1. Improving Quality of Care
The Experience of Community Health Clinic Ole, Napa
Robert Moore, MD MPH
Medical Director

2. Community Health Clinic Ole: Vital Statistics
12,000 patients
32,000 encounters
5 physicians, 7 midlevel providers
55% Spanish speaking
70% Hispanic
60% with no regular health insurance
5 clinical sites

3. Five Clinic Sites in Napa County
Calistoga
St. Helena
Vintners Health Center
Hope Center
Napa Valley College
Community Health Clinic Olé is a free-standing not-for-profit clinic governed by a board of directors composed of members of the community. We have five sites in Napa County.

4. Management Focus: Controlling Costs versus Improving Quality
An example from the Government sector

5. Problems we set out to solve
Old model of “Quality Improvement” was assigning blame for problems that occur.
How do we improve quality of care while maintaining fiscal strength of the organization?

6. Quality Improvement At Clinic Ole—Solutions
Electronic Health Record
Staff Training
Disease Tracking
Re-engineering
Creating a Culture of Quality

7. Evolution in our Thinking about Quality Improvement—Stage I
The more data for quality improvement, the better our quality of care will be
Electronic Health Record
Data Mining

8. 2 Year experiment with EHR—Barriers and Obstacles
Extensive search process
Unable to justify full-functioning system (will explain later)
Tested a low-cost internet-based solution for two years
Product discontinued in 2002: back to paper
Effect of system on quality and efficiency

9. EHR Lessons Learned I
True cost of implementation is at least three times the cost of the software, hardware, consultants, and external labor expenses including setup of templates, training etc.
This is due to the hours needed by clinic staff to devote to the system to implement it.

10. EHR Lessons Learned II
Even in the long term, EHRs do not inherently improve productivity, compared to paper medical record. The net effect on efficiency depends on the net effect of a number of possible features of an EHR.

11. EHR features affecting efficiency
Paperless (no duplicate paper record)
Lab/Radiology/Hospital interface for results
Variety of data entry modalities
Order entry integration
Integrated electronic prescriptions
Well-designed templates
Computers used in exam rooms
Rapid sign-in with security
System reliability (little/no downtime)
Re-engineering other office processes

12. EHR Lessons Learned III
The long-term success of any system change in Community Health Centers is related to the ability of this change to positively affect the bottom line of the health center.
Critical for clinicians to understand this: must understand the business implications for any quality improvement process
Even the best EHR, by itself, usually decreases clinical productivity: how to compensate for this?

13. Lesson IV: How to Sustain EHR
Improved payer mix
If favorable payer mix (High income per patient), and demand for more services: may increase clinician hours
Increased clinical efficiency (patients per hour)
Sustained increase in grant/donation income

14. Evolution in our Thinking about Quality Improvement—Stage 2
Better education of providers and staff will improve quality
System of formalized in-person trainings
Ongoing -based dissemination of clinical education
Barriers/Obstacles and How Overcome:
Shortage of Trainer time
Hesitation to take practitioners away from patient care time.
Quantity of medical knowledge needed to stay current

15. Evolution in our Thinking about Quality Improvement—Stage 3
Chronic disease tracking will improve our quality of care across a broad range of clinical conditions

16. Lessons Learned V
If the purpose of the Electronic Health Record is to improve quality of care, start by focusing on quality, rather than focusing on the Technology Solution.
Poor business case for EHR at Clinic Ole
Poor chronic disease tracking of most EHR systems, anyway
Focus on biggest quality needs (based on individual business cases for these needs); look for system to meet these needs

17. MediTracks implementation process
Choose processes to track
Use internal “experts” to define the current/ideal process in detail (flowchart helpful)
Create the MediTracks tracking infrastructure
Small scale roll-out of full tracking process
Define barriers to full implementation; correct barriers
Clinic-wide implementation
Continued evaluation and improvement (PDSA)

18. Choosing Conditions to Track
Divide all possible clinical quality projects into one of the following categories:
Projects that will improve clinic revenue
Projects required due to regulatory mandates
Projects that reduce risk of lawsuits
Projects which will cost the clinic money (although they may save the patient/insurer money)
Avoid category 4 projects unless they can be converted into category 1, through grants, quality bonus payments, etc.

19. MediTracks at Clinic Ole—Underlying Business Cases
Tracking Breast Cancer Screening
Tracking Cervical Cancer Screening
Tracking Vaccinations
Tracking Subgroup of Patients with Diabetes Mellitus
Tracking Patients with active and latent TB

20. Analyze process
Local clinic experts review current and ideal process and make flowchart
Process changes become evident
Change based on PDSA; small scale before rolling out to whole clinic

21. Lessons Learned VI
Once a clinic has MediTracks, the challenge to successful tracking is to consider each condition tracked as its own quality improvement project. Using the software is relatively straightforward.
Barriers and Obstacles:
Developing and Nurturing Super-users
Understanding how to harness power of the database to improve quality
Efficiency of the System
Useful mainly in clinical quality improvement, not other areas of quality improvement

22. Clinical Efficiency of MediTracks
Can be implemented with minimal provider effort; no negative effect on productivity
Requires support staff work; need business case to support this ongoing expense
Practice Management Interface essential to reduce support staff time needed for entering data.
New lab interface reduces staff time needed for tracking that follows lab parameters

23. Evolution in our Thinking about Quality Improvement—Stage 4
Project teams re-design clinic processes
Re-engineering of Patient Visit
Group medical Visits
Health Promoters
Behavioral Health Integration
Barriers and Obstacles:
Keeping projects moving forward
Sustainability
Local Expert Staff Turnover
Maintaining leadership focus
Lack of monitoring and feedback

24. Evolution in our Thinking about Quality Improvement—Stage 5
Developing an organization-wide culture of quality improvement

25. Developing a Culture of Quality in Community Health Centers
Entire Management Team must embrace the goal
Time commitment from management
Willingness to allocate staff time to quality activities
Need to think of quality in a broader sense
Clinical quality
Service quality
Management quality
Finance quality
Quality of Human Resources Management
Regulatory Quality

26. Building a Culture of Quality
Local QI leader needed
Excellent leadership skills (Credibility throughout organization)
Extensive training in quality improvement methodology
Excellent management skills
Deep understanding of how the clinic works
Medical Director or Chief operating officer

27. Implementing a Culture of Quality
Quality Improvement Teams
Every staff member assigned to a team
Choosing team projects
Choosing team leaders
QI steering committee
Train entire staff on principles of quality improvement
Series of all-staff trainings
More intensive trainings for QI team leaders

28. Benefits of a Culture of Quality
Improved job satisfaction
Better working relationships
More control over working environment
Building of leadership/management skills in project team leaders
Quality improvement spills over into personal lives of staff

29. Barriers and Obstacles to Developing a Culture of Quality
Numerous pre-requisites:
Stability (Lack of crisis):
Financial stability
Adequate level of staffing
Well trained staff
No political crisis in the community
Effective management team
Mutual trust
Shared commitment
No major areas of weakness
Wisdom coming from experience
Local QI leader

30. The Future? Balance Balanced Quality Improvement
Technology Enhanced QI balanced with QI projects that don’t require technology
Maintain prior gains while moving forward in new areas, in all 5 stages of QI:
Electronic Health Record
Training
Tracking
Process Re-design
Culture of Quality