Learning System: Engaging the Front-line in Improvement Paula Griswold Executive Director, MA Coalition   Chuck Lukasik Chief Operating Officer, Mount Auburn Professional Services

Mount Auburn Practice Improvement Program (MA-PIP) Skills training needed for health reform: Massachusetts Health Care Workforce Transformation Fund - Commonwealth Corporation Improving patient safety in office practice/ambulatory care Enabling practices to “improve your work, while you do your work” Create infrastructure for continuous learning Build on a proven model – federally-funded PROMISES program Enabling your practice to improve without disrupting patient care - Skills to be a learning organization - Engaging all practice staff to “ see problems and solve problems” - Same approach can improve patient safety, quality, patient experience, efficiency - Makes work more manageable

Challenges for MAPS MAPS overview Changing nature of office practice Engaged, empowered staff Effecting change across the network of 25 practices Chuck – you had said: Talk about MAPS How office practice has changed – measure quality and manage populations – need better training Staff empowerment, happy staff, getting them psyched Don’t even really care if they save money 2. While I sit at my desk, how can I get changes in these 25 practices – consistently across the network Common language, skills, people interested in reaching common goals, Directors as coaches – connection to that work, support and feedback

PROMISES was the model PROMISES tested the idea that even small primary care practices, with few resources to support change, can learn the skills to improve patient safety, and ultimately use that learning to support other improvement work. The PROMISES (Proactive Reduction of Outpatient Malpractice: Improving Safety, Efficiency, and Satisfaction) Project was supported by grant number R18HS019508 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ Explain Proactive Reduction in Outpatient Malpractice; Improving Safety, Efficiency and Satisfaction

Focus areas in PROMISES Reliability: Patient Safety Principles and Topics 3 priority processes: Test result management Referral management Medication Management Communication – with patients & among staff Reduce wasted time Improvement & Measurement: Quality Improvement techniques

PROMISES Activities Taught improvement techniques to improvement teams in the practice Coaches helped teams use improvement techniques Identify problem, understand causes Small tests of possible solutions Measure/assess results Community learning sessions to share results among the teams

Key learning from PROMISES The importance of coaches The power of community learning sessions The critical role of practice managers The value of small tests of change The importance of a clinician champion The power of engaging the entire team The importance of coaches to develop the skills of practice staff to apply the techniques in their own offices. The power of community learning sessions to reinforce and support the experience of practice staff by offering opportunities to share with and learn from staff from other office practices The critical role of practice managers in the leadership, ongoing discipline, and internal coordination of improvement work The value of small tests of change to a practice’s ability to manage improvement work while they continue to care for their patients. The importance of a physician champion

PROMISES Results: Exit Interviews “Before [PROMISES], … my whole time was spent just putting out fires, not really dealing with what is causing the fires… and now my whole approach is, "okay let's deal with the immediacy of the problem, but let's look further into how we can prevent this from happening again.” “As we did it piece by piece… it really wasn't a lot of time and the changes we made were so significant…” "We were able to conquer things that we did not even know existed... that is so wonderful and important in my practice, and I am so grateful for it. “...it was incredibly helpful”

PROMISES Chart Review Results: Number of Potential Adverse Events (no follow up of abnormal tests or medication values, high risk referrals) 68% reduction Statistically significant results from chart reviews demonstrated effectiveness. Pre-intervention chart reviews in 16 PROMISES practices found 126 potential adverse events* Dropped to 41 after the PROMISES program, a nearly 70% reduction *failure to follow up or document a follow up of an abnormal test result or referral to a specialist that could have resulted in an adverse event) Chart reviews showed a 57% reduction in serious potential adverse events ** from 23 instances to 10, after the PROMISES intervention

