Engaging Healthcare Practice Teams in Quality Improvement Mary Barron, RN / Nurse Care Manager UK Family & Community Medicine - Turfland

Overview Our primary care practice Our QI Team Journey: Early - Today Students as QI Team Leaders & Members Maintenance of Certification and CME/CE Training Resources Future QI engagement growth NOT Basics in QI Principles, but QI in Practice

Our Outpatient Practice NCQA PCMH Level 3 Recognized Primary Care practice located at the new UKHC Turfland location 17 Faculty Physicians, 2 Behavioral Science Faculty; 3 Licensed Clinical Social Workers; 21 Resident Physicians, 8 Nurse Practitioners; 2 Sports Fellow Physicians (all physicians part-time clinical FTE) Team-Based Outpatient Care with integration of transitions of nurse care, PharmD co-visits, & student social work case management Empanelment of approximately 23,000 patients

Our Inpatient Practice Primary Family Medicine Inpatient Service located at the 302 bed acute care Samaritan Hospital in Lexington Service operates in collaboration with UKHC Chandler Hospital, Markey Cancer Ctr., Gill Heart Institute, and Veterans Affairs Medical Ctr. Inpatient team includes 1Attending Physician, 1 PGY3 Resident, 2 PGY2 Residents, & 1 PGY1 Resident on resident one-month rotations 1341 Discharges CY2016 Inpatient team conducts outpatient followup visits for continuity Transitions of Care Nurse conducts telephonic care 2-days post hospital discharged practice patients to transition back into outpatient clinic

Our Journey- Early QI Projects HRSA Practice Based Learning and Improvement grant starting 2011; projects starting 2012 Resident Wednesday afternoon dedicated conference time for new resident-led clinic QI initiatives facilitated by faculty & UK Office of Quality & Safety leaders Projects focused on disease or preventative care topics for which quality data was chart audit or could be pulled by IT department by ticket request

Our Journey- Early QI Projects Trained and utilized the 8-Step Process for Problem Solving developed by Dr. John Kotter*, change management and transformation expert: *Dr. John Paul Kotter is the Konosuke Matsushita Professor of Leadership, Emeritus, at the Harvard Business School, a New York Times best-selling author, the founder of Kotter International, and a well-known thought leader in the fields of business, leadership, and change.

Our Journey- Early QI Projects Project successes: Resident QI Training and Scholarly Leadership Opportunities Opportunities to present QI work locally and nationally C) Establishment of care guidelines and sustainable change implementation D) Opportunity to complete Part IV Maintenance of Certification (MOC) Modules (diabetes modules utilized)

Our Journey- Early QI Projects Project limitations A) Data-driven improvement in real-time limited due to limited data reporting B) Non-engagement of other providers and staff in the process of change as a team C) Limited opportunity to complete Part IV Maintenance of Certification (MOC) Modules rather than practice initiated self –directed projects continuous cycles of change

And then came……. National Committee for Quality Assurance (NCQA) Patient –Centered Medical Home (PCMH) Recognition Survey https://ncqa.org

PCMH 2011 QI Standards & Factors Involve care team staff in the practice’s performance evaluation and quality improvement activities Implement Continuous Quality Improvement – addressing preventative, chronic, and vulnerable populations and utilization and satisfaction

Our Journey- Mid- QI Projects Engagement of All Providers and All Staff in formal Faculty or Nurse Practitioner led QI teams late 2014

Our Journey- Mid- QI Projects Providers and staff chose topic and team All Providers and Staff joined teams for practice quality perspectives and input from all areas of the practice (registration, medical records, nursing, provider, referral team) Cultivate a QI spirit of “no blame” Culture change and defining new roles- change from care team member to both care team and QI team member Inviting students as role members within teams

Our Journey- Mid- QI Projects All Team Members required completion of brief online training on basic principles of Change through the Institutes of Healthcare Improvement (IHI) Model for Improvement (http://www.ihi.org) Online trainings were completed by teams on: Overview of QI, Model for Improvement, PDSA Cycles, IHI Improvement Roadmap, How to Improve IHI offers free online training via their Open School at the above website. Training resources for the above (and more) via the Open School

Our Journey- Mid- QI Projects Dedicated QI Team 30- minute meetings twice per month with member assignments between meetings:

Our Journey- Mid- QI Projects Set meeting reminders agendas following education and guidance from IHI: A. Setting Aims B. Establishing Measures C. Selecting Changes D. Testing Changes E. Implementing Changes F. Spreading Changes Attendance, Meeting Notes and Project Documentation at time of meeting in preparation for next meeting

