Martha Rome, rn, mph milwaukee, wi
tarix 21.03.2017 ölçüsü 548 b. #12188
Improving Performance in Practice (IPIP) Change Package Coaching Practices Improving Healthcare State by State Martha Rome, RN, MPH Milwaukee, WI February 11, 2009 Aims of IPIP To dramatically improve patient outcomes by transforming the way we deliver primary care, focusing initially on measurable improvement in diabetes and asthma, but rapidly spreading to preventive services and other conditions To assist different types of practices in using practice redesign strategies to improve efficiency and implement best practices To align efforts and motivate action at the national, regional, state, practice and patient level Aligning Across Policy Levels
Build will on state level and create state infrastructure National specialty societies work through state chapters Specialty Boards provide clear expectations for maintenance of certification Partner with other organizations in the state AHEC, QIO, payers, businesses, state government Aligning state efforts creates the IPIP model National Team supports states with: Standard protocols Decision support tools Access to other practices who’ve done this work successfully Access to experts in the field Data aggregation and reports Model Improvement networks/collaboratives Quality Improvement Coaches: Support individual practices and improvement networks Onsite consulting Group meetings (in person and phone) Role of Quality Improvement Coaches Intensive (often) on-site work with the practice team Provide avenue to network activities and share best practices Focused approach for implementation starting with key process changes Move practices faster for basic implementation Create group momentum with regard to implementation and standardization Help practices ensure that all IPIP changes are implemented Assist practices in developing teams & standardized work flow Provide examples of tools (standing orders) and roles Assist practices with regular monitoring of implementation to ensure reliability Usual care works well if your plane is about to crash
The IOM Quality Report: Selected Quotes “The current care systems cannot do the job.” “Trying harder will not work.” “Changing care systems will.” Systems are perfectly designed to get the results they achieve Advantages of a General System Change Model Applicable to most preventive and chronic care issues Once system changes in place, accommodating new guideline or innovation much easier Early participants in our collaboratives using it comprehensively Essential Element of Good Chronic Illness Care What characterizes a “prepared” practice team?
Clinical Information System Provide reminders for providers and patients. Identify relevant patient subpopulations for proactive care. Facilitate individual patient care planning. Share information with providers and patients. Monitor performance of team and system. Delivery System Design Define roles and distribute tasks amongst team members. Use planned interactions to support evidence-based care. Provide clinical case management services. Ensure regular follow-up. Give care that patients understand and that fits their culture Self-management Support Emphasize the patient's central role. Use effective self-management support strategies that include assessment, goal-setting, action planning , problem-solving and follow-up. Organize resources to provide support To Change Outcomes (e.g., HbA1c) Requires Fundamental Practice Change Interventions focused on guidelines, feedback, and role changes can improve processes Interventions that address more than one area have more impact Interventions that are patient-centered change outcomes. Templates Related to Better Performance and Less Variation (IPIP practices)
IPIP Change Package High-leverage Changes Implement Registry Use Template for Planned Care Use Protocols Adopt Self-management Support Strategies Implement IPIP Changes in Steps Use Registry to identify asthmatics/diabetics prior to visit (this requires the work of implementing a registry or “fixing” the EHR) Use condition-specific decision support tool (e.g., visit planner) Create customized flow diagram and protocols to standardize the care process Nursing Standing Orders to increase reliable execution [examples] Standard Protocol [example] Specific Care Team roles: who does what in the protocol Implement a self-management support system Throughout: Frequent monitoring of reliability and investigation of failures for ideas about how to improve standard performance 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 Detailed Changes: Templates Determine staff workflow to support use of template Use template with all patients Ensure registry updated each time template used Monitor use of template Detailed Changes: Protocols Step 3: Use Protocols a. Select and customize evidence-based protocols to office b. Determine staff workflow to support protocols, including standing orders c. Use protocols with all patients d. Monitor use of protocols Protocols: Asthma-specific Assess and document asthma severity and control Prescribe appropriate asthma medications and monitor overuse of beta agonists Use Asthma Management plans Establish visit frequency protocol Assess and treat co-morbidities Assess, counsel, and prevent exposure to environmental triggers Protocols: Diabetes Check and treat BP <130/80 Check and treat cholesterol Check A1C and treat hyperglycemia Assess aspirin and prescribe if not using Assess need for eye exam and make referral if needed Assess nephropathy risk Perform foot exam Provide appropriate vaccines Self-management Support 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) Cincinnati Children’s Hospital PHO 44 geographically dispersed, sites Individual models and styles of practice “First Wins” Early adoption of registry Concurrent data collection: written parent symptom review and clinical interview Relationship between changing process and changing outcome
Impact of PHO Asthma Initiative
