Improving Performance in Practice (IPIP)Change Package

Coaching PracticesImproving Healthcare State by State

Martha Rome, RN, MPHMilwaukee, WI

February 11, 2009

Aims of IPIP

• To dramatically improve patient outcomes by transforming the way we deliver primary care, focusing initially on measurable improvement in diabetes and asthma, but rapidly spreading to preventive services and other conditions

• To assist different types of practices in using practice redesign strategies to improve efficiency and implement best practices

• To align efforts and motivate action at the national, regional, state, practice and patient level

3

Aligning Across Policy LevelsNational

State

Network

Practice

Patient

Build will on state level and create state infrastructure

• National specialty societies work through state chapters• Specialty Boards provide clear expectations for

maintenance of certification• Partner with other organizations in the state

– AHEC, QIO, payers, businesses, state government

• Aligning state efforts creates the IPIP model• National Team supports states with:

– Standard protocols– Decision support tools – Access to other practices who’ve done this work successfully– Access to experts in the field– Data aggregation and reports

Model

• Improvement networks/collaboratives

• Quality Improvement Coaches: Support individual practices and improvement networks – Onsite consulting– Group meetings (in person and phone)

• Reporting: monthly submission of performance measures

Documentation of knowledge and

performanceActivated physicianStarting point for QI

Collaborative practice

Using shared data

Improved outcomeswith physicians and

practices expert in QI

Schematic of IPIP Process

Enrollin IPIP

Statewide primaryCare practices

Knowledge Management

QIC

Role of Quality Improvement Coaches

• Intensive (often) on-site work with the practice team• Provide avenue to network activities and share best

practices• Focused approach for implementation starting with key

process changes– Move practices faster for basic implementation– Create group momentum with regard to implementation

and standardization• Help practices ensure that all IPIP changes are

implemented• Assist practices in developing teams & standardized work

flow• Provide examples of tools (standing orders) and roles• Assist practices with regular monitoring of implementation to

ensure reliability

8

Living with chronic illness is like piloting a small plane

9

To get safely to their destinationpilots need:

• Self-Management Support

• Effective ClinicalManagement

• Treatment Plan

• Close Follow-up

• Flight instruction

• Preventive Maintenance

• Safe Flight Plan

• Air Traffic ControlSurveillance

10

Usual care works well if your plane is about to crash

11

The IOM Quality Report:Selected Quotes

• “The current care systems cannot do the job.”

• “Trying harder will not work.”

• “Changing care systems will.”

12

Systems are perfectly designed to get the results they achieve

The Watchword

13

Evidence-basedClinical ChangeConcepts

A Recipe for Improving Outcomes

LearningModel

System ChangeConcepts

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

System change strategy

Select Topic

Planning Group

Identify Change

Concepts

Participants

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Action Period Supports

E-mail Visits Web-site

Phone Assessments

Senior Leader Reports

Event

A D

P

S

(12 months time frame)

14

Advantages of a General System Change Model

• Applicable to most preventive and chronic care issues

• Once system changes in place, accommodating new guideline or innovation much easier

• Early participants in our collaboratives using it comprehensively

15

Essential Element of Good Chronic Illness Care

Informed,ActivatedPatient

ProductiveInteractions

PreparedPractice Team

16

What characterizes a “prepared” practice team?

PreparedPractice Team

At the time of the visit, they have the patient information, decision support, people,

equipment, and time required to deliver evidence-based clinical management and

self-management support

17

What characterizes a “informed, activated” patient?

Patient understands the disease process, and realizes his/her role as the daily self manager. Family and caregivers are engaged in the patient’s

self-management. The provider is viewed as a guide on the side, not the sage on the stage!

Informed,ActivatedPatient

18

•Assessment of self-management skills and confidence as well as clinical status•Tailoring of clinical management by stepped protocol•Collaborative goal-setting and problem-solving resulting in a shared care plan•Active, sustained follow-up

Informed,ActivatedPatient

ProductiveInteractions

PreparedPractice Team

How would I recognize aproductive interaction?

19

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

Improved Outcomes

20

Clinical Information System

• Provide reminders for providers and patients. • Identify relevant patient subpopulations for

proactive care.• Facilitate individual patient care planning.• Share information with providers and patients.• Monitor performance of team and system.

21

Delivery System Design

• Define roles and distribute tasks amongst team members.

• Use planned interactions to support evidence-based care.

