1 HIVQUAL-US Funded by HRSA HIV/AIDS Bureau HIVQUAL-US In+Care Campaign, Developing Process Diagrams, and Tests of Change/PDSAs Nanette Brey Magnani, EdD, HIVQUAL US April 4, 2012

2 HIVQUAL-US Participants – Benjamin Harris – Erie FHS – Mandy Kastner – ARC/W – Shelton Kay – Crusader Health Center – Bessie Akuomah - CDOH – Alice Wightman – Heartland Health Outreach

3 HIVQUAL-US Check-in and Next Steps What can you do by our May 7 th meeting? Bessie – start with data; and enter it; 75% Mandy – working on VL suppression Benjamin – meet with case managers at monthly meeting; Outreach worker and care coordinator; identify reasons; fine tune how to link back in to care; Alice – pull team together; share/discuss data; develop initial draft of process diagram

4 HIVQUAL-US Shelton – meet eCW consultant; access to data; enter data into In+Care – MH screening QI Project - Develop Mental health screening process diagram – Then when eCW data is ready; review results and select QI focus

5 HIVQUAL-US Agenda Welcome: Unmute lines, interactive webinar with discussion, Q&A Updates: Next regional group meeting – Monday, May 7th; 9:30-12:30 at Erie Family Health Center; North Ave/ California (NE corner of park) In+Care Campaign progress Review and discuss examples of process diagrams Share some tests of change and team management tools Next Steps

6 HIVQUAL-US Site Visits – week of May 7th Near North – OA; 2-4

7 HIVQUAL-US QI Project Steps Step 1: Collect and Analyze Data. Step 2: Convene QI Project Team. Step 3. Investigate the Process Step 4: Implement PDSA(s) Step 5: Evaluate Results Step 6: Systematize Change

8 HIVQUAL-US Step 1: Performance Measures and Data In+Care Campaign Measures Gap in Care –% who did not have a medical visit with a provider w prescribing privileges in the last 180 days Medical Frequency: % who had a medical visit w a provider w prescribing privileges in each 6-month period of the 24-month measurement period w/ a min. of 60 days between visits Patients Newly Enrolled in Care: % who were newly enrolled with a medical provider w/ prescribing privileges and had a medical visit in each of the 4-month periods of the measurement year Viral Load Suppression: % of patients with a viral load less than 200 copies/ml at last VL test during the measurement year

9 HIVQUAL-US In+ Care Campaign Data Update March 15, Part C/D grantees are members of Greater Chicago QM Group 4 submitted data for February, registered, no data entry 5 not registered in database

10 HIVQUAL-US Initial Data for 4 Submitting Programs: Validate Data – Is it accurate? ProgramGap in CareVisit freq over two years Newly enrolled in care VL suppression #1 CCHC Patient total 15.7% % 218 ? 71% 267 #2 EFHS Patient total 1.62% % % 8 84% 185 #3 HB Patient total 18.6% % % % 1933 #4 Open Door Patient total 3% 361 Not submitted83.3% 12 76% % 103,259 – 163 org 3.6% - 3, org 5.4%--11, org *Nat’l -urban Top 10% Top 25% 67.4% 58,364 – 96 org 95.9%-7,928 –10org 90.4%-10,651-24org 59.4% 8,795 – 157 org 99.2% org 89.8% org 69% 119,656 – 157 org 87.7% -5, org 83.1%-17, org ARC/W: gap: 3% new pts: 83% retention: 63% VL supp: 74%

11 HIVQUAL-US February Data for 4 Submitting Programs MASSACHUSETTS – Part C ProgramGap in CareVisit freq over two years Newly enrolled in care VL suppression #1 Patient total 10.3% % 146 (15 ?) 80.4% 163 #2 Patient total 4% % % 8 94% 299 #3 Patient total 14.7% 157 #4 Patient total 10.9% % % 1 83% 71 *Nat’l –programs <500 Top 10% Top 25% 16.1% 103,760 – 166 org 3.7% - 3, org 5.5%--12, org 66.6% 58,990 – 99 org 96% - 7, org 90.1%--10, org 59.62% 8,823 – 160 org 100% org 91% org 69% 120,577 – 160 org 88.5% - 5, org 83.7%--17, org

12 HIVQUAL-US QI Project Steps Step 1: Collect and report data. (QM Committee report on performance measures.) (if no data, then develop a process diagram; work flow) Step 2: Convene QI Project Team (sub group), review data and set improvement goal Step 3: Investigate the cause: understand the process and causal analysis (Flow chart/process diagram; drill down data) Step 4: QI Project (PDSA) Step 5: Evaluate with QM Committee and Stakeholders. Step 6: Systematize changes.

13 HIVQUAL-US Step 2: Team Formation Who is on your QI Project Team? Do they need training? If so, can they be available for team training and commit to the schedule?

14 HIVQUAL-US Step 3: Investigate the Process and Causal Analysis Causal analysis tool – Drill down your data – Find out who is not meeting the measure – Find out why

15 HIVQUAL-US Step 3: Investigate the Process Process Diagrams – More deeply understand process improvement PDSA – change isolated vs clearly connected to process – Promotes better decision making Helps you to see your work at as a system, a whole Gathers team’s thinking Creates buy-in and consensus Functions as a procedure and thus can be used to create protocols and evaluate current ones Promotes wider understanding of process Resources : HIVQUAL Workbook – flow chart NQC: National Quality Academy Tutorials – flow chart

16 HIVQUAL-US Types of Processes in Health Care Flowcharts Patient flow Information flow Material flowClinical practice

17 HIVQUAL-US What does a process diagram look like? Also called flow chart; work flow (Six Sigma)

18 HIVQUAL-US Process Diagram Definition A process diagram or flow chart is a picture of the steps of a process to: – Understand the process – Identify potential sources of problems – id underlying causes – Outline the ideal process steps and address the causes – Enable communications with others

