1. Connecting All the Pieces – How Close Are We? Mike Davies MD, FACP Mark Murray and Associates Chinook Learning Session 5 September 27, 2006 1300-1415

2. Current State Patients wait FOR appointments Patients wait AT appointments A single patients’ care is fragmented among many providers Much prevention and chronic disease care has gone undone Regional teams and others have tried to fill the gap

3. Results Many patients don’t have a provider Many patients don’t have a provider Patients shop for provider with soonest access Patients shop for provider with soonest access Providers may churn visits Providers may churn visits Some patient problems go unaddressed Some patient problems go unaddressed Chronic disease care and prevention are an afterthought Chronic disease care and prevention are an afterthought Patients may not get as good of care as they need Patients may not get as good of care as they need

4. Every System is Perfectly Designed to Get the Results it Gets Paul Bataldin

6. Patient Needs Prevention Acute Out-patient Chronic Disease Lifestyle Screening*Alcohol/Drug Use Screen Immunizations (multiple) Cancer Screening male/female Mental Health Screen Acute Illnesses Medication Rx Exam & Diagnostic Tests Diagnosis/Treatment Acute Exacerbation Out-pt. Rx MonitoringEducationSelf-CarePrevention of hospitalizations

7. Prevention Acute Out-patient Chronic Disease Lifestyle Screening*Alcohol/Drug Use Screen Immunizations (multiple) Cancer Screening male/female Mental Health Screen Acute Illnesses Medication Rx Exam & Diagnostic Tests Diagnosis/Treatment Acute Exacerbation Out-pt. Rx MonitoringEducationSelf-CarePrevention of hospitalizations

8. System Flow Map PCN Physician Patient Dyad Patient Specialty Services: Physicians Diagnostics: Lab & Medical Imaging Acute Care Services Mental Health Family Health: Women’s Children’s Seniors Health: Access Centre (Living Options) Community Care Palliative Care Wellness (Public Health): Health Promotion Health Protection Legend: Direction of arrow denotes flow of work/patient/demand Demand at each step Supply at each step Variation at each step Wait time at each step Process time at each step Diagnostics: Lab & Medical Imaging

9. Result? Multiple venues to go for care Multiple venues to go for care Confusion Confusion Where do I go for what? Where do I go for what? Incomplete information Incomplete information What was done….where was it done? What was done….where was it done? Very expensive supply Very expensive supply Duplication Duplication Poor performance of tasks for population Poor performance of tasks for population “everybody” & “nobody” responsible “everybody” & “nobody” responsible Relatively poorer health levels Relatively poorer health levels

10. Care Expense Most to Least Expensive Most to Least Expensive O.R. O.R. ICU ICU In-Patient Care In-Patient Care Emergency Room Emergency Room Specialty Care Specialty Care Out-Patient Primary Care Out-Patient Primary Care Prevention Prevention Hospital Care

11. Results continued…. Patient Factors Patient Factors Multiple appointments: need to fit into schedule Multiple appointments: need to fit into schedule Multiple appointments: gas and time Multiple appointments: gas and time Multiple appointments: no-show Multiple appointments: no-show Provider Factors Provider Factors Not responsible for prevention/chronic care Not responsible for prevention/chronic care Unsure what has been done or not done Unsure what has been done or not done System factors System factors Provide staff, buildings, gas, cars, information for each chronic disease and prevention area Provide staff, buildings, gas, cars, information for each chronic disease and prevention area Patient illness at higher rate Patient illness at higher rate Patient death at higher rate Patient death at higher rate Reputation, Mission, Expense

12. Options Design a system where each patient need is met by a different provider? Design a system where each patient need is met by a different provider?

13. Are there alternative designs? Faced with the choice of changing one’s mind Or proving there is no need to do so, almost everyone gets busy on the proof. -John Kenneth Galbraith

14. Patient Needs Primary Care Team “Responsible for providing or Coordinating the majority of the patient’s Care” Specialty Care Home Care Tests And Services

15. Improvement Project Checklist The improvement project is an iterative process but also has some foundational principles. (ie. For good clinical care we must have good access and efficiency) The improvement project is an iterative process but also has some foundational principles. (ie. For good clinical care we must have good access and efficiency) The following checklist is meant to help the teams assess where they are at and help them focus their improvement energy The following checklist is meant to help the teams assess where they are at and help them focus their improvement energy