Challenges Focus on Hypertension Reinforced use of BP check visit – patient sees RN or Health Coach New protocol and training for MA to recheck BP if high prior to seeing PCP BP Loan Program Chart Reviews Discussion with PCPs at monthly meeting PCP Discussions Monthly PCP meetings Results of chart reviews drive PCP discussion Discuss clinical management of HTN Ask PCP with best results – what do you do? PCP Discussions Identifies common misconceptions – “uncontrolled patients are already on maximal doses of medications” Identifies target for improvement – importance of rechecking BP if uncontrolled and asking if patients took their medications on the day of the visit The Multidisciplinary Team: The key to successful planned diabetes care and quality improvement in our practice Robb Malone, PharmD UNC General Internal Medicine January 20, 2009 Change is scary
We assessed root causes and actions
Everything tipped in late 2007: How did we hit ‘The Tipping Point’? “The level at which the momentum for change becomes unstoppable.“ "Ideas and products and messages and behaviors spread like viruses do.“ The Tipping Point: How Little Things Can Make a Big Difference. Malcolm Gladwell What did we learn from the first 3 years? ‘Every system is perfectly designed to get the results it gets’ If we don't like the results we have to change the system- basically and radically Providers responded to data and information at the point of care Addressed unanswered questions We must build consensus and standardize We must diversify We need to move more quickly An epiphany: The run chart , reporting AVG A1c for our clinic 2004
Diabetes planned care
What we learned from 2003 to 2006 A successful program includes: A multidisciplinary team A registry with decision support for proactive care Consensus backed by evidence-based algorithms and standards Persistence and leadership are key Appropriately designed interventions or systems can overcome patient vulnerability We continually evolve, change is necessary and represents opportunity Embrace rapid cycle change and the MFI An example of our stepped care approach: Green Zone
An example of our stepped care approach: Yellow Zone
An example of our stepped care approach: Red Zone
Role of The Care Assistants Consists of 4 care assistants Care assistants see patients during provider visits Patient education Utilize the tools created by the database Assist the physician Facilitate proactive care, encourage intervention Address barriers, adherence, glucose monitoring, provide smoking cessation counseling, screen for depression Average A1c in our clinic now
Example 1 Lipid screening & management: A front desk interventionStatus of Lipid Management September 2004 55% of patients had total cholesterol tested annually Approximately 68% were prescribed statins Average total cholesterol = 185 mg/dl Average LDL = 99 mg/dl We set a goal that 90% of patients would be screened annually and prescribed a statin Front Desk Process List of patients with diabetes Whether or not labs need to be drawn We had patients that needed labs that were not getting triaged appropriately Front Desk Logs About 60 patients with diabetes/week 30 needed a lab drawn Only 15 had it drawn (50%) Pizza for 90% Fidelity 25/33 = 75% No pizza 34/36 = 94% PIZZA Example 2 Process measure improvement: Nurse-directed interventions, improving the promptsProcess to engage nurses Solidified divisional support for utilization of 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 recommendations Listened to nurses’ concerns Developed rapid means of feedback 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 Modified Intervention (version 3)
Simple procedure for tracking daily progress- Excel spreadsheet
Widespread, significant improvement noted
Provider satisfaction has improved: How has this affected the life of a physician? Delegating processes frees up time to focus on diagnostic and therapeutic issues A weight has been lifted Excellent to know how the practice performs Data has changed our conversations It is satisfying to show improved care Diabetes Improvement Across the Practice--Lessons Just working harder doesn’t lead to better outcomes Just making a policy doesn’t mean the process gets done Doctors in our system don’t follow algorithms or policies very well Other members of the health care team are better…and that is OK Each member must function at their highest level of skill Distractions will arise, challenges will occur 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 helps adapt and adopt strategies in their office IPIP Expectations Practices work on redesign of systems of care delivery Target improvement in diabetes or asthma This becomes how we practice healthcare —continuously tracking, sharing, and improving Participation in IPIP meets one requirement for maintenance of certification and qualifies for Continuing Medical Education (CME) credit Expectations re: Data Collect data on performance measures (required) Submit numerators and denominators to IPIP via QIC, state program or directly Reliable, quality care is provided to the entire population by using registry (or EHR with population management functions) What do we mean by data? Aggregate measures of quality Based on national standards (NCQA,AQA,HEDIS) Physician or practice-based Additional details enhance understanding of context and meaning (levels of data quality) Range of data sources (paper -> Electronic Health Record) Rely Upon Nationally Endorsed Measures Early in IPIP development, it became clear that the scope of determining “ideal” measures was beyond IPIP Other organizations exist to do this: NCQA, Physicians Consortium, National Quality Forum, Ambulatory Care Quality Alliance IPIP decided to only require measures that had been endorsed by a one or more of the above organizations Benefits and Downsides Mitigates the debate about individual opinions Dramatically improves our ability to align Reduces flexibility Often leaves us with more “clunky” measures (less sensitive to changes) Measures sometimes change slower than we would like (concerns about obsolete) Required IPIP measures are not the only measures practices should be using Use other measures to help ensure reliable processes and do small PDSAs The complete IPIP Change Package is in Word format on the Extranet. Look under Resources and then in the Change Package folder. The complete IPIP Change Package is in Word format on the Extranet. Look under Resources and then in the Change Package folder. References www.improvingchroniccare.org http://www.med.unc.edu/medicine/generalm/documents/DiabetesResearch.pdf www.ihi/org/extranet. http://www.med.unc.edu/medicine/generalm/documents/DiabetesResearch.pdf Dostları ilə paylaş:
