Practice Transformation: Improving Quality and safety using A team-based care approach

1. Practice Transformation: Improving Quality and safety using A team-based care approach W. Martin Smith Interdisciplinary Patient Quality and Safety Awards Program University of Florida Gainesville, Florida Christopher Scuderi D.O FAAFP University of Florida College of Medicine Jacksonville

2. Disclosures • I have no relevant disclosures… • Thank you to: • Our presenters • You for supporting this conference • Dr. Ashchi

3. BASICS • The University of Florida W. Martin Smith Interdisciplinary Patient Safety Awards Program is cosponsored by the UF College of Medicine Continuing Medical Education and the UF Self-Insurance Program. • This program provides start-up support for faculty and staff to design and implement projects focused on reducing the likelihood of adverse events or claims and/or patient safety and clinical process improvements.

4. STUDY BASICS • 6 UF Health CHFM Clinics in Jacksonville who differ in size and patient populations • Three 2 hour trainings with Ed Shahady MD spread over 1 year for each clinic • Certified as AHRQ TeamSTEPPS Trainer • Staff and providers evaluated clinics culture in standardized survey at 0,6 and 12 months • Data reviewed for each clinic • Survey data • A1C, LDL • Stakeholders Meeting

5. Details of Study • The majority of the care that primary care physicians provide revolves around the prevention and care of chronic disease. Safety and quality of this care is not possible without an effective office team, strong team communication and efficient office systems. Most of the errors for chronic disease and preventive care are related to errors of omission. • The objective of this project addressed this quality and safety gap by training 6 primary care practices (physicians and their office staff) on the tenets of team-based care using the Agency Health Care Research and Quality (AHRQ) Primary Care Version of TeamSTEPPS framework. Practices ranged from an office with one physician to a medium sized practice with 6 clinicians. • Each practice participated in a series of trainings by a TeamSTEPPS certified master trainer during a one year period. Each practice’s staff completed the Medical Office Survey on Patient Safety Culture (AHRQ) at baseline, midway and at completion of training to determine perceived changes in team based care behavior and quality of care and was used as a teaching tool during the training sessions. • We sought to demonstrate improved patient outcomes through improved office culture by tracking Hemoglobin A1c and LDL levels of our diabetic patients before and after the training was implemented. Additionally, we asked each medical director, practice manager, and lead medical assistant at the end of the study to describe changes in office culture and systems.

6. Details of Study • There were 90 people who participated in the medical office survey across 6 practices (26 clinicians, 61 staff, 3 unspecified). • For all practices combined, there was not a significant improvement in the Patient Safety Culture scores over time; however, several of the practices alone had improved scores. • A Chi square analysis of survey data between clinicians and non-clinicians showed significant differences in key areas of communication, working relationships and office procedures where clinicians had a more positive perception on communication items while staff had a more positive perception on quality/safety office practices. • All PCMHs saw a decrease in the mean Hemoglobin A1c results for their diabetes patients from before and after training implementation with a mean decrease of 0.16 (p value = <.0001) using the Wilcoxon sign rank test. Similar results were seen with the LDL cholesterol scores for these patients with a mean decrease of 4.01 (p value = .0001).

7. Conclusions • Success in implementing team-based care was dependent on how each practice embraced the training. • Two of the practices had leadership turnover that affected morale and operations • This was evident in the survey results and even patient outcomes. • Since we did not have a comparison group, improved patient outcomes may be due to other factors besides the team-based training.

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14. BEST PRACTICES • Daily rounds • Medical Directors should start their day saying hello to each team member and taking a pulse of the clinic • Make team meetings more interactive • Encourage meetings to be participatory from all members of the practice • Set a few measurable overriding goals for the year • Have the staff understand where they are going • Wildly Important Goals

15. BEST PRACTICES • Shadow partners • Have each member of your office shadow someone who does a different job • Be willing to call brief “short informative meetings” when necessary to clarify operations.  • Daily huddles • Encourage a morning huddle between medical assistants and providers.

16. BEST PRACTICES • Develop protocols to clarify roles • Clarify what are the expectations of your staff • Narcotics, late patients, dismissing patients • Standing protocols • Institute a monthly lunch ritual • Develop non-work related rituals

17. BEST PRACTICES • Give immediate positive group feedback for outstanding performers. • Let exceptional staff know they have done a great job • Debrief after major events • Take time to discuss lessons learned • Employ a suggestion box • Encourage input on how to improve

18. BEST PRACTICES • Consider quarterly meetings with sister offices • Try to learn from best practices • Cultivate a culture of understanding • Encourage communication that fosters team • Office leadership should be passionate team-builders • Enthusiasm and passion from leadership can propel the office in a positive direction

19. Common Struggles • Staff turnover • The poison pill • The whirlwind

20. Study Best Practices • Consistent leadership from Medical Director was most important factor we could identify • An engaged medical director was associated with better outcomes • Where there was leadership turmoil the staff environment struggled • Servant Leadership

21. Keys to Establishing a Primary Care Team Model • 1. Determine if there is a desire among your current office to pursue these change • 2. Identify a servant-leader to lead this change. • 3. Seek input from the whole team to develop a mission statement. • 4. Commit to regular team meetings at a minimum of once a month. • 5. Develop MA-provider teams who are regularly paired and have a daily morning huddle. • 6. Establish standing orders and protocols for chronic care and preventative care and ensure buy in of this throughout the practice. • 7. Allow for open discussion of processes and protocols • 8. Optimize your current EHR for chronic disease registries and improved patient access. • 9. Use these chronic disease and preventative care registries to establish a baseline and measure the team’s improvements. • 10. Educate, cross-train and provide opportunities for advancing your staff • 11. Consider adding/sharing second level team care (such as pharmacists, case managers) as the team becomes increasingly financially successful. • 12. Identify Wildly Important Goals and lead measures to address areas that need to be improved

22. The Gift of Team

23. In Summary • There are many challenges to practicing medicine • We have a noble calling and we must always rise above the challenges • We need to advocate and innovate to do what is best for our patients, staff and colleagues • Team-based care is a tool to help do that

24. QUESTIONS? Christopher.Scuderi@Jax.ufl.edu