Do-It-Yourself Health Reform: Use QI In Your Practice Now

1. Do-It-Yourself Health Reform:Use QI In Your Practice Now Ron R. Jones MD, FACP Summa Health System Department of Medicine Akron, Ohio Ohio ACP Practice Innovations

2. Future of Ambulatory Care • Six (Urgent) Aims for Improvement • Safe • Effective • Patient-centered • Timely • Efficient • Equitable Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC. National Academy Press; 2001:1

3. What are the components of the Patient-Centered Medical Home? • Physician-directed • Patient-centered • Cost-efficient (sustainable) • Capacity to coordinate high-quality, accessible care • Longitudinal care emphasized • Activate patients for effective self care; individualized care plans American Academy of Family Physicians, American College of Physicians, American Osteopathic Association, American Academy of Pediatrics. Joint principles of the patient-centered medical home (PC-MH). March 5, 2007. (Accessed September 2, 2008, at http://www.acponline.org/pressroom/pcmh.htm.)

4. PCMH National Demonstration Project: Initial Lessons • Required: “re-imagined practice” • EMR systems still lack essential features • Requires personal transformation for physicians • Change fatigue an issue • Smaller changes build on a functional core of physicians and staff to increase adaptive reserve • Transformation is essentially a local process Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient centered Medical Home. Nutting, et al. Annals of Fam Med 06.09.09

5. Most medical offices unprepared to operationalize quality outcome work • Ambulatory delivery design has a “one and done” mentality • Mechanisms to track key indicators for quality missing • QI is seen as a hospital or health organization activity • Underpowered systems for data capture • Poor coordination of patient health data across systems Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient centered Medical Home. Nutting, et al. Annals of Fam Med 06.09.09

6. Our office: the dream- and the reality • Our practice touts quality as a target but is actually designedfor throughput and billing capture • We are more physician andoffice centered than patient centered • Little experience with outpatient quality initiatives • Little team based problem solving • Resident learnersunprepared for outcomes driven office PCMH Office?

7. Health care reform: QI ready? Our aim is twofold: • Apply an effective QI strategy to a busy practice without negative impact on productivity or cost • Refine the steps that a resident graduate could use to add this functionality to existing practices Am I QI Ready? Using quality outcomes is a reform driver.

8. Practice Demographics: IMC Residency-based clinic: mixed faculty and resident practice • Average visits/day 120 Average age/years 61 African American % 49 Unmarried % 70 Unemployed % 80 Medicaid % 38 Uninsured % 31 Education/ years 11.4 Known diabetic diagnosis 9

9. Getting ready for change Reviewed successful approaches: • Reviewed evidence-based strategies • Institute for Healthcare Improvement • Breakthrough Model for Change • IOM: Crossing the Quality Chasm • We Selected PDSA methodology

10. What is a PDSA Cycle? • Study just 5-10 patients in each test • Set clear measures for success • Evaluate costs and effects of change while system resistance is low • Study impact with a few patients: adjust, re-test until new standard is ready for spread Act Plan Study Do More on PDSA use at: http://www.ihi.org

11. Using PDSAs as a Basis For Spread Small scale tests of change A P S D A P S D A P Small test Population S D Total Clinic Population Spread to become Standard of Care

12. Steps to build a quality focus for the practice What did we do? • Formed a change team • Used free software to create a baseline • Picked quality targets meaningful to our practice • Involved staff in designing a new process of care • Used short, small tests of change in 5-10 patients • Reviewed, tweaked, redeployed with update

13. Form a “Change” Team Change Team: a small sampling of the practice staff that will focus on simple measures of quality: • In a small office, involve 1 person from front desk, MA or nursing, provider champion (possibly you) • Plan to meet twice monthly • Download and use team formation materials from • Focus on active tests of change: avoid fatigue • More resources for the change team at www.improvingchroniccare.org

14. Use free software to perform a baseline quality measure • Consider using registry software that is free and downloadable • If you have adopted an EMR, there may be a registry function for some measures • Your affiliated hospital may already collect some outcomes and will help you with creating reports • Present your baseline data in comparison with national or regional outcomes for the disease (Motivates providers and staff together) • Downloads with on line support at www.cdems.com