Mount Auburn Practice Improvement Program Two year partnership built on PROMISES: Build a decentralized learning system – engage the practices Train MAPS directors as coaches to work with teams from selected office practices Train practice managers/clinicians/staff in the practices in reliability/ patient safety principles, and quality improvement techniques Working with their MAPS coaches Community Learning Sessions for clinicians and staff Builds on the PROMISES learning A collaboration to build a quality improvement infrastructure within Mount Auburn Trained coaches ( Sonya Sullivan, Susan McDonnell working directly with practices – also Lora Gross-Kostka) Trained practice managers Create an ongoing learning environment for MAPS & MACIPA practices As we work together - will discuss INTEGRATION WITH OTHER PROGRAM _ ONE PATIENT SAFETY PROGRAM

Our Goals for the Funder All participants will learn the principles of patient safety and quality improvement techniques Coaches will have skills to teach/support improvement teams Improvement teams in practices will use quality improvement techniques in their daily work Mount Auburn will maintain and expand the activities – continuous learning Improvement teams in practices will use quality improvement techniques in their daily work: conduct small tests of change, measure for improvement and select successful changes for implementation

Our Underlying Goals Decentralized learning system: Everyone is an “ everyday improver” Provide skills to achieve all types of improvement goals Engagement – Make the work more do-able Enhance joy and meaning in work

What we taught: What drives outcomes for patients? Daily work – everyday operations: 1. System Design/Reliability - are work processes well designed? - are defined work processes followed? 2. Culture Patient Outcomes Improving daily work: 1. Culture including commitment to safety and continual learning 2. “See problems” 3. “Solve problems” Engage Patients

all the assets of the patient.” Patient Engagement Clinical Relationship Practice Improvement Involve patients in their own care Patients help identify problems, design and test improvements How do we engage patients in this work? Patients’ perspective – identifying defects Patients’ suggestions for improvements Patients’ reaction to changes tested Patients on your improvement team “The greatest asset we have underutilized is all the assets of the patient.” Maureen Bisognano President and CEO Institute for Healthcare Improvement

What have we done during this project? Coaching the coaches 7 Community Learning Sessions 5 practices with improvement teams/efforts: Improve communication about need for colon cancer screening Improve effectiveness/efficiency of scheduling appointments with GI Specialist Increase percent diabetic patients who complete annual eye exams Improve communication with patients - patient agenda setting Improve rate of return of specialty tests & communication of results Improve the rate of return of FOBT test kits Tools and resources to support improvement work Last year – Remember Practice Manager Sandra DeFrancisco, Dr. Andrews Kelleher, Coach/Director Sonya Sullivan

MA-PIP Results Learned skills – 3 coaches, 5 practices Quality improvements (73% 97%; 29%  52%) Process changes/efficiencies (>15, $14,000-28,000) Front-line engagement in improvement- individual satisfaction, improving work Shared learning sessions Ongoing/spreading improvement activities

To Be Successful … Leaders call on teams to make care safer for patients – appreciate and celebrate the work Teams include front-line staff – experts in the process Teams engage patients in the improvement work Teams use the Model For Improvement and Reliability Principles Teams review & share improvement data Teams are supported – Mount Auburn Coaches Practice Manager Meetings Community Learning Sessions Teams use the Model For Improvement and Reliability Principles rather than just training/education, vigilance and hard work

Leadership View of Results Quality Improvements Process changes Staff Engagement Effecting change/improvements in practices

Exceptional organizations: Those who lead in healthcare…. Do not necessarily have access to more or unique resources. Constantly learn and apply what is learned, to maximize the effective use of existing resources. Incorporate the detection of problems as part of everyone’s job Are prepared to identify and solve problems When something works, plan how to spread it throughout the organization Leadership ensures that all staff are actively included, motivated, encouraged and given time to do this work Accelerating Improvement in Health Care Steve Spear Senior Fellow, Institute for Healthcare Improvement Senior lecturer, Massachusetts Institute of Technology, Sloan School of Management Faculty for the PROMISES (Proactive Reduction of Outpatient Malpractice: Improving Safety, Efficiency, and Satisfaction) Project

Patient and Family Engagement DPH Grant: Resident and Family Council Development and Engagement in Nursing Homes