• Provide clinical case management services.• Ensure regular follow-up.• Give care that patients understand and that fits

their culture

22

Self-management Support

• Emphasize the patient's central role.• Use effective self-management support

strategies that include assessment, goal-setting, action planning, problem-solving and follow-up.

• Organize resources to provide support

23

To Change Outcomes (e.g., HbA1c) Requires Fundamental Practice Change

• Interventions focused on guidelines, feedback, and role changes can improve processes

• Interventions that address more than one area have more impact

• Interventions that are patient-centered change outcomes.

Renders et al, Diabetes Care, 2001;24:1821

24

Templates Related to Better Performance and Less Variation (IPIP

practices)

25

IPIP Change Package

• High-leverage Changes– Implement Registry– Use Template for Planned Care– Use Protocols– Adopt Self-management Support Strategies

Implement IPIP Changes in Steps

1. Use Registry to identify asthmatics/diabetics prior to visit (this requires the work of implementing a registry or “fixing” the EHR)

2. Use condition-specific decision support tool (e.g., visit planner)

3. Create customized flow diagram and protocols to standardize the care process

• Nursing Standing Orders to increase reliable execution [examples]• Standard Protocol [example]• Specific Care Team roles: who does what in the protocol

4. Implement a self-management support system

Throughout: Frequent monitoring of reliability and investigation of failures for ideas about how to improve standard performance

27

Detailed Changes: Registry

1) Select and install a registry tool2) Determine staff workflow to support

registry use3) Populate registry with patient data4) Routinely maintain registry data5) Use registry to manage patient care

and support population management

28

Detailed Changes: Templates

1) Select template tool from registry or create a flow sheet

2) Determine staff workflow to support use of template

3) Use template with all patients4) Ensure registry updated each time

template used5) Monitor use of template

29

Detailed Changes: Protocols

Step 3: Use Protocolsa. Select and customize evidence-based

protocols to officeb. Determine staff workflow to support

protocols, including standing ordersc. Use protocols with all patientsd. Monitor use of protocols

30

Protocols: Asthma-specific

• Assess and document asthma severity and control

• Prescribe appropriate asthma medications and monitor overuse of beta agonists

• Use Asthma Management plans• Establish visit frequency protocol• Assess and treat co-morbidities• Assess, counsel, and prevent exposure

to environmental triggers

31

Protocols: Diabetes

• Check and treat BP <130/80• Check and treat cholesterol • Check A1C and treat hyperglycemia• Assess aspirin and prescribe if not using• Assess need for eye exam and make

referral if needed• Assess nephropathy risk• Perform foot exam • Provide appropriate vaccines

32

Self-management Support

• Obtain patient education materials (e.g., asthma action plans)

• Determine staff workflow to support SMS

• Provide training to staff in SMS techniques

• Set patient goals collaboratively• Document and monitor patient progress

toward goals• Link with community resources (schools,

service organizations)

33

IPIP System Diagram

Intervention/Change ConceptsKey Drivers Outcomes

Implement Registry

Determine staff workflow to support registry

Populate registry with patient data

Routinely maintain registry data

Use registry to manage patient care & support population management

Use Templates for Planned Care

Select template tool from registry or create a flow sheet Determine staff workflow to support template Use template with all patients Ensure registry updated each time template used Monitor use of template

Employ Protocols

Select & customize evidence-based protocols for asthma and diabetes Determine staff workflow to support protocol, including standing orders Use protocols with all patients Monitor use of protocols

Provide Self-Management Support

Obtain patient education materials

Determine staff workflow to support SMS

Provide training to staff in SMS

Set patient goals collaboratively

Document & monitor patient progress toward goals

Link with community resources

Use Registry to Manage Population Identify each affected patient at every visit Identify needed services for each patient Recall patients for follow-up

Planned Care

Care Team is aware of patient needs and work together to ensure all needed services are completed

Standardized Care ProcessesPractice-wide guidelines implemented per condition (asthma, diabetes

Self Management Support

Realized patient and care team partnership

Improved clinical outcomes for patients with diabetes and asthma

Measures of success:Diabetes: >70% BP < 130/80 >70% LDL < 100 mg/dl <5% A1c greater than 9.0% >80% received dilated eye exam >90% tested (or treated) for nephropathy >90% counseled to stop tobacco use

Asthma: >90% control assessed >90% with persistent asthma on anti-inflammatory medication >90% with influenza vaccination >75% with: assessment of control + anti-inflammatory + influenza vaccination

