Welcome NIPN Operations Training Washington, DC

Welcome
WA
2005
OR
ME
1999
2007
ID
2010
2011
MN
ND
MT
NIPN Operations Training
2011
SD
WI
WY
MI
NB
2011
UT
2011 2007
Washington, DC
CO
KS
MO
PA
OH
IN
IL
2003
CA
2005
MA
RI 2005
CT 2008
2007
IA
NV
VT
NY NH 2013
NJ 2012
NIPN and Collaborative Improvement and
Innovation Network
Wendy Davis, MD
DE
WV
2007
VA
MD 2012
DC 2005
KY
NC
AZ
NM
2005
2004
OK
2007
TN
AR
SC
2013
AL
GA
MS
TX
LA
FL
AK
IP
Pre-IP
October 2-4, 2013
Inactive IP
(not currently
participating)
Year IP joined NIPN
HI
National Improvement Partnership Network (NIPN)
Improvement Partnership (IP) Operations Training
October 2-4, 2013
What is a CoIN?
Collaborative Improvement &
Innovation Network to Reduce Infant
Mortality (CoIIN)
A CoIN, or Collaborative Innovation Network, has been described as a
cyber-team of self-motivated people with a collective vision, enabled
by the Web to collaborate in achieving a common goal by sharing
ideas, information, and work.1
Key Elements of a COIN are:
•
•
•
Being a “cyberteam” (i.e. most COIN work will be distance-based)
Innovation comes through rapid and on-going communication across all levels.
•
Describes how individuals will work (and learn) collaboratively to develop,
implement, and evaluate strategies to reduce infant mortality.
•
Adapted to reflect focus on both innovation and improvement
Collaborative Improvement & Innovation Network to Reduce Infant
Mortality (CoIIN).
1 Gloor PA. Swarm Creativity: Competitive Advantage through Collaborative Innovation Networks. New York: Oxford
University Press, 2006.
Wendy Davis, MD, FAAP
October 3, 2013
4
CoIIN Structure:
CoIIN: History

Regions IV and VI Priorities & Teams
January 2012: Infant Mortality Summit, New Orleans (Regions IV
and VI – AL, FL, GA, KY, MS, NC, SC, TN; AR,LA, NM, OK, TX)
5 state-identified priorities:




Designed to meet stated needs related to:
 Common evidence-based strategies to reduce infant mortality
 Shared, collaborative learning and action across states
March 2012: initiative launched to support the adoption of
collaborative learning and quality improvement principles and
practices to reduce infant mortality and improve birth outcomes
Developed in partnership with ASTHO, AMCHP, March of Dimes,
CityMatCH, CMS, and CDC
5
Reducing early elective
deliveries <39 weeks (EED)

Expanding interconception care
in Medicaid (ICC)

Reducing SIDS/SUID (SS)

Increasing smoking cessation
among pregnant women (SC)

Enhancing perinatal
regionalization (PR)
Strategy Teams

2-3 Leads (Topical Experts)

Data and/or Methods Experts
(as needed)

2 Staff from MCHB and Partner
Organizations

Self-selected Members from
each of the 13 states in Regions
IV and VI
Teams average 25-30 members;
state delegations range from 7-13
members.
6
1
CoIIN Structure: Region V Priorities
CoIIN: Structure (cont.)
4 region-identified priorities:
Lifespan: originally 12-18 months; Regions
IV & VI recently extended through August,
2014
 Support provided by contract through
MCHB
 Foci, activities, and outcomes are “team
driven”


Early elective deliveries (EED) <39 weeks

Preconception Health

Social Determinants

Reducing SIDS/SUID (SS)
States: IL, IN, MI, MN, OH, WI
7
8
CoIIN: Launch (Regions IV & VI)

Face-to-face meeting July 2012

Learning sessions on:




CoIIN: Launch (Region V)
Existing efforts to reduce infant mortality and improve birth
outcomes
Collaborative Learning
Quality Improvement

Infant Mortality Summit March, 2013

MCHB + AMCHP + ASTHO + Abt Associates +
VCHIP

Face-to-face meeting October 1-2, 2013
 Regions IV and VI update (report successes),
“peer to peer learning,” plan for next 11 months
 Region V – QI learning, priority selection, team
development
 Keynote: focus on Social Determinants (overarching priority selected by Region V)
Meeting Goals:




Promote team building (5 Strategy & 13 State Teams)
Provide training in methods for QI and collaborative learning
Offer a structured environment to plan, implement, and test
innovation
Provide an opportunity for State Teams to Report-Out on activities
and successes since January 2012 Infant Mortality Summit.
9
10
CoIIN: Challenges
CoIIN: Summary

Logistics

Regional, inter- and intra-State differences

Strategy-specific challenges

Adoption of collaborative practices under
challenging logistical circumstances
11

Launched in response to stated needs among the
13 States in Regions IV and VI; now extended to
Region V

Designed to help states use the science of quality
improvement and collaborative learning to
improve birth outcomes over a period of 12-18
months

Part of a portfolio of efforts to improve birth
outcomes and works in partnership with these
initiatives
12
2
CoIIN + NIPN: Opportunities?

Encouraged current participants to consider
outreach to IPs in states in Regions IV, V & VI


Questions/Discussion
Sustainability?
Potential for future projects of mutual interest

Infant Mortality reduction as a population health
objective of interest to IP members and partners

Infuse health disparities/health equity into IP
projects (e.g., expand approach to data collection
to include geographic mapping)
Thoughts?
13
14
IPs with expertise on each topic will begin these
facilitated discussions—please pick TWO
sessions to attend. There will be an
announcement when you should switch.
From Design to Documentation and Promotion:
Practical Approaches to Getting the Most out
of Each QI Project
Topics include:
•Project Design and Measure Selection
•Successful Practice Recruitment and
Engagement Strategies
•Managing Data and Conducting Analyses
(IN ROOM NEXT DOOR)
•Results Promotion and Dissemination
National Improvement Partnership Network (NIPN)
Improvement Partnership (IP) Operations Training
October 2-4, 2013
National Improvement Partnership Network (NIPN)
3rd Annual Meeting March 8-9, 2010
Paul E. Jarris, MD
Executive Director, Assoc. of State &
Territorial Health Officials (ASTHO)
Public Health and Improvement Partnerships:
Using QI to Strengthen Performance and
Improve Population Health Outcomes
Paul Jarris, MD
National Improvement Partnership Network (NIPN)
Improvement Partnership (IP) Operations Training
October 2-4, 2013
Veteran, VT 50
18
3



Paul E. Jarris, MD, MBA
ASTHO Executive Director
Public Health Accreditation Board (PHAB)
National Public Health Improvement Initiative
(NPHII)
Tool Development
◦ ROI
◦ Health Equity Index


ASTHO lead Collaboratives
Policy vs. microsystems
“The goal of the national accreditation program is to improve and
protect the health of the public by advancing the quality and
performance of tribal, state, local, and territorial public health
departments”
Accreditation is the measurement of health department
performance against a set of nationally recognized,
practice-focused and evidence-based standards


There are three prerequisites that a health department must
have to apply for accreditation: community health assessment,
health improvement plan, and department strategic plan
PHAB Standards and Measures contain 12 domains of
competency that look at health agency: Health Assessment,
Investigation, Information and Education, Community
Engagement, Policies and Plans, Public Health Law, Access to
Care, Workforce, QI, Evidence Based Practice, Administration
and Management, Governance
http://www.phaboard.org/



$32.5 million in CDC grants to 73
governmental entities (states, territories, a
few large cities and one tribe)
Focus is on QI and Performance Management
All grantees are required to address their
readiness for PHAB accreditation.

Each NPHII grant funds a Performance
Improvement Manager (PIM). Many grantees
also fund an Accreditation Coordinator:
◦ CDC provides networking and TA support for all
PIMs
◦ ASTHO provides networking and TA support for
Accreditation Coordinators in states.
4





Provide technical assistance and to assist state and territory
health agencies to
◦ Organize and prepare for accreditation
◦ Integrate performance management systems into the public
health infrastructure
◦ implement quality improvement in public health programs and
processes
Provide policy guidance to state and territory health officials and
executive leaders on accreditation and performance management
legislation
Educate the public health community on PHAB accreditation and
its impact of population health and the quality of public health
services.
Represent the state and territory health agency perspective
during the development and continuous improvement of the
PHAB Accreditation Program.

Aggregate public health benefit

Public health programs

ROI applied to QI in public health (ASTHO tool)

Savings in Medicaid Expenditures
ASTHO created tool for applying ROI to QI…..
◦ Reductions in standard operating costs
 Greater efficiencies realized
◦ Revenue enhancements
 Increased cost reimbursement
◦ Increased productivity of agency functions
 Increased service encounters
◦ Decreased time to produce outputs
 Reduced cycle time process

The Objective of Health is Twofold:

◦ Goodness – The best attainable average level.

◦ Fairness - The smallest feasible differences
among individuals and groups.
World Health Report 2000
Collaborate with United Health Foundation
Index will allow state health agencies to:
◦ Examine health status data (obesity, infant
mortality, tobacco use, etc.) by race/ethnicity, age,
income, and educational level
◦ Create goals based on state-level (State Health
Improvement Plan) and national-level (Healthy
People 2020) measures
5
Maternal and child health
Public health-primary care
integration
Million Hearts
Radiation readiness
Prescription Drug Misuse
Improving health rankings
National Prevention Strategy
Tobacco Control
Climate Change
Health in All Policies
Reduce early elective deliveries <39 weeks
Access to pre- and interconception care
 Smoking cessation
 Safe Sleep
 Improve perinatal regionalization
 Social Determinants of Health

D.C.
Puerto Rico

Taken Pledge
Virginia Apgar Award (8% Reduction)
Franklin Delano Roosevelt Award
(9.6% Prematurity Rate)

Eliminating Payment for EED:
Georgia (7/2013), New Mexico (4/2013), South
Carolina (1/2013), Texas (10/2011)

Bonus to Hospitals meeting Quality Targets:
Washington State (7/2013)

Requirement for Hospitals to use Evidence-Based
Guidelines: Michigan (1/2013)

Non-medically Necessary C-Sections Paid at Vaginal
Delivery Rate: Illinois (5/2012)

Current legislation on EED: Hawaii


State and Local Health
Agencies worked with
local hospitals,
obstetrical providers
and families to
increase awareness of
delivery to full term
Partnered with
Medicaid
ACTION



