Building PCMH Sustainability through Training Internal Quality Improvement Leaders Perry Dickinson, MD Nicole Deaner, MSW, Bonnie Jortberg, PhD, RD, CDE, Caitlin O’Neill, MS, RD

On completion of this seminar, participants should be able to: Discuss the program content in a resident leadership training versus a staff quality improvement (QI) team leader training. Describe implementation of the QI team leader training and resident leadership program. Discuss lessons learned from the program.

Project Overview The Colorado Family Medicine Residency PCMH Project: 3-year grant from the Colorado Health Foundation; began in December 2008 Goal: To transform the 10 Colorado FM Residency Programs into level II, PPC-PCMH NCQA medical homes through practice improvement and curriculum redesign Just completed 3-year grant cycle and were refunded for an additional 3 years

Who is Involved? University of Colorado School of Medicine, Department of Family Medicine HealthTeamWorks Colorado Association of Family Medicine Residencies Colorado Institute for Family Medicine

Two Parts of Project—Practice and Curriculum Redesign PCMH Residency Practice Curricular Redesign Practice Improvement

Practice Redesign Includes Practice Coaching: Assessment of current status in practice Feedback assessment and data to practice Assist in improvement team formation and identification of team leaders Serve as connection to resources Facilitation of QI and change process Goal is to establish a sustainable change & improvement process in the practice

Curriculum Redesign Initial assessment of resident competency and curricular PCMH content Facilitation and consultation for PCMH-related curriculum changes Changes to free up residents to participate in PCMH and QI efforts Development of an E-Learning platform for shared resource development across programs (lectures, modules, etc) Active involvement of residents in practice redesign process PCMH practices for residents to experience

Why we developed leadership training? Needed to build sustainable quality improvement processes at the practice level Importance of standardized QI tools and processes QI teams empower every level of staff to participate in the process Needed to address cultural transformation Shared leadership Identifying and growing formal and informal leaders Resident training Needed a way to train residents on the PCMH model of leadership

Resident and Faculty Leadership Training: Program Content 1.Defining the Medical Home 2.Today’s Care vs. Medical Home Care 3.Small Group Discussion 4.Characteristics of Effective Leadership 5.Leading Teams through Change 6.Evaluation

Defining the Medical Home Superb Access to Care Patients can easily make appointments and select the day and time. Waiting times are short and telephone consultations are offered Off-hour service is available Patient Engagement in Care Patients have the option of being informed and engaged partners in their care. Practices provide information on treatment plans, preventative and follow-up care reminders, access to medical records, assistance with self-care, and counseling Clinical Information Systems These systems support high-quality care, practice- based learning, and quality improvement. Practices maintain patient registries; monitor adherence to treatment; have easy access to lab and test results; and receive reminders, decision support, and information on recommended treatments. Care Coordination Specialist care is coordinated and systems are in place to prevent errors that occur when multiple physicians are involved. Follow-up and support is provided. Team Care Integrated and coordinated team care depends on a free flow of communication among physicians, nurses, case managers and other health professionals. Duplication of tests and procedures is avoided. Patient Feedback Patients routinely provide feedback to doctors; practices take advantage of low-cost, internet- based patient surveys to learn from patients and inform treatment plans. Publically available information Patients have accurate, standardized information on physician to help them choose a practice that will meet their needs Patient Centered Primary Care Collaborative (PCPCC)

My patients are those who make appointments with me Our patients are those who are registered in our medical home Patients chief complaints or reasons for visit determines care We systematically assess all our patients’ health needs to plan care Care is determined by today’s problem and time available today Care is determined by a proactive plan to meet patient needs without visits Care varies by scheduled time and memory or skill of the doctor Care is standardized according to evidence-based guidelines Patients are responsible for coordinating their own care A prepared team of professionals coordinates all patients’ care I know I deliver high quality care because I’m well trained We measure our quality and make rapid changes to improve it Acute care is delivered in the next available appointment and walk-ins Acute care is delivered by open access and non-visit contacts It’s up to the patient to tell us what happened to them We track tests & consultations, and follow-up after ED & hospital Clinic operations center on meeting the doctor’s needs A multidisciplinary team works at the top of our licenses to serve patients. Today’s CareMedical Home Care Daniel Duffy MD School of Community Medicine, Tulsa, OK 11

Small Group Discussion Questions Based off the differences listed above, what are leadership styles/qualities that are needed for a practice to be a successful PCMH? Have you observed these leadership styles/qualities in your residency program? If so, list out these leadership styles/qualities. Have you observed leadership styles/qualities in your residency program that you think impede becoming a PCMH? If so, list out these leadership styles/qualities.

Characteristics of Effective Leaders Individual reflection using the PCMH Leadership Assessment, then group discussion. See PCMH Leadership Assessment handout Points emphasized: PCMH leadership is a “team sport” – is less hierarchical and involves engaging all members of the staff/faculty/providers Important as a “leader” to know that you don’t (and can’t) possess all leadership qualities. Key is to indentify others that can complement skill sets.

