertension Heart attack Pneumonia Colorectal cancer Average blood sugar not measured for 24% 29,000 kidney failures - 2,600 blind Less than 65% received indicated care - 68,000 deaths 39% to 55% didn't receive needed medications - 37,000 deaths 36% of elderly didn't receive vaccine - 10,000 deaths 62% not screened - 9,600 deaths

8. Source: World Bank’s World Development Indicators, UC Atlas

9. "This week I conveyed to Congress my belief that any health care reform must be built around fundamental reforms that lower costs, improve quality and coverage, and also Protect Consumer choice," Barack Obama June 6, 2009

11. The IOM Quality report: A New Health System for the 21st Century • Institute of Medicine • “The current care systems cannot do the job.” • “Trying harder will not work.” • “Changing care systems will.” http://www.iom.edu/CMS/8089.aspx

13. Chronic Care Model or Planned Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

14. Primary Care as the key to Quality: Patient-Centered Medical Home (PCMH) The  patient‐centered  medical  home  is  a  model  for  care  provided  by   physicians  practices  that  seeks  to  strengthen  the  physician‐patient   relationship  by  replacing  episodic  care  based  on  illnesses  and   patient  complaints  with  coordinated  care  and  a  long‐term  healing   relationship. Reimbursement is central to PCMH and Quality Improvement Reform Proposal: fees + PCMH pay-per-patient + performance from system of quality

15. Characteristics of PCMH (National Center for Quality Assurance) 1. Team based care 2. Whole person orientation 3. Care coordination 4. Enhanced access 5. Systems for quality 6. Systems for safety

16. How do we know a clinic is a PCMH •   24/7 Access  and  Communication   •   Patient  Tracking  and  Registry   • Functions   •   Care  Management from a nurse • or other non-physician   •   Patient  Self‐Management  Support   •   Electronic  Prescribing   •   Test  Tracking   •   Referral  Tracking   •   Performance  Reporting  and     • Improvement, team reviews results   •   Advanced  Electronic  Communications

18. How do we have “systems of quality”?(One of the 6 requirements of a PCMH) • Set a goal (if you do not have a target, that is what you will hit) • Form a team • Take Small steps • Measure your progress- collect data

19. CORE STEPS IN CONTINUOUS IMPROVEMENT (i.e. diabetes) • Define a clear aim (reduced morbidity from diabetes) • Identify and define measures of success. (>40% < 7 A1c) • Form a team that has knowledge of the system needing improvement (physician, dia. Ed, scheduler) • Brainstorm potential change strategies for producing improvement. (add 20 min ed visit to >7) • Plan, collect, and use data for facilitating effective decision making. (measure A1c for ed vs. non ed) • Apply the scientific method to test and refine changes (id best curriculum & self-management)

20. What is the PDSA Cycle? Act Plan • What changes • are to be made? • Next cycle? • maintain modify add to the plan • Objective • Questions and • predictions (why) • Plan to carry out • the cycle (who, • what, where, when) Study Do • Complete the • analysis of the data • Compare data to • predictions • Summarize what was learned • Carry out the plan • Document problems • and unexpected • observations • Begin analysis • of the data

21. How do we get there? • Define a Problem • Set a Goal • Form a Team • Plan for a change using “small scale steps” • Do the change • Study- collect data & analyze change/outcome • Act – correct, repeat, spread, install

22. Achievements • In the first Diabetes Collaborative applying the CCM; enrolling 16,000 people with diabetes. • The national shared performance measure of “two Hemoglobin A1c (HbA1c) tests done within a year” increased by almost 300%. • Diabetes pilot patients had significantly reduced CVD risk (pilot>control), resulting in a reduced risk of 1 cardiovascular disease event for every 48 patients exposed(RAND Corp. Study www.improvingchroniccare.org).

23. Reading List for Residence First QI Application Session • ECU Getting Started Powerpoint Presentation • CQI Family Medicine CQI Introduction • Mike Hindmarsh chronic care model intro • IHI Improvement Methods Intro Web Site • http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/ • Tools: Cause-effect “Fish-bone” exercise • http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/Cause+and+Effect+Diagram.htm • Tools: Pareto Diagram Exercise • http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/Pareto+Diagram.htm

24. Resources http://www.ihi.org: Institute for Healthcare Improvement, tools to print , “how to” manuals http://www.healthdisparities.net: collaboratives done at HRSA clinics, Handbook for many chronic conditions (diabetes, asthma, CHF etc) http://betterdiabetescare.org: info for practitioners

25. Resources • http://www.Improvingchroniccare.org • Educational materials for patients http://www.ncdiabetes.org/ • http://www.aace.com • http://ndep.nih/gov • http://www/cdc/gov/team-ndep • http://www.diabetesatwork.org