- AGPAL & QIP€¦ · Quality Improvement Types of measures for assessing quality of care : •...

Practice Transformation Essentials: Using Data and Shifting to Patient‐Centered CareJ. Nwando Olayiwola, MD, MPH, FAAFP

Renee Blackman, RN

Objectives

• Understand the importance creating a culture of self‐examination and using data to inform all practice improvements during transformation to a Health Care Home, including clinical and operational data.

• Understand what is required to embed the key principles and practice to deliver patient‐centred care in primary care practices.

Not to be reproduced - AGPAL & QIP

1

Outline

• Recap of HCH Program Building Blocks & Quadruple Aim

• Discussion on Data in HCH Transformation

– Types of Measures, Purpose of Measurement, Data‐driven QI

• Improvement through root cause analyses

• Understanding the Patient Voice through Data

• Making the culture shift

• Capturing the patient voice and patient experience

• Empowering patients

• Summary

Today’s Icons

Let’s Talk! Group Activity Regroup and Reflect


2

Understanding The Patient Experience

• Patient Experience –https://www.youtube.com/watch?v=‐ajhrQQrYcU

What Did We Learn So Far?

Brief Review of the HCH Building Blocks and Quadruple Aim


3

Quadruple Aim

Quadruple Aim

• Enhancing patient experience

• Improving population health

• Improving cost efficiency and sustainability

• Improving the experience of health providers and the General Practice or ACCHS team


4

HCH Building Blocks & Modules

Does Data Matter?


5

What is Data?

We reviewed three different types of data:

• Patient data: Demographic details (age, address, Medicare number, contact details) can also include patient experience and engagement in their care

• Clinical data: Clinical care information (diagnoses, immunisations, allergies, HbA1c, BP, BMI)

• Practice data: Financial data (PIP payments, operational data, waiting times, SWPE, enrolled populations and referral rates)

What is Data‐driven Improvement?

The ability to use data collected through patient care and practice management to measure, analyse and improve the quality, efficiency and effectiveness of the care provided to patients.

“You can’t fatten a cow by weighing it”‐ Palestinian proverb


6

Why is data so important for patient‐centered care?

Measurement Purposes

Purpose of measurement:

• measurement for research

• measurement for judgement

• measurement for improvement

Provides feedback to teams, clinicians, and patients about:

• Health Care Home’s progress toward transformation

• Outcomes of the care they provide or receive


7

Quality Improvement

Types of measures for assessing quality of care :

• Structure based ‐ encompasses factors that affect the context in which care is delivered, structures and systems to assure quality of care.

• Process based ‐ sum of all actions in health care (diagnosis, treatment, preventative care and patient education processes)

• Outcome based ‐ the effects of health care on patients or populations (clinical, physiological and patient‐centred outcomes)

Types of Measures: The Donabedian Framework

Donabedian A, Wheeler JR Wvszewianski L. Quality, cost and health: an integrative model. Med Care. 1982 Oct:20(10):975‐92

Structures Processes Outcomes

The content of healthcare – facilities, equipment, personnel,

organizational characteristics, payment

models

Actions in healthcare including those of

patients and families

Effects on health status, quality of life,

knowledge, behavior, satisfaction


8

Let’s Talk!

• What types of data measures are your practices currently capturing? How would you classify them –structural, processes, outcomes?

• What challenges are you running into?

Suggestions for Data Measures at the Patient and Practice Level

What Else Can You Measure?


9

Patient experience and outcomes

Patient satisfaction survey

% patients complication

free in recovery

Pain scoreAverage patient

waiting time

Safety and reliabilityClinical incidents

ReadmissionsExceptions

from time out checklist

% correct equipment to hand

Efficiency and valueTurnaround

time% theatre utilisation

CancellationsDelays

(Late starts & finishes)

Leadership and high performing teams

Staff surveyTraining and development

Staff turnoverStaff

absence

What to Measure?

• Patient/Carer

• Symptoms

• Health Promotion/Disease Prevention

Clinical Need

• History

• Examination

• Investigations

Diagnosis • Intervention

• Procedure, Prescription, Advice, Referral

Management

• Call Recall Systems

• Repeat Prescriptions

Follow up

Clinical Process


10

Process Measures

Process Measures

% patient smoking cessation recorded% patient with BP recorded% patients on warfarin with INR within target range or recent INR measure% patients whose medications are reconciled when discharge summary received

•Patient/Carer

• Symptoms

•Health Promotion/Disease Prevention

Clinical Need

•History

• Examination

• Investigations

Diagnosis • Intervention


Management

•Call Recall Systems

•Repeat Prescriptions

Follow up

Outcome Measures

Mortality Morbidity Patient Experience Quality of lifeChanges in health related behaviour (e.g. giving up smoking)Harm Rate Wound Infection Adverse drug event Pressure ulcers

Proxy Outcome Measures

% diabetics with BP controlled with target range% Patient with CHD with cholesterol to target

Outcome Measures

• Patient/Carer

• Symptoms

• Health Promotion/Disease Prevention

Clinical Need

• History

• Examination

• Investigations

Diagnosis• Intervention


Management

• Call Recall Systems

• Repeat Prescriptions

Follow upNot to be reproduced - AGPAL & QIP

11

Understanding your Why and applying root cause analyses

Thinking Systems and Processes

Getting to the Roots

WHY?

