Ambulatory 401: Building Improvement Teams in Primary Care

1. Ambulatory 401:Building Improvement Teams in Primary Care WREN Conference November 13, 2009 Dr. Sally Kraft Stephanie Berkson

2. Workshop Overview • The Problem • Context • UW Health • The Solution • Physician-Manager Leadership teams • Ambulatory 401 Program • Key Concepts • Applied Learning • The Results • Lessons Learned

3. The Problem

4. Quality problems are everywhere, affecting many patients. Between the health care we have and the care we could have lies not just a gap, but a chasm. IOM Crossing the Quality Chasm 2001

5. Urgent Need to Improve Our US Health Care System • High costs • Rising costs • Disparities in care • Rising rates of uninsured • Medical errors • Growing physician dissatisfaction • Variable quality

6. Quality Improvement: Building High Performing Frontline Teams Berwick. Health Affairs 2002

7. The quality of the microsystem is its ability to achieve ever better care: safe, effective,patient-centered, timely, efficient, and equitable. The quality of an organization is its capacity to help microsystems do that. And the quality of the environment— finance, regulation, and professional education—is its ability to support organizations that can help microsystems to achieve those aims. Berwick. Health Affairs 2002

8. Context: UW Health

10. University of Wisconsin Medical Foundation • UW School of Medicine and Public Health’s academic group practice plan • 1,090 physicians (~300 primary care physicians) • Wisconsin’s largest multi-specialty medical group, one of the 10 largest medical groups in the nation • 48 practice locations • Epic electronic health record • Experience with quality • measurement, members of the WCHQ • Experience with design and administration of P4P

11. UW Health Driving Forces • Organization complexity • Multiple management structures within the same organization • Physician dissatisfaction • Not empowered to improve own practice environment • Need for structures to support delivery of quality care • High Primary Care physician turnover • Recruitment difficulties • Culture shift to local problem solving • Desire to move away from top down solutions • Desire to engage physicians in improvement efforts • Desire to create local accountability • Variable quality across primary care settings

12. Current UW Health Performance in WCHQ Size of the bubble is correlated to the number of eligible patients at each organization

13. UW Health Colorectal Cancer Screening Rates by Clinic UW Health Colorectal Cancer Screening Rates by Clinic 13 Size of the bubble is correlated to the number of eligible patients at each clinic

14. Failure to Build the System that makes it Inescapably Easy to do the Right Thing

15. The Solution

16. UW Health Strategy • Establish new “lead physician” role at all clinics • Pilot with Primary Care • Develop clinic leadership team • Partner lead physician with clinic manager • Promote key principles • Local ownership and accountability for clinical practice within an academic context • Team based delivery of care • Enhance lines of communication • Within site, across sites, across organization • Provide new leadership teams with basic improvement knowledge and skills

17. Ambulatory 401 Program:Building Improvement Teams • Course Objectives • Enhance and develop the physician-clinic manager leadership team • Learn to improve clinic processes & services delivered to patients • Review, learn and apply performance improvement techniques • Provide understanding of the UW Health structures and metrics Build the clinic team, practice and learn performance improvement skills, solve clinic problems Physician lead and clinic manager build the leadership team Build a network of clinics to share learnings

18. Ambulatory 401 Program Format Attendees • Clinic manager and clinic physician leader Time line: • Four, 2.5 hour sessions over 6 months Didactic training topics (including action learning during sessions): • Organizational overview & strategic priorities • Metrics used to monitor efficiency and quality of care • Clinic improvement team approach to change • Process improvement concepts, tools and techniques Applied training: • Each clinic team completed an improvement project • Project results presented and shared Ambulatory 401 Classes: • 9 General Internal Medicine Clinics completed; May 2008 • 11 Family Medicine Clinics completed; January 2009 • 14 Family Medicine Clinics completed; June 2009 • 8 Pediatrics Clinics in progress

19. Ambulatory 401:Curriculum • Leadership skills • Overview of health care quality and the need to improve • Model for organizational improvement • Understanding performance data • Team development • Effective meeting skills • System-based thinking • Performance improvement skills • FOCUS PDCA model

20. The “good” old days Medical care was cheap Quality was not defined and was not measured Physicians practiced autonomously Insurance companies didn’t exist Medical care was simple Medical care was an “art” more than a science Our current state Health care is expensive Quality is measured and reported Physicians practice in large groups, healthcare is integrated in systems Insurance companies are powerful Care is complicated Evidence and information are plentiful Ambulatory 401Why now?

