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1 Chronic Disease Toolkits: Spreading Quality Outcomes Simply Gerald H. Angoff, MD, FACC, MBA Steve Sarette, BA Presentation Outline It Introduction ti Setting the scene Quality Improvement Project Details Project Results Spreading Best Practice - The Toolkit Conclusions 1

2 INTRODUCTION Healthcare Quality Past Negative connotation: Bad apple search What went wrong and who is responsible Safety and adverse event occurrence based Driven by managerial top down directives and mandates People rather than process focus New Positive and supportive Collaborative Joint responsibility and accountability Focused on clinical outcome improvement in addition to safety and error Driven by provider and staff input and ownership Process rather than people focus 2

3 Dartmouth Hitchcock Comprised of a Medical Center (DHMC) and Physicians Network (DHC) and located in New Hampshire. Mission We advance health through research, education, clinical practice and community partnerships, providing each person the best care, in the right place, at the right time, every time. Vision Achieve the healthiest population possible, leading the transformation of health care in our region and setting the standard for our nation. D H High Level Statistics 1,700,000 total outpatient visits per year [990, primary care] 23,000 inpatient discharges 1,000 physicians 8,700 employees 1300 medical students, residents & fellows 5 Outpatient Divisions [each with multiple locations] that maintain a high degree of autonomy Data is from 2009 and rounded 6 3

4 Primary Care Governance at D H Regional Primary Care Center (RPCC) Sets standards and goals for: Preventative Care Mammography, Colorectal screening, Flu vaccination, pneumococcal vaccination Chronic Disease Management Diabetes, Heart Failure, Hypertension, Coronary Artery Disease Division 1 Division 2 Division 3 Division 4 Division 5 High degree of division autonomy to create processes that meet stated goals QI PROJECT DETAILS 4

5 Rethinking the Approach Division 3 1. Quality Improvement (QI) Committee formed for the entire Division. 2. QI Committee reviewed available metrics and selected hypertension control for a coordinated improvement initiative. 3. Committee included clinical and operational staff and shifted to a focus on outcomes improvement in addition to the traditional safety and error focus Choice of HTN for QI Measures and target benchmarks available Division 3 data below target benchmark and static (Target: 75%, Performance: 67%) CMS pilot project results: HTN deficiencies National data identifying HTN as major QI issue Available national guidelines for Dx and Rx: JNC- 7Guidelines Medical Home hypertension initiative 5

6 Hypertension Paradox Chobanian, AV. The Hypertension Paradox More Uncontrolled Disease Despite Improved Therapy. N Engl J Med 2009; 361: Patie ents with Controlled HTN 80% 75% 70% 65% 60% 55% Early Hypertension Control Results Hypertension Control Early Results Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Division 1 Division 2 Division 3 Division 4 Division 5 Target Wide variation between the 5 divisions. 6

7 Prioritizing HTN: Data October 2009 Division/Team PT COUNT BP<140/90 Division/Team PT COUNT BP<140/90 Division % Location 2 FP Team A % Family Medicine % Location 2 FP Team B % Internal lmedicine i % Location 2 FP Team C % Location 1 - FM % Location 2 IM Team A % Location 1 - IM % Location 2 IM Team B % Location 2 all FP % Location 2 IM Team C % Location 2 all IM % Location 2 IM Team D % Location 2 IM/Pedi % Location 2 IM Team E 6 33% Measurable Data available by site, by team, by provider by patient Registries currently tracking patient level detail QI Process Approach Included the process and tools used in many process improvement methodologies (Six Sigma, Lean, Clinical Microsystems) Clear Project Definition: Charter: measures, targets Transparent Communication: SharePoint for documents Current state analysis: flow chart, process documents, metrics Root cause analysis: Fishbone exercise, prioritization of root causes to drive change Workflow process redesign and implement in a systematic manner Continuous monitoring of the results to insure gains are maintained 7

8 HTN Outcomes Project Team Make up Multidisciplinary: physician, py nurse practitioner, clinical nurse, medical assistant, RN care coordinator, data coordinator, patient, process improvement specialist Geographic: 2 Locations within the division First meeting October 2009 Charter and Aim Statement (Division 3) Project Description / Opportunity Statement The current treatment for hypertension is falling short of meeting existing benchmarks and best practice. The opportunity exists to identify all the key elements of hypertension therapy and incorporate them into a redesigned workflow that achieves or exceeds benchmarks and best practice. Business Case Control of hypertension reduces the instance of morbidity bd and mortality of chronic disease. Payment models are being structured to compensate for improved performance against the stated benchmarks. Project Scope In Scope: Adult primary care patients. Care provided by outpatient primary care clinics. Patient education and self care. Out of Scope: Pediatric patients, specialty care, inpatient care Goal Statement 75% of patients meet blood pressure of < 140/90 (benchmark is 70%) Patients with Diabetes/Chronic Kidney: XX% of patients meet blood pressure of <130/80 Process to be inclusive patients and all health care team members Measures Blood Pressure Benchmark (<140/90) (clinic, home and ambulatory) Blood Pressure Benchmark Diabetic/Chronic Kidney (<130/80) (clinic, home and ambulatory) Resource Plan Project Lead(s): Project Coach: Project Sponsor(s): Team Members QI Committee Contact Information for Project Lead: 16 8