34

Cincinnati Children’s Hospital PHO

• 44 geographically dispersed, sites

• Individual models and styles of practice

• “First Wins”– Early adoption of registry– Concurrent data collection: written parent

symptom review and clinical interview

35

BMF Included

Cumulative Percent of Network Asthma Population Receiving "Perfect Care"

8/05Web Site

with RegistryLaunched

10/04Desktop PC

RegistryInstalled at Practices

3/05Self

ManagementCollaborative

8/04Pay for

PerformanceProgram

Announced

5/04Reliability

ImprovementCollaborative

1/04PerformanceFeedbackReports

10/03Project

InceptionRegistry

Established

1/05 Pay for Performance

Rewards Determined

3/31/06

"Perfect Care"

WITH Flu Shot

End 05-06 Season

3/31/05

"Perfect Care"

WITH Flu Shot

End 04-05 Season0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%Oc

t 03

Dec

03

Feb

04

Apr 0

4

Jun

04

Aug

04

Oct 0

4

Dec

04

Feb

05

Apr 0

5

Jun

05

Aug

05

Oct 0

5

Dec

05

Feb

06

Apr 0

6

Jun

06

Aug

06

Oct 0

6

Dec

06

Feb

07

Apr 0

7

Jun

07

PHO practices achieve > 80% reliability (“perfect care”)

36

Percent of asthma population with 1 or more CCHMC asthma related admissions ( Monthly )

0.0%

0.1%

0.2%

0.3%

0.4%

10/0

3 n=

1192

5

12/0

3 n=

1192

5

02/0

4 n=

1192

5

04/0

4 n=

1192

5

06/0

4 n=

1192

5

08/0

4 n=

1192

5

10/0

4 n=

1192

5

12/0

4 n=

1192

5

02/0

5 n=

1192

5

04/0

5 n=

1192

5

06/0

5 n=

1192

5

08/0

5 n=

1192

5

10/0

5 n=

1192

5

12/0

5 n=

1192

5

02/0

6 n=

1192

5

04/0

6 n=

1215

3

06/0

6 n=

1240

1

08/0

6 n=

1244

3

10/0

6 n=

1263

1

12/0

6 n=

1264

3

02/0

7 n=

1258

2

04/0

7 n=

1272

0

06/0

7 n=

1272

3

08/0

7

Percent Center Line Control Limits

10/03 project initiation

Center Line has been recalculated based on data from 11/05 through 12/06.

80% of Patients Receive “Perfect Care”

Relationship between changing process and changing outcome

37

Impact of PHO Asthma Initiative

ED Visits per 1,000

0

0.5

1

1.5

2

2.5

3

Baseline Improvement Period

ED

Vis

its

Comparison

PHO

Asthma Admissions per 10,000 Children

0

2

4

6

8

10

Baseline Improvement Period

Ad

mis

sio

ns

/10

,00

0Comparison

PHO

38

UNITE HERE Health CenterUNITE HERE Health Center

Founded 1914 by ILGWU

Union mergers over the years, now UNITE HERE

Comprehensive Primary and Specialty Care

Serves predominantly UNITE HERE members, their families and retirees and SEIU 32BJ members

1000 office visits/week

12 PCP’s, 40 specialists, all staff bilingual

On Site Physical Therapy, Radiology and Pharmacy

39

Primary Care TeamsPrimary Care Teams High functioning multidisciplinary teams with 2 hours protected meeting time every other week

Huddles

–Led by MA who does chart reviews day before

–First 20 minute appointment blocked

–Identify patients for health coach interventions

Cell phones and walkie-talkies

Protocols developed & incorporated into EMR templates

40

TeamworkTeamwork

• PCAs trained in monofilament testing, glucose diaries and ABC cards

• Standing orders for Pneumovax and ophthalmology appointments

• Pharmacy gets A1C lists for medication review

• Health Coaches for DM education, self management goal setting, BP checks and blood glucose checks

41

Transforming Medical Assistants into Transforming Medical Assistants into Health CoachesHealth Coaches

Curriculum developed for in-house training

Didactic and observational testing

Promotion to “Health Coach” after competency evaluation

Supervision by Nurse Practitioner and RN coordinator

42

Evidence Based CareEvidence Based Care

• All providers use the DM template

• Review and discussion of data at provider meetings

• DM always on the agenda

• Provider educational seminars

• Provider chart reviews

43

Challenges Challenges

% of patients with BP <130/80

40

50

60

70

80

90

May-05

Aug-05

Nov-05

Feb-06

May-06

Aug-06

Nov-06

Feb-07

May-07

Aug-07

Nov-07

Feb-08

May-08

Aug-08

Nov-08

Months

Per

cen

tag

e .

