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

2. 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

3. 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

4. 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

5. 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

6. 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.

7. 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)

8. 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

9. And then came……. National Committee for Quality Assurance (NCQA) Patient –Centered Medical Home (PCMH) Recognition Survey

10. 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

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

12. 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

13. 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 (
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

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

15. 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

16. 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

17. 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

18. 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

19. 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

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

21. UK Office for Value & Innovation in Healthcare Delivery (OVIHD)
QI Training Resources
UK Office for Value & Innovation in Healthcare Delivery (OVIHD) (

22. QI Training Resources
Institutes for Healthcare Improvement Open School (

23. 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

24. 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:
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.

26. 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

27. 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

28. 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

29. Part IV MOC Credit
American Board of Family Medicine (ABFM) options:
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

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

31. 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

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