9 Documenting the Current State Provider Medical Assistant Secretary Root Cause Analysis A fishbone diagram interactively involves all team members. 9

10 Completed Fishbone Prioritizing Root Causes Address Right Away (Quick Hits) Room not properly p set up for blood pressure measurement Staff not trained on proper blood pressure technique Providers not entering re measured BP readings into the EMR. Require Planning Patients need education on diet, exercise, medication and that hypertension is managed, not curable Not tracking patients patients fall through the cracks (shadow patients) Provider panels contain patients no longer seen by provider No standard plan of care in place to treat hypertensive patients Prescription treatment guidelines not readily available for providers Provider lack of discipline to address poor patient compliance 10

11 Improvements Slide 1 Address Right Away (Quick Hits) Improvement Room not properly set up for Rooms were equipped with armed blood pressure measurement chairs and BP equipment was relocated next to chair Staff not trained on proper blood pressure technique Providers not entering re measured BP readings into the EMR. Medical assistant BP measurement competency training Training providers on EMR BP entry Improvements Slide 2 Require Planning Patients need education on diet, exercise, medication and that hypertension is managed, not curable Not tracking patients patients fall through the cracks (shadow patients) Provider panels contain patients no longer seen by provider Improvement Patient education materials were created Guidelines for nurse education were drafted Medication renewal workflow to capture shadow patients Registry: Identification and contact of patients overdue for appointments or no longer being followed 11

12 Improvements Slide 3 Require Planning No standard plan of care in place to treat hypertensive patients Prescription treatment guidelines not readily available for providers Provider lack of discipline to address poor patient compliance Improvement HTN Care Plan template Laminated JNC 7 algorithms distribution The medication renewal workflow and registry identification and contact of patients overdue for appointments Workflow redesign to address the root causes identified Included three new roles Nurse Care Coordinator Data Coordinator Workflow Redesign 12

13 Data Registry Improvements Cleaned up the data: identified patients no longer active with D-H Identified the shadow patients : Those not actively being seen by their care teams Feedback from process to enhance registry in future PCP MRN PATIENT NAME Sex Age Last Primary Seen in Last 6 Care Visit Date Months SYS DIA Last PCP Visit Date Doe, John Patient, One F 58 4/5/2011 Yes /5/2011 Doe, John Patient, Two M 33 3/30/2011 Yes /30/2011 Doe, John Patient, Three M 34 10/14/2009 No Doe, John Patient, Four M 50 8/3/2010 No /3/2010 Doe, John Patient, Five F 64 9/20/2010 No /20/2010 Doe, John Patient, Six M 32 1/19/2010 No /1/2008 Doe, John Patient, Seven F 67 5/16/2011 Yes /16/2011 Doe, John Patient Eight F 23 4/14/2010 No /14/2010 Registry Management Dear Dr. I wanted to let you know that your team has been working on your HTN registry. Your current registry shows 57 patients with elevated blood pressure readings. Of those 57 patients: 20 were overdue for appointments they have been called this week 15 had already had appointments in the last month (the registry has a 2month lag) 22 have an upcoming appointments already scheduled I d like to thank you and your team for your commitment to quality care!! Everyone on the team plays a huge role in providing superior care to patients. Your June HTN composite percentage was 72% and the goal is 83%. By continuing to ensure that patients have follow up appointments scheduled, appropriate labs booked, proper BP technique and education, and superior medical management, I m certain the goal will be reached. 1. Support effort, use of the registry clearly identified 2. Process based: corrective action underway to contact and schedule patients 3. Provider results delivered in a positive context 13

14 PROJECT RESULTS Change 14

15 Patients with Controlle d HTN 100% 90% 80% 70% 60% Division 3 HTN Control Results 81% 81% 81% 82% 83% 83% 75% 76% 77% 78% 78% 77% 67% 67% 68% 69% 71% 72% 73% Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Apr 11 May 11 Division 3 Divisioni i Project Comparison BP<140/90 September 2009 BP<140/90 May 2011 Changein Performance Division 1 74% 82% + 8% Division 2 77% 81% + 4% Division 3 67% 83% + 16% Division 4 67% 70% +3% Division 5 61% 68% + 7% 15

16 90% Hypertension Control Later Results 85% N Patients with Controlled HTN 80% 75% 70% 65% 60% 55% Division 1 Division 2 Division 3 Division 4 Division 5 Target Team Comparison October 2009 May 2011 Division/Team BP<140/90 BP<140/90 Division 3 67% 83% Family Medicine 64% 83% Internal Medicine 68% 84% Location 1 - FM 65% 77% Location 1 - IM 65% 75% Location 2 all FP 63% 85% Location 2 all IM 70% 87% Location 2 IM/Pedi 65% 71% Location 2 FP Team A 66% 88% Location 2 FP Team B 60% 88% Location 2 FP Team C 63% 81% Location 2 IM Team A 69% 88% Location 2 IM Team B 71% 87% Location 2 IM Team C 72% 89% Location 2 IM Team D 69% 88% Location 2 IM Team E 33% 83% Reporting is also calculated at the team level to align with department structure We ve been able to track differences in performance by location [Location 1 has not performed as well] 16