15. Pick a simple quality outcome that is meaningful to your practice (PDSA-Plan) • We selected diabetes and chose to measure Per cent A1c ordered yearly (Process) Per cent of patients with A1c < 7 (Outcome) Per cent of visits where step up of care needed and given (Process) A1c (mean) for all diabetic patients (Outcome) • Other targets: preventative care, smoking assessment

16. Involve your staff in designing a new process of care (PDSA-Do) • Start with a process not being done consistently • Let the practice staff suggest a solution • Select simple measures for success (20% improvement or more) • Help the change team set up a test of the new process; include roles, fewest steps possible • Example: How to be sure an A1c was ordered annually on this patient?

17. Test the change for only 30 days or 30 patients (PDSA-Do) • Be sure everyone in the office is aware of the test • Too large or too long a trial can systematize a faulty approach • Watch for inefficiencies introduced by the design • Example: Add a routing slip to check off needed tests as patients are roomed: took longer to room them.

18. Review what happened and redeploy with any changes (Study, Act) • Ask the change team, “How did it go?” • Preserve what works; adjust what did not. • Retry using the adjusted approach. • Example: When routing slip was added, patients took longer to room. Next test: try doing the check during spare moments the day before using the list of scheduled patients. No loss of rooming efficiency. Spread the updated PDSA test to more patients.

19. Results: Diabetes measures Reflects 560 patients with diabetes seen over a 12 month period from 2008-2009. A registry integrated with EMR was used to run reports.

20. Becoming a PCMH: Changes & Challenges American College of Physicians Policy Monograph: 2006; Institute of Medicine

21. Making Change: Resistance is Normal Barriers you will encounter • Provider resistance • “We’re doing fine right now.” • “We don’t have time.” • “We can’t afford this.” • Staff resistance • “I already have so many other things to do.” • “That’s not my responsibility.” • “I can’t tell what the doctor did from the note.”

22. Lessons Learned: Changing the practice • Use a simplified, clear strategy agreed upon by entire office to measure and improve key quality measures. • Use small tests of change to minimize impact when they fail and gain acceptance by demonstrating “best practice” within your own office. • A “change team” with a physician team leader can help an office keep moving forward to develop a new culture of measurable quality, while managing “change fatigue”. • The greatest challenge is changing the operational goals of the practice to include regular quality measures and steps to improve.

23. TRANSFORM Curriculum at Summa IM How do we prepare residents to work in offices using the Patient Centered Medical Home? Teach EB for CCM Registry use Assess with EHR New delivery design Skill-based learning Foster change (PDSAs) Organize for care teams Reflect on safety, quality Manage office transition

24. References • American Academy of Family Physicians, American College of Physicians, American Osteopathic Association, American Academy of Pediatrics. Joint principles of the patient-centered medical home (PC-MH). March 5, 2007.(Accessed September 2, 2008, at http://www.acponline.org/pressroom/ pcmh.htm.) • Nutting, et al. Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient centered Medical Home. Annals of Fam Med 06.09.09 • Higashi, et al. Relationship between Number of Medical Conditions and Quality of Care N Eng J Med 2007 356: 2496-2504 Robert Wood Johnson funded evaluation of the Chronic Care Model and IHI Breakthrough Collaborative • Nutting, et al, Use of Chronic care Elements Is Associated with Higher-Quality Care For Diabetes. Annals of Family Medicine Vol 5, No. 1, Jan-Feb 2007 • American College of Physicians Policy Monograph: 2006; Institute of Medicine

25. References • Access practical information and download tools to begin implementation of chronic care model strategy for your office setting. http://www.ihi.org • Access NCQA overview and download an office evaluation worksheet for the patient centered medical home (PPC-PCMH) www.ncqa.org/ppc-pcmh. • Overview of the industry and medical collaborative medical home project guiding healthcare reform efforts nationally. http://www.pcpcc.net • Consensus guidelines for Diabetes: www.diabetes.org • Consensus guidelines for CHF or HTN: www.acc.org