Legislation to eliminate
Medicaid payment for
elective inductions/csections <39 weeks
Health department
received 4.1 M for
statewide Healthy Babies
Preterm birth rate has
dropped 6% in 1 year
saving Medicaid an
estimated $5.4M
RESULT
6

Began recruiting hospitals for voluntary “hard stop”
effort in Jan. 2011

Currently have 55 of 59 birthing hospitals enrolled,
affecting 95% of births

70% reduction in rate of induction <39 weeks
without medical indication

As of Jan. 1, 2013, NAS is a reportable condition
◦ Source of maternal opiate use is captured through
web-based portal available on Dept. of Health
website

Examining Medicaid claims data to provide insight into
opportunities for intervention to prevent and treat
opioid dependency in pregnancy
◦ Primary prevention strategies include: prevent
addiction from occurring, prevent pregnancy in
women taking narcotics
Cost of NAS in TN
Impact of NAS on Infant Health Care Expenditures, CY 2011
TennCare
non-LBWT
Births
TennCare Live
LBWT Births2
NAS Infants
45,205
40,437
4,768
528
Cost for Infant in first
year of life
$350,936,293
$171,336,964
$179,599,329
$33,249,612
Average Cost per child
$7,763
$4,237
$37,668
$62,973
Average length of stay
(days)
4.8
3.2
18.3
32.5
Number of Births
17P (17 alpha-hydroxyprogesterone caproate) is a
synthetic form of progesterone

TennCare Paid
Live Births1
Metric
◦
◦
While 17P is cost effective the calculations of ROI
have varied*

Percentage of Newborns in DCS Custody within One Year of Birth, CY 2011
2
Infants born in CY
2011
NAS infants
◦
Total # of Infants
55,578
528
◦
Total # infants in DCS
767
120
% in DCS
1.4%
22.7%
This sample contains only children that were directly matched to TennCare’s records based on Social Security Number.
Any infant weighing under 2,500g at the time of birth was considered low birth weight (LBWT).
~4,219 women qualify for 17P – 2,023 low income and
1,622 Medicaid.
Projected cost savings - $1,752,000 for Medicaid –
$4,558,400 for all women. 313 babies born full term.
* Based on compounded 17P cost, full course may be up to 20 shots
39
16.0
14.0
14.54 14.86 14.47
13.64
14.07
14.07
12.55
12.0
Deaths per 1,000
1
Served ~223 uninsured women, providing over 4021 doses
of medication.
95 clinics across the state requested free 17P for uninsured
patients. Most only had a few uninsured patients each
year.
11.04
10.0
8.0
6.0
4.0
2.0
0.0
All
Other
Regions
OH
MI
IN
IL
WI
MN
Total
Region V
7
16.0
14.54 14.86 14.47
14.0
13.64
14.07
14.05
Deaths per 1,000
12.55
14.07
Deaths per 1,000
12.0
10.0
8.0
6.0
4.0
10.00
9.00
8.00
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0.00
8.24
7.14
All
9.45
8.94
OH
MI
8.01
8.14
8.71
IN
IL
WI
Other
Regions
2.0
0.0
All
OH
MI
IN
Other
Regions
IL
WI
MN*
Total
Region V * U.S.-born mothers
Rate Ratio
2.32
Population Attributable
Fraction
16%
8.28
MN*
Total
Region V
2.31
2.51
2.24
2.48
2.63
3.05
2.43
18%
22%
13%
20%
14%
11%
18%
*US-born Black mothers
2.50
Excess Deaths per 1,000
2.00
1.00
58%
0.50
17%
-0.50
74%
35%
26%
distribution
33%
58%
1.50
0.00

Macro system view:

Policy focus
◦ Scope, scale, sustainability
due to gestational age
43%
47%
26%
16%
18%
OH
MI
IN
88%
137%
63%
IL
WI
42%
20%
due to higher mortality
among preterm infants
38%
MN^ Total
due to higher mortality
among term infants
-1.00
* Compared to All Other Regions
^ US-born Black mothers
ASTHO President’s Challenge on Healthy Babies
and Library of Best and Promising Practices:
www.astho.org/healthybabies/
ASTHO Making the Case for MCH Programs:
www.astho.org/Making_the_Case_for_MCH_
Programs/
◦ Statute, rule, regulation, payment, licensure
◦ ROI at system or Medicaid level

