All-Hands Meeting

1. All-Hands Meeting 3/26/09

2. Agenda • New organizational chart, staff changes, transition of clinics to the hospital, and updates –Mike Pignone and Malinda Williams • Residency changes and clinic impact for fy2010 - Paul Chelminski • NCQA Med Home and decision aid dissemination - Carmen Lewis • QI teams: A new way of business – Annie Whitney • Team 2 report – Stephanie Degraffenreid

3. Administrative updateMike Pignone and Malinda Williams

4. Administrative update • Dr. Tom Miller has been appointed Section Chief for Ambulatory Education and Practice • Dr. Cristin Colford has been appointed Clinic Director • Dr. Andrew Sampson will begin as ambulatory Chief Resident in June • We are in the process of identifying a new clinic manager, nurse manager, QI coordinator, and an additional RN • Conversion of specialty clinics to hospital-based status in progress; Geriatrics will be moving this Summer

5. Residency changes and clinic impact for fy 2010 Paul Chelminski

6. Fragmentation

7. Resident Clinic Improvement Background: Mandate to increase clinics from 108 to 130 over 3 years. An opportunity!! Objectives: • De-fragmenting clinic experience • Putting continuity into continuity clinics • Building ownership of environment • Building clinic cohesion

8. Resident Clinic Changes:Boots on the Ground • Full days in clinic while on consult months • Enhances continuity with patient • Enhances continuity with the clinic • Fewer morning “on-call clinics” • Early, more intensive exposure to ambulatory medicine • Intern Continuity Rotation

9. Intern Continuity Rotation • Four week rotation • 23 interns (2 per month) • Diverse learning environment • Continuity clinic • Same Day Clinic • Disease Management (Pain, Anti-Coag, DM) • Quality Improvement Sample Intern Schedule

10. Outpatient Chief Resident

11. Outpatient Chief Resident • Dr. Andrew Samspon, 2009-2010 • Dr.Krista Fajman, 2010-2011 • Housed in IMC • Responsible for ambulatory education of residents • Faculty (Clinical Instructor) in Department of Medicine

12. Outpatient Chief Responsibilities & Roles • Organize conferences • Develop and refine ambulatory curriculum • Spearhead quality improvement initiatives • Role model, mentor, leader • Implement structural changes in clinic • Lead clinic improvement teams • Scheduling and coordinating inpatient/outpatient duties.

13. Integration-Continuity

14. NCQA Med Home and decision aid dissemination Carmen Lewis

15. Improving Quality of Care in the ACC The next step……. Patient Decision Quality Initiative

16. Our Success, Progress, and Plans • Diabetes Care • Pain Management • Anti-coagulation • Ongoing CQI teams • Training Nurses, Staff, and Physicians in CQI techniques

17. CQI to Date • Focused on us (staff, nurses, CAs, docs) • Necessary but not sufficient • Need for more patient involvement • Take us to next level

18. Why is it important to include patients?

19. “What can I do as a patient?” Sara Malone at All Hands MeetingAug 2008

20. Is There a Need?

21. Institute of Medicine

22. Quality Measures

23. Patient Center Care Consistent with Our Goals • Provide high quality care to vulnerable patients • Continuous improvement • Evidence based • Compare to national standards

24. The PCMH Model • PCMH is a model for care that seeks to: • Strengthen the physician-patient relationship • Replace episodic, complaint driven care with coordinated/planned care • Promote a long-term, healing relationship

25. Why Now?

26. Why Now? • States are legislating shared decision making • UNC leader in the field • Help define quality and measures to become national standards • IMC will be submitting application for PCMH recognition from NCQA in the next year

27. Washington State Legislation

28. How Do We Get There?

29. Like We Have Before • PDSA cycles • Measures • Teamwork

30. Decision Aids for Patients • Implement these to help us achieve patient centered care • Decision aids provide patients with information and explore their personal values • Prepares them to interact with their doctor so they are able to express their preferences

31. Previous Work • Mail out • Reaches all potential eligible patients • About 10% viewed or requested decision aid • In clinic (Kylee Miller) • Approached 69% came to appt • Viewing • 66% viewed some • 36% viewed all • Pre-visit plus in as follow up clinic • Reached 75% • Almost all viewed

32. What is next?

33. Current Efforts to Implement Decision Aids • Working on automating the process as much as possible • Goal to continue to deliver decision aids for cancer screening ( colon cancer, prostate cancer) • Add symptom driven and chronic diseases

34. Vision for the future • Improve the care of our patients by providing care that is respectful and responsive to patients preferences and personal values