WHY?WHY?

WHY? WHY?Root Cause Analysis


12

Root Cause Analysis

Root cause analysis (RCA) is a systematic process for identifying “root causes” of problems or events and an approach for responding to them. RCA is based on the basic idea that effective management requires more than merely “putting out fires” for problems that develop, but finding a way to prevent them.

Root Cause Analysis

Goals

The primary goal of using RCA is to analyze problems or events to identify:

> What happened

> How it happened

> Why it happened…so that

> Actions for preventing reoccurrence are developed


13

Root Cause Analysis

Define the problem

Determine the causal

relationships

Identify effective solutions

Implement and track solutions

Strategies: Steps of RCA

Root Cause Analysis


14

Fishbone Diagram for RCA

5 Whys Mapping

Using a data‐inspired process of discovery for improvement

Define the problem: For example – Caught Speeding

Late for work

Woke up late

Alarm clock didn’t work

Batteries were flat

Forgot to replace batteries

WHY?

WHY?

WHY?

WHY?

WHY?


15

Not a blame game!

Deming/QI Theory:

Most problems are due to structural, process and systems issues, not individuals

Group activity

• An elderly patient in your skilled nursing facility is given Bactrim for a urinary tract infection and immediately breaks into hives and has significant wheezing.

• In your small group, apply a ‘5 Whys’ process map to understand the problem and propose the root cause.


16

Group Activity

• You are working as a practice facilitator for a small practice trying to adopt the HCH model, using registry reports to improve performance on tracking diabetes related outcomes and process measures.

• You arrive for a meeting with the practice leadership team and a very frustrated office manager comes to you and says “I’m so disappointed in our data and our doctors. Only 30% of our patients with diabetes have documented monofilament foot exams in this recent report.”

• Share your groups ‘5 Whys’

• How can an approach like ‘5 Whys’ be used to empower a team working in a HCH?

• How would you use a ‘5 Whys’ approach with your practices?

Regroup and Reflect


17

Intervention

Procedure

Prescription

Advice

Referral

StartPatient seen

in Consultation

Decision to Refer

Dictate Letter or complete referral form

Secretary processes referral

correspondence

Correspondence sent to provider

End

Many Steps = Many Potential Fail Points

•Patient/Carer

•Symptoms

•Health Promotion/Disease Prevention

Clinical Need

•History

•Examination

•Investigations

Diagnosis•Intervention

•Procedure, Prescription, Advice, Referral

Management

•Call Recall Systems

•Repeat Prescriptions

Follow up

Making it All Fit

The Culture Shift Around Data in the HCH


18

Introducing Data‐driven Quality Improvement into the culture

Optimise use of health information technology

Ensure patients, families and care team members are involved in quality improvement activities

Ensure all team members understand metrics for success

Establish and monitor metrics to evaluate improvement efforts and outcomes

Choose formal model for quality improvement

Importance of Continuous Quality Improvement

Quality management process that encourages the practice to continuously ask..

‘How are we doing?’and

‘Can we do it better?’

To reduce waste, increase efficiency, improve outcomes and increase staff and patient satisfaction


19

Where to start?

Which structure, process and outcome indicators to measure?

1What quality improvement strategy will I use?

2What tools to use to measure the indicators?

3How will information be used?

4

Review: SMART Goals and PDSA Cycles


20

Reinforcing Cultural Change

Recognise Recognise achievement and celebrate successes

ApplyApply data and information for continual improvement using the PDSA cycle

Measure and track Measure and track progress using valid data

UseUse visual symbols to focus attention on the goals – charts, diagrams, poster, vision boards

Establish Establish clear goals for improvement ‐ SMART goals

www.digitalhealth.gov.au/get‐started‐with‐digital‐health/what‐is‐digital‐health/importance‐of‐data‐quality

Practice Profiler (Precedence)

Clinical Audit Tool (CAT) (Pen Computing Systems)

Canning data extraction tool

(Canning)

CDSA Tool

Data Management Tools


21

Coffee Break

In the midst of all that data….

There is a patient….


