1. UNIVERSITY OF MISSOURI Family & Community Medicine It Takes a Village to Change a Process: A Health Systems Approach to Practice Improvement Conference on Practice Improvement Saturday, December 4 4:10-5:10 pm

2. UNIVERSITY OF MISSOURI Family & Community Medicine Presenting Today: Karl Kochendorfer, MD Assistant Professor of Clinical Family and Community Medicine Director of Clinical Informatics Adjunct Faculty, MU Informatics Institute Medical School: University of Illinois at Chicago Residency: University of Illinois at Chicago

3. UNIVERSITY OF MISSOURI Family & Community Medicine Presenting Today: Phil Vinyard, MHA, MBA, MDiv Practice Manager, Green Meadows Family Medicine Clinic, Woodrail Family Medicine Clinic, Fayette Family Medicine Clinic Graduate School: University of Missouri (MHA, MBA); Gordon-Conwell Theological Seminary (MDiv)

4. UNIVERSITY OF MISSOURI Family & Community Medicine Presenting Today: Jan Gace, LPN Phone & Floor Nurse, Green Meadows Family Medicine Clinic Nursing School: Columbia Public School of Practical Nursing

5. UNIVERSITY OF MISSOURI Family & Community Medicine A Little About Us: Mizzou!

6. UNIVERSITY OF MISSOURI Family & Community Medicine A Little About Us: MU Health Care

7. UNIVERSITY OF MISSOURI Family & Community Medicine A Little About Us: Family & Community Medicine 6 Family Medicine Clinics 100,000 Visits 46 Physicians 10 Other Providers 10 Research Faculty 2 Fellows 36 Residents 110 Nurses, Clerical Support & Management

8. UNIVERSITY OF MISSOURI Family & Community Medicine The Reason for Our Project: The Burden of Diabetes & Other Chronic Disease Half of all Americans have at least one chronic disease Of those with chronic disease, over 50% have multiple conditions Chronic disease causes 70% of all deaths

9. UNIVERSITY OF MISSOURI Family & Community Medicine The Reason for Our Project: The Burden of Diabetes & Other Chronic Disease Chronic disease causes 75% of health expenditures 1/5 of health dollars are spent on patients with diabetes Only 50% of recommended care is delivered to diabetics

10. UNIVERSITY OF MISSOURI Family & Community Medicine A Solution: Leverage EMR Information Tiger Institute for Health Innovation: Living Lab F&CM as early adopters of the EMR Incentives available for Meaningful Use

11. UNIVERSITY OF MISSOURI Family & Community Medicine Solution: Diabetes Summary Screen

12. UNIVERSITY OF MISSOURI Family & Community Medicine DM Quality Measures

13. UNIVERSITY OF MISSOURI Family & Community Medicine Concept of Perfect Care Healthcare IT News. 9/2008

14. UNIVERSITY OF MISSOURI Family & Community Medicine The Math of Perfect Care 3 Measures = 1/2 3 or 1 of 8 qualify 8 Measures = 1/2 8 or 1 of 256 qualify ~32x harder

15. UNIVERSITY OF MISSOURI Family & Community Medicine Quality Measures Implemented Information about DM Quality Measure screens discussed at Faculty meetings Physicians encouraged to check DM Summaries on patients and take action The results…

16. UNIVERSITY OF MISSOURI Family & Community Medicine Rampant Indifference

17. UNIVERSITY OF MISSOURI Family & Community Medicine Minimal Improvement after 1 Year Clinics with Care Coordinators: 2 FM Clinics between 10-15% 2 FM Clinics between 5-10% Clinics without Care Coordinators: 4 FM Clinics close to 0% 2 IM Clinics close to 0%

18. UNIVERSITY OF MISSOURI Family & Community Medicine It Takes a Village to Change a Process: A Health Systems Approach to Practice Improvement

19. UNIVERSITY OF MISSOURI Family & Community Medicine Our Village: Performance Improvement- Leadership Development Program Strategically develop and deploy performance improvement knowledge, skills and competencies of current and emerging clinical and non-clinical leaders throughout UMHC. Strengthen the UMHC performance improvement organizational culture. Improve UMHC's ability to provide high quality and safe patient care in a patient centered and cost effective manner.