Multi-stakeholder
◦
◦
◦
◦
◦
◦
◦
Cross Cabinet
Administrative and legislative branches
Public Private
Providers
Insurers
Community Groups
Consumer (patient) groups
Working Lunch
Food is located in the foyer
National Improvement Partnership Network (NIPN)
Improvement Partnership (IP) Operations Training
October 2-4, 2013
8
Take Home Messages
The Future of Pediatric Public
Health and Primary Care
• Building health and education readiness for the next
generation of children requires a focus on the one
science of early brain development addressing toxic
stress from pre-conception to early childhood
• Integration of medical home, home visiting and early
childhood system allows breakthrough strategies to
address toxic stress and the social determinants of
health
• Evidence-based practices, population-based approaches
and continuous quality improvement for primary care
practices and early childhood community services
defines MCH public health for the future
National Improvement Partnership Network
Operations Training: October 3, 2013
Arlington, Virginia
David W. Willis, M.D., FAAP
Director of the Division of Home Visiting and Early
Childhood Systems (DHVECS)
Maternal and Child Health Bureau
Health Resources and Services Administration
Department of Health and Human Services
49
50
A League Table of Child Well-Being
LIFE COURSE
Drivers of Developmental Trajectories
• Neurodevelopmental
Genetic,
Prenatal and
Neurodevelopmental Factors
Socialeconomic
environment
Attachment and
Relational
Patterns
(ACE Scores)
• Social-economic
• Relational
Relational Health
Source: UNICEF, 2013
51
52
Adverse Childhood Experiences (ACES)
in Early Childhood (age 0-5 years)
POPULATION
ATTRIBUTABLE
RISK
•
A large portion of many
health, safety and
prosperity conditions is
attributable to Adverse
Childhood Experience.
Adverse Childhood Experiences
Child had one or more Adverse Child or Family Experiences
Child had two or more Adverse Child or Family Experiences
National Prevalence for All Children
(0-17 years) [State Range]
47.9%
40.6% (CT) - 57.5% (AZ)
22.6%
16.3% (NJ) - 32.9% (OK)
25.7%
20.1% MD – 34.3% (AZ)
20.1%
15.2% (DC) – 29.5 (OK)
3.1%
1.4% (CT) – 7.1% (DC)
6.9%
3.2% (NJ) – 13.2% (KY)
7.3%
5.0% (CT) – 11.1% (OK)
8.6%
5.2% (NJ) – 16.6% (DC)
8.6%
5.4% (CA) – 14.1% (MT)
10.7%
6.4% (NY) – 18.5% (MT)
4.1%
1.8% (VT) – 6.5% (AZ)
National Prevalence for
Young Children (0-5 years)
IMPORTANT NOTE:
Questions about child abuse and neglect
were not directly asked about in the
survey—though are unlikely to lead to
substantially different overall rates since
ACES are so commonly co-occurring.
Socioeconomic hardship
Divorce/separation of parent
Death of parent
ACE reduction reliably
predicts a decrease in
all of these conditions
simultaneously.
Parent served time in jail
Witness to domestic violence
Victim or witness of neighborhood violence
Lived with someone who was mentally ill or suicidal
Lived with someone with alcohol/drug problem
Treated or judged unfairly due to race/ethnicity
53
Christina Bethell, PhD, MBA, MPH.
36.6%
12.5%
25.3%
9.9%
0.9%
4.5%
4.1%
2.8%
5.5%
5.5%
0.9%
54
9
Adverse Childhood Experiences and Health:
Prevalence Among All US Chidlren
Prevalence of CSHCN with Emotional, Behavioral or
Developmental (EBD) Problems, by Number of Adverse
Childhood Experiences and Age
25%
80%
20.2%s
19.0%s
18.1%s
20%
17.8%s
17.6%s
17.4%s
15%
9.3%s
7.4%s
6.6%s
6.2%s
5%
2.2%
0-1 (6.1%)
4-5 (18.0%)
6-7 (19.3%)
4.6%
8-9 (25.5%)
5.1%
5.0%
40%
51.9%
20%
Age in years
(Prevalence of 2+ ACEs indicated in parentheses)
0%
Non-CSHCN
Child with One Adverse Child Experience
Child with Two or More Adverse Child Experiences
Christina Bethell, PhD, MBA, MPH,
CAHMI.
55
How Early Experience Gets Into the Body
A Biodevelopmental Framework
Physical,
Chemical & Built
Environments
Physiological
Adaptations &
Disruptions
Nutrition
CSHCN
CSHCN with
EBD Problems
Christina Bethell, PhD, MBA, MPH
CAHMI.
56
Increasing Early Brain and Child
Development Focus
Lifelong Outcomes
Cumulative Effects
Over Time
GeneEnvironment
Interaction
36.0%
19.3%
Child with no Adverse Child Experiences
Environment of
Relationships
Two or more adverse
family experiences
25.2%
4.6%
10-11 (28.6%) 12-13 (28.4%) 14-15 (31.2%) 16-17 (31.9%)
Foundations of Healthy Development and
Sources of Early Adversity
One adverse family
experience
25.9%
6.9%
5.6%
2-3 (13.3%)
9.8%s
7.8%
3.6%
2.4%
0%
10.1%s
23.7%
60%
12.4%s
10%
Children With Chronic Conditions Are More Likely to
Experience ACEs. Children With ACEs Are
More Likely to Have Chronic Conditions
HealthRelated
Behaviors
Educational
Achievement
& Economic
Productivity
Physical &
Mental Health
• BUILDING HEALTH
• Mitigating toxic stress effects on health and
developmental trajectories
• Promoting the healthy early childhood
foundations of life-span health
• Promoting preventative mental health
• Promoting kindergarten readiness
• Strengthening the systems to address the social
determinants of health
Biological Embedding
During Sensitive Periods
57
We’re in the “building health and
developmental assurance”
business…
58
Relational Health
Physical health
Developmental health
Relational health
60
59
60
10
Building an Enhanced Theory of Change that
Balances Enrichment and Protection
Maternal, Infant and Early Childhood
Home Visiting (MIECHV)
New Protective Interventions
Significant Adversity
Healthy Developmental
Trajectory
• Section 2951 of the Affordable Care Act of 2010 (P.L. 111-148)
amends Title V of the Social Security Act to add Section 511:
• $1.5 billion over 5 years
• $100M FY2010
• $250M FY2011
• $350M FY2012
• $400M FY2013 / FY2014
• Grants to States and Territories
• 3% Set-aside for Grants to Tribes, Tribal Organizations, or Urban
Indian Organizations
• 3% Set-aside for Research, Evaluation, and Technical Assistance
• Requirement for Collaborative Implementation by HRSA and ACF
Supportive Relationships,
Stimulating Experiences, and
Health-Promoting Environments
Source: Harvard Center on Developing Child
61
62
Priority Populations
Evidence-Based Home Visiting Works
Improves parental capacity and efficacy
Strengthens positive parenting behaviors & reduces negative ones
Improves birth outcomes
Promotes healthy child development & links children to better, more
consistent healthcare
Identifies early developmental delays and links children to
appropriate services
Reduces maternal depression
Improves school readiness
Puts parents & children on a trajectory toward long-term health &
productivity
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Families in at-risk communities
Low-income families
Pregnant women under age 21
Families with a history of child abuse or neglect
Families with a history of substance abuse
Families that have users of tobacco in the home
Families with children with low student achievement
Families with children with developmental delays or disabilities
Families with individuals who are serving or have served in the
Armed Forces, including those with multiple deployments
63
64
Evidence-based Home Visiting Models
Age Ranges Served by Evidence-Based Models
Nurse Family Partnership (NFP)
Early Head Start- Home Based Option (EHS-HV)
Healthy Families America (HFA)
Parents as Teachers (PAT)
HIPPY (Home Instruction Program for Preschool Youngsters)
Healthy Steps
Family Check-up
Child First
Early Intervention Programs for Preschool Youngsters
Play and Learning Strategies (PALS)
The Early Start (New Zealand)
Oklahoma Community-based Family Resource and Support
Program
• SafeCare Augmented
• MECSH – Maternal EC Sustained HV Program
•
•
•
•
•
•
•
•
•
•
•
•
HIPPY
Model Name
Nurse-Family Partnership
Healthy Steps
Early Head Start
Healthy Families America*
Parents As Teachers**
Family Check-up
Prenatal
0
1
2
3
4
5
6
…
17
Age of Eligible Population
65
66
11
State Selection of Home Visiting Model
(April 2013)
Evidence Based Model
Number of States
Implementing
Healthy Family America
43
Nurse-Family Partnership
42
Parents as Teachers (PAT)
30
Early Head Start
26
Home Instruction for Parents of Preschool
Youngsters (HIPPY)
8
Healthy Steps
3
Child First
1
Family Check-Up
1
67
68
MIECHV Grantees FY10-14
FY10
FY11
FY12
FY13
FY14
Total Grants
69
95
118
119
113
Formula Awards (states ,
DOC, and territories)
56
54
53
53
53
9
10
12
9
19
New Competitive Expansion
Awards
Continuing Expansion Awards
New Development Awards
13
Continuing Development
Awards
Non-Profit Awards
13
19
• Benchmark Areas
• Maternal and newborn health (8)
• Child injuries; child abuse, neglect, or maltreatment;
emergency department visits (7)
• School readiness and achievement (9)
• Crime (2) or domestic violence (3)
• Family economic self-sufficiency (3)
• Coordination/referrals for other community resources (5)
31
6
13
6
1 (ND)
2(FL,WY)
1
3
25
25
25
Continuing Non-Profits
Tribal Awards (new and
continuing)
Data Collection on Six Goals
(Benchmark Areas)
• Between three and nine constructs (X) within each
area
• 34 or 35 constructs overall per grantee
22
69
Three Types of Measurement
Aspect
Quality Improvement
Performance & Results
Accountability
Evaluation & Research
Purpose
Improvement of services
Assurance, trends,
accountability
New knowledge, evaluation
Bias
Accept consistent, known
bias
Set measures to reduce
bias
Design to eliminate bias
Sample size
“Just enough” data, small
sequential samples
Aim for 100% available,
relevant data
Adequate for design, plus “just
in case” data
Hypothesis
Hypothesis flexible, changes No tests, no hypotheses
as learning occurs
Fixed, generally predetermined
hypotheses
Testing
Sequential tests, small tests
of change
No tests
One or two larger overall tests
of hypotheses
Measuring
improvement
Run charts, Shewhart
control charts, etc.
General trends, no tests
Statistical tests (e.g., t-test, pvalues, chi square)
Confidentiality of
data
Data used by those involved
with QI project
Data available for public
consumption and review
Research confidentiality
protections as needed
Adapted from IHI: Solberg, L I; Mosser, G; McDonald, S "The three faces of performance
measurement: improvement, accountability, and research." The Joint Commission Journal on
Quality Improvement. 23, No. 3 1997, pp. 135-47.
What is a CoIIN?
• A focus on both innovation and improvement yielding a
Collaborative Improvement & Innovation
• A CoIIN, or Collaborative Innovation and Improvement Network, has
been described as a team of self-motivated people with a
collective vision, enabled by the Web to collaborate in achieving
a common goal by sharing ideas, information, and work.
•
Key Elements of a CoIIN
• Being a “cyber-team” (i.e. most CoIIN work will be distance-based);
• Innovation comes through rapid and on-going communication at all
levels;
