Improving Performance in Practice :

1. Improving Performance in Practice: From IPIP to GQI

2. Objectives • Provide an overview of IPIP methods and rationale as it moves statewide under the GQI/NCHQA • Describe what we will do and what you will do • Introduce the change model and change packages • Introduce measurement

3. Adherence to Quality Indicators in the Medical Care Setting • Hypertension 64.7 • Depression 57.7 • Asthma 53.5 • Hyperlipidemia 48.6 • Diabetes 45.4 Percentage of Condition Recommended Care Received McGlynn et al. NEJM 2003

4. DiabetesRecommendations Health Systems Disease management Strongly Recommended Case management Strongly Recommended Self-Management Education Community gathering places Recommended Home - type 1 diabetes Recommended

5. North Carolina Chronic Disease Management Collaborative

8. IPIP: A National Initiative American Board of Medical Specialties American Academy of Family Physicians American Academy of Pediatrics American Board of Family Medicine American Board of Pediatrics Plus American College of Physicians American Board of Internal Medicine …funded by the Robert Wood Johnson Foundation

9. National IPIP: The Vision Dramatic transformation of office care with improvement of chronic disease care All Primary Care Disciplines—Family Medicine, Pediatrics, General Internal Medicine—across the whole state New approach to CME and linkage to Maintenance of Certification Part IV Started in two states (NC, CO) now spread to five more states (PA, MI, WA, WI, MN)

10. North Carolina Coalition Physician Leadership (NCAFP, NCPS, and the NCACP) Collaboration of NC AHEC and Community Care of North Carolina With active involvement and support from Medicaid State Employees Health Plan Blue Cross Blue Shield of NC Health and Wellness Trust Fund Division of Public Health MRNC/CCME (QIO) North Carolina Medical Society

11. Spreading Statewide Focus is providing help for doctors to transform their practice by building systems to reach every patient, every time Pilot: Eastern and Mountain, learn how to do it and spread it in each practice and across the state. Governor’s Quality Initiative/North Carolina Health Quality Alliance

12. IPIP Methods Overview Focus on providing help for doctors to change their practices rapidly by using data to drive the change Data Collection and Reporting Rapid Cycle Process Quality Improvement Consultants Quarterly dinner meetings to share learnings CME and MOC-IV credit

13. Learnings About Process From the Pilot Wave Common measures of quality take time Recruitment was not difficult MD championship, CCNC/AHEC regional leadership critical Regional strategy very successful QICs immensely popular Data systems are a large barrier, but can be overcome

14. Learnings:Can we improve care?

15. Diabetes Quality Improvement in Wave 1 after 9 months (n=12) %HbA1C <7 40 to 54% (40%) %HbA1C >9 20 to 11% (15%) %BP < 130/80 35 to 47% (25%) %LDL <100 36 to 50% (36%) Smoking advice 45 to 77% (80%) Foot exam 40 to 63% (80%) Eye exam 24 to 35% (60%) Nephropathy 38 to 62% (80%)

16. Asthma Quality Improvement after 9 months (n=5) Severity Classification 68 to 80% Controller Medication 94 to 94% Flu Shot 38 to 67%

17. IPIP in North Carolina Making it work for you! Individualized office system assessments Practice data collection with internal reporting to immediately impact care

18. What You Can Expect From IPIP QIC to work with you on office systems changes Help establishing database of your patient population Tools and methods for changing your practice Comparisons to other practices, with opportunity to learn from them CME and MOC IV credit Some financial support Access to national leadership in quality improvement

19. What IPIP Expects From You Formation of a practice team to champion change, review and submit data Implement registries, templates of care, practice protocols and support for self management Frequent analysis and small changes in your practice, with tests of change Participation in quarterly meetings to share your learning with other practices Regular engagement with your QIC

20. IPIP Reimbursement Initial $1000 after identification of clinical improvement team, attendance at kick-off meeting and beginning submission of baseline data Second $1000 after submission of baseline and six months of data and participation in network activities. Third $500 after 12 months of data and establishing a sustainable culture of quality improvement in your practice. CME will be provided for ongoing activities

21. IPIP/GQI/NCHQA: Vehicle for Leadershipin Communities and Across the State One definition of quality across payors One audit of quality per practice across all payers Help us learn how to help other doctors transform their practice and respond to pay for performance initiatives Developing permanent community based support for practice improvement

22. Questions????? • We need your advice, understanding and help • If we haven’t addressed what’s on your mind, TELL US PLEASE!

23. Changing Office Systems Model for Improvement: How to Change Change Packages: What to Change

24. Chronic Care Model Community Health System Health Care Organization Resources and Policies Practice Level ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

25. Model forImprovement Act Plan Study Do What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? • Workflow Analysis • Brainstorming • Nominal Ranking • Try again? • Change it? • Dump it? • Small tests of change • 2 pts. 1 doc • Quick tests with feedback • Data pulls • Check sheets • feedback

26. Change Model: Key Elements • PDSAs are a generalized approach, but personalized for your practice • Pilot and Spread • Emphasize Learnings • Rapid small cycles!

27. Repeated Use ofthe Cycle Changes That Result in Improvement A P S D DATA D S P A A P S D A P S D Hunches Theories Ideas

28. What is a Change Package? • A change package is an evidence-based set of changes that are critical to the improvement of an identified care process. • Ed Wagner MD Improving Chronic Illness Care. org

29. IPIP Change Package Organization • High-leverage Changes • Detailed Changes • Change Tools

30. IPIP Change Package • High-leverage Changes (12-18 months) • Step One: Implement Electronic Database – clinical information systems • Step Two: Use Template for Planned Care – delivery system design • Step Three: Use Protocols – decision support • Step Four: Adopt Self-management Support Strategies

31. P P P P P P A A A A A A D D D D D D S S S S S S S S S S S S D D D D D D A A A A A A P P P P P P A A A A A A P P P P P P S S S S S S D D D D D D P P P P P P A A A A A A D D D D D D S S S S S S Changes in Parallel Self- Mgmt Support Delivery System Design Decision Support Clinical Information Systems Community Resources Organization Strategies for Each Component of the Care Model = Initial work in IPIP = Areas to work after initial work is complete

32. Detailed Changes: Registry • Select and install a registry tool • Determine staff workflow to support registry use • Populate registry with patient data • Routinely maintain registry data • Use registry to manage patient care and support population management Step One: Implement an electronic database:

33. Detailed Changes: EHR Step One: Implement and Electronic Database: • Learn capability of EHR for registry functions (identifying patients, flowsheets or disease templates and data reporting) • Improve use of EHR to support registry function • Routinely maintain correct use of EHR • Use EHR as registry to manage patient care and support population management

34. Detailed Changes: Templates • Select template tool from registry/EHR or use a flow sheet • Determine staff workflow to support use of template • Use template with all patients • Ensure registry updated each time template used • Monitor use of template Step Two: Use a template for guided care:

35. Detailed Changes: Protocols • Select and customize evidence-based protocols to office • Determine staff workflow to support protocols, including standing orders • Use protocols with all patients • Monitor use of protocols Step Three: Implement Protocols

36. Self-management SupportStep Four: • Obtain patient education materials (e.g., asthma action plans) • Determine staff workflow to support SMS • Provide training to staff in SMS techniques • Set patient goals collaboratively • Document and monitor patient progress toward goals • Link with community resources (schools, service organizations)

37. Monitoring the Process • Critical step in high-leverage changes • Different than measurement data • To inform Improvement Team • Goal is 90% reliable processes • Requires work and planning • Can decrease frequency when process is at 90%

38. IPIP Change Package Tools It’s not the tools, it’s the process…in your setting with your staff and your patients • Housed on IPIP Extranet • Organized by Change • Adding Tools from Practices

40. In Summary: Change Package • Includes details about making changes, measures, assessment scales and tools • A resource for practices and QICs • Offers guidance and resources • Remember: Teams testing these changes in a small, rapid-cycle style, will help adapt them to your individual practice and adopt strategies throughout your entire office.

41. Questions?

42. Measurement Practical Examples

43. Key Points for PDSA Cycles • Do cycles on smallest scale possible • Think baby steps • “Failed” cycles are learning when small (trial and learning) • Pilot, then spread

44. Example 1: A Children’s Clinic • Aim: Improve asthma outcomes (reduce ED and hospital visits by 50% and improve patient well-being) by: • improving care process in office • improving patient self-management skills • First step: Identify asthma patients (so they can assess symptoms and improve management)

45. Improve Severity Classification: Cycle One • Plan • Find and label charts of all asthma patients • Theory: we can feasibly label charts of all asthmatics • Do • Computer run of all asthma diagnoses • Study • N = 3500 • Too many patients to label • Act • New cycle: focus on sickest patients

46. Improve Severity Classification: Cycle Two • Plan • Start with sicker patients • Theory: we can feasibly label charts of our sickest asthmatics (seen in ED or practice recently) • Do • Asthmatics seen in ED and in practice in last 2 months identified by computer • Asthma patients identified as they come into office • Study • N= 75, easy to accomplish • Act • Begin labeling these charts

47. Example 3:Nurse-directed services: Improving the prompts

48. Interventions June 2006 Developed prompting for nursing staff Poorly accepted by providers and nurses. Lacked consensus. Weak follow-up and reporting.

49. Process to Engage Nurses • Solidified divisional support for utilizationof the intervention • Developed educational session with nurses • Meeting introduction by medical director • Revisited intent of the yellow sheets • Reiterated the role of the nurse as an integral member of our team • Reviewed evidence behind our recommendations • Listened to nurses’ concerns • Developed rapid means of feedback

50. Items to be Included in Nurse Assessment • Assess as indicated on the prompt • Depression screening • Smoking assessment and intervention • Eye referrals • Monofilament testing • Pneumococcal vaccination