Improving Clinical Flow ECHO Collaborative Change Package

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2 Primary Drivers (driver diagram) Change Concepts Change Ideas Examples, Tips, and Resources Engaged Leadership Develop culture for transformation Use walk-arounds and attendance at team meetings to talk about the rationale and importance for change Ensure productive dialogue and decision making within team to foster engagement and alignment Build the practice s values on creating a team-based and patient-centered culture into processes for staff hiring and training Explore understanding of a change, importance of a change, and confidence to make the change when working with staff, when making decisions, and when resistance arises Use active listening to gain deeper understanding of the successes, challenges, barriers to change and as a response to resistance Attend team meeting 2x month Do 2 walk-arounds per week asking 5 Brief Questions Schedule protected team time of 1 hour per week for QI Schedule day-to-day leader for 1 hour per day for QI Make Project ECHO aim and team update a 5-minute standing agenda item for every meeting Talk no more than 10% of time in next encounter with staff person Hold discussions among groups within the organization about the changes, surface the successes and challenges Hold monthly review meetings

3 Ensure sustainable change Lead the collective understanding of the business case Ensure key staff have protected time beyond direct patient care to fully participate in transformation activities Clarify the vision, goals, and roles for change Sustain alignment among sponsors up, down, and across the organization through regular meetings about the change Continually review and clarify priorities Maintain ongoing review to ensure progress, sustain engagement and alignment, and address barriers and resource needs Provide clear structure and goals for each stage of improvement: testing, implementation, spread, and sustainability Create transparency around key revenue drivers and expenses Optimize opportunities to reduce expenses and enhance revenue while maintaining service quality Review and ensure the charge master is current Maximize point of service collections Understand the costs of turnover Staff work to the top of their licenses

4 Quality Improvement Strategy Choose and use a formal model for quality improvement (QI) Adopt a QI method and use it consistently to solve operational and clinical problems Create a shared language and culture for quality improvement Link QI training to role in improvement team Set clear improvement goals, expectations, and priorities Use the Model for Improvement for the Improving Clinical Flow ECHO Collaborative during team time and testing of ideas Identify improvement team day-to-day leader, team members, sponsor, and physician champion Compose Collaborative aim for the team Answer What are we trying to accomplish? for every change idea tested using a PDSA cycle Decide how team will know if the test succeeded or failed before the test begins Use clinic data to prioritize initial area of focus Empanelment Providers and care teams see their own patients, patients see their own Establish and monitor metrics to evaluate improvement efforts and outcomes, and ensure all staff members understand the metrics for success Assign all patients to a provider panel Specify which metrics are linked to QI efforts Regularly use data in meetings and communications Use data for improvement, not judgment Periodically review metrics and evaluate trends over time Optimize the use of health information technology for population management, creating huddle summary tools, registry monitoring, etc. Create systematic procedures and timelines for reporting data for use in the Collaborative such as leadership reviews, staff meetings, teleecho clinic Review and update panel assignments on a regular basis Engage providers and support staff in conversations about empanelment Assign a Panel Manager Evaluate panel size based on clinical FTE Create data collection plan for Collaborative data, test plan for ease of collection, and adjust as needed Establish a standing agenda item to review Collaborative data at the beginning of each team meeting, after the review of the Collaborative aim and the PDSAs; check for understanding Display run chart data in common staff areas Test which reports are most useful for patient care and the care teams Use the 4 cut method to empanel most patients Test various staff roles with the Panel Manager tasks Profile the diagnosis codes for a typical panel in your clinic Test processes to monitor patient panels and PCP assignments