22

The ever so important 4th Aim

Capturing the Patient Experience

One Aim Still Eludes Us:Patient Experience

Enhancing patient experience• Improving population health• Improving cost efficiency

and sustainability• Improving the experience of

health providers and the General Practice or ACCHS team


23

Context

• Risk stratification• Voluntary enrollment• Tiered bundled payment• Shared care plan

• Organised, evidence based care• Patient centre interactions• Care Coordination• Enhanced access

• Engaged leadership• Patient enrolment• Quality improvement strategy• Continuous & team based healing relationships

What HPA is evaluating

Patient Centred Medical Home (PCMH)

HCH program

• Training, facilitation & support• Program processes• Care planning• Patient engagement/activation• Other aspects of the PCMH

• Leveraging other PHN/LHN initiatives

Other support/ infrastructure

What is HPA trying to answer?

1. How was the HCH model implemented and what were the barriers and enablers?

2. How does the HCH model change the way practices approach chronic disease management?

3. Do patients enrolled in HCH experience better quality care?

4. What are the financial effects of the HCH model on governments, providers and individuals?


24

The Patient Voice: What Does it Mean?

Patient Satisfaction

Patient Activation

Patient Information

Patient Decision‐Making

Patient Experience

Patient Engagement


25

What are we really trying to understand?

“The goals of Patient Experience are to increase patient loyalty, increase market share and exceed the Patient’s expectations. The goals of Patient Engagementare to get folks invested in their own care by providing opportunities and structures for patients and their families to become active participants in healthcare. ”‐ Patient & Family Centered Care Partners


26

Approaches to Hearing the Patient Voice

Let’s Talk!

• Let’s Talk!What types of approaches are your practices taking to hear and understand the patient voice and experiences?


27

Clinician AssessmentsClinician

AssessmentsPatient Focus Groups,

InterviewsPatient Focus Groups,

InterviewsPatient Surveys Patient Surveys

Strategies for Assessing Experience and Engagement of Patients

Strategies for Assessing Experience and Engagement of Patients• Liddy et al (2015)

• Mixed Methods Study – analyzed over 2000 eConsults (PCP survey analysis and thematic review of free text comments)

• Following the closure of each eConsult, PCPs completed short survey with multiple‐choice and open‐ended questions regarding the eConsult

– Q3: Please rate the overall value of the eConsult service for your patient: Minimal 1 2 3 4 5 Excellent

• Most PCPs felt eConsult had a positive impact on patient care by: 1) providing reassurance to patients, 2) reducing burden of time and travel, and 3) offering educational opportunities to PCPs applicable to future cases

Source: Liddy, C., Afkham, A., Drosinis, P., Joschko, J., & Keely, E. (2015). Impact of and satisfaction with a new eConsult service: a mixed methods study of primary care providers. The Journal of the American Board of Family Medicine, 28(3), 394‐403.

Engagement or Experience?


Assessments


28

Source: Liddy, C., Afkham, A., Drosinis, P., Joschko, J., & Keely, E. (2015). Impact of and satisfaction with a new eConsult service: a mixed methods study of primary care providers. The Journal of the American Board of Family Medicine, 28(3), 394‐403.

Strategies for Assessing Experience and Engagement of Patients• Mixed Methods Study – analyzed over 2000 eConsults(PCP survey analysis and thematic review of free text comments)

• Following the closure of each eConsult, PCPs completed short survey with multiple‐choice and open‐ended questions regarding the eConsult

– Q3: Please rate the overall value of the eConsult service for your patient: Minimal 1 2 3 4 5 Excellent

• Most PCPs felt eConsult had a positive impact on patient care by: 1) providing reassurance to patients, 2) reducing burden of time and travel, and 3) offering educational opportunities to PCPs applicable to future cases

Liddy et al 2015



Assessments

Strategies for Assessing Experience and Engagement of Patients• Observational case‐control study (Virtual Consults – VC vs Traditional Consults‐ TC)

• Sample of patients who had VCs requested by physicians (N = 270) were matched with patients who had TCs requested by physicians (N = 270), by patient age, gender, reason for the consult, and specialty department.

• Patients invited to complete satisfaction survey

• Patients who completed a satisfaction survey indicated they were satisfied with their care, regardless of the kind of consult

Palen et al 2012

Source: Palen, T. E., Price, D., Shetterly, S., & Wallace, K. B. (2012). Comparing virtual consults to traditional consults using an electronic health record: an observational case–control study. BMC medical informatics and decision making, 12(1), 65.

Patient Surveys Patient Surveys


29

Patient Survey: Ratings 1‐10 on a Likert Scale

N Mean Median Min Max p value*

Rating of Primary Care Physician

Virtual consult (VC)

127 8.69 9 0 10 0.99

Traditional consult (TC)

138 8.69 9 4 10

Rating of Medical care


128 8.67 9 0 10 0.51


139 8.55 9 3 10

Rating of Specialist Recommendations


41 8.71 10 0 10 0.63


65 8.51 9 1 10


Patient Survey Excerpt

Please choose from the following statements that best reflect this visit:• I was given a referral for a visit to see a

specialist• This doctor discussed getting information

from a specialist with me and later contacted me to share the specialists’ recommendations

• This doctor discussed getting information from a specialist with me but was only going to contact me if changes to my care was needed

• This doctor discussed getting information from a specialist with me but I haven’t heard about recommendations at this time

• This doctor and I did not discuss getting additional specialist information at this visit

• Have you see seen the specialist yet? Y N If no, skip to question 16.