• Work in patterns characterized by meritocracy, transparency, and
openness to contributions from everyone.
Gloor PA. Swarm Creativity: Competitive Advantage through Collaborative
Innovation Networks. New York: Oxford University Press, 2006.
23
24
12
CoIIN: Design to Action -- Vision
Know-Do Gap
Use the Model for Improvement to
guide Strategy Team work, including:
1. Identify a Quality Improvement Aim. (Plan)
MIECHV: HV CoIIN
•
•
•
•
2. Use Team members (Expert Leads and
State Representatives) to identify
strategies that work. (Plan)
3. Identify process and outcome measures
based on chosen Strategies. (Plan)
Breastfeeding
Developmental screenings
Maternal Depression
Engagement/transition
What we know
4. Implement strategies to “test” change.
(Do)
What we do
5. Measure progress (outcomes and
processes). (Study)
Yesterday
6. Adjust strategies as needed. (Act)
25
•
•
•
•
•
•
•
Recruit Participants (10-100 Teams)
Select Topic Areas
(Constructs)
Expert
Meeting
Pre-work
P
LS 1
S
S
LS 2
D
A
D
A
S
Planning
Group
P
P
D
A
Holding
the Gains
LS 3
AP1
ADVANCING CQI IN HOME VISITING / 3
Tomorrow
Source: Adapted from Institute for Healthcare Improvement (IHI)
26
Breakthrough Early Childhood Systems
Activities
Home Visiting Learning Collaborative
(CoIIN)
Develop
“Change
Package”
Today
AP2
Project LAUNCH (SAMHSA)
Help Me Grow
ECCS (Early Childhood Comprehensive Systems)
Building Bridges
Race to the Top - ELC States
TECCS (Transforming Early Childhood Community Systems)
Place- Based Initiatives
• California: First 5 Alameda County, Magnolia Place
• Children’s Service’s Council Palm Beach County
• Promise Neighborhoods (US Department of Education)
Expert Support
Source: Adapted from IHI, BTS Collaborative.
LS – Learning Session
AP – Action Period
ADVANCING CQI IN HOME VISITING / 10
76
27
TECCS
(Transforming Early Childhood Community Systems)
Help Me Grow
(P. Dworkin, 2013)
Community Outreach
Child Health Provider
Training/Screening/Surveillance
to promote the use of HMG
and provide networking
opportunities among families
and service providers
“Do you have questions about how your
child is learning, behaving or
developing?”
Centralized Telephone
Access
Point for connecting children and
their families to services and care
coordination. Provide feedback
and follow-up
Child
mental
health
Early
Interven
-tion
Support
groups
for
grandpar
-ents
Faithbased
programs
Head
Start
Home
Visiting
Parenting
education
ADHD
support
groups
Hispanic
resource
center
Domestic
violence
shelter
Advocacy
groups
29
Source: Halfon, 2013
78
13
The Five Conditions of
Collective Impact Success
Take Home Messages
• Building health and education readiness for the next
generation of children requires a focus on the one
science of early brain development addressing toxic
stress from pre-conception to early childhood
• Integration of medical home, home visiting and early
childhood system allows breakthrough strategies to
address toxic stress and the social determinants of
health
• Evidence-based practices, population-based approaches
and continuous quality improvement for primary care
practices and early childhood community services
defines MCH public health for the future
• Common agenda – shared vision
• Shared Measurement – collecting data and measuring
results consistently
• Mutually Reinforcing Activities – differentiating while
still coordinated
• Continuous Communication – consistent and open
communication
• Backbone Organization – for the entire initiative and
coordinate participating organizations and entities
Source: J. Kania and M. Kramer, 2011
79
80
Contact Information
David W. Willis, MD, FAAP
Director, Division of Home Visiting
and Early Childhood Systems
Maternal and Child Health Bureau, HRSA
301-443-8590
[email protected]
Meaningful Measurement and Evaluation Efforts
in the Improvement Partnerships:
Spotlight on Innovation and Opportunities for Discussion and Input
Colleen Reuland, MS Oregon Pediatric Improvement Partnership
October 3rd, 2013 - Washington DC
National Improvement Partnership Network Meeting
81
Key Areas We Will Cover
1. Measure specific strategies for gathering and displaying
information
2. Leveraging Partnerships
•
•
Utilizing national and state-level data
Partnership with Medicaid/CHIP
3. Staffing measurement and evaluation in your IP
•
•
Internal models
Contract out models
Format: Examples of Innovative Strategies & Group-Level Discussion
2013 NIPN Operational Meeting
Facilitation by the Oregon Pediatric Improvement Partnership (OPIP)
Measure Specific Strategies
Measures related to screening
o Developmental
o Autism
o Newborn
o Mental health
Asthma
Medical Home Office Reported Tools
Patient Experience of Care Surveys
Provider/Office Staff Experience Surveys
2013 NIPN Operational Meeting
Facilitation by the Oregon Pediatric Improvement Partnership (OPIP)
14
Screening Measures:
Examples from IPs
Example from Arizona:
Developmental Driver Diagram of Developmental Screening
• Arizona
• Alabama
• Indiana
• BOPS
86
Example from Alabama:
Screening for Early Childhood Issues
Example from Indiana:
MCHAT Screening
•
Four Numbers Gathered:
1.
2.
3.
4.
•
•
87
Screened
Passed
Failed
Referred
Proportions then shown (describe numerator and
denominator)
Numbers shown by AGE and by Practice
88
15
Example from BOPS:Newborn Screening
Newborn Results Recorded in EMR and Discussed with Parents by 2 Months of Age
BOPS, 2013
100%
80%
60%
40%
20%
0%
Example from BOPS:
Recorded
Jan-13
94%
Feb-13
95%
Mar-13
91%
Apr-13
93%
May-13
93%
Jun-13
98%
Jul-13
94%
Discussed
84%
87%
87%
86%
88%
93%
94%
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Recorded
Volume
243
253
233
263
239
210
246
Discussed
Volume
218
226
201
238
219
192
222
Example from BOPS: Routine Mental Health Screening
Newborn Results Communicated to Parent
Routine Mental Health Screening at Annual Well Child Visits
BOPS, 2012-13
Newborn Results Recorded in EMR and Discussed with Parents by 2 Months of Age
BOPS, 2013
100%
100%
90%
80%
80%
70%
60%
60%
50%
40%
40%
Jul 2013
All Sites Now Implementing
30%
20%
20%
1st Full Month of
Implementation
Nov 2012
10%
0%
0%
Recorded
Jan-13
94%
Feb-13
95%
Mar-13
91%
Apr-13
93%
May-13
93%
Jun-13
98%
Jul-13
94%
Discussed
84%
87%
87%
86%
88%
93%
94%
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Recorded
Volume
243
253
233
263
239
210
246
Discussed
Volume
218
226
201
238
219
192
222
Measures Related to Asthma
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
PSC-17
0%
17%
34%
37%
48%
52%
63%
68%
74%
44%
72%
Y-PSC-17
0%
19%
41%
43%
55%
64%
69%
77%
77%
42%
61%
Apr
667
468
May
675
473
4-11 Visits
12-18 Visits
Oct
0
0
Nov
811
547
Dec
629
432
Jan
814
521
Feb
602
392
Mar
633
424
Jun
626
400
Jul
1765
1334
Aug
2027
1634
Example from Arizona
• Arizona
• Indiana
96
16
Example from Arizona
Example from Indiana
Asthma Quality Improvement Dashboard
Asthma Action Plan: Percentage with plan in
the chart
100
90
80
70
60
50
40
30
20
10
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Education: Percentage of patients with asthma
who have education re: proper use of spacer
device
100
80
60
40
20
0
97
Jan
Example from Indiana
Feb
Mar
Apr
May
Jun
Jul
Aug
Example from Indiana
Education: Baseline Chart Review Data
100
90
80
Practice 1
70
Practice 2
60
Practice 3
50
Practice 4
Practice 5
40
COMBINED
30
20
10
0
Risks of smoking
Flu shot
Spacer device education/reminder
Triggers and irritants
Office Reported Tools Assessing Medical Home
• Example of tools:
– NCQA PCMH 2011
– Medical Home Index/ MHI– Revised Short Form
• Tool required CHIPRA National Evaluator
– Home grown tools
• Important factor for IPs to consider
– Require facilitation and engagement
• Particularly true for the MHI-RSF given it is anchored to the MCHB
definition of CYSHCN
– Not uncommon for practices to report they are in a
different place than they may be
– Not uncommon to see scores go DOWN over course of
learning collaborative
2013 NIPN Operational Meeting
Facilitation by the Oregon Pediatric Improvement Partnership (OPIP)
Office Reported Tools Assessing Medical Home:
Tips from IPs Around Facilitation and Helpful Strategies
• Arizona:
– GAPS tool for NCQA PCMH recognition.
– QI meeting – Take notes and then go over processes
• Indiana:
– Found significant issues with NCQA for pediatrics.
• Helpful to choose a chronic condition
• Work within processes for the quality improvement of chronic conditions
with careful labeling and reflection as to how it generalizes to other
conditions.
– Sharing challenges of other practices also helps.
•
•
•
•
Ask what is going well?
Offer time to reflect on the things going well;
Suggest that processes can always be improved;
Say if you were doing this process extremely well a year from now, what
would it look like?
• How do we get there between now and then?
• Ask them to reflect on what they are doing well, how can they do more of
that elsewhere?
2013 National Improvement Partnership Meeting
Facilitation by the Oregon Pediatric Improvement Partnership (OPIP)
17
Office Reported Tools Assessing Medical Home:
Tips from IPs Around Facilitation and Helpful Strategies
• New Mexico
– Leverage the art of coaching
• Consider the team and team personality and what the site needs to be successful
– Focus site’s attention on an area of success and then circle back around after they have
improved ‘change’ morale and momentum
– Read“Crucial Conversations” and use the book’s strategies.
• Washington DC
– Depends on measure/big picture.
– When data integrity is critical to reporting/deliverable- be explicit up from the start with
coaching/expectations
• Oregon
– Collecting three office reported tools (NCQA PCMH, MHI-RSF, and Oregon Patient Centered
Primary Care Homes)
– For MHI created talking points for each item for the QI staff to use
• OR team held individual calls with non-OR sites
– Create an inventory of strategies and processes practices are using that are attesting to “yes”
– Read “Crucial Conversations” and use the book’s strategies
– Leverage separate staff that are for evaluation and measurement
– Emphasize the importance of comparative data in a learning collaborative model
2013 National Improvement Partnership Meeting
Facilitation by the Oregon Pediatric Improvement Partnership (OPIP)
Improvements in MHI-RSF Quality Domains:
State-Level Average Scores and Changes Observed
Reporting Measures of Medical Home:
Example from Oregon
Across T-CHIC: Average Change in
MHI-RSF Overall and Domain Scores by State
100%
90%
Percent of a Perfect Score
80%
70%
60%
50%
40%
30%
20%
10%
0%
MHI-RSF Overall Percent
Score
Domain 1: Organizational
Capacity
Domain 2: Chronic
Condition Management
Alaska Scores
Tri-State Children’s Health Improvement Consortium (TCHIC)
Domain 3: Care