5 providers and care teams Assess practice supply and demand, and balance patient load accordingly Use panel data and registries to proactively contact, educate, and track patients by disease status, risk status, selfmanagement status, community and family need Establish standard work for ongoing monitoring and adjustment Evaluate the supply of clinic appointments Evaluate demand for clinical care Manage demand variation proactively Create alternatives to face-to-face care such as or phone care Optimize patient involvement in care Segment patient panels based on needs Develop systems for follow up and support of care plan needs and selfmanagement goals Create actionable data aligned with care team roles and responsibilities to meet patient need Link education and periodic follow-up needs to patient portals as available Test the roles of each care team member in ensuring assignment to a PCP/Care Team Test max-packing a visit, meaning the patient gets all they need in the visit Test alternatives to office visits for tasks that do not need an office visit, such as filling out paperwork Test the RN role in helping to manage the daily care of patients with visits Test strategies to identify individuals with complex and higher needs, run reports on specific panel segments, obtain clinical staff input on patients who need enhanced care Test how to use registries or panel reports in daily huddles Test care team member roles for care plan follow-up, outreach, and care delivery Optimize the Care Team Establish and provide organizational support for care delivery teams accountable for the patient population/panel Commit to provide care in multidisciplinary teams Facilitate and support care team functioning Track and report organizational metrics by team as well as by provider Nurture an organizational culture that supports team-based care Facilitate trust among care team members Create contingency plans for events such as vacations, last minute changes in provider availability, known high or low demand times like flu season or summer Dedicate resources for team-building exercises to help team members develop trust and a coordinated way of working together Establish vacation plans and policies Plan for sudden provider absences Anticipate unexpected increases in demand Develop scripted language for common occurrences such as scheduling challenges, cancellations

6 Develop clear roles and responsibilities for every member of the care team so that they function at the top of their skill sets Periodically assess how staff members spend their time Expand the roles of members to take on tasks previously done by providers or not done at all Evaluate phone activity and subsequent workflows, patient flow, and information flow Redesign workflow processes and document the tasks, workflow, care team member role, materials, training, and support needed to create standard work Leverage messaging and tasking in the electronic health record (EHR) Test MA delivering preventive care per protocol (e.g. immunizations, ordering cancer screening, assessments such as monofilament Research state policies regarding licensure and scope of practice for various roles Test having administrative/front desk staff triage incoming calls, make appointments, fill out forms as much as possible Test using LPNs (as nursing scope allows) to triage patient phone calls or s and only refer to RNs or providers those patients requiring clinical assessment or decision making Test having medical records staff extract external data (lab, referrals) and enter into the electronic health record Test having centralized staff review registries and send exception reports to practice teams Test having front office, MAs, and nurses review registries (or exception reports) to identify patients needing services and call them. Train staff to conduct motivational interviewing, brief action planning, etc. For additional information and resources on this topic, visit: Encourage and enable staff to work independently Develop standard work processes for the delivery of common services and incorporate them into practice workflows and into the electronic health record Maximize the use of standing orders, which enable staff to independently perform key clinical tasks without having to involve the provider Test and refine standard work to reach the right protocol Review the board requirements for licensed positions Include when to ask for help Use daily or frequent huddles with all care team members (for resources on huddles, see les&=search)

7 Locate core team members in close proximity with each other Establish effective communication systems in the care team Use pre-visit planning to ensure all patient needs are identified and all needed information is available at time of visit Communicate among care delivery team throughout the day Use visual flags to smooth flow of the patient visit Establish regular all staff meetings Demonstrate documentation and billing Ensure annual review for all staff Retrain staff after review for additional information and resources on this topic Help patients understand what they can expect in a teambased model of care Ensure that patients are able to see their provider or care team whenever possible Name care teams or designate with a symbol or color Include team care as part of your practice description Co-locate team and the patient care areas for their panel Link patients to a provider and care team so both patients and provider/care team recognize each other as partners in care Train front desk and scheduling personnel regarding importance of provider/care team continuity for patients Provide scripts that promote continuity for staff to use when scheduling appointments Include care team name on business cards for patients Create marketing materials and website design Post pictures of the care teams in patient areas Create a script for staff to use to describe the teambased model with patients Provide a welcome to the practice orientation and information contains resources/tools such as: Patient Partner Packet; Patient Welcome Packet Ensure warm handoffs from Provider to individual care team members and the patient Create letters for new patients to introduce the team Update the practice website with team-based care information Leverage PCP assignment in EHR and test which staff member role is best able to verify PCP on each visit