19 HIVQUAL-US Creating a Process Diagram and Next Steps in Implementing PDSA 1.Agree on use and level of detail 2.Define starting and ending points 3.Document each step 4.Follow each branch to the end 5.Review and agree on the steps and diagram 6.Identify problem steps and list underlying causes next to the step 7.Discuss tests of change (interventions) to address key causes. 8.Develop a PDSA plan and implement. Flowcharts

20 HIVQUAL-US Most Commonly Used Process Diagrams/Flowchart Symbols Activity/step Start, end Decision yes, no Wait symbol Connecting lines Flowcharts

21 HIVQUAL-US Improving Patient Retention Delta Regional Medical Center – Greenville, MS Wright Primary Care Center – Scranton, PA

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24 HIVQUAL-US Improving VL Suppression Rates Arnot Ogden Medical Center, Elmira, NY St. Elizabeth’s, Utica, NY Brockton Neighborhood Health Center, Brockton, MA

25 HIVQUAL-US Model of Hotspotters team activities – test new process Patients on HAART with HIV viroload over 100 Patients not seen in 6 months CM follows up with CBOCM follows up with the patient □ Schedule medical appointment with the provider □ Schedule case management review with CM (if needed, to follow up on patient’s issues) Review most recent clinic and adherence data for the client Identify individual retention problems Contact the patient with lab results (NP) □ Schedule f/u bloodwork □ Schedule visit with NP to discuss the lab results □ Schedule appointment with Treatment Adherence Counselor Collection of Data by QI Coordinator (based on Excell spreadsheets, eMD and AIRS reporting) □ Review outcome of interventions at the end of the month. □ Update viroload information and follow up on scheduled appointments □ Review client’s chart in eMD for possible coordination of care needs. Meeting of the Team (second Friday of the month), review of the data

26 HIVQUAL-US Treatment Adherence for people with VL Self-Assessment Do they know which meds to take, how many, and when? Review Missed Doses Are they missing doses of their medication? Medication Education Provide medication and treatment education. Identify Barriers Figure out how many doses missing and why? Review Medication Guidelines Are they taking it appropriately (i.e., with food, without splitting, with other meds)? Develop Care Plan Set client-focused goals to overcome adherence barriers (if client is agreeable). Resistance Testing Determine if resistance has occurred and if a med change needs to happen. Reassess for Readiness Determine if client is ready to take medications (confidence and importance).

27 HIVQUAL-US Overall Findings Start of the project – November clients on the list - 25% no-shows - 75% VL over % female/77% male Current data - March clients - 13% no-shows - 13% new clients - 73% VL over % female/74%male 22 patient from November list remain on it in March 18%(4) no-shows/82%(18) VL over % female/68% male (note: higher number of women remaining on list for longer time) All of the clients remaining on the list were outreached to schedule an appointment, repeat VL, run a resistance test and/or see Treatment Adherence Counselor. Patients with VL over 100: 61%(11) VL down, 28% (5) VL up, 2 – no change 2 clients restarted medications recently 5 clients with severe mental health problems – 4 enrolled in MH care 1 client refusing care, 1 about to be closed (MIA).

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29 HIVQUAL-US Team: Task/Next Steps to complete Step 3. Investigate the Process Draw a process diagram of your current process. Use flip chart paper, 8 ½ x 11” paper for each step Tape to a wall for others to see Could make it participatory by discussing with others to get their input Circle key problem steps. Write causes of the problems next to each problem step. Discuss and select interventions that can address the key causes. Share with other members of team/clinic for feedback.

30 HIVQUAL-US Step 4: PDSA What changes address key causes? Develop a plan. Try it out. Measure. Did the change make a difference? Why? Or why not? Is there a need for another change?

31 HIVQUAL-US PDSA Examples HIV Patient Alert System (Arnot Ogden, St. Elizabeth’s) Self management goal setting form (in conjunction with individualized care plans) New Patient visit form (BHNC) Teach back tool for understanding importance of taking medication (BMHC, St. Elizabeth’s)

32 HIVQUAL-US HIV Patient Alert System with Team In combination with pt goal setting and individualized care plans Red YellowGreen

33 HIVQUAL-US Lawndale Christian Health Center - Sonji

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36 HIVQUAL-US Funded by HRSA HIV/AIDS Bureau HIVQUAL-US Take Your HIV Medicine On Time and Every Day Educator name: 36

37 HIVQUAL-US CD4-T The CD4 T cells in your body are your friends. They are like a factory, making things that protect you from infection. 37

38 HIVQUAL-US HIV CD4-T But HIV is a clever virus. It hijacks your good CD4 T cells, and turns them into an HIV factory. Then you get a lot of HIV (a big Viral Load). 38

39 HIVQUAL-US Your HIV medicines stop that HIV factory! When you swallow HIV pills, they go from your mouth to your stomach, then into your blood to defend your CD4-T cells. HIV HIV Medicine CD4- T 39

40 HIVQUAL-US If you take your medicine ON TIME and EVERY DAY, you keep enough medicine in your blood to defend you, and you will usually feel better. 40

41 HIVQUAL-US Additional PDSAs Wright Primary Care Center Improved review lists (measured by comparing list of weekly scheduled appointments) Scheduling appointments for patients by the nurse and NP and given a card Delta Regional Medical Center Involve District Social Worker after the first letter is sent

42 HIVQUAL-US Team Management Tools

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45 HIVQUAL-US Lancaster General Hospital. Comprehensive Care Center.