Leading Teams Through Change

Leading and Facilitating Staff Through the Stages of Change Shock: educate and communicate Defensive retreat: educate, communicate, and sell (“burn the boats”) Acknowledgment/Acceptance: sell and train Adoption: reinforce and recognize

Lessons Learned and Evaluations Thus Far Lesson learned: Residents and faculty need to be part of the QI team process before including in the leadership training Evaluations: Have conducted resident/faculty leadership training in all 10 practices Evaluations very positive: average 4.0 on 1-5 likert scale that the training was helpful Training attendees responded that they found they found the group discussions and Q & A sections the most helpful

Staff Team Leader Training

Staff leadership & involvement are key to successful transformation Effective and empowered teams and team members indicate a positive transformational practice culture Staff are the sustainable change agents in practices Staff bring action and forward momentum to change Staff have the organizational skills in the practice, your role is key to: Maintaining data boards Coming to meetings with agendas Making sure there are minutes Knowing your patients Filling out AIM statements, PDSAs, etc. On the ground modeling, communication, management 19

Positive movement & spread directly related to staff & teams 20

A high level of staff engagement & high functioning teams with supportive leadership = foundation for change. 21

Staff Leadership Training: Program Content 1.Quality Improvement Teams - Who what where and why? 2.Finding your QI Team leaders 3.How to Run an Effective Meeting: The importance of managing while Leading 4.Keys to Group Facilitation 5.The Change Process: quality improvement tools for your back pocket (AIM statements, process mapping, PDSA’s)

A team with members that represent all areas of the office A team with regular meetings, at least twice/month A team tasked with implementing change efforts Who is a “Quality Improvement Team?”

Shared leadership Identify a provider and staff co-leader for each team. Help provider and staff delineate roles for the team meetings. Give provider and staff time to “huddle” outside of meetings to connect. Make team leader roles formal and train leaders. Each should run the team meeting in the other’s absence. Having both as team leaders: Models a new model of provider & staff interaction Improves communication with whole practice, i.e. if staff needs training/communication then staff member does this & provider to provider messaging. Provider ideally contributes clinical expertise and accountability in the practice 24

Why use teams for change? Helps the practice understand the overall practice system, what’s actually happening Increases the diversity of perspectives Increases the number of staff empowered to identify and seek solutions to problems – “shared leadership” Helps create conditions for success, buy-in and momentum – 20% want change, 50% on the fence, 30% against change

Characteristics of Effective Team Leaders Responsive to data Encourages open exchange of ideas Not always “the expert” – asks for help Organized Available/visible Respected – informal leader Action-oriented Approachable Reliable

Expectations of the Team Leader Sets the vision Encourages participation Make sure there is an agenda, a recorder & timekeeper Creates a safe environment where ideas are easily expressed and not negated Makes sure that action items are followed up on & accountability Helps teams use quality improvement process Uses data to make sure changes are improvements

How to Run an Effective Meeting

Why is a Well Run Meeting Important? Meetings are the time/space where quality Improvement teams do their work Well-planned and well-conducted meetings promote buy-in Staff and providers are time-pressured Early successes build momentum

Five ‘Must Have’ Tools for Effective QI Team Meetings Agenda Note taker &Time keeper Clear objective or goal for team Assigned action items Use of QI tools – Aim statements, process mapping, PDSA cycles

Keys to Group Facilitation Facilitate: to make easier

Guidelines for Facilitators 1.Come prepared & organized (effective meeting tools) 2.Be intentional about making sure everyone participates 3.Address/name conflict or tension. (reframe as needed – “launder” language) 4.Summarize group discussion & decision(s) 5.Be aware of diversions from crucial conversations Case study example

Resistance Resistance always occurs in one form or another in all task-oriented groups It is good when it surfaces problems, finds errors, or makes a good idea better – when it’s overt. Resistance is bad when it is covert or driven underground (sabotage, malicious compliance, etc.)

The Change Process: quality improvement tools for your back pocket 34 Aim Statements Process Mapping PDSA (Plan-Do-Study-Act)

Quality Improvement Steps Global AIM statement 3. Process mapping/work flow analysis 1. Area of focus 5. PDSA (plan-do-study-act) State what you Intend To improve ‘Map out current state and or ideal state What do you want to work on? Perform small tests of change 4. Model for improvementAIM, measures, ideas

36 Aim Statement Create an aim statement that will help keep your focus clear and your work productive: We aim to improve : (Name the process) In: (Clinical location in which process is embedded) The process begins with : (Name where the process begins) The process ends with : (Name the ending point of the process) By working on the process, we expect : (List benefits) It is important to work on this now because: (List imperatives) Global Aim Statement

3. Process Mapping and Work Flow Analysis Documenting the patient journey, not as the ideal, but as it is, and involves confirming it with data. A clear and comprehensive picture of the way business is done. One of the steps of process redesigning. 37

Process mapping helps teams Identify waste and barriers to the workflow Consider all features that impact the process Provide details that can be evaluated later Help understand the status quo of the process Prepare future analysis

39 HTN Process Map

4. Model for Improvement 40 AIM Measures or data Ideas Test Ideas and changes in cycles for learning and improvement

41 PDSA Cycle # ___: Plan: The change: (What, who, when, where and who responsible?) Prediction: (What do we expect to happen?) Data: (What information, who, what, where when collected?) Do: What was tested? What happened? Observations? Problems? Study: Summarize what was learned and compare to prediction. Act: What adjustments should be made for the next cycle, what will next cycle be?)

Coach Lessons Learned Until practices identify formal team leaders and provide training, the quality improvement process is often stalled QI tools are not only critical to the ‘process’ but end up being excellent team building activities Practices that have gone through the training and empowered staff and teams have made significant progress Without leadership support, the QI team and leaders won’t be able to sustain their work Data is critical to ongoing improvement work 42

Questions and Discussion Presentation and materials will be made available on the FMDRL