1. Chronic Disease Management
Learning Session 1
Chronic Disease Management

2. Session Opening

3. Faculty/Presenter Disclosure
Speaker’s Name: Speaker’s Name
Relationships with commercial interests:
Grants/Research Support: PharmaCorp ABC
Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd
Consulting Fees: MedX Group Inc.
Other: Employee of XYZ Hospital Group
Please fill out all applicable areas (highlighted in red). One slide per speaker.

4. Disclosure of Commercial Support
This program has received financial support from [organization name] in the form
of [describe support here – e.g. educational grant].
This program has received in-kind support from [organization name] in the form
of [describe the support here – e.g. logistical support].
Potential for conflict(s) of interest:
[Speaker/Faculty name] has received [payment/funding, etc.] from
[organization supporting this program AND/OR organization whose product(s) are
being discussed in this program].
[Supporting organization name] [developed/licenses/distributes/benefits from
the sale of, etc.] a product that will be discussed in this program: [enter generic
and brand name here].
Please fill out all applicable areas (highlighted in red).

5. Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been
mitigated].
Refer to the College of Family Physicians of Canada’s “Quick Tips” document.
Please fill out all applicable areas (highlighted in red).
Please visit the following link for the CFPC’s “Quick Tips” document:

6. Agenda Welcome and Introductions 15 minutes Gap in Care 10 minutes
Patient experience minutes
Approach to chronic care (including GP experience) 10 minutes
Application of the Chronic Care Model minutes
Developing Registry minutes
Break minutes
Breakout: minutes
FP: Decision Support (including short CME?) Recall overview
MOA: Brief Decision Support and Detailed Recall
Action planning and PSP support minutes for practices
chronic care appraoch: Concept of planned, role of the patient registry, and proactive recall

7. Housekeeping
Please put your cells on vibrate or turn them off. Washrooms are here and there. We know emergencies sometimes come up so please feel free to leave the room if you need to take a call
We’ll be taking a 15 min coffee break at _____ and then there will be ______ when we finish at ______
In your bags, you have everything you’ll need today. We are making space for discussion throughout. You can write questions on sticky notes on your table before the coffee break, and we’ll find time to answer them. There are also flags you can use to mark any page you want to refer back to

8. Welcome and Introductions

9. Where You are Now  Where You Would Like to Be
What are your challenges or frustrations supporting patients with Type 2 diabetes?
How do you currently support these patients & how is this working?
What are you hoping to get out of the CDM module focusing on diabetes –Type 2?
table discussion- where you are now, where you would like to get to
We want to take a few mins to get an idea of where you are now and where you would like to be by the end of the module
Discuss and elect one person to report back
7.5 mins & please elect someone to report out to the larger group
I summarize
Sounds like there are a lot of frustrations. Hopefully implementing what you learn will result in a more rewarding experience for both you and your patients.

10. Ground Rules Respect all ideas and opinions Share experiences
On time back from break

11. Gap in Care

12. Death is inevitable, but a life of protracted ill-heath is not.”
“Most chronic diseases do not result in sudden death. Rather they are likely to cause people to become progressively ill and debilitated, especially if their illness is not managed correctly.
Death is inevitable, but a life of protracted ill-heath is not.”
Everyone has to die of something
“Most chronic diseases do not result in sudden death. Rather they are likely to cause people to become progressively ill and debilitated, especially if their illness is not managed correctly.
Death is inevitable, but a life of protracted ill-heath is not.”
Reference: Preventing Chronic Disease: WHO Global report 2005
Source: Preventing Chronic Disease: a vital investment: WHO Global Report. World Health Organization 2005.

13. Patients with Chronic Diseases in BC 2010/11
Major issues for seniors
This show the numbers of patients in the province with specific chronic conditions, the major conditions that cause a decrease in the quality of life are:
Osteoarthritis
Diabetes
Asthma
COPD and
Heart Failure
Source: BC PHC disease registers based on fiscal year 2010/11.
Source: BC Ministry of Health, Primary Health Care Disease Registers, 2010/11

14. One in Three British Columbians has one or More Chronic Conditions
Of even more significance is that many people in BC have more than one chronic conditions
Source: Medical Services Plan (MSP) and Discharge Abstract Database (DAD) data, 2010/11

