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

2. 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

3. Challenges for MAPS MAPS overview Changing nature of office practice
Engaged, empowered staff
Effecting change across the network of 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

4. 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 R18HS 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

5. 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

6. 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

7. 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

8. 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”

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

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

19. 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

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