A14/B14 The presenters have nothing to disclose Nurse Billing: Spreading Initiatives in the Region IHI National Forum December 10, 2013 Presenters: Carrie Gerhard, MD Jean Krause, CQO Objectives After this session, participants will be able to: Extrapolate our experience in spreading standard work into your own disparate departments Show proficiency in using basic quality improvement tools Continue the conversation about implementation of nurse only billing 1
Disclosures Dr. Gerhard none Jean Krause none clgerhar@gundersenhealth.org jmkrause@gundersenhealth.org Gundersen Health System Service Area covers 19 counties in three states; Western Wisconsin, Southeast Minnesota and Northeast Iowa Over 48 clinic locations Physician led organization Clinic Founded in 1891 and Hospital in 1902 2
Our Service Area Leading across geography Navigate the challenge of standardization of work across multiple rural clinics separated by many miles Independent practices Distance provided protection from initiatives of the Mother Ship Standardization and elimination of waste was the new goal Doing the same thing and speaking the same language is important 3
It is not the strongest of the species that survives nor the most intelligent that survives. It is the one that is most adaptable to change. Charles Darwin My Checklist for Spread Make communication your mantra Search out the early adopters Persevere 4
It is the interval between stimulus and response in which the leader emerges. My Checklist for Spread Make communication your mantra Search out the early adopters Persevere micro motivation 5
Where did I start? Learning Community at Gundersen Physician Leadership group focused on building competency in quality improvement Gundersen Improvement System Integrating the human side of change and the process side of change Our assignment: to select and complete a improvement project Gundersen Improvement System As leaders we need to be skilled in leading people thru change and skilled in how to manage and make change in the processes of care. 2012-2013 Goal Establish common language among leaders around the Gundersen Improvement System (GIMS) Develop skills in coaching others in improvement 6
Why is being competent in improvement methods important to me as a leader? It is our job to know it well enough to lead, teach, encourage and coach others in improvement It is our job to be consistent in modeling the use of standard improvement methods It is our job to go and see and engage staff in doing the work, in solving problems and improving the processes It is our job to create an expectation that improvement is a part of everyone's daily work Jeff Thompson, CEO Gundersen Improvement System GIMS Continuous Improvement Create a Shared Need Lean thinking: Go and See, Use A3 Engage Staff Understand the Problem How will it help Ethyl? 7
GIMS Gundersen Improvement System Gundersen Improvement System E-learning modules IHI Open School Classes GIMs Training Class face to face 90 Day Improvement Cohorts Leader book club and coaching Required training in 2012-2013 for leadership Physician/Administrative partners All Improvement Needs Focus on the Patient First Focus on Higher Quality and Safer Care with Affordability Engage Employees Closest to the Work (Teamwork) Evidence Based/Ideal Design Lean Thinking to Eliminate Waste Measurement 8
All Improvement Requires Change, Not All Changes are Improvement 9
The Human Side of CAP prepares a leader to lead people throughout the change that is occurring This focuses on the human side of change The Process Side of Various Improvement Frameworks (MFI, PDSA, Lean) help us accomplish improvement work This focuses us on the technical side of change 10
How will we know? 2012-13 Performance Review Question for Executive, Administrative Director, Director Positions LEADERSHIP AND IMPROVEMENT COACHING Demonstrates the knowledge, skills and behaviors required of leaders in a lean improvement organization: Consistently models the use of standard improvement methods, including the A3 Cascades improvement methodology to direct reports through teaching and coaching Demonstrates effective coaching behaviors to ensure understanding and heighten integration of quality improvement measures Creates the expectation that improvement is part of our daily work across the organization Identifies accountability measures to assist staff in measuring success How will we know? Employee Perspective Survey Custom Question I have participated in an A3 problemsolving session 11
My Improvement Project Institute i-stat testing of INRs (international normalized ratios) in my home clinic for chronic anticoagulation Align with two other clinics in the MN region Standardize the process of nurse billing Why was this project important? Aligned with the Triple AIM Improve the health of our patients by allowing us to give them their INR results immediatelyavoiding and catching mistakes. Decrease medical costs by improving control of INR and decreasing morbidity associated with out of range INR. eliminates the wasted time that our nurses spent later trying to reach patients by phone with results and allows us to bill for that very important time. Improves the patient experience by eliminating more painful venous puncture and wait time. 12
