Workshop D/E 28: Improving Access and Surgical Quality in the US Military. December 13, 2017

Transcription

1 Workshop D/E 28: Improving Access and Surgical Quality in the US Military December 13, 2017

2 MHS Strategic Partnership with IHI 2 Objective A: Learn from International Network of Strategic Partners Objective B: Training Opportunities to Support HRO Transformation Develop and Implement a Framework for High Reliability Objective C: Design and Lead System-wide Improvement and Spread Objective D: Rapid-cycle Innovation

3 MHS Learning Partnerships: Surgery and Access Participants (20-30 Teams) Select Topic (Develop Mission) Leaders to Improvement Project Training Pre-Work Dissemination MHS and Service Leaders Surgical Quality Develop Framework & Changes LS 1 P P A D A D A S S LS 2 LS 3* P S AP1 AP2 AP3 D LS 4 LS Learning Session *Virtual AP Action Period (listserv) Visits Supports Phone Conferences Assessments Holding the Gains Sponsors Monthly Team Reports

4 Surgical Quality Learning Partnership 4 Overall Aim: Decrease surgical harm in participating Military Treatment Facilities (MTFs) Topic areas chosen by MTFs Surgical Site Infection, Readmissions for Pain, UTI, VTE Engagement: 22 teams from the Army, Navy, Air Force, and National Capital Region Results: 7/22 SQLP teams achieved a score of 4.0: significant improvement in team s determined aim.

5 Outcomes Primary Drivers Leadership commitment at all levels to manage towards a culture of safety and continuous improvement Secondary Drivers Define and Manage for Quality Change the Work Environment Enhance the Patient and Family Relationship Change Concepts Focus on Core Process and Purpose Use Proper Measurement Invest More Resources in Improvement Take Care of Basics Consider People in the Same System Listen to patients/families Develop Alliances & Cooperative Relationships Co-design care Reduce Harm and Improve Perioperative Outcomes Provide reliable, appropriate and timely care to reduce incidence of Perioperative Harm Develop a teamwork culture attuned to reducing perioperative harm Reduce Infections and Events Reduce Readmissions and Returns to OR Reduce Variation Change the Work Environment Focus: Surgical Site Infections Focus: Urinary Tract Infections Focus: Prevent Venus Thromboembolism Focus: Cardiac Complications During Surgery Focus: Return to OR Focus: Readmissions Assessment/Action Standardize Communication & Team Response Standardize processes that can be standardized Develop and Provide Effective Team Training Operate as a Team Design for Partnership in care delivery and invest in patient engagement Design for Partnership Invest in Improvement Care Delivery Environment Transparent Communication Engage Patients and Family Develop and Provide Training

6 SQLP Measurement Strategy 6 Designed to engage teams to improve in areas of surgical quality where they identified the greatest need Adapted classic BTS measurement structure Linkages with NSQIP Most teams examined process reliability data (e.g. timely antibiotics; huddles; post-surgical debriefs)

7 Access to Care Learning Partnership Overall Aim: Decrease delays in access to care. Engagement: 23 teams from the Air Force, Navy, and National Capital Region; 19 Primary Care, 4 Specialty Care Results: Sixteen of the 23 ACLP teams achieved improvement or met the MHS goal for one or more ACLP outcome measure (Third Next Available or Continuity) and process measures.

8 Secondary Drivers Understand and balance supply and demand Primary Drivers Reduce the backlog Access Improvement Principles Reduce appointment types Develop contingency plans Improve Access to Primary and Specialty Care Core measures: 1. 3 rd next available appointment 2. Supply of visits Demand for visits 3. Aity s 1. Cycle time 2. Continuity 3. anel size (primary care) or Case Load (specialty care) Efficiency Improvement Principles Reduce demand Optimize the care team Balance demand and supply of nonappointment work Synchronize patients, providers, information, rooms and equipment Anticipate and predict patient needs Optimize rooms, staff, and equipment Manage constraints