Our Journey- Mid- QI Projects Team Successes: All teams completed 2+ cycles of PDSA change with measurable improved outcomes for patients and practice Two teams received approval through UK CECentral Part IV MOC program to utilize project for maintenance requirements Two projects were presented by residents at the state KAFP meeting and the national STFM Practice Improvement Conference Practice held its first annual QI Symposium with patients and colleagues showcasing the successful practice improvements

Our Journey- Mid- QI Projects Team Limitations: Continued limitations on real-time data for process change Faculty led teams should be considered for resident led teams Dedicated Team meeting time limitations Some providers utilized projects for Part IV MOC (and staff for CE), but not all due to time limitations

Our Journey- Mid- QI Projects Changes for 2016 Teams from Lessons Learned: Engagement of Residents as Team Leaders Increased Dedicated Team meeting time from 1 hour per month to 2 hours per month Reduction of teams from 6 to 5 teams with more members, but still disease or care focused Timeline adjustment for project completion to better enable all teams to have option of utilizing improvement work for Part IV MOC and continuing education for all team members Opportunities for real-time data available

Today’s QI Projects Team Focus Change for 2017 Team themes changes from disease or care focus to broad healthcare delivery focus (reduction of 5 to 4 teams) Integration of the real-time data via electronic Clinical Quality Solutions (CQS) for patient clinic outcomes and population health planning to guide new data-driven quality initiatives Further emphasis on designated team lead and documentation Exploration of next level QI training and facilitation Exploration of new options for Part IV MOC and CE credit Exploration of Patient Advisory Board Members joining QI teams

Team Focus Change to Delivery Process: Today’s QI Projects Team Focus Change to Delivery Process:

UK Office for Value & Innovation in Healthcare Delivery (OVIHD) QI Training Resources UK Office for Value & Innovation in Healthcare Delivery (OVIHD) (https://chsr.med.uky.edu/chsr-office-value-innovation-healthcare-delivery)

QI Training Resources Institutes for Healthcare Improvement Open School (http://www.ihi.org/education/ihiopenschool)

Students as Practice QI Team Members Benefits for Practice & Student Experience a practice commitment to work towards improvement with a team approach including goal setting and review QI Principles training Assist in data collection and analysis Leadership in team meetings and PI reporting for outcomes and continuing education/certification Goal Setting planning and review

Part IV MOC & CME/CE Credit Our team members have utilized the UK affiliated provider option of project submission for review and approval for ABFM MOC Part IV credit with UK CECentral: www.cecentral.com/moc UK CE Central was approved in 2013 to be a Portfolio Sponsor by the Multi-Specialty MOC Portfolio Approval Program that develops, monitors and approves quality improvement (QI) projects for MOC Part IV credit for actively participating UK HealthCare-affiliated physicians.

Part IV MOC & CME/CE Credit UK CE Central option cont’d Some Details: 1) 2 Phase application submission- ideally before project starts and after the project completion 2) At least completion of 2 PDSA cycles of change required along with baseline and 2 cycles of post PDSA data 3) Documented engagement of providers in the project

Part IV MOC & CME/CE Credit UK CE Central option cont’d Advantages: Multiple providers engaged in the project under one application for review and approval CE Central personnel report credit to providers’ board upon approval and participation verification CE Central personnel review application for completeness prior to submission to committee review Option to also receive CME credit for project if requested to CE Central prior to project start

Part IV MOC & CME/CE Credit UK CE Central option cont’d Tips: Contact person for submission: Chris Dennison Review project completion and submission dates with CE Central to assure your project will meet the calendar deadlines for review for the year that you would like to have it considered for MOC For other staff (or students), several Kentucky Boards (including Kentucky Board of Nursing) have options/applications for individual submission of completed projects for which physicians have received CME credit and the individual would like to request credit. Check with your board and see if this is an option and the requirements

Part IV MOC Credit American Board of Family Medicine (ABFM) options: https://www.theabfm.org/moc Submission Options: 1) Alternative Performance Improvement Activities Approval Program Self-Directed Performance Improvement Efforts Contact Person: Nichole Lainhart Residency program pilot (ResPIP) to better accommodate resident requirements currently

Plans for the Future And then came….MACRA Foundation for Population Management Teams conduit for other clinic initiatives

Some First Steps As a practice, determine your reasons/goals for implementing a formal QI program and who will be involved. Determine preferred quality and process improvement training resources that best fits your practice Determine data limitations upfront Empower staff members (and students) to be leaders in information retrieval – go-sees, literature search, contact people Allot dedicated practice time to QI efforts Dedicated person to be in charge of meeting schedule, reminders, and agenda Prioritize as a team the areas of greatest need for change by following chosen change process Determine the desirable benefits from your QI efforts i.e. improved patient outcomes, patient and provider satisfaction, meeting continuing education or maintenance requirements

“ The significant problems we have cannot be solved at the same level of thinking with which we created them.” - Albert Einstein