15. Care Gap for Chronic Conditions
10.5
45.4
48.6 58
64.7 68 73
75.7 25 50 75
100
Alcohol Dependence
Diabetes Mellitus
Hyperlipidemia
COPD
Hypertension
Coronary Artery
Disease
Prenatal Care
Breast Cancer
Looking at evidence based care, this graph shows the percent of recommended care being received by patients with specific chronic conditions.
Questions to ask the audience:
How might this reflect in your practice?
Should we be aiming for 100%?
% of Recommended Care Received

16. Diabetes Patients Receiving Guideline-Based Case
The Ministry is committed to providing performance information related to primary health care indicators to support continuous quality improvement in the delivery of evidence based care for patients. British Columbia has established a number of guidelines and protocols for the delivery of evidence based care for patients with chronic conditions which can be seen at: Clinical Practice Guidelines and Protocols in British Columbia.
BC's guideline and protocol for diabetes recommends that patients with diabetes receive two A1C tests per year. Reporting on the percentage of diabetes patients receiving two A1C tests per year is used as a proxy measure for the complete suite of items outlined in the guideline and protocol.
Questions to the audience
How does this compare to your practice?
What might affect whether or not you meet this target for an individual patient?
May 28, 2012
B.C. Home » Ministry of Health » Primary Health Care » PHC Resources » Performance Reporting
Ministry of Health
Performance Reporting

17. “Every system is perfectly designed to produce the results it gets.”
Dr. Donald Berwick, CEO Institute for Healthcare Improvement
Key Points
1. In the past, deficiencies were attributed to bad physicians who just didn’t do the right thing. The emphasis needs to be on the system and the care it delivers.
2. The literature hasn’t been organized in such a way that makes it easy to understand what health care providers were doing and how they were doing it to achieve better results.
We need to read the literature and look at who was on the team, what they did, how they interacted with each other and the patient, what visit intervals were like, etc.
Clinical trials are more than just one drug vs. another. They create a system of regular, routine care and follow-up, with standardized assessments.
3. Research is primarily condition-specific because of funding sources.
We need to be able to provide care in a framework that is similar no matter if the patient has asthma, depression or multiple sclerosis.
We need to do this for our own sanity and for our patient’s who can’t be expected to deal with a system where they have 5 case managers, 7 providers and charts in every one of those places.

18. Module Aim

19. Aim Statement
To improve the care for patients living with chronic disease through targeted strategies in the GP office, as evidenced by:
A1C - Process: every 6 months; Outcome: <7.0%
Lipids (LDL) – Process: every 6 months; Outcome: F:….; M:….
BP – Process: every 6 months; Outcome: < 130/80
Foot exam – Process: every 12 months
Eye exam- Process: every 12 months
Self-management goals: - Process: documented
And possible ACR – Process: every 15 months; Outcome: F:….; M:….
In the past, and in several jurisdictions in the world, incentives are in place for physicians who reach certain targets in the care of patients with conditions like diabetes
Questions to the audience:
Describe how setting targets for patient chronic disease indicators, like Hgb A1c, lipids, etc., would or would not be useful in your practice?
How could you make use of measurement when following patients with chronic conditions?
Facilitator notes:
This can open a discussion of process vs outcome measures and surrogate measures.
These were targets that have been in place in the past as related to the care of patients with diabetes.
Question to the audience:
What do you think of these targets for diabetic patients?

20. We will accomplish this by focusing on the following areas:
Development of patients registries – practice population approach
Building follow-up processes in GP practice
Implementation of relevant GPAC guidelines (e.g. Diabetes) for care
Developing processes to ensure all relevant information and tests are ready for each patient visit
Expanding the role of the MOA in CDM care
Supporting self-management with CDM patients
Planned proactive care – NOT reactive, episodic care

21. Patient Experience

22. Approach to Chronic Care (Including Family Physician Experience)

23. The Approach

24. The CDM Approach Population health approach
Target multiple patients with same chronic conditions
Planned proactive care
Uses clinical practice guidelines and protocols
Patients become active in own care

25. Benefits for Patients
Experience proactive care rather than reactive care
Patients who need follow-up will get it
Continuity of care
Improved patient outcomes and quality of life
Improved patient experience
Fewer and shorter hospital stays

