1. TRANSFORMING YOUR PRACTICE TO THE NEW MODEL OF PLANNED CARE (even without an EMR) John Testerman, MD, Ph.D. Linda Deppe, D.O. Cynthia Glasgow, CFNP, CPHQ Loma Linda University Dept. Family Medicine 1

2. Loma Linda University Family Medical Group Clinic 20 faculty clinicians 0.3 to 1.0 FTE 20 residents 74,000 clinic visits annually About 2,000 patients with diabetes 2

3. The “Lone Wolf” traditional practice culture 3

4. Culture Change Working together as a team 4

5. PRACTICE TRANSFORMATION ASSUMPTIONS Physicians want their patients to get good care Doctors change only in response to data they trust to achieve a goal they support 5

6. Practice Transformation requires: 1.Shared Vision Where are we going? 2.Good Data Are we there yet? 3.Strategies & Techniques How do we get there? 6

7. Part I: Developing a Common Vision Promote Epiphanies –Get people away from campus. –Send to conferences & leadership training Retreats –Department leadership –Whole department Faculty Seminars Leadership Books –“Good to Great”, – “Crucial Conversations” –“If Disney Ran Your Hospital” 7

8. Finding our calling as a department— the view from 30,000 feet “Called to excellence, compassion and wholeness.” FFM identity statement “Family physicians are driven by the need to help make people whole by humanizing medicine and achieving quality care.” 8

9. “Your vocation is the place where your deep bliss meets the world’s deep need.” –Joseph Campbell 9

10. 10 Strengths NeedsPassions Calling

11. Finding Our Sweet Spot Strengths: –A strong sense of who we are –Good clinic leadership and management –Collecting and interpreting data –Engaged physicians and staff –Whole person care What we care about: –“Excellence, compassion, wholeness” Needs with respect to chronic disease care: –We are in the midst of a national quality revolution but nobody on campus is using QI tools to improve chronic disease care. 11

12. Vision for excellence in chronic disease care Leadership in modeling, teaching & improving chronic disease care 12

13. Strategy Begin with Type II Diabetes and achieve NCQA and ADA designated status Extend to other chronic diseases using successful strategies Develop student and resident learning and research experiences in chronic disease care Research best ways to deliver chronic disease care 13

14. An Evolving Vision (We didn’t start there!)

15. We started with an incorrect assumption Since our clinicians are knowledgeable, our patients should be receiving the best, evidence-based, chronic disease care.

16. 16 “MY PATIENTS ARE ALL GETTING GOOD CARE!”

17. Was it true? Resident QI projects on preventive and chronic disease care—results not good Our response—more educational interventions, handing out and discussing practice guidelines Follow-up audits—still not good Knowledge is not enough! 17

18. “There must be something wrong with the data.”

19. The chart self-audit shocker 19

20. A Flawed Practice Model “Practicing alone together” Quality of chronic disease care dependent on physician time, memory and patient showing up Office visit-focused practice Reactive care—acute care model 20

21. Diabetes Visit Quickly list everything you should think about, cover or do as part of a diabetes office visit 21

22. THE GREAT QUALITY MYTH caring + knowledge & skill = quality If patients aren’t receiving good care, then somebody must be either uncaring or incompetent or both. 22

23. “Every system is perfectly designed to produce the results that it does achieve.” –Paul Bataldan To improve the results, improve the system Fix the problem, not the blame 23

24. SYSTEMS MATH 101 1 X 0 = 0 1,000,000 X 0 = 0 Good people X poor processes = POOR CARE Really good people X poor processes = POOR CARE 24

25. To Really Improve Quality Look for flaws in processes Design systems that make it easy to do the right thing and hard to do the wrong thing 25

26. Paradigm Shift Driven by self-examination and data. Rumors of a “better way.” Had to learn by experience that by improving processes and collaborating as teams with staff we could deliver better chronic disease care. 26

27. Process Improvement Example: Improving Diabetic Foot Care QI project to improve compliance with diabetes care guideline: 1.Foot inspection done & documented at every diabetic visit 2.Documented comprehensive foot exam, including monofilament exam, at least yearly 27

28. 28

29. Foot exam not done in diabetic patient PHYSICIAN Didn’t know guideline Failed to document Not enough time Forgot PATIENT Can’t remove shoes Not aware of need Didn’t come in STAFF Didn’t have pt. remove shoes Didn’t know guideline CAUSE AND EFFECT ANALYSIS 29