9 ACLP Measurement Strategy 9 Recommended: Third Next Available Primary Care: Future & 24 Hour Specialty Care: New Patients & Return Visits Continuity Demand/Supply/Activity Optional: No Shows Nurse Advice Line Activity Teleconference Activity

10 Learning Partnership Leadership Track 10 Purpose: to support senior leaders in leading transformational change. Activities: Monthly Calls; Invited to attend Learning Sessions Goals: To engage MHS senior leaders interacting with the improvement teams Teach senior leaders about the improvement methodology guiding the Learning Partnerships Plan for spread and sustainability of the learning from the teams to improvement areas system-wide.

11 Leadership Track Topics Covered 11 Driver diagrams Role of the Senior Sponsor Communication strategies Leading change and building will Personal mastery System change Improvement Science The business case Optimizing the Care Team Assessment of Maturity of Improvement efforts Effective leadership reviews Workforce considerations Overcoming resistance to change Reliability theory Staff retention, reliability, patient engagement Sustaining and Spreading Improvement High Reliability at MHS

12 Improving Access in the US Military ACLP DM Team Experience and Results 355th Medical Group Davis-Monthan AFB, AZ

13 Session Objectives 355th Medical Group Team Members Aim Statement Primary Care Manager Team Continuity Clinical Median Third Next Available Strategic Alignment Changes Tested Next Steps Lessons Learned Plan for Sustainability Questions

14 Team Members Col Mark Nassir, Medical Group Commander (Sponsor) CMSgt Anna Parker, Medical Group Superintendent Lt Col Jennifer Garrison, Commander, Medical Support Squadron (Project Lead) Lt Col Scott Carbaugh, Commander, Medical Operations Squadron Lt Col Thomas Kibelstis, Chief of Medical Staff Lt Col Amy Kinnon, Chief Nurse Major Leigh Kimmel, Flight Medicine Flight Commander Captain Maggie Smith-Davidson, Provider Captain Shannon Pace, Health Care Integrator 1Lt Angelique Sanders, Group Practice Manager 1Lt Tiana Kimura, Management Information Systems Flight Commander SMSgt Michael Van Pamel, Superintendent SSgt Arielle Cabico, Medical Pediatric Technician Mrs. Leah Ferguson, Family Practice Office Manager Mrs. Ashley Oliver, Patient Safety Manager Mr. David Smith, Data Quality Manager

15 Initial Aim Statement Continuity of Care (Family Health Clinic) Increase Primary Care Manager (PCM) Continuity From 66% To 77% Increase PCM Team Continuity From 86% to 90% Access to Care Plan-Do-Study-Act (PDSA) Cycles

16 Primary Care Manager Team Continuity PCM Team Continuity AF Goal: 90% % Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17

17 Clinic Median Third Next Available- 24HR AF Goal: < or = 1 day As Of 1 Sep 17, Third Next Available-24 Hr =.08% Third Next Available Goal

18 Strategic Alignment Coordinated Strategy MHS AFMS Line AF MTF IHI / Trusted Care Principles Support Our Strategy High Quality, Safe, Evidence-Based, Patient-Centered Care Access To Care Provider/Team Continuity Patient Engagement

19 Changes Tested Family Health Access to Care Pilot Removed Carve-Outs Increased Access by 25% New Provider Template Mix for Appointment Type Scrubbed Demand to Meet Patient Needs Family Health Super Team (4 to 3) Increased PCM Team Continuity Family Health Open Encounters Reviewed Daily at Patient Safety Huddles Decreased overdue Open Encounters by 90% Tricare On Line Patient Portal Secure Messaging Relay-Health Trained all MDG Staff which Increased Response Time by 22%

20 Changes Tested Pharmacy Over The Counter Medication Distribution Behavioral Health Optimization Program (BHOP) Increased BHOP utilization by 50% Decreased Mental Health intakes by 32% Allergy Clinic Support Increased Immunotherapy and testing capacity Improved patient safety Decentralized Check-in Patient satisfaction Improve patient safety Centralized Checkout Increase Secure Messaging enrollment and third party collections Decreased risk for patient safety event Provider orders confirmed Referrals confirmed

21 Next steps Maximize Secure Messaging Nurse Embedded at Appointment Line Pending adequate staffing Improves utilization of direct access and improves PCM access Acute Clinic Increase acute access Reduce workload on nurse staff

22 Lessons Learned to Share with Other Teams Importance of Staff Buy-In Consolidation of 4 Teams Down to 3 Teams Maximizing Clinical Resources Increased PCM/PCM Team Continuity (25% Access To Care increase) Enhanced Team Communication Importance of TOL Patient Portal Secure Messaging Relay-health Training Boosted Team Comfort Level Improved Response Time/Zero Overdue Improved Patient Experience Appointment Clerks Call Patient Day Before Appointment Reduced No-Shows Improved Patient/MDG Communication Trust Instituted Patient Integration Program (7 Patients Sit On MDG Committees) Instituted Patient & Family Experience Coordinator Pilot to Serve Community

23 Lessons Learned to Share with Other MTFs Leadership MUST buy in to CPI without being too riskaverse Be OK with failure almost everything is recoverable Consider using personnel as a Leatherman Don t chase the metric use as a tool to guide improvement Maximizing resources and robust CPI has limitations at some point must accept that you can only do your best without crushing your people Sometimes less is more Look at full body of extra work taken on by a short staff not just the direct patient encounters (ie Public Health Assessments, Telephone Consults)

24 Plans for Sustainability Continue the IHI team as a Continuous Process Improvement (CPI) Committee Evaluate processes and use data to decide on process improvements Continue to include entire team in the planning and decision process

25 Questions?

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27 Members Senior Sponsor: Dr David Lawton, Department Chief of Surgical Services Project Lead: Dr Patrick Golden, General Surgeon Project Team Members: CPT Natheia McMillan (Anderson), OR Nurse Dr Darrell Ferguson, Anesthesia Mr Jonathan Bonney, OR Tech

28 Our Aim Statements By Jan 2018, we intend to reduce the return to OR rate and morbidity by 50% within the Surgical Services. We intend to develop a reliable process for standardized huddles which will occur prior to the start of each operative day with debriefs 95% of the time or more after the surgical case. We will also reduce OR turnover times by 25% or more.

29 Changes Tested 29 Creating additional morning huddle guide boards for every room Debrief tracker assessments Morning huddle observances Turnover & morbidity tracking Staff satisfaction Patient Safety Decrease in case issues

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31 Month Average Minutes Per Turnover OCT NOV 2017 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV Average Minutes Per Turnover (All Services)

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33 Audit Results 33 OR Morning Huddle Compliance Oct. Nov. Dec. Jan. ROLLING AVERAGE 1. Morning Huddle Started by % 68% 100% 60% 66% 2. Circulator Present 56% 100% 100% 80% 84% 3. Surgeon Present 36% 68% 100% 80% 71% 4. Scrub Tech Present 36% 100% 100% 80% 79% 5. Anesthesia Present 56% 100% 100% 100% 89% 6. Equipment Issues 32% 88% 100% 100% 80% 7. Foley's Discussed 36% 72% 100% 96% 76% 8. Medications Addressed 32% 72% 100% 92% 74% 9. Antibiotic Addressed 36% 72% 100% 96% 76% 10. Anesthesia Addressed 36% 76% 100% 96% 77% 11. Interruptions Present 36% 88% 100% 100% 81% 12. Positioning Addressed 32% 80% 100% 100% 78% 11. Block Needed 36% 88% 100% 100% 81% OR Morning Huddle Compliance Jan. Feb. Mar. Apr. May June July Aug Sep Oct Nov ROLLING AVERAGE 1. Morning Huddle Started by % 92% 100% 92% 92% 88% 84% 96% 92% 100% 96% 92% 2. Circulator Present 85% 96% 100% 100% 100% 96% 100% 100% 96% 100% 100% 98% 3. Surgeon Present 92% 92% 100% 96% 92% 88% 84% 96% 92% 100% 96% 93% 4. Scrub Tech Present 92% 100% 100% 100% 100% 96% 100% 100% 100% 100% 100% 99% 5. Anesthesia Present 85% 92% 100% 96% 100% 96% 100% 100% 92% 100% 100% 96% 6. Interruptions Present 92% 100% 100% 100% 100% 92% 100% 100% 100% 100% 100% 99%