Coordination
Oregon Scores
Domain 4: Community
Outreach
Domain 5: Data
Management
Domain 6: Quality
Improvement
West Virginia Scores
Summary Created by Oregon Pediatric Improvement Partnership (OPIP)
Reporting Measures of Medical Home:
Example from Oregon
Goal of the Health Reform Efforts:
Achieve the Triple Aim
Patient Experience of
Care Surveys
108
18
Patient Experience of Care Surveys
Patient Experience of Care Surveys
1.
2.
3.
4.
5.
6.
7.
8.
•
Arizona
Idaho
Indiana
Oregon
Vermont
New Jersey
South Carolina
Washington DC
•
•
•
•
•
•
•
2013 National Improvement Partnership Meeting
Facilitation by the Oregon Pediatric Improvement Partnership (OPIP)
Patient Experience of Care Surveys:
Example of Indiana
2013 National Improvement Partnership Meeting
Facilitation by the Oregon Pediatric Improvement Partnership (OPIP)
Question 2 - Does your doctor/nurse offer your family information about
health and wellness appropriate to your child’s developmental stage?
(This includes information about child developmental, mental health,
healthy weight, and nutrition, physical activity, sexual developmental and
sexuality, safety/injury prevention, and oral health)
• Indiana
– Short survey for the practices in the MHLC
– Adapted from
1)
2)
Arizona
– Survey on care coordination
Idaho
– Primary Health Pediatrics Family Survey
– St. Luke’s Developmental Pediatrics
Indiana
– Short survey for the practices in the MHLC which was adapted from Family Voices, “FamilyCentered Care Self-Assessment Tool – Family Tool” and Center for Medical Home Improvement,
“the Medical Home Family Index: Measuring the organization and Delivery of Primary Care for
Children with Special Health Care Needs”.
Oregon
– CAHPS HP-CC
– CAHPS CG PCMH
– MHI- Family Index
Vermont
o CAHPS survey
o Chronic Illness Project – Internally designed survey used for patients who have transitioned from
pediatric to adult care.
New Jersey
– Medical Home Family Feedback Survey
South Carolina
– CAHPS
Washington DC
– CAHPS
– Adolescent Surveys
3.00
Family Voices, “Family-Centered Care Self-Assessment Tool – Family Tool”
Center for Medical Home Improvement, “the Medical Home Family Index:
Measuring the organization and Delivery of Primary Care for Children with
Special Health Care Needs”.
– Provided the adapted survey and asked the practices to survey
everyone who came into the office over a two week period.
– Provided English and Spanish versions of the survey
• Practices sent the surveys after the two week period.
– Provided a summary report of the survey data back to the practices.
• This demonstrated to the practices a process to collect patient experience of
care data over a short period of time and to use the data to inform the
practice, identify areas for change or improvement, etc.
2.50
2.00
3 - Always
2- Often
1.50
1- Sometimes
0- Never
1.00
0.50
Key To Success: We provided the tool and summarized the data.
0.00
Practice 1
Question 14 - There is a staff person(s) or a “care coordinator “ who will
help you with difficult referrals, payment issues, & follow-up activities.
Practice 3
Practice 4
Practice 5
Practice 6
Practice 7
Practice 8
Overall
Average
Question 15 - Office staff help you to connect with family support
organizations & informational resources in your community & state.
3.00
3.00
2.50
2.50
2.00
2.00
3 - Always
2- Often
1.50
1- Sometimes
0- Never
3 - Always
2- Often
1.50
1- Sometimes
0- Never
1.00
1.00
0.50
Practice 2
0.50
0.00
Practice 1
Practice 2
Practice 3
Practice 4
Practice 5
Practice 6
Practice 7
Practice 8
Overall
Average
0.00
Practice 1
Practice 2
Practice 3
Practice 4
Practice 5
Practice 6
Practice 7
Practice 8
Overall
Average
19
Washington DC:
Adolescent Health Care Survey
Washington DC:
Adolescent
Survey
2013 National Improvement Partnership Meeting
CAHPS, CAHPS Everywhere!
But is the data used to improve care?
OPIP Activities Related to Patient Experience of Care
Surveys
ECHO: Enhancing Child Health in Oregon
• Part of T-CHIC
• Medical Home Learning Collaborative (8 sites)
 CAHPS CG PMCH Child (5 pediatric practices)
 CAHPS CG PCMH Child AND Adult (3 Family Medicine)
•
Patient-Centered Primary Care Institute
• Medical home learning collaborative anchored to Oregon PCPCH standards
• Standards emphasize practice-level use of the CAHPS
• Nearly all practices attesting to OR PCPCH using in-office, convenience
sample
• Within our PCPCI Collaborative focused facilitation efforts on enhanced
engagement with families and improved methods for convenience, in-office
administration
11
7
FEDERAL CMS:
CHIPRA CORE MEASURE
SET
Overview of targeted efforts
• T-CHIC: Tri- State Children’s Health Improvement Consortium
o Leverage Medicaid/CHIP measurement work related to CAHPS
o Trying to utilize state EQR and Core Measure funds for practicelevel data gathering and feedback reports
o CAHPS Clinician and Group-Level, Patient Centered Medical Home for
participating practices
o Standardized administration via DataStat
•
T-CHIC
ECHO
PCPCH
USE of the data to guide and inform
improvement efforts (Analysis and
reporting)
X
T-CHIC, State
(3), Practice
(21)
X
(Project,
Practice (7)(
X
(General,
Bay Clinic)
Project-level use of the data to guide
curriculum
X
X
Practice level administration & collection
X
X
X
(Bay Clinic,
In office &
Generally)
Practice-level engagement to guide
improvement
X
X
X
Federal CMS
Core Measure,
NCQA CAHPS
CG PCMH
PCPCH, CCO
Incentive
Metric
PCPCH, CCO
Incentive
Metric
11
9
CAHPSHealth
Plan
(HP)
CAHPS- HP
with the
Children
Chronic
Conditions
State
Sponsored: CCO
Incentive
Metric; Some
CCOs Also
Collecting
Through CPCI &
Other Efforts
CAHPS Clinician
and Group (CG)
Emphasized in
PCPCH, But
Unstandardized
Data Collection,
Many practices
collecting data
and doing
nothing more
CAHPS CGPatientCentered
Medical Home
Supported by
T-CHIC
(Includes
ECHO),
Including
CYSHCN items,
Q-CORP
piggybacked
off effort
11
8
Efforts OPIP is Involved with Related to Patient Experience of Care
Policy briefs to inform improvements
Facilitation by the Oregon Pediatric Improvement Partnership (OPIP)
OPIP Analysis of the CAHPS CG PMCH Data
Analysis conducted overall, and then by state and by
practice
o Includes Adults CAHPS CG findings for the
Family Medicine Practices
CAHPS CG PCMH findings related to the following
factors:
o Child
o Respondent
o Practice
o MHORT Quality Domains
Variations in quality of care observed by these factors
Implications of these variations
12
0
20
Variations in CAHPS CG PCMH Findings
by Age of Child
OPIP Analysis of the CAHPS CG PMCH Data
Children & Youth with
Special Health Care Needs
(CYSCHN)
Child CAHPS CG PMCH
Only
Respondent
Characteristics
CAHPS CG PCMH Quality Domain Achievement Scores For
Which There Were Significant Differences by Age of Child
100%
Ethnicity
CYSHCN
Age of
Respondent
Race
Number of consequences
Education
Age of Patient
Type of Consequences
Language survey
completed
Achievement Score
Characteristics of
Persons Care Being
Reported About in
Survey
80%
60%
40%
20%
General Health Status
0%
Mental Health Status
Child Development
0 up to 5 years
12
1
Child Prevention
5 years up to 12 years
Self-Management
12 years and up
Tri-State Children’s Health Improvement Consortium (TCHIC)
Facilitation by the Oregon Pediatric Improvement
Partnership (OPIP)
Variations in CAHPS CG PCMH Findings
by Child’s Health Status
OPIP Analysis of the CAHPS CG PMCH Data
Practice
Characteristics
Variation in the CAHPS CG PCMH Quality Domain
Achievement Scores by Child Characteristics
Reported in the Survey
CAHPS CG PCMH Quality Domains
Access
Variable
Specification
n
%
Child
Communication
Development
Child
Prevention
SelfOffice Staff
Management
NCQA PCMH Quality
Domains
Specialty of Docs
CYSHCN
Age of
Respondent
Type of Practice (FQHC,
Private, part of Large System)
Number of
consequences
Education
Type of Consequences
Excellent/Very Good 1487
86%
80.49
94.13
63.20
56.52
32.68
91.64
Geography
Good/Fair/Poor
243
14%
72.34
92.23
56.13
50.12
36.16
86.82
Percent of Patient Population
Pediatric
Excellent/Very Good 1434
83%
80.35
94.12
62.40
56.22
32.53
91.61
Number of Pediatric Patients
Good/Fair/Poor
17%
74.63
92.74
61.30
52.58
36.27
87.84
Percent of Visits Publicly
Insured
Child's General Health
Status
Child’s Mental Health
Status
296
Bold, blue text is used to indicate a p value of <0.05 for difference between average score within each group. For these domains for which
there is a significant difference in quality, the cells are shaded to indicate which group has the highest score (green).Where applicable,
the group with the lowest score is in red.
Tri-State Children’s Health Improvement Consortium (TCHIC)
Facilitation by the Oregon Pediatric Improvement
Partnership (OPIP)
Characteristics related to
Access
12
4
Variations in CAHPS CG PCMH Findings
by CYSHCN Who Experience Significant Consequences
Kinds and Types of Special Health
Care Needs Identified
% of Survey Respondents with that Consequence
Alaska
Oregon
West Virginia
Sites
Sites
Sites
Variation in CAHPS CG PCMH Quality Domain Achievement
Scores by Level of CYSHCN Consequences
T-CHIC
(of N=1739
(of N=207
(of N=723
(of N=809
Surveys with CAHMI
Surveys with
Surveys with
Surveys with
Responses)
CAHMI Responses) CAHMI Responses) CAHMI Responses)
1) Prescription medication need/use
22.1%
13.0%
18.0%
28.1%
2) Limited or prevented in ability to
function
7.1%
10.1%
5.8%
7.4%
12.9%
12.6%
11.6%
14.1%
6.0%
10.1%
4.7%
6.2%
10.4%
11.1%
9.4%
11.0%
3) Above routine use of medical
care, mental health or other
health services
4) Specialized therapies
(OT, PT, Speech)
5) Counseling or treatment
emotional, behavioral or
developmental problems
Tri-State Children’s Health Improvement Consortium (TCHIC)
Facilitation by the Oregon Pediatric Improvement
Partnership (OPIP)
Achievement Score
CAHMI CYSHCN Screener: Specific
Consequences and Needs
MHI-RSF
Quality Domains
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
*
*
Access
Communication
Child
Development
Less than 3 Consequences on the CAHMI Screener
Child Prevention Self-Managenent
Office Staff
3 or More Consequences on the CAHMI Screener
* Variation is statistically significant
Tri-State Children’s Health Improvement Consortium (TCHIC)
Facilitation by the Oregon Pediatric Improvement
Partnership (OPIP)
21
Domains within Medical Home Measures
Across T-CHIC/ECHO
OPIP Analysis of the CAHPS CG PMCH Data
Practice
Characteristics
Practice Quality Indicators
Specialty of Docs
NCQA PCMH
Previous Patient Experience of
Care Survey
Type of Practice (FQHC, Private, part
of Large System)
QI or Other Medical Home
Efforts as of Baseline
Geography
NCQA PCMH Certified at the
Time of the Survey
Percent of Patient Population
Pediatric
EMR Maturity Levels

