Cross‐fertilizing Our Team’s Knowledge and Ability to Improve Quality through the PPRNet Model

1. Cross‐fertilizing Our Team’s Knowledge and Ability to Improve Quality through the PPRNet Model Tim Tobolic MD Byron Center Family Medicine ttobolic@bfmpc.com

2. Cross‐fertilizing Disclaimer I do “Keynote” (PowerPoint on steroids) I hate “PowerPoint” Steve Forced me to do Powerpoint. So I had to relearn how to do PowerPoint. I have NO financial relationship to MUSC, PPRNet or the information in this presentation. So, I am not sure why I had to use Powerpoint.

3. “It is not necessary to change. Survival is not mandatory.” ...W. Edwards Deming

4. PPRNET History • Solo > Small group (5) • 1999 PPART • c. 2004 PPRNET • 4/2009 “Sold out” - “captured” - “sold again”. Raised in captivity - “Epic” diet • 9/2010 “Escaped” captivity > solo • 12/2010 Chose PPART because of PPRNET • 2012 PCMH Designation

5. PPRNet Early days • Champion in our office manager - embraced PPRNet Model. • Participation agreed on by Drs., but lackluster participation • PPRNET Quality Improvement Team, Project leaders • Invited PH - a mistake since they stole Office Manager but better for her. • Steve Proposal for “distribution of wealth” (Steve = Obama visionary) • Newsletter, QI and Patient satisfaction info for large group.

6. Fertilizing BCFM with PPRNet Trip Model • Prioritize Performance • Involve All Staff • Delivery System Redesign • Patient Activation • Population-based Medicine • EMR Tools

7. Byron Center Family MedicineStrategic Plan MISSION To provide a innovative patient centered family medicine home that exceeds patient expectations and improves the quality of life of our patients and the community. Strategic Plan Incorporates PPRNet model and strategies

8. Health Maintenance • PPRNet gave meaning to Health Maintenance • In “Cross Fertilzing” Terms - HM = the ultimate fertilizer spreader • “Get the Red Out” • “Need to look at date” • Constant updating • Helps with Independent thinking. • Chronic Disease (Cross Ferilization) relationships • are better understood! • 11 months is the new 12 • 5 months is the new 6 • Patient Activation = Educate patients on the what and why of HM needs.

9. EMR / HM Tools Multiple simple embedded QT to help push and pull information and identify needed HM Here for acute problem, check on HM needed Push Result it to HM

10. EMR Tools • Multiple simple QT reminders embedded in Progress Note, Refill, Problem, Lab Result Templates Calling for Refill Open related Lab HM, OV, Lab Needed? Get it done !

11. We should work on our process, not the outcome of our processes. ...W. Edwards Deming

12. C-TRIPColorectal Screening • Our First experience with TRIP • Multifaceted - PPRNet Model • Focus on Preventive Screening • Staff Involved • Engaging patients • Meaningful use of PPART • Practical use of HM, Dot Codes • Cross Fertilize team ability and knowledge -put us ahead of the curve on quality incentives for payors

13. C-TRIPColorectal Screening Results of project

14. MS-TripMedication Safety • Bring in ALL medications to each visit. • Keep medication in original labeled bottle • Dispose of outdated, not used meds. • Bring All meds to consultants, hospitals, ER, UC

15. MS-TRIPMedication Safe Sack Project

16. CKD-TRIPChronic Kidney Disease • Evaluation group • TEAM Knowledge base - higher • Understand relationships to medication • Understand relationship to other chronic disease, labs - HTN, Lipids, CBC, GFR, ACE/ARB, NSAIDS • “CKD Tool” - complicated (thanks Cara Litvin) but so far very helpful • Higher level of patient ed. - NKDEP information • One of our payors just introduced CKD as a quality measure - fertilizer is working !

17. PPRNet Projects • Focus on important Quality Initiatives - Preventive care & Chronic disease management. • Staff - Not researchers or statisticians but better idea about research, process. evidence-based care. • Skills transferable (cross-fertilize) other projects and office processes • PPRNET Projects cross fertilizes many PCMH domains and many payor quality initiatives + incentives • Staff better understand the multiple links between chronic diseases -eg: Working on DM “cross-fertilizes quality improvement in HTN, CV disease, Immunizations, Lipids.

