HIT Innovations to Build an Empowering and Learning Culture March 2, 2016 Jignesh Sheth, MD, Senior Vice President for Clinical Operations Courtney Dempsey, Clinical Innovation Specialist
Conflict of Interest Jignesh Sheth, MD and Courtney Dempsey have no real or apparent conflicts of interest to report.
Agenda Identify learning objectives Link learning objectives to HIMSS STEPS Review Davies Award winning case studies Take away messages Questions
Learning Objectives 1. Identify the clinical value of consistent and continuing healing relationships with patients and colleagues 2. Define the benefit of standardizing individual and collective workflow distribution and accountability for outcomes 3. Influence change management through a defined organization-wide quality improvement progress tool
The Wright Center methodology aligns with the HIMSS Value Steps Learning Objective One SATISFACTION and TREATMENT/CLINICAL Learning Objective Two ELECTRONIC SECURE DATA Learning Objective Three PATIENT ENGAGEMENT AND POPULATION MANAGEMENT and SAVINGS http://www.himss.org/valuesuite
Learning Objective 1: Identify the clinical value of consistent and continuing healing relationships with patients and colleagues
I suppose leadership at one time meant muscles; but today it means getting along with people. Mahatma Gandhi
Local Problem Frustrating fragmentation within complex care delivery and medical education systems Global dissatisfaction with continuity of care identified by patients, physicians, staff and residents
Specific Challenges: Care Delivery Patients identify with one primary care physician Care is provided afterhours and on weekends, outside of physician s normal working hours Patient s needs are unpredictable, requiring open access Medical Education Scheduling patients under resident physicians complicates billing Inconsistent resident schedules make it very difficult to reschedule followup with the same resident Resident outpatient schedules change last minute
Intended Outcome: Empanelment Ensure patients consistently see familiar primary care providers, inclusive of residents, at every visit Improve provider and patient satisfaction with continuity of care Enhance residents training experience
Design and Implementation: Qualis Platform Creating Three Color-Coded Teams Number of patients allocated per team, based on provider FTE presence Panel capacity = (210 x FTE x patients per day)/3.7 Patients were assigned to a team based on appointment history Continuity through strategic scheduling within each team Sample Panel Capacity 210=working days/year; 3.7=average visits per patient per year
Design and Implementation: Assigning Residents to Color-Coded Empanelment Teams Optimized scheduling to ensure 2-3 residents from varying years of training were present in the outpatient clinic, per team, at all times The final empanelment list was published and shared with all staff in the outpatient clinics
Empaneled Team Composition: 2 physicians 2 extenders 2-3 MAs 1 LPN 0.3 care manager 4-5 residents from each PGY
Design and Implementation: Label Patients Charts, Color-Code Appointment Schedule Chart alerts informed the scheduling staff of patients team designation Color-coded EHR check-in screens verified the patient is scheduled correctly
Design and Implementation: Establishing Scheduling Process Driven by Empanelment Staff was trained on the value of the empanelment process for the patients, the practice and overall organizational mission Staff performance reports were developed to show compliance with proper color-coded scheduling Scheduling compliance goal of 90% was established
Team-Based Empanelment Compliance Report
Individual Empanelment Compliance Report
Utilization of Health IT Quality HEDIS measures were identified Focus on change management to fuel patient-centric outcomes Minor report revisions to clarify which member of the team saw each patient Data configured into individual and empanelment team metrics for care delivery process and health outcomes Reports are available through a web-based portal for easy access, updated monthly and used for performance evaluations
Monthly Empanelment-Based HEDIS Report
Resident Satisfaction with Empanelment Avg. 33% Average Increase: 42% Average Increase: 27%
Patient Satisfaction with Empanelment: CAHPS Results Average Improvement: 6.5%
Lessons Learned Leadership needs to prioritize the necessity of care coordination and continuity of care for patient satisfaction and resident education Empanelment improved physician, resident, staff and patient satisfaction The cost of developing and implementing EHR-driven empanelment was nominal in comparison to the value created Active promotion of team-based attitudes is vital with physicians who are used to independence
Learning Objective 2: Define benefits of standardizing individual and collective workflow distribution and accountability for outcomes
Health IT has the ability to create streamlined and more effective organizational processes to enhance internal communications, data reporting and collective alignment for shared, higher purpose. Linda Thomas-Hemak, MD President/CEO, The Wright Center