Definition of nurse only visit Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually the presenting problems are minimal. Nurse billing Face to face time with the patient Requires documentation of history, assessment, and plan Under the order and supervision of a provider with co-signature 13
For our project Indication for anticoagulation INR result Current dose of Coumadin and adjustments Any changes to health, diet, medications Identity of the nurse Identity of the provider and co-signature of the provider Nurse visit only that day Different date INR testing and medication management BP checks requiring intervention Med refills requiring intervention Strep testing requiring intervention Ear wash with evaluation 14
Seeing the provider that day Same date Tobacco counseling Inhaler and asthma teaching Coding CPT code 99211 Less than or equal to 30 minutes RN011 Greater than 30 minutes with time documented 15
How to start The first step is to work on the process side of change. For that I turned to a tool called Project Plan 16
Project Title Name of your project or change initiative in 5 words or less Examples: Anticoagulation Management Catheter Infections Pressure Ulcers Notification Process for Alerts related to Radiology Reads Purpose Why are we doing this? Why do we need to work on this? Why do we want to meet the associated goals? Straight forward and easy to read and understand Helps focus the direction of the work Provides the AIM or Target 17
Scope What is In Scope? What will be accomplished as part of this work? What will be included as part of the project? Identify where project starts & ends Identify the customer of the project What is Out of Scope? What will NOT be accomplished as part of this work? What will not be included as part of the project? Background Background Information Gather information about the current process/issue What data currently exists to support the project? History (who, when, what, how) Explore previously attempted solutions What other problems/projects are linked with this one? Have you researched current or best practices in other organizations? 18
i-stat improvement project Purpose Scope Background A-ha moment 19
Group Project Plan Think about your own changes/problems/projects Fill out Template Title Purpose Statement In/Out of Scope Background 20
i-stat improvement project Current state Our flow chart was ugly Elevator Speech Tool for creating shared need Foster a sense of excitement Create readiness for change Brief What is the project about? Why is it important to do? What will success look like? What we need from you? 21
i-stat improvement project 100,000 Lives Campaign Elevator Speech "We will celebrate each other because the patients whose lives we save cannot join us, because their names can never be known. Our contribution will be what did not happen to them. But we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might not have known, and holidays will be taken, and work completed, and books read, and symphonies heard. And gardens will be tended that, without our work would have been only beds of weeds." 22
Group Elevator Speech Think about how you would motivate your group, what emotions could you harness? What would you elevator speech be? What is the project about? Why is it important? What will success look like? What do we have to do? i-stat improvement project Flow chart the future state Test changes in One Clinic Small Plan Do Study Act cycles Get Ready to Spread 23
i-stat improvement project Huddle to spread ideas La Crescent Clinic 24
La Crescent Clinic La Crescent Clinic 25
La Crescent Clinic Conference Room Video Huddle 26
How would we know this would be successful? 27
Measurement Make measurement a priority from the beginning Consider how you will display the data Make it visible for staff 28
Run Chart Rules Common Cause vs Special cause variation Trend: 5 or more data points in one direction Shift: 6 or more data points above or below the median An astronomical data point 29
Improvement never ends What happens when your best laid plan goes astray? A3 30
Patients aren t waiting for a nurse visit after the i-stat INR is done Go and See Gemba Real Place Patients aren t waiting for a nurse visit after the i-stat INR is done PDSA 31
What helped me be successful? My Checklist for Spread Make communication your mantra Search out the early adopters Persevere 32
Process side of change Project plan Flow map Run chart A3 to solve problems Human side of change Engaging staff who do the work Elevator Speech Use of the video huddles 33
Nurse Billing Nurses can bill for face to face services CPT codes Role of the provider Objectives After this session, participants will be able to: Extrapolate our experience in spreading standard work into your own disparate departments Show proficiency in using basic quality improvement tools Continue the conversation about implementation of nurse only billing 34
Questions 35