44

Focus on HypertensionFocus on Hypertension

• Reinforced use of BP check visit – patient sees RN or Health Coach

• New protocol and training for MA to recheck BP if high prior to seeing PCP

• BP Loan Program

• Chart Reviews

• Discussion with PCPs at monthly meeting

45

CHART REVIEW FOR UNCONTROLLED CHART REVIEW FOR UNCONTROLLED HYPERTENSION IN PEOPLE WITH DIABETESHYPERTENSION IN PEOPLE WITH DIABETES

 Number of patients: 122 BP at last PCP visit: <140/90 72 (59%) >140/90 50 (41%)

Was BP rechecked after first reading: Yes 37 (30%) No 86 (70%)  Number of medications for HTN: 0- 14 (11%) 1- 28 (23%) 2- 34 (28%) 3- 26 (21%) 4- 13 (11%) >4- 6 (5%) 2 or fewer 76 (62%) 3 or fewer 102 (84%) Was uncontrolled HTN identified as a problem: Yes 82 (67%) No 40 (33%)  Took medications for HTN on day of visit: Yes 33 (27%)

No 24 (20%) Not in note 51 ( 42%) N/A 8 (7%)

46

PCP DiscussionsPCP Discussions

• Monthly PCP meetings

• Results of chart reviews drive PCP discussion

• Discuss clinical management of HTN

• Ask PCP with best results – what do you do?

• Share best practices - start with combination drugs

47

PCP DiscussionsPCP Discussions

• Identifies common misconceptions – “uncontrolled patients are already on maximal doses of medications”

• Identifies target for improvement – importance of rechecking BP if uncontrolled and asking if patients took their medications on the day of the visit

48

The Multidisciplinary Team: The key to successful planned

diabetes care and quality improvement in our practice

Robb Malone, PharmDUNC General Internal Medicine

January 20, 2009

49

Change is scaryChange is hardChange is an opportunity to improveChange is complicatedChange is necessaryChange requires leadershipSuccessful change requires a well designed, active team

Water cooler discussions

50

We assessed root causes and actionsRoot Causes Actions

Continuity of care is poor because providers have limited clinical time

Make clinical pharmacists available to patients daily

Patients often miss follow-up appointments

Call patients to remind them of appointments

Transportation barriers can hinder care Increase phone management; 1-800 number; transportation program

Physicians lack time and skill to provide proper diabetes education

Pharmacists provide individualized education

Patients have low education and literacy Design interventions that do not rely on literacy

Physicians contribute to clinical inertia by failing to escalate therapy

Need agreement on evidence-based treatment algorithms; Pharmacists use algorithms to escalate therapy with physician sign-off

Tracking of patient outcomes is poor Design registry to allow better tracking of patients

51

Everything tipped in late 2007:How did we hit ‘The Tipping Point’?

• “The level at which the momentum for change becomes unstoppable.“

• "Ideas and products and messages and behaviors spread like viruses do.“

– The Tipping Point: How Little Things Can Make a Big Difference. Malcolm Gladwell

Consensus driven growth that focused on the teamwork, contribution from all, and leadership development in QI

Acceptance from the late majority and laggards

52

What did we learn from What did we learn from the first 3 years?the first 3 years?

• ‘Every system is perfectly designed to get the results it gets’

• If we don't like the results we have to change the system- basically and radically

• Providers responded to data and information at the point of care– Addressed unanswered questions

• We must build consensus and standardize

• We must diversify

• We need to move more quickly

53

An epiphany: The run chart , reporting AVG A1c for our clinic

2004

Average A1c

77.17.27.37.47.57.67.77.87.9

8

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A1c

(%

)

Average A1c

77.17.27.37.47.57.67.77.87.9

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Diabetes planned care• Patient registry• Robust decision support• Prompting and stratification of patients by risk

– Stepped care approach

• All patients eligible and recruited for care• Patient-centered education• Care coordination• Expanded standardization and algorithmic care• Extensive quality reporting• Adoption of the Model for Improvement (MFI)

55

What we learned from 2003 to 2006What we learned from 2003 to 2006• A successful program includes:

– A multidisciplinary team

– A registry with decision support for proactive care

– Consensus backed by evidence-based algorithms and standards

• Persistence and leadership are key

• Appropriately designed interventions or systems can overcome patient vulnerability

• We continually evolve, change is necessary and represents opportunity– Embrace rapid cycle change and the MFI