21. Berwick. Health Affairs 2002 Kotter. Harvard Business Review 2007

22. How do we get started? Problem Identification What do we do that is valuable? What do we do that isn’t valuable? Lean Thinking (from Toyota improvement model): Seeing and eliminating waste, i.e. eliminating anything that doesn’t add value to the process Eliminate Keep

23. Value Stream Map A tool to identify non-value added steps in a process. This can be a good starting point to identify problems and their causes. Steps: Define start and end points of the process Identify all current steps in the process, with stakeholders Identify non-value steps (waiting, variation, rework) Validate current state process Create ideal value stream map (only value added steps)

26. Brainstorming A group exercise designed to generate lots of ideas. This should be fun! Get everyone involved. Encourage creativity. Get excited! Steps: • Review the topic with the whole group • Give people time to think silently about the topic • Each person writes down an idea on a card—one idea per card (or write down all ideas on a flip chart) • Post the cards or flip chart papers on the wall • Continue until all ideas have been recorded

28. Affinity Diagram A tool to group large numbers of ideas into clusters so that patterns and categories can be identified Steps: • Ideas from your brainstorming session are posted on cards on the walls • Silently members of the group move the cards into distinct areas on the wall. Cards can be moved multiple time, from cluster to cluster • After the cards have been grouped silently, the entire team identifies “headers” for each cluster

29. Affinity Diagram

30. Multiple small improvement projects, each one building from the earlier project. What do you want in your clinic? Clinic leaders keep the improvement efforts moving forward toward the goal Beginning of Amb 401, Assess your current clinic

31. Ambulatory 401 Physician lead and clinic manager build the leadership team. Build a network of clinics to share learnings Build the clinic team, solve problems Share our learnings Cause and effect (root cause analysis) Small tests of change (PDCA) Creating the vision (brainstorming), Assessing our starting point (SWOT analysis)

32. The Results

33. Ambulatory 101/401 History

34. Results: Teams Made Improvements! • January 2009 Family Medicine class • 11 improvement projects completed • 10 with data documenting improvements in care • June 2009 Family Medicine class • 10 improvement projects completed • 9 with data documenting improvements in care

35. Project Example Change Leader: Cindy Haase, Clinic Manager Team Members: David Quoeff, MD, Joan Premo, RN, TL Improving INR Result Times, Sun Prairie Clinic Aim Statement: We will improve timely communication of INR results to the patient with a goal of contacting the patient with the results within 4 hours or less from the time the lab results are reported for 95% of patients getting INR labs by Jan 1, 2009 focusing on: 1. Developing and implementing a protocol for RN’s to communicate med changes to patients 2. IS changing Epic workflow: All INR results going into both MD and RN Results pools Initial Findings: From 47% to 90% contacted w/in 4 hrs Follow-up Findings: 99% contacted w/in 4 hrs Patients Contacted w/ INR Results in 4 hrs

36. Results: Participants Found Program Valuable • 88% of GIM respondents agreed that the information was helpful to their role as a clinic leader • 95% of Family Medicine respondents agreed that participation has or will lead to improvements in their clinic • 95% of Family Medicine respondents agreed that improvement tools presented were useful

37. Results: Participants Found Program Valuable We have had QI improvement projects all along...but I learned new techniques to discover how to evaluate the current process and then to move on to designing a new process. I think we are set and will continue using the skills/methods we have learned and apply them to future problem areas in the clinic. In this way it has been helpful. - Spring 2009 Ambulatory 401 Participant

38. Lessons Learned

39. Lessons Learned • Selecting the right person is key • Site participation in selection of the individual is important • Video conferencing can work for some aspects but not ideal particularly for project sharing • Teams presentations are critical –teams learn quickly from each other ---networking is enhanced • Structured presentations allow for focus on work accomplished • Time and existing work loads are an issue • Flexibility required –never ending conflicts for time • Provides a strong foundation for all other improvement activities • Must be viewed as a long term investment –impact on patient satisfaction, MD satisfaction, manager satisfaction, staff / MD retention, practice efficiency , communication, ownership

40. Opportunities • Bring in the Patient. Identify strategies to bring patient input into improvement work. • Anyone can be a Champion. Everyone within the clinic has the potential to be a change leader; champions do not have to be limited to physicians and clinic leadership. • Share Improvements. Maximize e-communication tools to share improvement work. Organize improvement projects by topic i.e. results reporting, access, care management. • Improve Together. Clinics with similar challenges and priorities could work together to develop improved processes. • Research. Critical evaluation to understand why improvement interventions succeed or fail across a range of care settings.

41. Challenges • Disseminating innovations and improvements • Sustaining improvements • Aligning “top down” and “bottom up” priorities

42. The Need to Improve…. Very seldom, under existing conditions, does a patient receive the best care which is possible to give with the present state of medicine.

43. The Need to Improve is Historical Very seldom, under existing conditions, does a patient receive the best care which is possible to give with the present state of medicine. The Flexner Report 1910

44. Very seldom, under existing conditions, does a patient receive the best care which is possible to give with the present state of medicine. The time to improve is now.