26. Benefits for GP Care is proactive, not reactive
Better use of time and resources
Guidelines provide ‘template’ for improved patient care
Improved management of complex care patients
Increased quality of life (work & personal)
Increased practice revenue

27. Commitment and Expectation
Heavier lifting upfront
Expansion of the MOA role and interdisciplinary care
Learning sessions & action period changes
Conference calls
On-going support from RST
Willingness to make changes

28. It’s all worth it! % of CHF Patients on Appropriate Meds 93% 0% 20%
40%
60%
80%
100%
Jun-03
Jul-03
Aug-03
Sep-03
Oct-03
Nov-03
Dec-03
Jan-04
Feb-04
Mar-04
Apr-04
May-04
% of CHF Patients on Appropriate Meds %
Goal
Provincial CHF Collaborative

29. Application of Chronic Care Model

30. 1.Developing your registry

31. The Patient Registry
A list of all patients with a chronic disease (e.g. Diabetes)
Patient’s progress is tracked using the EMR or on flow sheets if on paper charts
Use of the EMR or flow sheets facilitates implementation of planned recall process

32. Identify Eligible Patients
Billing review
Paper chart review
EMR
Physician Profile Analysis Report
Lab result report
Look for all patients for whom:
The chronic condition has been billed but not coded in the problem list
All patients who fit criteria for the diagnosis of the condition:
HTN:
2 manual BP readings at separate visits greater than140/90
2 automated BP readings at separate visits greater than 135/85
Diabetes:
Diabetes can be diagnosed using any of the following criteria:
FPG§ of ≥ 7.0 mmol/L. 
A1C¶ of ≥ 6.5%.12 See notes for contraindications.
2hPG of ≥ 11.1 mmol/L in a 75g OGTT.
In a patient with classic symptoms of hyperglycemia (e.g., polyuria, polydipsia, and unexplained weight loss), a random plasma glucose (PG) ≥ 11.1 mmol/L.**
In the absence of symptomatic hyperglycemia, if a single lab test is in diabetes range, a repeat confirmatory test (preferably the same test) must be done another day (in a timely fashion).
In case of symptomatic hyperglycemia, a repeat test is not required. Diagnosis is confirmed.
In individuals who are suspected of type 1 diabetes, confirmatory testing should not delay treatment.
If the results of two different tests are both above diagnostic cutpoints, the diagnosis is confirmed
Heart Failure
Measurement of LVEF less than 40% in reduced-EJ Heart Failure
COPD
post-bronchodilator spirometry measurement indicates that there is airflow limitation which is not fully reversible (FEV1 / FVC ratio < 0.7 or FEV1 / FVC < lower limit of normal values).

33. Physician Profile Analysis
Secure and confidential report
Practice demographics
Complexity of patient population
Identifies potential gaps in care
Comparison to BC patients as a whole
Highlights your chronic disease patients
Mini-practice profile can be obtained from MSP. All physicians should be receiving this yearly. It gives a high level view of the patients that are identified as having one physician as their primary provider.
Information on billings, referrals, imaging and lab requests on these patients is aggregated and presented in a report form for the physician to peruse. It provides information as noted on this slide.
Since most of the MSP information arises directly from the MSP billings that physicians (specialists and FPs), laboratories, facilities and imaging sites generate related to the patient, this information also relies on the associated diagnostic coding associated with any one billing.
As we all know, diagnostic coding associated with billing can often be inexact, resulting in associations that don’t tell the whole story about patient complexity nor are they completely inclusive about all medical issues.

34. Physician Profile Analysis
This graph shows the distribution of patients in a panel based on age and gender in one practice: This is a demographic breakdown of the patients who had at least one visit during this time period. The population tree describes the age distribution of patients visiting a physician practice and compares this to the averages across all GPs in BC.
This is information that can come from the practice mini-profile, from the EMR’s own reporting feature or dashboard, or can come from the Health Data Coalition dashboard for a practice.