56

An example of our stepped care approach: Green Zone

Low Risk

A patient with any of the following:A1C < 7.5% AND BP < 140/85

ANDGlobal Assessment Good

Stepped-Care Stratification

Patient Care PlanAll new or recent onset patients are encouraged to attend our group

class.1. CDE visits per request (Medical Intervention).2. Assistance and care coordination at PCP visit per request only.3. RD MNT‡ as needed.4. Passive medication management.5. Phone follow-up as needed.6. Toll-Free telephone access and after hours nurse support.7. Automated lab ordering

Continuous Clinical Reassessment

~ 40% of our patients

57

An example of our stepped care approach: Yellow Zone

Moderate Risk**

A patient with any of the following:A1C 7.5 to 8.5% AND BP 140-160/85-90

ANDGlobal Assessment Fair

Stepped-Care Stratification

Patient Care PlanAll new or recent onset patients are encouraged to attend our group

class.

Quarterly CDE visits (Medical Intervention).1. Intense medication management.

If not on ASA, start.If not on Statin, start.

2. Assistance and care coordination at most PCP visits.3. Target 3 RD MNT‡ visits per year.4. Phone follow-up as needed.5. Toll-Free telephone access and after hours nurse support.6. Automated lab ordering and interpretation

Continuous Clinical Reassessment

~ 35% of our patients

58

An example of our stepped care approach: Red Zone

High Risk**

A patient with any of the following:A1C > 8.5% OR BP > 160/90 OR

Global Assessment PoorOR No ASA or Statin

Patient Care PlanAll new or recent onset patients are encouraged to attend our group class.

1. Bimonthly CDE visits (Medical Intervention).2. intense medication management.

If not on ASA, start.If not on Statin, start.

3. Assistance and care coordination at every PCP visit.4. Target 3 RD MNT‡ visits per year.5. Yearly Nutrition class referral.6. Monthly to biweekly phone follow-up.7. Toll-Free telephone access and after hours nurse support.8. Automated lab ordering and interpretation

Stepped-Care Stratification

Continuous Clinical Reassessment

~ 25% of our patients

59

Role of The Care Assistants• Consists of 4 care assistants

• Care assistants see patients during provider visits– Patient education

– Utilize the tools created by the database

– Assist the physician

– Facilitate proactive care, encourage intervention

– Address barriers, adherence, glucose monitoring, provide smoking cessation counseling, screen for depression

60

Average A1c in our clinic now

Average A1c

77.17.27.37.47.57.67.77.87.9

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Average A1c

77.17.27.37.47.57.67.77.87.9

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Example 1 Lipid screening & management:

A front desk intervention

62

Status of Lipid Management September 2004

• 55% of patients had total cholesterol tested annually

• Approximately 68% were prescribed statins• Average total cholesterol = 185 mg/dl• Average LDL = 99 mg/dl

• We set a goal that 90% of patients would be screened annually and prescribed a statin

63

Front Desk Process

• List of patients with diabetes• Whether or not labs need to be drawn

• We had patients that needed labs that were not getting triaged appropriately

• Looked at front desk logs and process

Plan/Do

Study

64

Front Desk Logs

• About 60 patients with diabetes/week

• 30 needed a lab drawn

• Only 15 had it drawn (50%)

Study

65

Pizza for 90% Fidelity

• 25/33 = 75% No pizza

• 34/36 = 94% PIZZA

Act-Plan

Study

66

Percent of Patients with Total Cholesterol Tested Yearly

0

20

40

60

80

100S

ep-0

4O

ct-0

4N

ov-0

4D

ec-0

4Ja

n-05

Feb

-05

Mar

-05

Apr

-05

May

-05

Jun-

05Ju

l-05

Aug

-05

Sep

-05

Oct

-05

Nov

-05

Dec

-05

Jan-

06F

eb-0

6M

ar-0

6A

pr-0

6M

ay-0

6Ju

n-06

Jul-0

6A

ug-0

6S

ep-0

6O

ct-0

6N

ov-0

6D

ec-0

6Ja

n-07

Feb

-07

Mar

-07

Apr

-07

May

-07

Jun-

07Ju

l-07

Aug

-07

Sep

-07

Oct

-07

Nov

-07

% T

ota

l C

ho

lest

ero

l T

este

d Start Automated

StopAutomated

StopAutomated

Re-Start Automated

Front desk fidelity

67

Average Lipid Results

75

100

125

150

175

200

Jul-

05

Au

g-0

5S

ep

-05

Oct

-05

No

v-0

5D

ec-

05

Jan

-06

Fe

b-0

6M

ar-

06

Ap

r-0

6M

ay-

06

Jun

-06

Jul-

06

Au

g-0

6S

ep

-06

Oct

-06

No

v-0

6D

ec-

06

Jan

-07

Fe

b-0

7M

ar-

07

Ap

r-0

7M

ay-

07

Jun

-07

Jul-

07

Au

g-0

7S

ep

-07

Oct

-07

No

v-0

7

Re

su

lts

(m

g/d

l)