16. Improvement Project Checklist For each of the 7 categories rate your improvement progress to date For each of the 7 categories rate your improvement progress to date 1.0 No Activity 1.0 No Activity 2.0 Activity; No Changes 2.0 Activity; No Changes 2.5 Began testing; no measurable progress 2.5 Began testing; no measurable progress 3.0 Testing; initial measurable progress 3.0 Testing; initial measurable progress 3.5 Testing multiple changes; measurable progress in at least 2 items 3.5 Testing multiple changes; measurable progress in at least 2 items 4.0 Reached goals 4.0 Reached goals 4.5 Surpassed goals; spread to wider area 4.5 Surpassed goals; spread to wider area 5.0 Results are leading edge nationally 5.0 Results are leading edge nationally

17. Pre-Work Create an Improvement Team Create an Improvement Team Representation Representation Clinic Management, Provider Expertise, Day to day Leader Clinic Management, Provider Expertise, Day to day Leader Leaders/Change Agents Leaders/Change Agents Leaders/Team has enough clout to institute change Leaders/Team has enough clout to institute change Authority to trial changes and implement success Authority to trial changes and implement success Ability to allocate necessary resources Ability to allocate necessary resources

18. Pre-Work Regular meeting schedule Regular meeting schedule Planned time for an regular attendance of: Planned time for an regular attendance of: Improvement team meetings Improvement team meetings Practice/Business meetings Practice/Business meetings Clinic-wide meetings Clinic-wide meetings

19. Pre-Work Ensure adequate resources support are available for improvement project Ensure adequate resources support are available for improvement project Time to collect measures Time to collect measures Administrative time Administrative time Resources to support the improvement process Resources to support the improvement process

20. Pre-Work Mechanism for sharing learnings Mechanism for sharing learnings Storyboards Storyboards Oral reports Oral reports Measurements posted in common area Measurements posted in common area Others? Others?

21. Pre-Work Understand and commit to rapid learning cycles Understand and commit to rapid learning cycles Aim, Measure, Change Aim, Measure, Change Plan, Do, Study, Act Plan, Do, Study, Act

22. Pre-Work On the supplied checklist, provide your rating on your teams Pre-Work activities to date: On the supplied checklist, provide your rating on your teams Pre-Work activities to date: 1.0 No Activity 1.0 No Activity 2.0 Activity; No Changes 2.0 Activity; No Changes 2.5 Began testing; no measurable progress 2.5 Began testing; no measurable progress 3.0 Testing; initial measurable progress 3.0 Testing; initial measurable progress 3.5 Testing multiple changes; measurable progress in at least 2 items 3.5 Testing multiple changes; measurable progress in at least 2 items 4.0 Reached goals 4.0 Reached goals 4.5 Surpassed goals; spread to wider area 4.5 Surpassed goals; spread to wider area 5.0 Results are leading edge nationally 5.0 Results are leading edge nationally

23. Access - Aim Provider patient relationship sacrosanct Provider patient relationship sacrosanct Care delivery model supports the physician patient dyad Care delivery model supports the physician patient dyad

24. Access - Aim Commitment to Panel Commitment to Panel Committed to managing all the care needs of their panel Committed to managing all the care needs of their panel Doing today’s work today Doing today’s work today

25. Access - Measures Measures collected to support access aims Measures collected to support access aims Time to third next / Future open capacity Time to third next / Future open capacity Panel size Panel size Demand/supply/supply used Demand/supply/supply used Fail to keep appointment Fail to keep appointment Continuity Continuity

26. Access - Changes Advanced Access Advanced Access Balance supply and demand Balance supply and demand Eliminate bad backlog Eliminate bad backlog Offer of same day visit Offer of same day visit Anticipate changes in demand and supply Anticipate changes in demand and supply Develop contingency plans Develop contingency plans

27. Access - Changes Use of measures to inform and shape practice Use of measures to inform and shape practice Share measures broadly Share measures broadly Interpret measures to inform practice Interpret measures to inform practice Record and report failed trials as well as successful trials Record and report failed trials as well as successful trials