30. MOST COST-EFFECTIVE STRATEGY: MA Staff have diabetes patients remove shoes 30

31. Results of Diabetic Foot Project 31

32. 32

33. Diabetes Task Force Chaired by FNP with CPHQ –Clinician and staff representatives Set goal of NCQA/ADA Diabetes designation Began by creating Diabetes care flow sheet 33

34. Diabetes Flow Sheet Weight Lipids A1c’s Microalbuminuria testing Retinopathy screens 34

35. Problems Physicians didn’t have time to fill out the flow sheets Flow sheets ended up in various places in the chart Foot exams decreased when we stopped reporting back data No chart cue for documenting foot exams 35

36. Interventions LVN Diabetes Coordinator began “prepping” charts for diabetes visits –filling in flow sheets –placing in correct place in chart –attaching lab and referral forms Set up Excel-based diabetes registry for reports 36

37. Joined Lumetra Diabetes Collaborative Project—test whether designing and implementing a diabetes progress note will improve compliance with diabetes care guidelines 37

38. Implementation of Diabetes Progress Note Reminders to cue compliance with ADA clinical care guidelines Enhance documentation Supplement Diabetes Flow Sheet (already in place) 38

39. Diabetes Progress Note Elements 1.Demographic data 2.Hx of Present illness 3.Past Medical History 4.BS/Diet/Exercise/Meds 5.Review of Systems 6.Physical Exam 7.Detailed Foot Exam 8.Labs Reviewed 9.Assessment 10.Referrals 11.Plan 12. Education – discussed vs handouts 13. Goal for next visit 14. Billing Codes 39

40. Process for Creating & Implementing First draft developed by Diabetes Care Task Force Clinician revisions solicited by memo and in person 2 week pilot test with further revisions Nursing staff trained to include form on chart for all diabetes visits 40

41. Measured Variables 1.Code specific 2.Educational activity 3.Lab results reviewed 4.Complete foot exam 5.Monofilament 6.Goal written for next visit 7.Referrals discussed 41

42. Form Users Documented Foot Exams & Monofilament Test More (p <.001) 42

43. Form Users Documented Goals & Education More (p <.0001) 43

44. Form Users Documented Review of Labs More (p <.001) 44

45. Coding done equally by both groups (p >.05) 45

46. Faculty 2005 N = 178 46

47. MAKE IT EASY TO DO THE RIGHT THING ! A diabetic visit requires caregiver to address & document ~ 30 items –depression (the patient’s) and human error make the task overwhelming –form cues the needed information collection –form makes excellent documentation easy –form does not duplicate items from existing diabetic flow sheet New DM progress note made it easy to ask, assess, refer, plan, and assign ICD-9 codes while documenting care during visit as well as help patient and clinician set goal(s) 47

48. Difficulties We Addressed After the Study Form placed on “wrong chart” –Diabetic patient who was here to discuss other issues –Stated reason for visit and final agenda often were not the same –When should the form be used? 48

49. Some physicians resisted participation 49

50. KEY INTERVENTIONS Regular group, team and physician-specific data feedback Recognition of top teams and individuals 50

51. Other useful things Physician participation with designing and implementing interventions Faculty seminar sessions on population-based care and systems process improvement Strong support by clinic medical director and department chair 51

52. Progress maintained in Faculty Clinic 52

53. Residency Clinic 53

54. Refined Vision/New Culture By working as a team and improving processes, we learned we could deliver higher quality care than we could working alone. Group pride--We are doing something which no other clinic on campus is doing 54

55. Lessons Learned 1.Too much planning from the top results in uneven clinician and staff buy-in 2.Involve front-line clinicians and staff in planning and implementation 3.Clinicians are unlikely to change behavior without data they trust 4.The clinicians can’t do this alone 5.Improvements don’t last without regular measurement and feedback 6.We really needed disease registry software 7.Don’t cut travel and meeting budget 55

56. What we learned that works Have a shared vision Involve clinicians & staff Deliver care with teams Physician-specific data that matters 56

57. Postscript 2 nd collaborative with CAFP DocSite disease registry software Collecting NCQA data EMR implementation in progress 57

58. 58

59. Contact Information John Testerman, MD, Ph.D. Chair, Dept. Family Medicine jtesterman@llu.edu 909-558-6505 Linda Deppe, DO Clinic Director Ldeppe@llu.edu 909 558-6505 Cynthia Glasgow, FNP-C Nurse Practitioner/QI Coordinator Cjglasgow@llu.edu 909 558-6505