1. University of Missouri
Team:
Jim Acton, MD Julie Mullen (CF Parent)
Connie Fenton, RN Kecia Nelson, MSW, LCSW
Natalie Harris, BHS, RRT Harjyot Sohal, MD
Hannah Holzum, RD, LD Danielle Staudenmyer, RD, LD
David Isaacs (CF Patient) Grace Sullivan (CF Parent)
Erin Jackson, Adm. Asst. Bob Zanni, MD (Coach)

2. 5Ps Summary PURPOSE PATIENTS PROCESS Process PATTERNS PROFESSIONALS
To be the best at preparing patients and families for and ushering them through a positive and seamless transition and transfer of their care from the Pediatric CF program into the Adult CF program at the University of Missouri.
PATIENTS
Process
PROCESS
PATTERNS
PROFESSIONALS
Peds and Adult core CF teams
Administrative assistants
Others
Inpatient support teams
Outpatient support teams
Consulting services
Reacted to pts approaching or passing 21 yo or other events/complications
Highly variable and inconsistent
Not organized or planned
Little if any coordination between peds and adult teams
Little if any organization to teaching and preparation before transition
No feedback from patients and families

3. Creation and Use of an Obeya Room

4. Theme of transition/transfer (and additional improvement themes)
We will create a transition process in which care will be seamless, comprehensive, standardized, and individualized; patients will be informed, activated, and engaged; healthcare teams will be prepared and proactive; patients, families, and care teams will be highly satisfied; and our center’s outcomes will be among the best reported anywhere.
Clinic Efficiency
We will improve the efficiency and effectiveness of CF clinic appointments to achieve shorter time in clinic for patients and families, optimize “facetime” and minimize “downtime” during appointments, optimize clinic efficiency for healthcare providers, and maximize satisfaction in the clinic process for patients, families, and healthcare providers.
Mental Health Screening

5. Change ideas and PDSA cycles with measures
Transition
Patient satisfaction surveys
Clinical summary form
Pre-transition clinic combined team meeting
Introduction “bundle” – letter, Adult team info packet, map, tour
Combined transition clinic
CF Rise assessment schedule (responsibility, knowledge)
Clinic Efficiency
Patient itinerary for clinic visits
Clinic roadmap
Clinic time study

6. SDSA and Playbooks
Guidelines for standard periodic CF Rise assessment of knowledge and skills – both before and after transition
Guidelines for standard education and coaching based on needs assessment
Transition tracker spreadsheet
CF Rise tracker spreadsheet

7. Dashboard to track measures over time

8. Examples and benefits of Effective Communication
Regularly scheduled team improvement meetings – both separate and combined
Scheduled quarterly combined team meetings to coordinate transition of patients
Increased use of meeting skills and tools – conversational skills, agendas, minutes, roles
Access to shared documents and calendar
Use of patient itinerary and roadmap in clinics
Structure for communicating before and during clinic
More effective – fewer missed care opportunities
More efficient – better use of time for everyone

9. Still some areas of concern, opportunities for improvement
Relational Coordination Survey impact on daily delivery of CF care services and improvement of processes
Baseline results showed us we had many areas of weakness = opportunities for improvement
Attention to communication was embedded in many of our change concepts (eg, use of communication skills, development of communication tools, consistent meetings)
Follow-up results show improvement in most areas, some very significant (eg w/ clinic staff and supervisors)
Still some areas of concern, opportunities for improvement

10. Patient/family engagement in improvement
Two parents and an adult patient/student
Appreciated the effort everyone makes to give the best care possible
Recognized the value in the team’s dynamics – unique strengths, respect for different opinions and perspectives
Improved their trust and working relationship w/ care team
Appreciate that their opinions are valued
Feel much more involved in their child’s care moving forward
Patients and families offer:
Enthusiasm, commitment, engagement, motivation
Unique experience and insight - the only “inside view”
Diverse skills and interests
Learnings
Having a “team” of parents and patients can help with challenges of other commitments and conflicts
Genuine transparency leads to trust and collaboration

11. General lessons learned
A standardized, step-wise program to acquire CF knowledge and skills → pts/families are better prepared and have better experience
Pts/families offer unique insight and energy to QI and we need to better facilitate their involvement
Technology can help bridge gaps when teams are geographically separated, but intermittently meeting in person is critical
Improving efficiency is important not only to decrease wasted time and resources but also to free up time for ongoing improvement efforts
Effective communication can have a significant impact on how a team performs and the results they get, so we must pay close attention and practice good communication skills and strategies

12. Improvement plan for April through October
Transition
Ensure the process changes are solidly embedded in our practice
Follow the transition process and assessment into the adult clinic
Monitor and refine our process and outcome measures
Identify focus and submit poster for NACFC
Clinic efficiency
Analyze preliminary time study data
Identify next change concepts, measures, and PDSA cycles to improve clinic process
Mental health screening
Map process and analyze needs