Enhance Access and
Continuity

Identify and Manage
Patient Populations

Plan and Manage Care

Provide Self-Care Support
and Community
Resources
Number of Pediatric Patients
Percent of Visits Publicly Insured
Characteristics related to Access
12
7

Track and Coordinate
Care

Measure and Improve
Performance
CAHPS CG PCMH
MHI-RSF
(specific CYSHCN)

Organizational Capacity

Chronic Condition
Management

Care Coordination

Community Outreach

Data Management

Quality Improvement/
Change
 Access
 Communication
 Self-Management
Support
 Office Staff
 ComprehensivenessChild Development
 ComprehensivenessChild Prevention
128
PCPCI Learning Collaborative Call:
Comparison of NCQA PCMH and CAHPS CG PCMH
Related to Access
CAHPS CG PCMH
After Hours Access
Patient Experience of Care Surveys: How They Are Part
of Your Medical Home Transformation Efforts
NCQA PCMH Element 1B
After-Hours Access
Q19. Usually or always able to get care needed from
provider's office during evenings, weekends, or holidays
•Objective of the Calls:
T-CHIC
 Review PCPCH standards (Current and Proposed Revisions) that
relate to Patient Experience of Care Survey
T-CHIC
Oregon
Oregon
Childhood Health
Practice
#1
Associates
of Salem
Childhood Health
Practice
#1
Associates
of Salem
The Children's Clinic
PortlandPractice
Pediatric #2
Clinic
The Children's
PracticeClinic
#2
↑
The Children's Clinic
TualatinPractice
Pediatric #3
Clinic
↑
Practice #3
↑
 Review key issues for practices to consider in implementing patient
experience of care surveys
Family Medical
Group#4
NE
Practice
Family Medical
Group
Practice
#4NE
HillsboroPractice
Pediatric #5
Clinic
St. Luke's Eastern Oregon
Practice
#6
Medical
Associates
Hillsboro Pediatric
PracticeClinic
#5
↓
St. Luke's Eastern Oregon
Practice #6
Medical Associates
↓
WindingPractice
Waters Clinic
#7
Winding
Waters #7
Clinic
Practice
↑
0%
Worse
20%
40%
60%
80%
100%
 Review key issues for practices to consider in USING information
from patient experience of care surveys
 Questions and Answer
Woodburn Pediatric
Practice
#8
Clinic
Woodburn Pediatric
Practice
Clinic #8
 Review the different versions of the CAHPS, and how the CAHPS
Clinician and Group – Patient Centered Medical Home
complements the PCPCH standards
0%
20%
40%
Worse
Score
Better
↑↓Statistically significantly higher/lower than State score.
60%
80%
Score
12
9
100%
Better
13
0
Clinic Spotlight: Bay Clinic Pediatrics
• Patient experience of care
OPIP Support of Bay Clinic Pediatrics
• Patient-centered administration
– CAHPS CG PCMH (with CYSHN Screener)
– Fielded for Two Months (July-September)
– Mapped out process for administering in the office
– Created survey administration materials
•
•
•
•
• Methods
– Part of department strategy, clinic-wide/cultural commitment
• Healthy competition between providers
– Promotion (front desk, waiting rooms, exam rooms)
– Administration
• Web-based or paper versions (depending on patient preference)
disseminated by PROVIDERS at all visits for a pre-determined interval
(2 months)
• In addition, surveys are being sent by mail to a subpopulation- CYSHN
identified by gestalt for each provider
Posters for the parent
Scripts for office staff
Letters
Survey monkey version
• QI Coaching
– Process for who how data will be reviewed
– Process for how improvement opportunities
– Levers to use with CCO
• Analysis and reporting
– Feedback reports of data
13
1
13
2
22
Planning Your Administration:
Outline the Steps and Assign Roles
13
3
13
4
Provider and Office Staff
Experience Surveys
• New Mexico
– ENM uses surveys at the end of each initiative (Survey Monkey )
• Washington DC
– Survey practices in our LC’s- pre- mid-LC and post about
experience/satisfaction with LC
– Share results with participants as part of project calls/summary
• Oregon
– Learning Sessions
• Pre-Meeting
• Post- Evaluation
– Collaborative Calls
• Evaluation
– Experience Based Design: Video Vignettes
13
5
2013 National Improvement Partnership Meeting
Items in Provider/Office Staff Survey:
Example from Oregon
Leveraging Other Groups Data for QI
•
•
•
•
•
•
2013 National Improvement Partnership Meeting
Facilitation by the Oregon Pediatric Improvement Partnership (OPIP)
Facilitation by the Oregon Pediatric Improvement Partnership (OPIP)
Vermont
– Birth certificate data
– National and state registries (state immunization, Cystic Fibrosis Foundation, etc)
– Insurers
Arizona
– Working with 3 other states and are able to share data .
– Compare AZ data to national registry.
• Examine the amount of providers in other states vs. the amount of providers
currently working on registry in Arizona.
Kentucky
– MCO data on metrics (well-child, immunization, Chlamydia, asthma)
New Jersey
– Immunization data from the State.
– Data from the CDC, Advocates for Children of NJ (Kids Count)
Oregon
– Early Intervention data, reporting back to PCPs
BOPS
– National data on adolescent STI screening, adolescent mental health screening,
pediatric mental health screening and early childhood developmental screening
2013 National Improvement Partnership Meeting
Facilitation by the Oregon Pediatric Improvement Partnership (OPIP)
23
Leveraging Partnerships with Medicaid/CHIP to Use
Data to Guide Inform QI:
Positive Experiences
1.
2.
3.
4.
5.
6.
Leveraging Partnerships with Medicaid/CHIP to
Use Data to Guide Inform QI: Positive Experiences
Alabama
– Developmental screening billing data in a specific project for baseline data.
– CHIPRA core measure with data elements in our AI projects.
Oregon
– Core measure data
– Exploring “child id” across public systems
– Leveraged External Quality Review to have MCOs collect robust medical chart
review data related to develpomental screening, referral and follow-up
Utah
– Work state public health department and Medicaid
– We work directly with one of the data coordinators to ‘massage’ the data to
meet our needs.
Alabama
Idaho
New Jersey
Oregon
Utah
Washington DC
South Carolina – See Follow-Up Slides
2013 National Improvement Partnership Meeting
Facilitation by the Oregon Pediatric Improvement Partnership (OPIP)
South Carolina’s Work Around the CHIPRA
Quality Measures
– Introduced 18 of 24 quality core measures
Jan 2011:
Emergency Department visits **
st
Well-child visits (WCV):1 15 mo. **
Developmental Screening 1st 3 yrs. **
Follow-up ADHD medication **
QTIP PDSAs
Jan 2011 to August 2013
South Carolina’s Work Around the CHIPRA
Quality Measures
180
153
160
July 2011:
Access to Primary Practitioners **
Preventative Dental Services **
CAHPS
144
133
140
117
120
100
February 2012
Frequency of Ongoing Prenatal Care
% of live births < 2,500 grams
C-Section
Asthma … w/ 1+ Asthma ED visit **
July 2012
BMI **
Pediatric Hemoglobin A1C testing
January 2013
Follow-up …Mental Illness
July 2013
Adolescent Well-Care Visits**
Timeliness of Prenatal Care
Immunizations for adolescents
Chlamydia Screening
** SC received approval American Board of
Pediatrics (ABP) to offer MOC credits on 10
quality measures. See ** plus Family
Centered Care and Behavioral Health
80
60
75
75
69
56
44
31
40
20
20
8
4
1
1
3
1
7
2
2
0
0
141
Example from South Carolina
142
Example from South Carolina
143
144
24
Leveraging Partnerships with Medicaid/CHIP to Use
Data to Guide Inform QI: Barriers Encountered
Idaho:
• Tried to use our Medicaid data team for reporting
baseline information. Experienced significant barriers.
New Jersey:
• This has been a real challenge
Washington DC
• Engaged with DC Medicaid at IP start-up, but this aspect
has been less of a focus
• DC Medicaid has undergone successive changes in
leadership, priorities.
Building Measurement into Your IPs:
Staffing Models
New Mexico:
o 1.5 FTE related to data central: turning raw data into fast feedback reports so coaches can
communicate with sites; managing our access data base; and assisting with creation of online
data collection (Google Docs/Drive)
o 1.0 FTE MPH to help with data synthesis and overall program evaluation and reporting. Since this
person is new plan is to have this person more involved with up front design of measures and
management of database
o Added the 1.0 FTE MPH and 0.5 data analyst because our increased work and changes in the
way we share data with sites required more people
Bronx
o Evaluation Expert: 0.05 FTE, Project Director and Assistant each at 1 FTE
Utah
o QI coaches and Senior Program Manager are trained in measurement and data and help facilitate
the processes in all our projects
Washington DC
– We have grown our own staff/capacity- still learning & growing. Not as strong in evaluation as in
front end QI coaching, data collection.
– Growth is subject to funding- hard to sustain steady FTE’s when projects come & go.
– Identified alternate funding in academic health system to sustain baseline functionality
Building Measurement into Your IPs:
Staffing Models
Vermont
o Have staff specifically focused on measurement and data.
o Also have contracted with specifically to provide evaluation to other national and
state level organizations.
Oregon
o Staff specifically focused on measurement and data, but from a senior level.
 Found not enough work for a junior-level, analyst only position.
 Exploring models to share analyst staff with other in Department
Arizona:
o We have some staff who are responsible for collecting the data and putting
together the slides to share with practices on phone calls.
New Hampshire:
o Jo Porter (.05 FTE), Research Director for the NHIHPP, is serving as our
data/evaluation design lead,
o Data collection and reporting will be done by a Holly Tutko (.25 FTE), NH PIP
Project Director and a Research Associate (TBD, 30 FTE).
Sharing an Analyst in Another Department
in Same Organization
 Vermont
• Share staff with College of Medicine through UVM routinely.
• This model has worked well when a % of shared staff’s FTE is paid through
the IP.
 Kentucky
• Within our department of pediatrics, there is a health services research unit
(brand new) and we can obtain statistical support there
 New Jersey
• Utilized the same analyst for several different QI projects/initiatives – currently
we work with 2 different researchers.
• As all of our programs are preventative or wellness oriented, within the context
of a medical home framework, using the same analyst has helped them to get to
know our agency and team, and how we work as a team.
Contracting Out for Measurement and Evaluation
1.
2.
3.
4.
5.
AL
ID
New Jersey
South Carolina
Utah
Break.
Snack is located in foyer.
Provided by:
Each share the positive and negative experiences.
National Improvement Partnership Network (NIPN)
Improvement Partnership (IP) Operations Training
October 2-4, 2013
25
Session Objectives
• Attendees will learn best practices and share
strategies on how to teach QI with limited time
• Attendees will learn how to recognize when a
participating practice should be let go from a
project
• Attendees will discuss how to promote honesty
in practice teams’ data collection
Teaching Quality Improvement – Effective QI
Coaching Strategies
Tamara N Johnson, MPH
Quality Improvement Coach
Goldberg Center for General Pediatrics and
Community Health
Children’s National Medical Center
Mary Jo Paladino, MSA
Executive Director, CHIP-IN for Quality
Child Health Improvement Partnership Indiana
National Improvement Partnership Network (NIPN)
Improvement Partnership (IP) Operations Training
October 2-4, 2013
DC snapshot
• Primary Care Access, 2005
• Poverty in DC, 2000
Teaching QI When Time is a
Factor
Tamara John, MPH
Quality Improvement Coach
District of Columbia Partnership to Improve Children's Health Care
Quality
Children’s National Health System
Dark green Moderate
to Highly privileged
areas
Yellow, Orange & Red
 less privileged
blocks in order of
increasing adversity
Barriers to QI
DC-PICHQ
•
•
•
DC Partnership to Improve Children’s Healthcare Quality
– Launched November 2005 with start-up funding & guidance from VCHIP & Commonwealth
Fund
– Matching funds & institutional home: Children’s National Medical Center (D.C.)
• Key partnerships with DC Medicaid, DC AAP chapter, academic health centers, FQHC’s and
