1. Greg Maeder, MD, MBA Rebecca Peterson, MA Lead St Anthony Family Medicine Residency. Westminster, CO

2. St Anthony model for training resident leaders How QI teams fit in the model How QI topics are selected

3. 100 hours/1 month dedicated to health systems management experiences This curriculum should prepare residents to be active participants and leaders in their practices, their communities, and the profession of medicine. Each resident should be a member of a health system or professional group committee.

4. 100 hours/1 month dedicated to health systems management experiences Residents must receive regular reports of individual and practice productivity, financial performance, and clinical quality, as well as the training needed to analyze these reports. Residents must attend regular FMP business meetings with staff and faculty members to discuss practice-related policies and procedures, business and service goals, and practice efficiency and quality.

5. Residents should complete 2 scholarly activities At least 1 of which should be a quality improvement project

6. First Year-Participant -Become familiar with process/tools Second Year-Project Leader -Facilitate meetings/projects -Lead QI team Third Year-Manager/Supervisor -Population management -Lead Pods

8. Purpose of QI teams History of our PCMH journey Job roles Review of available tools/resources Expectations Yearly Timeline (deadlines) Mock QI meeting Choose QI project Vague idea Other residents/staff sign up

9. Selecting a successful project “Small bites” Realistic Measurable Meaningful

11. Quality Improvement Teams 2 nd Year Resident leader 6-9 members All faculty and residents involved Staff optional Meet twice monthly

12. July – Open enrollment, select projects Aug-Dec – PDSA cycles, SOP development Jan – final data analysis Feb – poster production March – research forum April-June – training/implementation

13. AIM: To improve care of patients with Diabetes Mellitus at the SANFM by ensuring performance of annual foot exams, with a specific goal of >80% of patients having one completed within the previous 1 year. INTENT: Completion of foot exams is a small but measurable change that can increase referrals to Podiatry when needed, or pursuit of medical management for neuropathy. The ultimate goal of this change is to improve patient care, efficiency in performance of foot exams, and patient satisfaction. Aim Statement Changes Being Implemented Implemented Next Steps Lessons Learned Data Improving Care for Diabetics Through Improved Screening for Peripheral Neuropathy Team Members ST. ANTHONY NORTH HOSPITAL 3.20.14 PILOT #1: Specific roles and procedures were outlined for monofilament foot exams. The clinic is divided into “Pods” of different colors. The Orange Pod providers served as the test group, while the remainder of the clinic served as the control group. Specific roles included the provider identifying patients due for foot exams at the time of huddle, MAs asking the patient to remove their shoes and socks and placing a monofilament on the counter as a visual reminder to the provider, and the provider performing and documenting the foot exam appropriately in the EMR. The foot exam was to be completed regardless of the reason for the patient visit. PILOT #2: During the second study the standardization of the process was expanded to the entire clinic. Diabetic flow sheets were delivered to the providers with the patient’s face sheet instead of being delivered directly to the MAs. MAs were asked to have all patients with diabetes remove their shoes whether they were known to be due for a foot exam or not. In both studies the primary outcome measure was the percentage of patients due for foot exams who received them and had them documented appropriately. In the second pilot the reason for the visit was also tracked, as represented by the lines on the second graph. PILOT #1: Overall the Orange Pod performed better than the clinic as a whole, however since all MAs had to be trained, there was likely bleed-over into the remainder of the clinic. The team worked with providers to identify common reasons for missed foot exams such as it being an ER or acute care visit, or a new patient. It was also apparent that the Diabetic flow sheets were not always reaching providers. PILOT #2: The data shows that compliance dropped off after the first week, possibly as momentum dropped. Additionally, a change in Diabetic flow sheet distribution from the front desk back to the MA’s, which led to a lapse in flow sheets reaching providers. Lastly, acute follow-up visits were found to be the greatest source of missed exams. RECOMMENDATIONS: -Improve identification of diabetic patients even when scheduling for other medical issues, possibly through collaboration with schedulers -Continue outreach through case management for scheduling of diabetes-focused visits - Improve clinic-wide communication such that the efforts of our team build upon current and evolving processes. Staff Team Lead: Janette Neel, MSRD, CDE Resident Team Leads: Eleanor Price, DO; Christina Zarza, MD Staff: Beverly Gallegos, RMA; Cecelia Valdez; Daisy Tarango, Martha Kalin Residents: Brian Baker, DO; Mara Motley, MD; Stephanie Chiu, MD Faculty: Laura Strickland, MD; Jessica Devitt, MD

15. “Small bites” Effective, sustainable, realistic Rapid PDSA cycles (every 2-4 wks) Small scale pilots Delegation Shared accountability Simplify tools Define job roles Keep staff and residents motivated

16. “The single biggest problem in is the illusion that it has taken place.” George Bernard Shaw

17. Steering committee – Meets twice monthly QI teams each report monthly Feedback Communication

19. Projects that are too large Too much time spent on Plan + Do Not enough time on Study + Act

21. Support/Back-up for QI Fill in as meeting facilitator Mentor PGYII Team member Pod Leader Multidisciplinary team Population management Meet quality metrics from health organization