35. Physician Profile Analysis
Patient Complexity analysis
The Adjusted Clinical Grouping (ACG) software from Johns Hopkins University categorises patients based primarily on the level of comorbidity indicated by clinical diagnoses. Diagnoses from both MSP claims and hospital records were included as input to the ACG software. To make the number of categories more manageable for reporting, they can be grouped together into a smaller set of levels called Resource Utilisation Bands (RUBs). Individuals within a RUB are expected to require a similar amount of healthcare resources. More information about ACGs can be found at the Johns Hopkins website: <
This information is not available from the individual EMR reports, nor from the HDC dashboard but other reports on patient panel complexity, including the presence of co-morbidities and frailty are available IF the physician’s practice is to record information in discrete data fields (not typing everything in a text box like in a word processor) and the physician is coding problems appropriately in his/her patient’s problem list.

36. Physician Profile Analysis
Performance Figures for Diabetes and Heart Failure:
The table shows the number of a physician’s patients who have been diagnosed with Diabetes, CHF, or Hypertension. Performance percentages are shown for patients with Diabetes and CHF, based on proxy measures for the delivery of recommended care. The receipt of 2 or more A1C tests within the year is used as a proxy measure for recommended care of each patient with diabetes. The presence of an ACE or ARB is used as a proxy measure for recommended care of each patient with CHF.
This information is also available from individual EMR reports or dashboards (depending on the EMR) and is available from the HDC dashboard.

37. Physician Profile Analysis
The table shows the performance details for each patient in the practice who has been diagnosed with Diabetes, CHF, and/or Hypertension. The table is further restricted to include only patients who have met the rules for Majority Source of Care (MSOC) with the
practice. MSOC patients received the majority of their GP services from the practice. Only patients with three or more GP services (over all GPs) can meet the MSOC rule.
As for the summary information on the previous page, the receipt of 2 or more A1C tests within the year is used as a proxy measure for recommended care of patients with diabetes, and the presence of an ACE or ARB is used as a proxy measure for recommended care of patients
with CHF.
FACILITATOR: Use this slide to lead a small table discussion of the pros and cons of using these kinds of indicators as proxies for a patient’s chronic disease management:
Write list of pros and cons for 2 minutes in silence by yourself
Share list for one minute each with a partner in diads
Partners present a summary of ideas to the table
Facilitators collect summaries for collation and sharing after this learning session or at the next learning session.

38. Collecting and Entering Baseline Data: Sources
Database (search function of EMR)
Billing analysis
Chart review
Benefits of proper problem list coding and discrete data entry.
Why develop registries (panels) of patients with common conditions?
Knowing things about a group of patients has value in several contexts.
1. Knowing and uniquely identifying a group of patients by a problem or attribute allows a practice to look at this population of people as a percentage of their total practice. This gives the practice what the prevalence is of this condition in the practice and, given that the practice has a demographic similar to comparative provincial demographics, the ability to compare whether the condition is being identified and patients labelled appropriately. This is a check for data quality in that it shows whether there is a variation from what would reasonably be expected to be found in that practice. (e.g. Practices should have about 8% of their patients labelled as diabetics, practices significantly higher or lower than this may indicate a unique aspect of the practice population that should be explored or it may indicate that too many patients are inappropriately being labelled diabetics or that the diagnosis of diabetes in the practice is being missed and more screening done)
2. Given that a practice now appropriately identifies their patients as having a condition or attribute, this can be used as the denominator in assessing the care by using either process or outcome indicators as the numerator (e.g. number of diabetic patients who have a current A1c done in the last 6 months)
3. One step farther, should the practice be interested in quality improvement by making practice changes, by having the panel (registry) of patients, they can follow this identified panel over time. They can follow a process or outcome measure as the numerator, with the specific registry as the denominator and follow a run time graph over time to watch change and get feedback on the effect of any interventions.
4. Having a registry (or panel) allows tracking of CDM billing as it looks for coded profile items (COPD, HF, HTN and DM), for those specific conditions
5. Having a registry allows office workflow, such as sending a task to request an action on a panel of patients, all identified in that registry (all patients with chronic pain on opioids, etc.)
6. Generic care plans can be assigned to a panel or registry of patients, e.g. all patients eligible for end of life care can have the PSP EoL tasks assigned to their charts.

39. Collecting and Entering Baseline Data: Baseline Data
Include most recent data from the previous 12 months of care
If the most recent measure is earlier than 12 months, leave it blank
If no data available that fits the criteria for a specific measure, leave it blank

40. EMR Content for registry
The various methods of running reports or dashboards to identify patients with specific disease conditions varies between EMRs.
Contact PSP Central for the access to Dashboards or information on running reports for a specific EMR.