provider community, managed care plans (Medicaid)
– Sharing & mentoring from VCHIP and NIPN state improvement partnerships
Vision: To improve healthcare quality & outcomes for children in the District of Columbia (& region)
– Goals:
• Build an enduring regional partnership (& funding)
• Engage provider participation & leadership with key stakeholders: government & payers
• Utilize demonstrated quality improvement (QI) methodologies to promote incremental
change at practice- and system-based level
• Produce data-driven & measurable outcomes
District of Columbia: unique jurisdiction, demographics & region
– Metropolitan Washington DC region: DC, MD and VA
– 3 state governments, Medicaid programs, AAP chapters, politics
•
Provider Time
•
Fear of the unknown
•
•
–
QI Is too hard!
–
Bad experience with QI
Staffing
–
QI coaches
–
Practice
•
Small staff
•
Comfort with project topic
•
Lack of leadership
•
Part time Staff
How do you overcome these
barriers and teach the basics
of QI in 1 hour or less?
Technology
–
EHR implementation
–
No control/limited access
•
Distance
•
Competing priorities
26
Working/ Driving in the DMV
Asthma QI Learning Collaborative 2012-2013
• DC is only 68 sq.
Miles
• Has some of the worst
traffic in the nation
– Drivers spend ~67 hrs.
a year in traffic
Improving Asthma Care in
Pediatric Practice
QI MOC program 2012-2013
• ~50 practices, 202 active participants
in DC, MD and VA
• Partnered with: Maryland & DC AAP,
IMPACT DC
• ABP MOC Part 4 credit (25 points) &
CME Credit (Up to 33.5 hours)
Site visit planning: Organization is Key
The more you can do beforehand the better!
• Meet with your project team and decide what the
project should look like
–
–
–
–
Number of Learning Sessions
Number of chart audit reports
Number of team meetings
Roles and Responsibilities for participating
providers/practices
– What are your expectations for participation
– Flexibility vs. requirement
Create a Project Map
Helps to quickly identify project activities
Created using Microsoft VISIO or PPT
Children’s National Health Network
Asthma Learning Collaborative
Project Work Flow
The Planned
Asthma Visit
Practical Asthma Education
Advanced Asthma
Management
December 19th 2012
Molly Savitz, MSN, FNP
Caitlin Munoz, MSW, MPH
Stephen Teach, MD
November 7th,2012
Molly Savitz, RN
Rhonique Harris, MD
October 3 2012
Kick-off meeting
Quality Improvement
101/ Introduction to
Pediatric Asthma
November
QI Conference Call
With Team
Leaders
December
QI Conference Call
With Team
Leaders
January
QI Conference Call
With Team
Leaders
February
QI Conference Call
With Team
Leaders
March
QI Conference Call
With Team
Leaders
Practice
Team
Meeting
Practice
Team
Meeting
Practice
Team
Meeting
Practice
Team
Meeting
Practice
Team
Meeting
Practice
Team
Meeting
Provider Responsibilities
Created using Microsoft VISIO or PPT
Coding to Improve
Reimbursement
April 3rd 2013
Mark Weissman, MD
April
QI Conference Call
With Team
Leaders
Pulling It All Together
May 14th 2013
Panelist: Asthma Experts
May
QI Conference Call
With Team
Leaders
Practice
Team
Meeting
June
QI Conference Call
With Team Leaders
Practice
Team
Meeting
Practice
Team
Meeting
Office Detailing
Site Visits
Nov-12
Oct-12
10/3/2012
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jun-13
10/31/2012
Baseline
November
Chart audit
Chart audit
30 Charts
10 Charts
December
Chart audit
10 Charts
January
Chart audit
10 Charts
February
Chart audit
10 Charts
March
Chart audit
10 Charts
PDSA Cycle/Progress
Report
2
(January-February)
PDSA Cycle/Progress
Report
1
(November-December)
Create easy to read guidelines:
Breathing Easy: Environmental
Management of Asthma
March 7th 2013
Molly Savitz, MSN, FNP
Jerome Paulson, MD
Joy Purcell, Esq.
January 29th 2013
Dinesh Pillai, MD
Hemant Sharma, MD
April
Chart audit
10 Charts
May
Chart audit
10 Charts
June
Chart audit
10 Charts
PDSA Cycle/Progress
Report
3
(March-April)
Practice Responsibilities/ Requirements
Created using Microsoft VISIO or PPT
CNHN Obesity Learning Collaborative
Team Requirement
CNHN Asthma Learning Collaborative
How to earn MOC Part 4 Credit as a Provider
Watch the live
webinar
Kick-off
webinar
Option 1
Mandatory Activities
for the Practice Team
Watch the
recorded webinar
Option 2
1 team meeting
a month for
9 months
1 baseline chart audit
1 chart audit a month for 8
months
Total of 9 meetings
Total of 9 chart audits
Submit 1 meeting report a month
to QI TeamSpace by the 5th of the
following month.
All members earning MOC credit
should be present. (2)
Submit 1 baseline chart audit to
QI Team Space by Oct 31, 2012.
30 charts must be reviewed.
Residents: 20 Charts must be
reviewed (2)
1 QI conference call a month
Total of 8 Calls
Yes
Submit a signed presentation
attestation form
No
I cannot receive
credit
Yes
1 monthly call with the QI team
All practice members are
welcomed to participate.
Attendance is required from at
least 1 member working towards
MOC credit.
Submit 1 chart audit report a
month to QI Team Space by the
5th of the following month.
10 charts must be reviewed. (2)
Mandatory Provider Activities
You are the documented
provider for a minimum of 12 patients
over the course of the entire project
3 PDSA projects
Total of 3 reports
Yes
You attended a minimum
of 5 out of 9 team meetings
You attended/watched at least4
webinars
Yes
Conduct at least 3 PDSA projects
over the course of the Learning
collaborative.
Submit 3 PDSA reports on QI
team space by the end of the
reporting month. (3)
Yes
Minimum of 1 chart per provider per
audit report
Yes
Yes
Yes
Your initials are documented
monthly on the practice chart
audit tool for at least 12
patients over the course of
the project
Your Name is documented
on at least 5 submitted team
meeting forms
1) Providers can only earn earn MOC
part 4 credit if all chart audits and reports
are submitted to QI Team Space by
June 30,2013
Yes
Team requirements are completed
Yes
Yes
Yes
Submitted a signed
presentation attestation form
for each webinar*
Please refer to: “How to earn MOC Part 4 credit:
Team Requirement ” to confirm that all
requirements are met before data submission.
Yes
2) For chart review and team meeting
requirements, please review: How to
earn MOC part 4 credit as a provider.
Providers are now eligible for MOC part 4
credit if all individual provider requirements are
met.
Please refer to: “How to earn MOC Part 4
credit as a Provider” to confirm that all
requirements are met before data submission.
*Rules for submitting webinar
If you did not meet the minimum
requirements for any of the
mandatory activities, your
participation will be reviewed on a
case by case basis.
No
Yes
I do not
receive credit
I receive MOC
Credit
attestation forms:
♦ All forms should be submitted by
June 30, 2013
♦4 out of 7 submitted attestation
forms must be submitted within 30
days from the day the recorded
webinars are posted.
27
Workbook tools with directions: Chart Audits
Pre-visit planning
Created using Microsoft Word & Excel
• Talk to your subject experts:
– Discuss your project measures and how they should
be documented
• Create practice friendly tools with directions for:
–
–
–
–
QI basics
Data collection
Meeting notes
PDSA Reports
Tools cont.
The Site Visit: Scheduling the visit
• Plan a time that works best for both you and the practice:
– Try to schedule 45 minutes- 1 hr. time slots
Beware of the time constraints
 Early morning- Limited time for questions because patient visits are scheduled to
begin and providers will need to prepare for the day.
 Lunch: Providers might come in late or sporadically because they are finishing up
with their patient visits and they may leave early to prepare for their next visit
 End of the day: Providers may be late because they are finishing up with patients,
but they will have more time to ask questions if something is not clear
During the Site Visit
• Create a basic Handbook/Cheat Sheet that you
can provide to your practices and coaches
– This helps to:
• Structure your time
• Set the tone and expectations for the project
Site visit Breakdown:
IP Project Site visit
Practice Coach name:
Email:
Phone:
Today’s Agenda
1) Introductions
2) Review of Project Work Flow
3) How to earn credit
1) Team
2) Provider
• Guide the conversation
• Provide guidance when the QI coach leaves
• Bring a snack for the practice- it makes the visit
easier
4)
5)
6)
7)
8)
Review of QI TeamSpace
Chart Audits
Monthly Meetings
PDSA Cycles
Questions
Thank you for your time!
Site Visit Tips:
•
Send them your site visit packet ahead of time
so they know what to expect
•
Include all of your handouts and
instructions
•
If you need a computer with internet access,
make sure there is one available or bring your
own.
•
If you use a website to collect data provide
step by step instructions on how access the
site
•
Provide due dates when you can
•
Leave enough time to discuss PDSA cycles
Be flexible with your agenda
28
After the coach has left…..
What have other IP’s done?
• VCHIP
– Large group training sessions with ongoing support using coaching calls
•
• New Jersey:
Create the tools you need to make life
– Practices should have a committed project team in place
easier throughout the project:
•
• Face-to-face visits works best
Schedule your Learning Sessions and
– Assess the practice level of understanding and commitment
– Allows the IP to bring resources from the community to create sustainable
collaborations
Team leader calls during lunch
–
These are recorded for those who cannot
• IHAWCC
attend live
–
– Face-to Face visits combined with , WebEx, individualized phone calls & practice updates
Practice teams can discuss their practice
• Alabama
changes with each other during project calls
•
–
•
– Do not employ individual practice coaches to visit practice teams
• Use monthly webinar calls , A QI tool of the month and refresher on clinical guidelines
• The project physician or QI manager will help practices who are struggling
Chart Audit results:
Have a 1-2 day turnaround time
• Arizona:
Access to the QI Coach/ Content experts
– Send the agenda and slides a few days before so practices can review and come
prepared with questions/discussions
– Allow less time to review data and more time to discuss barriers/successes/idea sharing
through Email and phone
Teaching QI
Measures and Data
Teaching Quality Improvement –
Measures & Data
Mary Jo Paladino, MSA
Executive Director, CHIP-IN for Quality
Child Health Improvement Partnership Indiana
Indiana Experience: 3 examples
Medical Home Learning Collaborative
Chronic Condition Management – Asthma
Developmental Screening - MOC
National Improvement Partnership Network (NIPN)
Improvement Partnership (IP) Operations Training
October 2-4, 2013
Medical Home Learning Collaborative
The MHLC Structure
• Three year Indiana Community Integrated
Systems of Services (IN CISS) grant
– Nine in October 2009
– Nine in October 2010
• Diverse in size, demographics, location and
culture
• All implementing AAP’s Medical Home Tool Kit
in their practices
http://www.pediatricmedhome.org/
• Bi-weekly Conference Calls
• Face to face site visits every 8-12 weeks
• Annual Spring and Fall Meetings
29
Conference Call Topics
AAP National Center for Medical Home Implementation
and Center for Medical Home Improvement
-
Building Your Medical Home ~ Toolkit ~
•
•
•
•
•
•
•
•
•
•
•
Updates
Huddles
Quality Improvement Team Meetings
Pre-planned Visits
Improved Access
Buy-In to Medical Home
National Committee for Quality Assurance (NACQ) Standards
Electronic Health Records – Meaningful Use
Registries
Family / Parent Partner Recruitment and Involvement
Medical Home Billing Codes
 Supports your development and/or improvement of a pediatric
Medical Home.
 Prepares you to apply for and potentially meet the National
Committee for Quality Assurance (NCQA) Physician Practice
Connections® Patient Centered Medical Home (PPC-PCMHTM)
Recognition program requirements.
 Offers capacity to chart progress
 Web site: http://www.pediatricmedhome.org
Tracking Your Progress
30
6
Scores on the Medical Home Index
for the Indiana Medical Home Learning
Pre
Collaborative
6
Scores on the Medical Home Index
