1. 1 Quality Improvement Series Session 7- System Redesign Windy Stevenson lammersw@ohsu.edu Cindy Ferrell

2. 2 Today’s Agenda

3. 3 Recap Problem: The DCH ambulatory clinic problem lists are incomplete and inaccurate. Patients with BMI>85%ile do not have obesity listed on their problem lists. Drivers: 1.Improve patient care- facilitate decision support 2.Improve provider efficiency (reduce chart review) Lessons Learned: We have to narrow our scope Just saying we fix the system is woefully inadequate Everything is more complex than we expect Random audits of an ill defined product are not helpful We are still limited by our access to data

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5. 5 Changing behavior By changing motivationBy making the right thing the easy thing Culture change Convince every provider that this is important so that he/she REMEMBERS to change behavior Systems change leading to eventual culture change Reconfigure the system so it doesn’t matter in the beginning if it is important to providers This works in a system with immediate feedback (treats or shock collar) This works when there is no natural consequence (fence) Let’s say your dog keeps running into the street

6. 6 Two Real-life examples

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8. 8 The Science of Reliability Reliability LevelReliability Expression Reliability RateFailure Rate Level 110‾¹80-90% reliable1-2 failures in 10 opportunities Level 210‾²95% reliable<5 failures in 100 opportunities Level 310‾³99% reliable<5 failures in 1000 opportunities Level 6 (Six Sigma) 10‾6<5 failures in 1,000,000 opportunities

9. 9 How do we get from CHAOS to Level 1?  Work harder next time  Feedback on compliance  Increase awareness and vigilance –Also known as work harder

10. 10 How do we get from Level 1 to Level 2? –Real time identification of failures –“forced function” check lists –Redundancy –Make the right thing the easy thing –Provide decision aids

11. 11 So, what’s our first AIM? Specific we are intentional and focused Measurable we can prove we’ve had an impact Actionable there are no known insurmountable barriers Realistic it’s within our scope Timely we’ll do it within a time frame

12. 12 Our First AIM: ____ % of patients of ____ age seen by _______ in the ________ clinic(s) with a BMI > ____ %ile will have _______ listed on their problem list by ______ (date)

13. 13 Let’s envision our ideal state  Process Mapping

14. 14 How do we get there?

15. 15 Obesity and Meaningful Use- more opportunity The percentage of patients 2 ‐ 17 years of age who had an outpatient visit with a PCP and who had evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year.

16. 16 Take Home Points (review) Real (sustainable) change comes from changing systems, not changing within systems Be specific about what you want to accomplish, and why; be intentional Focus on patients Start before you think you are ready; don’t get paralyzed