41. Break… 41

42. MOA Breakout: Decision support and recall

43. MOA’s on the move video MOAs on the Move video:

44.
The main chronic diseases, such as hypertension, diabetes, heart failure, COPD, and depression, all have provincial guidelines available at the BC Guidelines website:
These guidelines provide evidence-based best recommendations for care of patients with a condition, recognizing that care must be individualized to each patient. The guidelines also provide tools for screening, diagnosis, patient education, workflow recommendations and resources.

45. Recall Process Define tasks Define roles and responsibilities Doctor
MOA and other team members
Patient
Map out the process to ensure a smooth work flow process

46. Map Out the Process
A process map is a planning and management tool that visually describes the flow of work. Process maps show a series of events that produce an end result. A process map is also called a flowchart, process flowchart, process chart, functional process chart, functional flowchart, process model, workflow diagram, business flow diagram or process flow diagram. It shows who and what is involved in a process and can be used in any business or organization and can reveal areas where a process should be improved.
Purpose of process mapping
The purpose of process mapping is for organizations and businesses to improve efficiency. Process maps provide insight into a process, help teams brainstorm ideas for process improvement, increase communication and provide process documentation. Process mapping will identify bottlenecks, repetition and delays. They help to define process boundaries, process ownership, process responsibilities and effectiveness measures or process metrics.
Understanding processes
One of the purposes of process mapping is to gain better understanding of a process. The flowchart below is a good example of using process mapping to understand and improve a process. In this chart, the process is making pasta. Even though this is a very simplified process map example, many parts of business use similar diagrams to understand processes and improve process efficiency, such as operations, finance, supply chain, sales, marketing and accounting.

47. Using the EMR for Patient Recall
Each EMR has a different User Interface and process for recalling patients.
Two powerful tools are useful when working to improve longitudinal care for patients living with chronic conditions: patient registries and an automated recall system. 
The two components complement each other to create improvements in care at the same time as streamlining administration. Patient registries track patient outcomes related to changes in care and help you monitor how treatment aligns with clinical guidelines. Automated patient recall ensures chronic patients are seen when they need to be and simplifies arrangements for lab tests, specialist referrals and patient education sessions. Together, these tools can increase your comfort in supporting chronic disease patients while also improving clinical outcomes and care processes.
Use the appropriate EMR recall process outlines with the audience

48. Physician Breakout: Decision-support and recall (Including short CME)

49.
BC Guidelines are clinical practice guidelines and protocols that provide recommendations to B.C. practitioners on delivering high quality, appropriate care to patients with specific clinical conditions or diseases. These “Made in BC” clinical practice guidelines are developed by the Guidelines and Protocol Advisory Committee (GPAC), an advisory committee to the Medical Services Commission. The primary audience for BC Guidelines is BC physicians, nurse practitioners, and medical students. However, other audiences such as health educators, health authorities, allied health organizations, pharmacists, and nurses may also find them to be a useful resource.

50. CME content to be delivered by specialist (Optional)
to be created by local specialist
Optional if Specialist providing subject matter expertise on a specific condition for focus at this Learning Session

51. Diabetes Key Indicators
A1C – Process: every 6 months; Outcome: <7.0%
Lipids (LDL) – Process: every 6 months; Outcome: F:….; M:….
BP – Process: every 6 months; Outcome: < 130/80
Foot exam – Process: every 12 months
Eye exam – Process: every 12 months
Self-management goals: - Process: documented
And possible ACR – Process: every 15 months; Outcome: F:….; M:….
% of patients living with diabetes who have an A1C <7
% of patients living with diabetes who have a Systolic BP ≤ 130
Percentage of patients living with diabetes who have A1C levels checked at least 2 times/yr.
Percentage of patients living with diabetes who have had their blood pressure checked at least once in the past 6 months.
The percentage of patients living with diabetes who have had their ACR checked once in the past year.
% patients with the specified disease that have documented self management goals.