for the Indiana Medical Home Learning
Collaborative
5
5
4
4
3
3
2
2
Pre
Pre
1
1
0
0
Chronic Condition Management –
Asthma MOC
• Practices chose their measures
• Identified through collaborative discussion 4 measures:
1) Education
2) Asthma Action Plans
3) Diagnosis Specific Coding
4) Controller Medication
• Baseline data and monthly chart reviews
• Asthma Quality Improvement Dashboard
• Maintenance of Certification (MOC)
Example: Asthma Action Plans
AIM: Within a year have 80% of patients with asthma action plans
in their charts
Plan Do
Act
Study
Distribute
asthma action
plans to patients
with asthma
Build an asthma
registry and
choose a tool
No action plan in
chart, schedule
follow asthma
appt.
Chart reviews
and patient
feedback
Asthma Quality Improvement Dashboard
Asthma Baseline Chart Review
Education
Asthma Action Plan
Data
100
90
80
Practice 1
Practice 2
Practice 3
Practice 4
Practice 5
COMBINED
70
60
50
40
30
20
10
0
100
90
80
70
60
50
40
30
20
10
0
Practice 1
Practice 2
Practice 3
Practice 4
Practice 5
COMBINED
Asthma Action Plan: Percentage with plan in
the chart
100
90
80
70
60
50
40
30
20
10
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
In Medical Documention Goals met or
Record
barriers
Diagnosis Specific Coding
120
100
80
100
Practice 1
Practice 2
80
Practice 2
60
Practice 3
Practice 3
40
Practice 4
20
Practice 5
COMBINED
0
"well" or "Not well"
controlled
Severity code
100
Practice 1
60
Education: Percentage of patients with asthma
who have education re: proper use of spacer
device
Controller Medications
120
Practice 4
40
80
60
40
Practice 5
20
COMBINED
0
Persistent asthma on controller Meds
20
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
31
Development Screening MOC
• MCHAT 18 and 24 month screens
–
–
–
–
–
–
How many children seen for 18 month visit
How many children screened
Number of Pass
Number of Fail
Number of Referrals
If not referred, why?
Neee
Discussion with Practices
after looking at the Data
• What surprised you?
• What works well / what would you tell others/
helpful hints?
• What were some of challenges and how have
you addressed them?
• What would you like to see happen next?
32
Lessons Learned
• Find the leader who does QI naturally and label
what they do
• Identify a problem, brainstorm, try something, get
feedback, make a change – that is PDSA
• Start small
• Celebrate early successes, it helps build
enthusiasm and buy in
• Use data to inform
Activity
• Break into 4 groups
• Each table has a different topic
• Each table needs a recorder and someone to
report out
• Paper at each table will describe the scenario
Objective
After the Coach Leaves: Strategies
to Increase Practice QI Sustainability
• To understand key steps in ensuring practice
level sustainability throughout the course of a
project.
R.J. Gillespie, MD, MHPE, FAAP
Medical Director
Oregon Pediatric Improvement Partnership
NIPN Operations Training Meeting, Arlington, VA
October 2013
As the Project Starts
• Understanding Clinic’s Change Culture
• Knowing who the clinic needs to be engaged
• Getting the backing of clinic leadership
Key thought: Understanding how the practice
typically addresses change and decisionmaking will facilitate project spread.
As the Project is Underway
• Developing “healthy habits” as a team
• Understanding common pitfalls to change, as
well as facilitators to change
Key thought: Helping coach the practice as
they experience both pitfalls and facilitators
to change will help them maintain a
functioning team.
33
As the Project Finishes
• Leaving the practice with a long-term
infrastructure
• Spreading QI skills and knowledge to other
practice members
Key thought: QI skills and knowledge can’t live in
the brain of a single individual (or small group of
individuals) if change is to be sustained.
Food for thought
• Given that medical home transformation is a
flexible, long-term process…
How can you build your project team and do your
project-level work in a way that sustains the work
beyond the timeframe of the learning
collaborative?
Enabling and Sustaining Change: Who do
you Need to Engage?
• Who will the change affect - directly and indirectly?
• What are the drivers and barriers to change?
• Who needs to be involved, consulted, informed?
– Remember that often means engaged participation of the
non-provider office staff (can sink or float a project)
• To what extent will contextual and cultural factors such
as team dynamics or differences in approach between
departments affect the success of change?
• How can I develop a shared vision?
AS THE PROJECT STARTS
INTENTIONALLY BUILDING THE PROJECT TEAM &
ENSURING CLINIC-LEVEL ENGAGEMENT
Key Questions: Understanding Your Clinic’s
Change Culture
• How are changes made in your practice?
• Who holds decision-making authority in your
practice?
• How can you engage other providers to
participate in changes made during the
learning collaborative?
• What are the structural supports needed to
maintain continued growth as a medical
home?
Lessons from the National Center for
Medical Home Improvement (CMHI)
• Evaluated practices that improved on their
“medical home”ness AND sustained their
improvements
• Lessons from these sustained innovators:
“If you do nothing else…”
– Identify your population of CSHCN
– Gain family participation/feedback
– Develop the capacity for practice-based care
coordination and the use of care plans
Adapted from Cooley, W.C. (2012, June). Care coordination – Assuring a family-centered approach [PowerPoint
Slides].
34
Maxims of Patient Centered Care
The needs of the patient come first
Nothing about me without me
Every patient is the only patient
From: D. Berwick. What ‘Patient-Centered’ Should Mean: Confessions of an Extremist. Health Affairs,
28, no.4 (2009): w555-565.
Key Steps in Leadership Driving Change
• Senior leadership (clinical
and administrative) must
play an active and visible
role
• Change should be
conducted by a
multidisciplinary team
• Leadership needs to create
a sense of urgency and
dissatisfaction with the
status quo
Leadership Driving Improvement
• Who are the key leaders that are needed to
achieve this development in practice and where
are they positioned?
• Does this leadership reflect the range of
stakeholders?
• How do we develop a shared vision amongst the
leaders?
• Are there any gaps in leadership and how can this
be addressed?
• How can the vision be shared to inspire and
engage leadership at all levels?
Engaging Others
• Leadership is needed at all levels to drive
forward continuous improvement. Leadership
involves:
– inspiring, enabling and transforming others
– facilitating and supporting change
– developing staff
– and acting as a role model for others.
Simple Steps to Implement Now
• Working on team identity and function
– Are you meeting regularly outside of practice facilitation
visits? Do you create an agenda? Are you dividing
accountabilities?
• Finding ways to share project information, goals, aim
statements with others
AS THE PROJECT IS UNDERWAY
STEPS TO IMPLEMENT AS THE PROJECT IS RUN:
FORMING “HEALTHY HABITS” AS A TEAM
– What are the avenues for sharing information with other
providers and staff? Are there standing meetings that you
need to get yourself on the agenda for?
• Publicizing project data with other staff members,
providers
– How is performance data shared with others in the
practice?
35
Conducting Pilots in a Way that Engages
Different Types of Adopters in Your Clinic
• Small tests of change are critical before wide-spread
clinic level changes are conducted
• Pilots should test:
– Different processes
AND
– Can engaged different providers and stakeholders in
testing out the change
• By being part of the test, can become an advocate for the change
• Intentionally recruit internal “thought leaders” in the
pilot testing
• Intentionally recruit people that approach project
differently in the practice
Common Pitfalls in Change
• Implementation that requires fundamental
changes in established routines are harder to
implement.
• Limiting participation to a few people playing
traditional roles.
• Absence of a dedicated support structure.
• Continued dependence on a few individuals to
sustain momentum.
Factors supporting sustained change
• A culture of openness and transparency
• Staff at all levels involved
• A system for communication of good practice
development projects
• Clear organizational goals in respect of quality
• Coordination of activity across projects
• National and local initiatives within a coherent
operational plan
• A financial infrastructure to support development
of practice and associated education
Structural Supports
• Implementing large scale change calls for
dedicated support structures
• Success increases if multiple tactics are used
• Quality Improvement Strategic Plan may
facilitate long term change
AS THE PROJECT FINISHES
FINE-TUNING QUALITY IMPROVEMENT EFFORTS:
BUILDING A QI INFRASTRUCTURE FOR YOUR CLINIC
What a QI committee Should Do
• Medical home “transformation” is about broad systems
change. Assessing and improving the practice based on
recognized medical home definitions require QI.
• Interpreting policy / health reform changes and how that will
impact the clinic also informs QI.
• Building the clinic’s Adaptive Reserve should be a primary goal
of the QI committee.
– Other providers / office staff should be competent in QI
– “Sensemaking” is an adaptive reserve skill that needs to be fostered
• Consider developing a QI Strategic Plan.
– If a practice has a lot of projects going on…how do they connect to each other
and inform the direction that the clinic wants to take?
– What are the goals of the clinic related to improvement?
36
Adaptive Reserve
• What’s predictive of medical home
transformation is the characteristics of the
practice themselves…specifically adaptive
reserve
• The ability of a practice to be resilient, to
bend, and thrive survive under force.
Facilitates adaptation during times of
dramatic change.
Template for Strategic Plan Components
What is Sensemaking?
• “Sensemaking is the process through which the fluid,
multilayered world is given order, within which people
can orient themselves, find purpose, and take effective
action. Organizations don’t discover sense, they create
it.” --Don Berwick
• When it comes to quality measures, sensemaking is the
process of creating a story about data to give that data
meaning within a clinical context.
• Once you can give the data meaning within a practice,
an action plan becomes a simple next step.
QI Committee Structure
• Multidisciplinary team is needed
– Nursing staff, front office, operations, parent, tech staff,
etc.
– Only way to ensure that clinical processes are improved
broadly
• Need to determine clear accountabilities for tasks of
the committee, meeting schedule, leadership, etc.
• Consider how to insert the committee into the existing
governance structure.
• Parent Advisory Committee should be considered.
Some materials from QI Committee should be vetted
through a parent group.
Engaging families and/or youth
• In working with practices, this is difficult but
meaningful in many ways
• Some ideas for how to engage families:
– Recruiting families for QI teams or standing clinic committees
– Focus Groups
• Recruit a group of parents to discuss specific topics
• Example: focus group to review service needs for CYSHCN
– Parent Advisory Group
• Can also be subject-specific, or have the agenda driven by the parents
– Survey patients and families about their experience of care
• Formal surveys
• Shorter surveys of topics of interest
Final Thoughts
• Sustainability needs to be considered as soon
as the practice is engaged in a project
• Specific knowledge and skills can be imparted
during the project
• Sustainability is easier if an infrastructure is
developed
• Engaging families and patients will hold the
practice’s “feet to the fire” as they continue
their QI efforts
37
THANK YOU!
Please Complete the Evaluation Form
National Improvement Partnership Network (NIPN)
Improvement Partnership (IP) Operations Training
October 2-4, 2013
38