Local Problem Clinical performance measures were not reported or tracked at staff, provider or resident level Lack of organizational infrastructure to hold providers, residents and staff accountable for personal and team-based performance Staff and residents did not recognize their direct impact in larger organizational performance for mission delivery
Internal Response: Performance Assessment and Competency Evaluation (PACE) Cards Understanding current workflow and process mapping Creation of PACE Cards with specific, trackable performance measures for every employee Individual measures used to generate team-based PACE Cards
Dynamic Workflow Design
Intended Outcome: PACE Cards Standardize the care delivered Drive development of relevant skill sets Enhance accountability and job satisfaction Increase productivity and performance at individual, team, departmental and corporate level Determine metrics-driven annual bonus distribution Drive career advancement attractive for recruitment and retention
Design and Implementation: PACE Cards Updated monthly and posted on a web-based portal, with role-specific access Regularly reviewed by executive leadership and used for semi-annual performance-based evaluation Learner PACE Cards provide unique clinical relevance for patient-centered population management skillsets reported as educational outcomes
User A s user.anon@thewrightcenter.org 555.555.5555 Example of Individual PACE Card
Utilization of Health IT: Steps to Implement PACE Cards 1. Determine necessary measures for data to be valid and meaningful 2. Create required EHR-based reports 3. Develop an IT interface to extract, process and display data 4. Share individual and team-based metrics transparently via web-based portal
Lessons Learned HIT framework: Enables collective outcomes by connecting individuals daily work to a higher purpose of mission delivery Inspires and ensures staff accountability Data available through a web-based portal: Enlightens individuals, teams and departments Increases productivity and optimizes outcomes Promotes identification of waste in alignment with strategic goals
Demonstration of Outcomes: Direct Correlation between CPT Compliance and Revenue CPT Compliance (%) 64.61 67.02 62.71 CPT Compliance (%) 59.21 42.22 61.11 Monthly Revenue ($) $221,187 $243,200 $241,547 Monthly Revenue ($) $20,317 $14,700 $16,509 Team-Based Metrics Individual Metrics
Learning Objective 3: Influence change management through an organization-wide quality improvement progress tool
The highest levels of performance come from people who are centered, intuitive, creative and reflective - people who know to see a problem as an opportunity. Deepak Chopra
Local Problem Need to develop current and future workforce skillsets to implement stackable, continuous improvement projects to enhance: Patient care delivery processes Health outcomes Educational outcomes Physician and resident PDSA rapid system improvements were not universal experiences and lacked consistent, timely hand-off and organizationwide dissemination
Internal Response Investment in IT infrastructure to reliably track venue-specific PDSAs for all staff Contractual obligation for all staff to complete 6 PDSAs annually Performance-based bonus tied to validated PDSA engagement
Design and Implementation: Web-based PDSA Management Tool PDSA participation at individual, team and site-specific levels and areas of impact reported Sponsors oversee progress; users attach data/share tasks The tool allows effective hand-off Scalable insights are transferrable internally and spreadable to external organizations Location-specific data provides internal leadership with objective testimonies of value created in partnering organizations
Intended Outcome Trackable outcomes with potential for replication in other care venues Scalable framework for change management and measurable improvement Shared database to house successes/lessons learned Staff accountability and improved health outcomes Innovation and learning ignited at all organizational levels Educational outcomes metrics
Theory in Action EHRgenerated fluid registries and PACE Cards
Successful PDSA-Driven Workflow Redesign PDSA 1: Breast Cancer Screening PDSA 2: Diabetes Mellitus Self-Management Support Goals PDSA 3: Meaningful Use E-Prescribing Formulary Check PDSA 4: Tobacco Cessation
Plan: Create a report and visual management tools. Engage internal staff and staff at partnering mobile x-ray company. Plan Do Do: Empower and train mobile x-ray staff to call, schedule and upload patient reports Act: Meaningful partnership with an external vendor proved to improve patient care outcomes Act Study Study: Mammograms completed within a month spiked: 169 on-site mammograms in a year PDSA 1: Breast Cancer Screening Problem: Lack of up-to-date preventative breast cancer screening/mammograms