52. Work Flow In your team you will need to discuss:
Who will update patient flow sheets and when
Who will enter new data and when (ex. Lab results)
Who will maintain the registry i.e. inputting data, adding and removing patients

53. 3. Putting recall into place

54. Recall Process Define tasks Define roles and responsibilities Doctor
MOA and other team members
Patient
Map out the process to ensure a smooth work flow process

55. Map Out the Process

56. Activity Instructions
Define steps in recall process
Define timelines
Month prior
Within 24 hours of visit
During visit
After visit
Include roles and responsibilities
You have 25 minutes for this activity
Create a recall process for one or more panels of patients with chronic condition(s)

57. Team Involvement “ People will support what they helped to create.”
Donald Kirkpatrick

58. Team Roles
In your teams, discuss some roles for providing best possible care, such as:
Completing in clinic tests as required (A1C, foot exams, Spirometry, ect)
Coaching patients on medications and tests required
Following up on self management goals
Others?

59. Planning for Action (30 minutes)

60. Model for Improvement: 3 Fundamental questions
Aims
Measures
Change ideas
The Model for Improvement contains three questions that any successful improvement effort must address. These questions come from years of research into what will help improvement projects be successful.
1. The first question “What are we trying to accomplish?” is about creating an aim statement that focuses our improvement work. The aim statement should be measurable, specific, and should require taking the status quo off the table in order to achieve it.
2. The second question “How will we know that a change is an improvement?” requires that the team decide on how it will measure its progress in reaching the aim. For example: you don’t know whether your golf game is improving unless you keep track of the number of strokes per round.
3. The last question, “What changes can we make that will result in an improvement?” help us consider the set of changes that will lead toward improvement, toward the aim. We are not making change for the sake of change, we need to utilize a set of evidence-based changes that have been shown to be effective in improving the measures. A great place to start in selecting which changes you will try is the change package provided to you. In the change package you will find an outline of key changes that will help you reach your practice aims in End of Life care. 17

61. Practice aims: What are we trying to accomplish?

62. Focus Your Improvements
With your team, choose the specific goals you would like to achieve for your patients.
Focus on 1 or 2 areas to start and expand over time.

63. Practice Measures: How will you know a change in an improvement?

64. Moving forward … with measurement
“If it is not measured, it's not medicine.”
- Dr. Marshall Dahl
“Some is not a number, soon is not a time.”
- Dr. Don Berwick
“Without data, everyone is perfect.”
- Dr. Paul Murray
“Data drives improvement.”
- Dr. Neil Baker
“The pride in which you wallow, without data may be hollow.”
- Dr. Dan MacCarthy
Measures are often one of the hardest aspects of improvement for teams, but are essential not only to tell how your changes are leading to the outcomes you would like achieve, but also to show progress towards your goals.
Without measurement you will not know which improvements have reaped benefits over time nor how far you have come.
It’s usually not until after we have made a change and would like share with others that we realize how remiss we were not to measure from day 1. 64 64

65. Measurement The purpose of measurement is for learning not judgment
It is important to note that the purpose of measurement throughout PSP modules is not to compare and judge teams on their progress, but to learn how changes they are trying are contributing to their end goal, and to share with peers. Most of us are more familiar with measurement for judgement, and therefore it can be daunting to measure our progress on clinical measures and share with colleagues. You can rest assured that any measurement conducted during your improvement work, will be used for your own learning and development and that of your peers and not to judge your performance as a clinic or clinician.

66. Change Ideas – what changes can you make that will result in improvement?

67. Finding Changes CDM change package Team ideas Peer changes
Once you have set your aim, and chosen your measures you need to start testing changes.
In your change package you will find descriptions of the various changes you can try and the resources that support them. These changes are derived from best practice guidelines and are proven ideas that can improve patient care. The changes are written so that they can be applied to any clinic setting and will need to be contextualised to your practice setting.
Your team may also have some ideas from what they have heard on specific changes to try.
Another powerful source of ideas will be your peers in the module.