28. Access On the supplied checklist, provide your rating on your teams Access activities to date: On the supplied checklist, provide your rating on your teams Access activities to date: 1.0 No Activity 1.0 No Activity 2.0 Activity; No Changes 2.0 Activity; No Changes 2.5 Began testing; no measurable progress 2.5 Began testing; no measurable progress 3.0 Testing; initial measurable progress 3.0 Testing; initial measurable progress 3.5 Testing multiple changes; measurable progress in at least 2 items 3.5 Testing multiple changes; measurable progress in at least 2 items 4.0 Reached goals 4.0 Reached goals 4.5 Surpassed goals; spread to wider area 4.5 Surpassed goals; spread to wider area 5.0 Results are leading edge nationally 5.0 Results are leading edge nationally

29. Efficiency - Aim No unnecessary wait at the appointment No unnecessary wait at the appointment Check in MA to Room MD Enters MD Leaves Check out

30. Efficiency - Aim Keep/increase value added time Keep/increase value added time Greatest constraint is the provider Greatest constraint is the provider Optimized ‘Red Zone’ time Optimized ‘Red Zone’ time

31. Efficiency - Measures Measures collected to support efficiency aim Measures collected to support efficiency aim Cycle time Cycle time Flow maps Flow maps Number of interruptions Number of interruptions

32. Efficiency - Changes Optimized office environment Optimized office environment Balance supply/demand for non-appointment work Balance supply/demand for non-appointment work Synchronize patient, provider and information Synchronize patient, provider and information Predict and anticipate patient needs Predict and anticipate patient needs Optimize rooms, staff and equipment Optimize rooms, staff and equipment

33. Efficiency On the supplied checklist, provide your rating on your teams Efficiency activities to date: On the supplied checklist, provide your rating on your teams Efficiency activities to date: 1.0 No Activity 1.0 No Activity 2.0 Activity; No Changes 2.0 Activity; No Changes 2.5 Began testing; no measurable progress 2.5 Began testing; no measurable progress 3.0 Testing; initial measurable progress 3.0 Testing; initial measurable progress 3.5 Testing multiple changes; measurable progress in at least 2 items 3.5 Testing multiple changes; measurable progress in at least 2 items 4.0 Reached goals 4.0 Reached goals 4.5 Surpassed goals; spread to wider area 4.5 Surpassed goals; spread to wider area 5.0 Results are leading edge nationally 5.0 Results are leading edge nationally

34. Teamwork - Aim Clear goal or Mission Statement Clear goal or Mission Statement (What are we trying to accomplish?) As an operational team As an operational team As a clinical team As a clinical team As an improvement team As an improvement team

35. Teamwork - Aim Defined/Measurable Objectives Defined/Measurable Objectives (How will we know we accomplished it?) As an operational team As an operational team As a clinical team As a clinical team As an improvement team As an improvement team

36. Teamwork - Measures Measures to support teamwork aims Measures to support teamwork aims “Vital signs” “Vital signs” Provider/staff satisfaction surveys Provider/staff satisfaction surveys Activity analysis Activity analysis

37. Teamwork - Changes Optimized Team Optimized Team Leadership committed to improvement Leadership committed to improvement Service agreements Service agreements Job descriptions (functions) Job descriptions (functions) Signals, hand-offs and huddles Signals, hand-offs and huddles Reduce interruptions and distractions Reduce interruptions and distractions

38. Teamwork On the supplied checklist, provide your rating on your Teamwork activities to date: On the supplied checklist, provide your rating on your Teamwork activities to date: 1.0 No Activity 1.0 No Activity 2.0 Activity; No Changes 2.0 Activity; No Changes 2.5 Began testing; no measurable progress 2.5 Began testing; no measurable progress 3.0 Testing; initial measurable progress 3.0 Testing; initial measurable progress 3.5 Testing multiple changes; measurable progress in at least 2 items 3.5 Testing multiple changes; measurable progress in at least 2 items 4.0 Reached goals 4.0 Reached goals 4.5 Surpassed goals; spread to wider area 4.5 Surpassed goals; spread to wider area 5.0 Results are leading edge nationally 5.0 Results are leading edge nationally

39. Clinical Care - Aim Deliver consistent reliable care (planned care) Deliver consistent reliable care (planned care)

40. Clinical Care - Aim Deliver best possible care for patients with chronic conditions Deliver best possible care for patients with chronic conditions

41. Clinical Care Deliver best possible care for preventable disease Deliver best possible care for preventable disease

42. Clinical Care - Measures Measures to support Clinical Care aims Measures to support Clinical Care aims Use of protocols Use of protocols Number of patients at clinical goal Number of patients at clinical goal Number of patients/population receiving prevention care Number of patients/population receiving prevention care

43. Clinical Care Optimized Clinical Care Optimized Clinical Care Know which patients should be receiving what care Know which patients should be receiving what care Opportunistic care delivery Opportunistic care delivery Patient involvement in decision making Patient involvement in decision making

44. Clinical Care Defined linkage to specialist/RHA programs Defined linkage to specialist/RHA programs

45. Clinical Care On the supplied checklist, provide your rating on your teams Clinical Care activities to date: On the supplied checklist, provide your rating on your teams Clinical Care activities to date: 1.0 No Activity 1.0 No Activity 2.0 Activity; No Changes 2.0 Activity; No Changes 2.5 Began testing; no measurable progress 2.5 Began testing; no measurable progress 3.0 Testing; initial measurable progress 3.0 Testing; initial measurable progress 3.5 Testing multiple changes; measurable progress in at least 2 items 3.5 Testing multiple changes; measurable progress in at least 2 items 4.0 Reached goals 4.0 Reached goals 4.5 Surpassed goals; spread to wider area 4.5 Surpassed goals; spread to wider area 5.0 Results are leading edge nationally 5.0 Results are leading edge nationally

46. Delivery System - Aims Increase reliability Increase reliability Decrease redundancy Decrease redundancy Manage variation Manage variation

47. Delivery System – Aims EMR supports clinical and operational systems EMR supports clinical and operational systems Reminder system Reminder system Panel profile Panel profile Identification of patients with selected conditions Identification of patients with selected conditions Measurement of clinical indicators/outcomes Measurement of clinical indicators/outcomes

48. Delivery System - Measures Measures to support Delivery System aims Measures to support Delivery System aims Chart audits Chart audits System and process flow mapping System and process flow mapping

49. Delivery System - Changes Standardized processes Standardized processes Streamlined processes Streamlined processes Just-in-time information Just-in-time information Contingency plans Contingency plans Office automation Office automation

50. Delivery System On the supplied checklist, provide your rating on your teams Delivery System activities to date: On the supplied checklist, provide your rating on your teams Delivery System activities to date: 1.0 No Activity 1.0 No Activity 2.0 Activity; No Changes 2.0 Activity; No Changes 2.5 Began testing; no measurable progress 2.5 Began testing; no measurable progress 3.0 Testing; initial measurable progress 3.0 Testing; initial measurable progress 3.5 Testing multiple changes; measurable progress in at least 2 items 3.5 Testing multiple changes; measurable progress in at least 2 items 4.0 Reached goals 4.0 Reached goals 4.5 Surpassed goals; spread to wider area 4.5 Surpassed goals; spread to wider area 5.0 Results are leading edge nationally 5.0 Results are leading edge nationally

51. Sustainability/Spread Strategies to maintain momentum Strategies to maintain momentum

52. Sustainability / Spread On the supplied checklist, provide your rating on your teams Clinical Care activities to date: On the supplied checklist, provide your rating on your teams Clinical Care activities to date: 1.0 No Activity 1.0 No Activity 2.0 Activity; No Changes 2.0 Activity; No Changes 2.5 Began testing; no measurable progress 2.5 Began testing; no measurable progress 3.0 Testing; initial measurable progress 3.0 Testing; initial measurable progress 3.5 Testing multiple changes; measurable progress in at least 2 items 3.5 Testing multiple changes; measurable progress in at least 2 items 4.0 Reached goals 4.0 Reached goals 4.5 Surpassed goals; spread to wider area 4.5 Surpassed goals; spread to wider area 5.0 Results are leading edge nationally 5.0 Results are leading edge nationally

53. Interpreting Scores “There is no quality without access.” “There is no quality without access.” If you don’t have an access score of “4”, then priority is to work on access If you don’t have an access score of “4”, then priority is to work on access If access score is 4, then work on office efficiency. If access score is 4, then work on office efficiency.

54. Access Score 4.0? YES NO Priority work on Access Efficiency Score 4.0? Teamwork Score 4.0? NO Priority work on Efficiency YES Clinical Care Score 4.0? Ongoing maintenance and spread of Access and Efficiency Ongoing work on Teamwork and Clinical Care Summary View

55. Team Meeting Discuss your individual assessments of your teams improvement progress Discuss your individual assessments of your teams improvement progress Review/create an action plan for your high leverage change areas Review/create an action plan for your high leverage change areas ? Other activities ? Other activities