It Takes a Village to Change a Process: A Health Systems Approach to Practice Improvement

1. It Takes a Village to Change a Process: A Health Systems Approach toPractice Improvement Conference on Practice Improvement Saturday, December 4 4:10-5:10 pm

2. Presenting Today: • Karl Kochendorfer, MD • Assistant Professor of Clinical Family and Community Medicine • Director of Clinical Informatics • Adjunct Faculty, MU Informatics Institute • Medical School: University of Illinois at Chicago • Residency: University of Illinois at Chicago

3. Presenting Today: • Phil Vinyard, MHA, MBA, MDiv • Practice Manager, Green Meadows Family Medicine Clinic, Woodrail Family Medicine Clinic, Fayette Family Medicine Clinic • Graduate School: University of Missouri (MHA, MBA); Gordon-Conwell Theological Seminary (MDiv)

4. Presenting Today: • Jan Gace, LPN • Phone & Floor Nurse, Green Meadows Family Medicine Clinic • Nursing School: Columbia Public School of Practical Nursing

5. A Little About Us: Mizzou!

6. A Little About Us: MU Health Care

7. A Little About Us:Family & Community Medicine • 6 Family Medicine Clinics • 100,000 Visits • 46 Physicians • 10 Other Providers • 10 Research Faculty • 2 Fellows • 36 Residents • 110 Nurses, Clerical Support & Management

8. The Reason for Our Project:The Burden of Diabetes & Other Chronic Disease • Half of all Americans have at least one chronic disease • Of those with chronic disease, over 50% have multiple conditions • Chronic disease causes 70% of all deaths

9. The Reason for Our Project:The Burden of Diabetes & Other Chronic Disease • Chronic disease causes 75% of health expenditures • 1/5 of health dollars are spent on patients with diabetes • Only 50% of recommended care is delivered to diabetics

10. A Solution: Leverage EMR Information • Tiger Institute for Health Innovation: Living Lab • F&CM as early adopters of the EMR • Incentives available for Meaningful Use

11. Solution: Diabetes Summary Screen

12. DM Quality Measures

13. Concept of Perfect Care Healthcare IT News. 9/2008

14. The Math of Perfect Care • 3 Measures = 1/23 or 1 of 8 qualify • 8 Measures = 1/28 or 1 of 256 qualify ~32x harder

15. Quality Measures Implemented • Information about DM Quality Measure screens discussed at Faculty meetings • Physicians encouraged to check DM Summaries on patients and take action • The results…

16. Rampant Indifference

17. Minimal Improvement after 1 Year Clinics with Care Coordinators: • 2 FM Clinics between 10-15% • 2 FM Clinics between 5-10% Clinics without Care Coordinators: • 4 FM Clinics close to 0% • 2 IM Clinics close to 0%

18. It Takes a Village to Change a Process: A Health Systems Approach to Practice Improvement

19. Our Village: Performance Improvement-Leadership Development Program • Strategically develop and deploy performance improvement knowledge, skills and competencies of current and emerging clinical and non-clinical leaders throughout UMHC. • Strengthen the UMHC performance improvement organizational culture. • Improve UMHC's ability to provide high quality and safe patient care in a patient centered and cost effective manner.

20. PI-LDP Program Design • Performance Improvement Capacity Building • Learning by Doing • Performance Improvement Organizational Culture Building

21. PI-LDP Program Design

22. Members of Our Team and our Advisors Team: • Karl Kochendorfer, MD (Director of Clinical Informatics) • Phil Vinyard, MHA, MBA (Practice Manager) • Donna Neal, RN (Nurse Manager) • Rhonda Polly, APRN (Chronic Care Nurse) • Jan Gace, LPN (Phone & Floor Nurse) Advisors: • Carl Hooker, MHA (Finance) • Tim Hogan, PhD (F&CM Department QI Officer)

23. Aim Statement The Family Medicine Green Team will increase the percentage of our diabetic patients with perfect care from 10% to no less than 50% by June 30, 2010.  This will be accomplished by using a multidisciplinary approach, process change, education and utilization of eight quality measures.

24. Fishbone Diagram

25. Fishbone Diagram: Computer

26. Fishbone Diagram: Culture

27. Fishbone Diagram: Resources

28. Fishbone Diagram: Medical Practice

29. Fishbone Diagram: Patients

30. Fishbone Diagram: Staff

31. Driver Diagram

32. Interventions Considered • Opportunistic Approach • Proactive Approach • Patient Engagement Approach

33. Opportunistic Approach Every time a patient with diabetes comes for a clinic visit, review their quality measures and take action

34. Process Flow Chart

36. Proactive Approach “Run the list” of diabetic patients and pro-actively contact them about missing items.

37. Run the List: By Patient

38. Run the List: By Category

39. A Train Wreck…

40. A Train Wreck…

41. Correcting Primary Provider

42. Patient Engagement Approach Educate the patients about the types of services they should be receiving.

43. Patient Letter

44. Patient Letter

45. Patient Letter

46. Automated emails w/ graph

47. Outcomes!

48. Outcomes to Date Decided to focus on diabetes quality indicators as a practice improvement project Completed workflow process and began piloting and training for our intervention

49. Lessons Learned • Having data doesn’t mean improvement • Integrate the data into your workflow • Training needs • Learning how to use the reporting tools • Documentation, e.g. eye and foot exams • Team effort (e.g. buy-in, resources, meetings) • Physician engagement • Automate, Automate, Automate

50. Future Steps • Re-establish new target • Add incentive payments • Integrate PDSA • Continue Ninja Group Meetings • Improve “Proactive” approach • Improve “Patient Engagement” approach • Expand to other Family Medicine & Internal Medicine Clinics • Assist our physicians with their Board Certifications