68. Example: Registry What is it? A list A database What is it used for?
Tracking progress
Proactive recall
What types are there?
Paper list
Excel spreadsheet
Binder
Flagged chart
EMR based
Today you heard mention of a patient registry which is a tracking system of patients with common health concerns. Having these types of registries is a good way of keeping the elements of a health condition in check.
They have been commonly used for chronic conditions such as diabetes or hypertension. With a Registry, at a glance you can make sure blood work is done, that the patient has been seen, meds are up to date etc.
A registry can be kept to manage the care of patients at the end of their life as well possibly in a checklist format or visit by visit format etc. It can also contain important information about the patient regarding family contact information and phone numbers of other specialties or services that the patient is accessing. You have probably started thinking of names of people who fit the Surprise question. Naturally what do you do….. Start a list. A list is a good first step toward creating a registry. It is with this list that you start thinking about the things that you would like to monitor with your End of life patients.
It can be kept in many ways such as a paper list, an excel spread sheet, a binder or a flagged chart or tailored somehow in an EMR for specific identification.
Have a conversation about what you would like your registry to look like, and also discuss how you are going to start picking patients and once you do pick patients, what do you do with the people that you picked?
Talk to your PSP coordinators about ways that they can help you get started and support your implementation of the module

69. Testing changes: What will you start when you get home?
Once you have chosen where you would like to focus first, you will need to start testing these changes.

70. All patients receiving guideline based care!
Just try it!
All patients receiving guideline based care!
Cycle 3 A P S D
DATA
Cycle 2 A P S D
Cycle 3: Test the use of the CDM flow sheet with every patient for 1 week. Does you office process support this? What changes are needed?
Cycle 1 A P S D
Cycle 2: Test the use of the CDM flow sheet with 3 more patients. Did your adjustments work? Can you do this at scale?
Often when we want to change something we do not test the changes at all, we just implement.
Improvement work involves testing the changes you would like to try on a small scale and learning from what went well and what didn’t
When you are starting to test changes it is important to note that cycles build on each other to reach the goal you have set.
This is a good example of how to test the use of screening tools for pain.
Start with 1 patient and build as you learn.
Use of Flowsheets
Cycle 1: Test the use of the CDM flow sheet with 1 patient during an upcoming office visit, how did it work with the length and flow of the visit? Do you need to make adjustments?

71. Where to start: What changes can we make that will result in an improvement?
What are you going to do next Tuesday?
What is the plan?
Remember to think about how you will measure/track improvement.
Record on Action Plan and report back in 15 min.
Break out into your assigned groups. Begin to plan what changes you try. Refer to PDSA template:
Aim – be specific
Measures
3) Plan test of change – Who? what? when? and how?
Plan
Question(s) to answer  
Plan to carry out the test of change (who, what, when, where) 
Plan for measurement (who, what, when, where) 
Predictions – What do you think will happen? (why) Do
Carry out the plan 
Keep track of what worked and what didn’t 
Begin analysis of the data
Study
Complete the analysis of the data 
Compare data to what you predicted would happen 
Summarize what was learned
Act
What changes are to be made? Adopt, adapt, or abandon the change? 
Plan for your next test of change (next PDSA cycle) 
Some things to think about as you are planning: Remember Who? What? When? And How?
Specific areas to consider are:
Identifying patients early : Registry development
Identifying and collaborating with local team members
Initial discussions with 3-5 patient around end of life
Expanding the MOA role in screening
Identifying community resources
Referral to specialty or community resource
Have teams report back in 15 min
Pick one person from each table to report out Coordinator documents each team's PDSA on a flip chart or action plan
Your coordinator will support you throughout the Action Period

72. Action Period Expectations
Try tests of change.
Measure and track your progress.
RSTs practice visits.
Support throughout the action period you can expect:
Practice visits from the coordinator.
During your discussion, outline how the action plan, data tracking sheet, and PDSA cycle template.
Identify patients early : Registry development
Identifying and collaborating with local team members
Initial discussion with 3-5 patient around end of life
Expand the MOA role in screening
Identify community resources
Referral to specialty or community resource 72

73. Action Plan – Team Activity
Create your action plan with your practice team (e.g. each physician and MOA)
Who … is going to do the task
What … define specific tasks, in detail
When… time required for task
How … after hours, on weekends, etc.
You have 20 minutes for this activity

74. Next Learning Session Date
Please make a note of the date of the next learning session – evening session, same format to be expected.
Thanks to the physician facilitators for their leadership in this module.
Again, we at PSP are here to support you and coach you each step of the way.

75. Practice Support Program
For more information
Practice Support Program
West Broadway
Vancouver, BC V6J 5A4
Tel: