1. Nanette Brey Magnani, EdD, HIVQUAL US April 4, 2012
In+Care Campaign, Developing Process Diagrams, and Tests of Change/PDSAs
Nanette Brey Magnani, EdD, HIVQUAL US
April 4, 2012

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

3. Check-in and Next Steps
What can you do by our May 7th 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. 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. 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. Site Visits – week of May 7th
Near North – OA; 2-4

7. 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. 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. In+ Care Campaign Data Update March 15, 2012
11 Part C/D grantees are members of Greater Chicago QM Group
4 submitted data for February, 2012
2 registered, no data entry
5 not registered in database

10. Initial Data for 4 Submitting Programs: Validate Data – Is it accurate?
Gap in Care
Visit freq over two years
Newly enrolled in care
VL suppression
#1 CCHC
Patient total
15.7%
223
53%
218 ?
71%
267
#2 EFHS
1.62%
185
92.7%
151
87.5% 8
84%
#3 HB
18.6%
1590
58.5%
1538
59.8%
157
73.7%
1933
#4 Open Door 3%
361
Not submitted
83.3% 12
76%
423
16.12%
103,259 – 163 org
3.6% - 3, org
5.4%--11, org
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
*Nat’l -urban
Top 10%
Top 25%
ARC/W: gap: 3% new pts: 83% retention: 63% VL supp: 74%

11. February Data for 4 Submitting Programs MASSACHUSETTS – Part C
Gap in Care
Visit freq over two years
Newly enrolled in care
VL suppression #1
Patient total
10.3%
146
90%
146 (15 ?)
80.4%
163 #2 4%
270
89.5%
239
87.5% 8
94%
299 #3
14.7%
157 #4
10.9% 55
49.4% 77
100% 1
83% 71
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
*Nat’l –programs <500
Top 10%
Top 25%

12. 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.
Nanette 12

13. 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. 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. 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. Types of Processes in Health Care
Information flow
Patient flow
Material flow
Clinical practice
In health care organizations, we have different types of processes that impact the flow of day to day activities.
•We have patients who flow through the system. Patients arrive, wait, are treated, wait, get follow-up appointments, sometimes wait some more, and then leave.
•Equally important, we have information flow. Providers need up-to-date medical records. Case managers document new patients’ housing status. Clients need information about care and service options.
•Then we have the flow of materials. Does your facility have a perfect medical record retrieval rate? Think about distribution of medical supplies, cleaning products, trash removal…all of these are types of material flow that affect the quality of care.
•Clinical practice guidelines often are expressed as algorithms that show one step, followed by the next. Evidence-based clinical practice is also a process, one that involves a “flow” of process steps.
Flowcharts

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

18. 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
By drawing a picture of a process using a flowchart, a team can make sure it fully understands how the process really works as opposed to how people might think it works. Flowcharts help us to visualize processes so that they are easier to improve.
Building a flowchart:
• Provides a fast and efficient way to understand the process
• Identifies potential sources of problems and provides a clear frame of reference for pinpointing the part (or parts) of the process that requires change
Outlines the ideal process steps the quality improvement team tries to develop through their efforts
• Finally, it enables the quality improvement team to communicate graphically to others what they are doing and why

19. Creating a Process Diagram and Next Steps in Implementing PDSA
Agree on use and level of detail
Define starting and ending points
Document each step
Follow each branch to the end
Review and agree on the steps and diagram
Identify problem steps and list underlying causes next to the step
Discuss tests of change (interventions) to address key causes.
Develop a PDSA plan and implement.
Let’s take a look at the steps to create a flowchart:
Agree at the beginning what the flowchart should accomplish and the level of detail you will need to accomplish that goal.
Then, identify the first and last step of the process. This sounds easier than it is. It can be hard to clarify exactly where the process begins and ends, but it is critical that you set these boundaries at the beginning.
Then begin filling in the steps, from first to last. If you come to a decision point, a diamond, choose the most-often occurring path and continue it all the way to the end; then go back and complete the second branch. You’ll get terribly confused if you don’t.
When you’re done, review the chart: read it out loud to the group for accuracy and make sure everyone understands it.
If you uncover parts of the process that aren’t clear, don’t guess. Assign someone on the team to find out “what really happens,” gather additional input and report back.
Flowcharts

20. Most Commonly Used Process Diagrams/Flowchart Symbols
Activity/step
Connecting lines
Start, end
Decision
yes, no
Here are a few of the most commonly used flowchart symbols. The references at the end of this Tutorial provide you with sources for more symbols, if you want. But at first, keep your charts simple and rely on these.
A single rectangle denotes an activity, or a step in the process
The elongated oval shows the first and last steps in the process
A diamond indicates a decision. From the diamond, the process can go in different directions. A helpful hint is to use the diamond to indicate a question that can be answered with “yes” or “no.” If yes, then follow these steps. If no, then follow these steps. Diamonds are often clues that a re-work loop will follow.
The large “D” shaped symbol (think of it as an abbreviation of “delay”) shows that something or someone has to wait. Wait symbols are very helpful in flowcharts, because they indicate bottlenecks in a process.
Page connectors can be handy if your flowchart extends past one page.
Wait symbol
Flowcharts

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

23. DeD

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

25. 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 CBO
CM 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. 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. Overall Findings - 54 clients Start of the project – November 2011
- 60 clients on the list
- 25% no-shows
- 75% VL over 100
- 23% female/77% male
Current data March 2012
- 54 clients
- 13% no-shows
- 13% new clients
- 73% VL over 100
- 26% female/74%male
22 patient from November list remain on it in March
18%(4) no-shows/82%(18) VL over 100
32% 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).

29. 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. 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. 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. HIV Patient Alert System with Team In combination with pt goal setting and individualized care plans
Red Yellow Green

33. Lawndale Christian Health Center - Sonji

36. Take Your HIV Medicine On Time and Every Day
Educator name:

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

38. But HIV is a clever virus.
CD4-T
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).

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

40. 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.

41. 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. Team Management Tools

45. Lancaster General Hospital. Comprehensive Care Center.