35. Decision Aid DVDs are in circulation! For this, contact Alison Brenner or Chris DeLeon. Alison and Chris sit in the West Wing’s old nurse triage. Call them at 6-0106. This is Chris: This is Alison: These are the Decision Aid DVDs

36. QI teams: A new way of doing business

37. Quality ImprovementWhat are our goals/mission? • We: • strive to excel in providing high-quality, innovative care for medically complex patients • employ a care model that promotes a strong doctor-patient relationship and continuity of care • believe in a team approach to care, everyone in our practice contributes to patient care • embrace the principles of quality improvement (establish practice standards, monitor our performance and adjust our practice to improve care)

38. QI Team Meetings • In the past, QI work has been focused in Enhanced Care and individual resident projects • To support our mission and goals we need all clinic staff involved • So we created four CLINIC QI TEAMS • Each team has a facilitator (Malinda, Tim S, Jo W, Judy M) • All staff are a member of a team • Teams meet twice a month (plus once a month staff meeting) • Weekly huddles are encouraged in common work areas

39. QI Team Meetings The first clinic-wide QI meeting was held 1/15/09 All staff completed baseline survey of clinic processes Multiple processes identified for improvement Top four processes: Refills, answering phones, messaging and appointment system Other processes: Pre-authorization of services, phone advice, referrals, scheduling procedures, reporting diagnostic testing

40. What is our QI process? Utilize the model for improvement What are we trying to accomplish? How will we know that changes are an improvement? What changes can we make that will result in an improvement? PDSA mentality Plan a test/change, Do the test/change, Study the results, Act – more tests or implement change? Support all staff by providing QI training

41. QI Team WorkTeam 2 Report:Stephanie Degraffenreid

42. QI Team 2: Focus=RefillsTeam Representative:Stephanie Degraffenreid • Goal: Standardized, reliable, and timely resolution of refill requests and prior authorizations • Areas of concern: • We have a 72 hour policy re responding to refill requests • Refill algorithm was unclear • Significant rework as pharmacies and patients call/fax while awaiting response • Providers often limit refills on chronic meds to 1-2 vs. prn

43. Changes made: Moved a nurse from the clinic to the phone room answers patient calls processes resident refills and prior authorizations Now reevaluating volume of refills, nurse calls, and prior authorizations Next Steps: Want to engage residents in the process Currently identifying examples and determining volume of limited refills provided on chronic meds Evaluating staff opinions re changes that were made re Prescription refills Assessment of OCB admin staff Spend a lot of time on phone with refills Additional message needed on phone tree re refill policies (like 6-1459) QI Team 2: Focus=RefillsTeam Representative:Stephanie Degraffenreid

44. QI Team 1: Focus=Call Routing • Goal: Reduce number of misdirected calls and transfers. • Changes made: • Removed provider option from voice message. • Home health, pharmacy and nurse calls go to nurse in phone room. • OCB staff have received GE training and are able to schedule appointments. • Enhanced Care message shortened. • Located a toll-free number for the hospital: 1-866-595-3175. • Reduced stress for nurses and staff because less paging and messages.

45. QI team 3: Focus=Messaging • Goal: Standardized, reliable delivery of patient communication to providers with ability to track performance • Assessments performed: • Survey by Liz Thomas of provider messaging preferences • 59 responses • 25 attendings and 34 residents • Preferences • 71% WebCIS message, 29% email, 12% pager, 7% in person • Frequency of use • 32% check WebCIS greater than 10 times a day • 48% check their email 1 to 3 times a day • Next steps: • Investigate messaging system through Clinic Support Website

46. QI Team 4: Focus=Check-in Flow • Goal: Improve efficiencies in the check-in process for patients and staff • Changes implemented: • Standardized front desk materials and work stations • Add second addressograph and credit card machine at each desk • Review and standardize scripting to improve data capture before pts come to clinic  • Cross training of all front desk staff to improve patient flow • Next steps: • Develop a system to assign residents to one side of clinic consistently • Improve communication of provider assignments (who is in clinic and where) • Review procedures for prompt rooming of “first patient” in AM and PM

47. QI Teams: Next Steps • Train more clinic staff in QI • Health Care System sponsors Six Sigma QI training • Some team facilitators have attended yellow belt training • Goals: • All Division staff complete yellow belt training • Identify Attendings interested in training • QI leaders complete Green belt training • Get more providers on teams • Drs. Miller, Colford, DeWalt and Lewis will be joining teams • Dr. Liz Thomas is first resident to join QI team

48. We need you Dr. ______