8 Create standard work for roles, tasks, common processes Provide scripts to help patients understand organizational commitment to continuity Ensure IT systems/ehr have a prominent field to designate PCP and establish processes to ensure this field is filled in Create procedures for common processes Document processes, tasks, and roles in process maps and in a written process Ensure job descriptions, hiring procedures, training, and support are in line with standard work Create processes to update procedures periodically Understand variation in roles and processes and decide what level of variation is needed Organized, Relationship- Based Care This driver encompasses the work that teams do together on behalf of their patients (as opposed to the Manage the panel of patients to efficiently and effectively meet patient care needs Use planned care according to patient need Identify high-risk patients and ensure they are receiving appropriate care and case management services Use point-of-care reminders based on clinical guidelines Understand and manage practice systems external to the visit: calls, refill requests, forms, etc. Plan staff interactions with patients based on their identified needs Use pre-visit planning to ensure all patient needs are identified and all needed information is available at time of visit Test the best use of EHR reminders and staff roles More detailed information about improving workflow and removing waste is available on IHI s website

9 structural work of committing to and establishing strong care teams, which is the focus of the Optimize the Care Team driver) Improve workflow Use automation (e.g., EHR) to prompt for guideline-based care Remove or decrease steps in a process Do tasks in parallel Move steps in the process closer together Find and remove bottlenecks Synchronize patient, provider, and information Standardize rooms, equipment, patient flow, and information flow Ensure that all is ready (e.g., room, equipment, information) for the patient and provider interaction Complete work in real-time Identify and remove Minimize transportation of materials or waste information that is unnecessary Identify process steps that can be eliminated Match inventory to needs; keep stock levels that match actual demand Decrease motion (i.e., wasted time staff or providers spend looking in multiple places for an item or have added steps to accomplish a task Reduce rework due to operational mistakes that occur in the process (such as redrawing blood due to wrong order) Use visual cues such as colored cards for inventory of supplies Place printers and other equipment close to staff who use them regularly Test how to not batch calls for patient requests Ensure supply areas are cleaned and restocked in a standard way Re-supply or staffing is determined according to the actual demand of the patient or staff needs Draw the actual movement of staff and patients (staff and patient flow) in a spaghetti diagram; rearrange clinic and supplies to provide clear linear path Patients as Partners Listen to customers (patients and families) Create strategies to receive patient input on QI team, surveys, focus groups, other Obtain feedback from patients and families about their health care experience and use this information for quality improvement Open each team meeting with a patient story relating to the improvement work and PDSA tests Ask a patient advisor to do a 30-minute observation of the current process Involve a patient in teaching staff a communication technique that is being tested

10 Provide care within the context of what matters to the patient Include patients and families as advisors to or members of the QI team Utilize patient and family input to gain insight into specific areas (e.g., materials, patient care processes) Involve patients in developing their care plans: co-create care plans with patients Clarify which staff role will have standard work expectation to support patientdirected self-management goals Ensure support for diversity and the health literacy needs of patients Respect patient and family values and expressed needs Encourage patients to expand their role in decision making, health-related behaviors, and self-management Establish trusting relationships Communicate with patients in a culturally appropriate manner, in a language and at a level that the patient understands Assess the need for self-management support at every visit Ask a patient advisor to collect data by doing after-visit calls Ask patient advisors to draft 1 st version of a script for staff to use to describe the team-based model Hold focus groups to get input on a change that s being tested (e.g., how to assign the PCP, materials created to message who is on their care team) Begin the patient visit with a question (e.g., What do you need today? ) and listen Test MA role for Brief Action Planning