18. COLORECTAL MEDICATION SAFETY CKD Requests for Project Support AAFP TOBACCO AAFP IMMUNIZATIONS STAY INVOLVED YES DEMANDING BUT NEVER LET UP Cross Fertilizing Education I don’t have time to do it all The Professors from MUSC PPRNet Projects

19. Cross Fertilizing = Cross Training “Quality is everyone's responsibility.”...W. Edwards Deming

20. Old Staff = MA + Front Desk + Billing + Chart people + Office Mgr. • Greet Patient • Triage Patient • Bp, Ht, Wt. • Call in Refills • Answered Problem Calls • Give Labs to Doc • Made Appointments • Arranged Referrals • Billed

21. OLD Office Visit • “I don’t know, you’ll have to ask the doctor” • “The Doctor will tell you what you need.” • “You better talk to the doctor, he will order the colonoscopy if he thinks you need it” • Patient: “Who’s that person working at the front desk” • “The doctor will be in to tell you why you need those tests”

22. New (PPRNet Powered)Staff = Team Office Visits • Greet / Triage • BP, Ht, Wt, BMI • Review Medications • Review Medication Safety • Review all meds each visit • Recommend meds - eg. Aspirin Use • Better Knowledge of drugs & interactions. Health Maintenance • Understand / Explain /Discuss HM item needs • Better Understanding HM time tables • Patient Education • Prevention / Chronic Disease Guidelines

23. New (PPRNet Powered) Staff = Team Standing Order • Order needed labs • Order and Do Immunization • Order preventive: Colorectal screen / Pap / Mammogram • POC Testing - A1c, Spirometry System Redesign • Order Previsit labs • Reminder calls (Human vs Electronic • Follow up No Shows • Cross Trained Phone Calls • Now More Comprehensive • Order screenings • Lab Result Discussion and follow up ordered EMR • Deal with Interface • Order Entry • Data Entry, Tracking • Previsit Planning • Labs, Paperwork • TCV Visit • WebView (anticipated)

24. New Office Visit • “Yes I know I need a colonoscopy, Mary already ordered it.” • “Jackie already took my urine to check my kidneys” • “They wouldn’t give me any more medication till I came in to get my blood pressure (or my A1c, or my lipids, etc) checked.” • “Nikki caught me and told me I need to be back here in October for my labs and she scheduled a diabetic eye exam and a colonscopy“ • “I know, I was already told I need to bring in all my medications at the next visit.” • “I almost forgot my visit till Shannon called to remind me.” • “I’ll just talk to Shannon - “When I Check out” - “When I call in next time” - “If I Need anything” • “Don’t worry Doc, They will let me know when I need ........” • New Office Visit - a different level of patient understanding, empowerment and expectations.

25. Staff (on PPRNet) has Evolved • Intense • Involved • Aggressive • Empowered • Persistent • Comprehensive • LOOK AT THE BIG PICTURE! • Confident and Convincing. • Knowledgable • More Accurate! • Better Communicators • Attitude of Excellence • Caring • Patient Experience • PPRNET and PCMH savy • Better Team Culture • Better at creative thinking • Better and more comfortable patient educators • Better at getting needed data.

26. It is not enough to do your best; you must know what to do, and then do your best. ...W. Edwards Deming

27. Value = Projects • Involvement Investment in PPRNET projects • Site Visits • Individual and Team project focused training • HM tools - enhancements • PPRnet Webinars • Best Practices discussed

28. PPRNET Meetings • Involvement in PPRNET Meetings • Educational • Networking with “experts” • Carry back (“fertilize”) other team members • HM tools - enhancements • Realize they are not alone !

29. “Defects are not free. Somebody makes them, and gets paid for making them.” ...W. Edwards Deming

30. Share the Wealth • Staff play significant role in meeting quality guidelines. • PPRNET education has been significant part of that . I could never do it alone. • Team Knowledge + Patient Activation + Quality Improvement = Enhanced Incentive Payments with several payors. • Staff should share in those enhanced payments • Approx 15-20% of income in 2013 estimated to be incentives. • PPRNet “Best Practice” is worth something!

31. WEPWage Enhancement Program Old method • Come to work, put individual patient in room, answer physician messages, do refills, go home, get paid. • “Bonus” based on personal characteristics and individual performance. New Method • Value in independent thinkers but team players, innovation, understanding of data, registries, quality parameters, patient education, recommended prevention or community based care. • “Wage” based on outcome, team activity, quality incentives.

32. PPRNet Motivation “Best Practice” / “High Performance” Awards - OF COURSE

33. PH

34. PCMH • PPRNet Model made PCMH process easier • PPRNet Background reduced learning curve • BCBS List the PCMH Requirements • Its about the patient • Look at the Employeed evaluation. • Show picture of the BCBS protocol and list points

35. Why It Works • Intensity • Continue to improve skill • Continue to Improve the Processes • Consistency in process • Every Encounter Every Time = Opportunity • Teamwork - Challenging / Rewarding • Develop a better understanding of the knowledge we gain • Yes its hard, time-consuming

36. Celebrate

37. “The job can't be finished only improved to please the customer.” ...W. Edwards Deming