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35 OCT 2016 NOV 2017

36 Audit Results 36

37 Lesson Learned 37 Implementing mandatory morning team huddles and debriefs have displayed a decrease in return to OR rates, and decrease in OR turnover times. We learned that through improved team communication problems are being identified early and lead to better overall patient outcomes. Utilizing the NCO floor coordinator and Nurse floor coordinator to correct issues that go into the debrief tracker, before the case starts assist. Leadership involvement is a MUST!!!

38 MHS IHI Learning Collaborative and our MHS Operating Model for High Reliability CHRISTIAN L. LYONS, PT, DPT, OCS, ATC Lt Col, USAF, BSC Chair, MHS IHI Steering Committee 13 DEC 2017 Governance Implementation Planning Team Pre-Decisional Deliberative Matter For Official Use Only Within DoD

39 Tri-Service Tri-Service Pre-Decisional Deliberative Matter For Official Use Only Within DoD 39

40 Identified MHS Clinical Communities Phase A Proof of Concept 1. Behavioral Health 2. Neuromusculoskeletal 3. Primary Care 4. Women and Newborn Next for Proof of Concept 5. Dental Clinical Communities create a network that functions at all levels of the MHS (i.e., MTF, Region Headquarters, Enterprise) to enable bottom-up performance improvement initiatives to be spread enterprise-wide Pre-Decisional Deliberative Matter For Official Use Only Within DoD 40

41 Vision of MHS Enterprise-level Clinical Communities Purpose: To enable front line clinicians to drive Enterprise-wide performance improvements in readiness and health; empower Enterprise-level Clinical Communities to create conditions for high reliability at the point of care (processes, standards, metrics); establish MHS standards and clinical outcomes and hold ourselves accountable. Put patient interests at the center of health care delivery Align to the MHS Quadruple Aim, 5 MHS Domains of Change, and 8 MHS HRO Guiding Principles Tri Service approach to clinical problems Organize by high-volume, high-risk groups of interrelated care processes that house and align clinical specialties Prioritize readiness Serve as a primary mechanism for: Improving patient outcomes Eliminating preventable harm and waste Improving performance and innovation Maximizing value Developing MHS process standards Reducing variability Embedding learning and safety culture across military treatment facilities (MTFs) of all Service Components Pre-Decisional Deliberative Matter For Official Use Only Within DoD 41

42 IHI Learning Collaborative and MHS Clinical Communities Pre-Decisional Deliberative Matter For Official Use Only Within DoD 42

43 MHS IHI Learning Collaborative Empowering Front Line Operators Engaging Provider Teams directly to instill and grow Process Improvement - 23 Military Treatment Facilities Access to Care Improvement - 22 Military Treatment Facilities Surgical Quality Improvement - 4 Learning Sessions Participants Concurrent Use of Open School Curriculum (as of 30 Sep 17) - 1,461 Enrolled - 5,508 Courses Completed IHI Basic Certificates in Quality and Safety earned Lessons Learned - Interaction / Collaboration between teams yielded greatest dividends - Missed opportunity for better coordination combining like local projects - Leadership engagement is paramount 43 Pre-Decisional Deliberative Matter For Official Use Only Within DoD