20. UNIVERSITY OF MISSOURI Family & Community Medicine PI-LDP Program Design Performance Improvement Capacity Building Learning by Doing Performance Improvement Organizational Culture Building

21. UNIVERSITY OF MISSOURI Family & Community Medicine PI-LDP Program Design

22. UNIVERSITY OF MISSOURI Family & Community Medicine Members of Our Team and our Advisors Team: Karl Kochendorfer, MD (Director of Clinical Informatics) Phil Vinyard, MHA, MBA (Practice Manager) Donna Neal, RN (Nurse Manager) Rhonda Polly, APRN (Chronic Care Nurse) Jan Gace, LPN (Phone & Floor Nurse) Advisors: Carl Hooker, MHA (Finance) Tim Hogan, PhD (F&CM Department QI Officer)

23. UNIVERSITY OF MISSOURI Family & Community Medicine Aim Statement The Family Medicine Green Team will increase the percentage of our diabetic patients with perfect care from 10% to no less than 50% by June 30, 2010. This will be accomplished by using a multidisciplinary approach, process change, education and utilization of eight quality measures.

24. UNIVERSITY OF MISSOURI Family & Community Medicine Fishbone Diagram

25. UNIVERSITY OF MISSOURI Family & Community Medicine Fishbone Diagram: Computer

26. UNIVERSITY OF MISSOURI Family & Community Medicine Fishbone Diagram: Culture

27. UNIVERSITY OF MISSOURI Family & Community Medicine Fishbone Diagram: Resources

28. UNIVERSITY OF MISSOURI Family & Community Medicine Fishbone Diagram: Medical Practice

29. UNIVERSITY OF MISSOURI Family & Community Medicine Fishbone Diagram: Patients

30. UNIVERSITY OF MISSOURI Family & Community Medicine Fishbone Diagram: Staff

31. UNIVERSITY OF MISSOURI Family & Community Medicine Driver Diagram

32. UNIVERSITY OF MISSOURI Family & Community Medicine Interventions Considered Opportunistic Approach Proactive Approach Patient Engagement Approach

33. UNIVERSITY OF MISSOURI Family & Community Medicine Opportunistic Approach Every time a patient with diabetes comes for a clinic visit, review their quality measures and take action

34. Process Flow Chart

35. UNIVERSITY OF MISSOURI Family & Community Medicine

36. UNIVERSITY OF MISSOURI Family & Community Medicine Proactive Approach Run the list of diabetic patients and pro-actively contact them about missing items.

37. UNIVERSITY OF MISSOURI Family & Community Medicine Run the List: By Patient

38. UNIVERSITY OF MISSOURI Family & Community Medicine Run the List: By Category

39. UNIVERSITY OF MISSOURI Family & Community Medicine A Train Wreck…

40. UNIVERSITY OF MISSOURI Family & Community Medicine A Train Wreck…

41. UNIVERSITY OF MISSOURI Family & Community Medicine Correcting Primary Provider

42. UNIVERSITY OF MISSOURI Family & Community Medicine Patient Engagement Approach Educate the patients about the types of services they should be receiving.

43. UNIVERSITY OF MISSOURI Family & Community Medicine Patient Letter

44. UNIVERSITY OF MISSOURI Family & Community Medicine Patient Letter

45. UNIVERSITY OF MISSOURI Family & Community Medicine Patient Letter

46. UNIVERSITY OF MISSOURI Family & Community Medicine Automated emails w/ graph

47. UNIVERSITY OF MISSOURI Family & Community Medicine Outcomes!

48. UNIVERSITY OF MISSOURI Family & Community Medicine Outcomes to Date Decided to focus on diabetes quality indicators as a practice improvement project Completed workflow process and began piloting and training for our intervention

49. UNIVERSITY OF MISSOURI Family & Community Medicine Lessons Learned Having data doesnt mean improvement Integrate the data into your workflow Training needs Learning how to use the reporting tools Documentation, e.g. eye and foot exams Team effort (e.g. buy-in, resources, meetings) Physician engagement Automate, Automate, Automate

50. UNIVERSITY OF MISSOURI Family & Community Medicine Future Steps Re-establish new target Add incentive payments Integrate PDSA Continue Ninja Group Meetings Improve Proactive approach Improve Patient Engagement approach Expand to other Family Medicine & Internal Medicine Clinics Assist our physicians with their Board Certifications

51. UNIVERSITY OF MISSOURI Family & Community Medicine Questions? Karl Kochendorfer, MD kochendorferk@health.missouri.edukochendorferk@health.missouri.edu Phil Vinyard, MHA, MBA vinyardp@health.missouri.eduvinyardp@health.missouri.edu Jan Gace, LPN gacej@health.missouri.edugacej@health.missouri.edu Rhonda Polly, APRN pollyr@health.missouri.edupollyr@health.missouri.edu Donna Neal, RN neald@health.missouri.eduneald@health.missouri.edu

52. UNIVERSITY OF MISSOURI Family & Community Medicine