• Using any number from 0 to 10, how satisfied are you with the recommendations made by the specialist for this problem? __________

• Did you have any questions about the recommendations made by the specialist for this problem? Y N

– If YES, using any number from 0 to 10, how satisfied are you with your ability to ask questions about the specialist recommendations for this problem? __________

• Skip to question 16.

• At this visit, the doctor you saw asked for input from a specialist to help take care of your concern at that visit. Please tell us:

• Using any number from 0 to 10, how satisfied are you with the time it took you to hear about additional recommendations for care of this problem? __________

• (A‐CAHPS question #PK2) Did this doctor who asked the specialist for input seem informed and up‐to‐date about the care recommended by specialists for your problem? Y N

• If this doctor is not your personal care physician, does your personal care physician seem informed and up‐to‐date about the care recommended by specialists for your problem? Y N N/A (this doctor is my personal care physician) Don’t know

Source: Palen, T. E., Price, D., Shetterly, S., & Wallace, K. B. (2012). Comparing virtual consults to traditional consults using an electronic health record: an observational case–control study. BMC medical informatics and decision making, 12(1), 65.

Adapted the survey from the modified Adult Ambulatory Care Consumer Assessment of Health Plans Survey (A‐CAHPS)


30

Source: Olayiwola, James, Tuot et al. Understanding the Potential for Patient Engagement in Electronic Consultation and Referral Systems: Lessons from one Safety Net System. Health Services Research 2017

Strategies for Assessing Experience and Engagement of Patients• Questions centered around patient experience with subspecialty visits, perceived coordination of PCC and subspecialty care, communication with and between PCCs and specialists about the electronic consultation process, potential patient or family/caregiver roles in the consultation process, and desirability of such potential roles

• Specialist open‐ended focus group questions explored potential for patient or family/caregiver role in the consultative process

• PCC survey examined perceptions of the potential for patient or family/caregiver roles in the electronic consultation process

• Olayiwola, Tuot et al (2017‐ in press)

• Mixed methods: Triangulation study of patients (focus groups), PCCs (survey) and eCR specialists (focus groups)

• Focus groups conducted with English, Spanish and Cantonese speaking patients

• Open‐ended focus groups

Patient Focus Groups


Clinician Assessments

Patient Focus Groups

PatientSurveys

Patient Advisory Councils

One Additional Strategy for Assessing Experience and Engagement of Patients


31

Patient Advisory Councils

Developing a Patient Experience Program

Source and handout ‐ https://www.stepsforward.org/Static/images/modules/49/downloadable/patient_experience.pdf

6 Key Steps

1. Assess the current state of

patient satisfaction

2. Define your “North Star”

3. Engage key stakeholders in

experience design

4. Develop and implement your

patient experience strategy

5. Analyze feedback and

determine impact

6. Recognize accomplishments

and improve over time


32

Group Activity: Design Your Patient Experience Goal!• HPA is working with AGPAL to better understand

how the HCH initiative has improved patient experience and patient outcomes.

• Your practice is responsible for providing them with a brief review of its performance in these areas.

• As a group, come up with what you will capture, how to measure it, and what you will glean from it

Group Activity: Tools Available

Patient Assessment Goal

Patient experience

Patient activation

Patient engagement

Patient outcomes

StrategyClinician assessments

Patient focus groups or interviews

Patient committees or advisory groups

Patient Surveys

Measures Structures Processes OutcomesPractice or patient‐level

Participants Leadership Clinicians Patients Staff


33

Regroup and reflect

• Share your patient experience goals and ideas with the group

• What did you come up with?

• How can you make it actionable?

Empowering Patients in the Health Care Home


34

Let’s Talk!

• What approaches have you used in your practices to empower patients:

– in their care?

– in decision‐making?

– in quality improvement?

– in practice level change?

Family Consultations and conferences

Shared medical appointments – Gary Eggar’s research

Group Education – Inala’s My Health for Life and obesity work

Bolton Diabetes Cards

Medicine Sick Day Cards

Training patients to ask questions

Shared decision‐making

How Do We Empower Patients in the New Model?


35

• We are ALL the Patient Experience• We are all the patient experience ‐https://www.youtube.com/watch?v=iBLQnThJ6w0

Thank You!


36

Date post:	31-Jul-2020
Category:	Documents
Upload:	others
View:	0 times
Download:	0 times

- AGPAL & QIP€¦ · Quality Improvement Types of measures for assessing quality of care : •...

Documents