Visual Management Tool and Demonstrated Success Exception report: number of female patients between 40-85 Number of completed mammograms
PDSAs are Stackable and Contiguous During outreach, patients who had bilateral mastectomies without appropriate EHR documentation were discovered Documentation inaccuracy was a significant source of patient frustration A follow-up patient-centered registry cleanup PDSA focused on chart reviews and cleanup An exception report for these patients was added to our original report
Plan: Utilize HIT to create and display monthly compliance reports with documented SMS goal setting at all care member levels Plan Do Do: Incorporate SMS compliance report into performancebased PACE Cards Act: Link individual measures to PACE Cards to improve care delivery and hopefully health outcomes of the population served Act Study PDSA 2: Diabetes Mellitus Self-Management Support (SMS) Goals Problem: Non-compliance with trackable, consistent documentation of problem-specific SMS goals Study: Significant and sustained improvement in SMS Goal Setting compliance within a month of the PDSA
Plan: Educate staff to select Get Coverage button with every erx refill. Provide visual management tools for coaching and supporting behavior change Plan Do Do: A daily compliance report was reviewed with the nursing staff by physician leaders to promote accountability Act: Visual management tools successfully engaged staff to actively change their behavior Act Study Study: After a few weeks of coaching and utilizing this report, nursing staff consistently engaged to take the extra step PDSA 3: Meaningful Use E-Prescribing Formulary Check Problem: Non-compliance with Checking the Drug Formulary with Each Electronic Prescription Refill Request (erx)
Exception report given to nursing to verify EHR MU Measure for e-rx Formulary Check Compliance Get Coverage visual cue
Trending in line graphs below shows that erx PDSA improved two providers EHR MU Formulary Check Compliance in month 1 Provider A 40.15 78.89 PDSA Start Date Provider B 31.65 88.24 PDSA Start Date
Plan: Create and display a monthly compliance report tracking number of patients counseled and revenue generated Plan Do Do: Monthly metrics were added to individual PACE Cards Act: 82% of patients who completed the expanded program reported behavior change. Subsequent 12- month contract was awarded. Act Study Study: A significant increase in number of patients served resulted in generated provider/program revenue PDSA 4: Expanded Efforts for Tobacco Cessation Problem: Lack of monitoring and follow through of trained staff negated the potential of the partnership
Our Tobacco Free Northeast PA Partnership Referrals and Revenue
Summary of Lessons Learned Creation of PDSAs fosters engagement of all staff in improving patient care and medical education Metrics inspire value-driven results from team members Objectivity is vital for performance-based incentives Change/organic practice transformation occurs when successes can be easily replicated within individuals workflow and improvements are spread system-wide Trackable methods are necessary to improve processes and outcomes Aligned community partnerships are extremely powerful
Financial Considerations Creation Time (PDSA framework): 60 hours (in-house IT programmer) @ $55/hour (avg.): ($3,300) Training Time: 56 hours (trainer, staff, providers) @ $25/hour (avg.): ($1,400) Total: ($4,700)
Financial Considerations Expenses Full time IT programmer (avg.): ($50,820) Capital investment/ implementation: ($19,262) Total: ($70,082) Revenue Increase in revenue/providers: $4,032 Meaningful Use: $165,750 CMS/PQRS incentives: $6,715 Total: $176,497 Total Soft Return on Investment: $106,415
Avoiding Potential Loss/EHR MU Penalties Expenses Potential Medicare 2% reduction: ($13,553)* Potential Medicaid Meaningful Use loss: ($85,000) Total: ($98,553) Revenue Total Medicare shared savings $150,000 Example with: 10 providers 1,100 unique Medicare beneficiaries 6,520 total Medicare encounters *Annual Medicare revenue of $677,647
Summary of Realized Value of Health IT Empanelment: Provider/resident satisfaction improved by 33% Patient satisfaction improved by 6.5% Patient care/clinical outcomes increased by 4-11% PACE Cards: Created platform for secure data to drive daily work PDSA Tracker Tool promoted a CQI learning culture: Enabled collective engagement/financial savings Drove population management improvements http://www.himss.org/valuesuite
Authentic healthcare delivery transformation to achieve the ultimate goal of enhanced access, health outcomes, affordability and satisfaction requires strengthening patient-centered care continuity and team-based relationships through integrated, enabling HIT. Health IT Enhanced Access Affordability Health IT Quadruple Aim Health Outcomes Satisfaction/Joy Health IT Health IT
Jignesh Sheth, MD shethj@thewrightcenter.org Courtney Dempsey dempseyc@thewrightcenter.org The Wright Center Scranton, PA @WrightCenterGME The Wright Center for Graduate Medical Education Thank You TheWrightCenter.org Questions?