17 Provider Panel Performance October April More More Frequency Frequency Improvement was seen among the vast majority of providers. It was not a select few carrying the whole, but a systematic improvement for the whole division. Sustaining the Gains Sharing of metrics at department meetings, posting in department in public view at the team and provider level Continued review of the registries (every other month) and creation of registry reports that need to be worked Ownership of the results at the provider and team level Celebrating success. Sharing success stories at team meetings. Asking top performers to share their best practice tips and tricks. Project team continues to meet on a periodic basis to review results Addressing variation among two different locations. One location is lagging the other. 17

18 Celebrate Success SPREADING BEST PRACTICE THE TOOLKIT 18

19 Toolkit History The variation in the success of the divisions identified the need to more effectively share best practice. The D-H decentralized organizational structure has limits to implementing a single standard. Decision was made to package the best practices in approach and results into a toolkit to share with all divisions. Toolkit Audience Toolkit is designed d to be used by Quality Improvement Pro s (QIPs). QIPs are high performing individuals within each department given advanced quality improvement training. Use the toolkit to implement the identified best practice standards in their departments while allowing for deviation based on site specific needs. 19

20 Toolkit Structure Uses central repository [SharePoint] to store the documents Includes partially filled in templates for the following gproject documents: charter, meeting agendas and data displays. A single PowerPoint template containing all necessary documents to facilitate completion and report out. Document library containing : Successfully completed improvement efforts Procedure documents Patient education Staff education Additional resource documents are made available Toolkit: Process Overview 1. Complete Project Charter document (AIM/Team/Coach) / 2. Document current process flow 3. Identify root causes of poor HTN control 4. Identify and prioritize improvements to root causes 5. Assign and track improvements 6. Project communication 7. List of available project coaches 20

21 Toolkit: SharePoint Website Toolkit: Project Charter 21

22 Toolkit: Project Timeline Toolkit: Meeting Agenda sample 22

23 Toolkit: Slide examples Toolkit: Root Cause>Improvement Matrix Registry Management Root Cause Improvement Reference Material Patient s cancel or no show Contact patients Patient contact for scheduled visits that have not protocols Providers have a difficult been seen HTN Registry time tracking non compliant patients Shadow patients. On PCP panel, but only show up in Urgent Care proactively. Identify them using the registry Management Process Patients no longer seen by Review patient How to use the PCP still appear on the panel Data is not accurate lists with providers to identify non patients HTN Registry 23

24 Toolkit: Best Practice Flow Toolkit: Usage Use of the HTN toolkit has not been widespread to date. Many factors have contributed including; implementation ti of a new EHR and lack of an organizational mandate. The HTN toolkit process is being utilized in the Division 3 as a template to improve diabetic care. The results from this project will contribute to the creation of a Diabetes Toolkit. Tracking toolkit web hits through SharePoint reports to quantify the usage [recent enhancement] 24

25 Diabetes Control Project Charter Definition of a diabetic Removing registry inappropriate pts and data Lag time How data abstracted from EMR Measurement Methods Machine Patients Availability of specialty care Point of care equipment In house optometry Education of what is available globally Cost of change: staffing, availability, equipment, space cause Point of care testing Labs not ordered Per protocol orders Plan of care Pre work: before visit actions Working the registry Plan of care definition Timely follow up Diabetic definition: knowing who is counted Referral for education: when to refer Buy in to population health Equipment for POC testing EMR documentation: change from CIS to edh Diabetic flow sheet Management of registry data RN discretion: enabling care cause Privilege of action: enabling staff Scheduling: follow up after each visit Education: global cause Pts don t go to the lab Cost and availability of eye exams, specialty care Patient education Global resources availability Silos Acting organizationally cause Customer service cause Diabetes Root Cause Analysis Diabetes Control Materials/Resources Providers Staff Organizational Culture 25

26 Tool Kit Advantages Uses proven methodologies Developed from successful projects Empowers local l teams to implement improvement within their management area Multidisciplinary ground up approach Fosters cultural acceptance and buy-in Allows rapid deployment Creates a standardized approach which can be extended to other chronic diseases for which outcome improvement is increasingly critical CONCLUSIONS 26

27 Conclusions Outcomes improvement increasingly is the focus of healthcare quality A process and data driven methodology based on business QI techniques works in healthcare Critical success factors include crafting a multidisciplinary project team and obtaining provider buy in through cultural change A tool kit can be fashioned to capture and replicate process based QI projects Clinical outcomes improvement results more from process rather than provider intervention Spreading best practice across the entire organization has not been solved and is still a work in progress Questions? 27