Total Chol

LDL

Average Lipid Results

75

100

125

150

175

200

Jul-

05

Au

g-0

5S

ep

-05

Oct

-05

No

v-0

5D

ec-

05

Jan

-06

Fe

b-0

6M

ar-

06

Ap

r-0

6M

ay-

06

Jun

-06

Jul-

06

Au

g-0

6S

ep

-06

Oct

-06

No

v-0

6D

ec-

06

Jan

-07

Fe

b-0

7M

ar-

07

Ap

r-0

7M

ay-

07

Jun

-07

Jul-

07

Au

g-0

7S

ep

-07

Oct

-07

No

v-0

7

Re

su

lts

(m

g/d

l)

Total Chol

LDL

Focus on testing and utilization led to improved lipids

68

Example 2Process measure improvement: Nurse-directed interventions,

improving the prompts

69

Process to engage nurses

• Solidified divisional support for utilizationof the intervention

• Developed educational session with nurses– Meeting introduction by medical director– Revisited intent of the yellow sheets– Reiterated the role of the nurse as an integral

member of our team– Reviewed evidence behind recommendations– Listened to nurses’ concerns

• Developed rapid means of feedback

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Items to be included in nurse assessment

• Assess as indicated on the prompt– Depression screening

– Smoking assessment and intervention

– Eye referrals

– Monofilament testing

– Pneumococcal vaccination

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Modified Intervention (version 3)

Feedback and change in clinical focus led to significant revision of the yellow sheets

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Simple procedure for tracking daily progress- Excel spreadsheet

Completed by ancillary staff

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Bring on the pizza

Progress with mixed results

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Widespread, significant improvement noted

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Provider satisfaction has improved: How has this affected the

life of a physician?

• Delegating processes frees up time to focus on diagnostic and therapeutic issues

• A weight has been lifted

• Excellent to know how the practice performs

• Data has changed our conversations

• It is satisfying to show improved care

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Diabetes Improvement Across the Practice--Lessons

• Just working harder doesn’t lead to better outcomes

• Just making a policy doesn’t mean the process gets done

• Doctors in our system don’t follow algorithms or policies very well– Other members of the health care team are

better…and that is OK

• Each member must function at their highest level of skill

• Distractions will arise, challenges will occur

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In Summary: Change Package

• Includes details about making changes, measures, assessment scales and tools

• A resource for practices and QICs• Offers guidance and resources• Remember: Teams’ testing helps adapt

and adopt strategies in their office

IPIP Expectations

• Practices work on redesign of systems of care delivery

• Target improvement in diabetes or asthma

• This becomes how we practice healthcare —continuously tracking, sharing, and improving

• Participation in IPIP meets one requirement for maintenance of certification and qualifies for Continuing Medical Education (CME) credit

Expectations re: Data

• Collect data on performance measures (required)

• Submit numerators and denominators to IPIP via QIC, state program or directly

• Reliable, quality care is provided to the entire population by using registry (or EHR with population management functions)

What do we mean by data?

• Aggregate measures of quality– Based on national standards

(NCQA,AQA,HEDIS)– Physician or practice-based– Additional details enhance understanding of

context and meaning (levels of data quality)– Range of data sources (paper -> Electronic

Health Record)

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Rely Upon Nationally Endorsed Measures

• Early in IPIP development, it became clear that the scope of determining “ideal” measures was beyond IPIP

• Other organizations exist to do this: NCQA, Physicians Consortium, National Quality Forum, Ambulatory Care Quality Alliance

• IPIP decided to only require measures that had been endorsed by a one or more of the above organizations

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Benefits and Downsides

• Mitigates the debate about individual opinions

• Dramatically improves our ability to align• Reduces flexibility• Often leaves us with more “clunky” measures

(less sensitive to changes)• Measures sometimes change slower than we

would like (concerns about obsolete)

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Required IPIP measures are not the only measures practices should be using

Use other measures to help ensure reliable processes and do small PDSAs

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• The complete IPIP Change Package is in Word format on the Extranet. Look under Resources and then in the Change Package folder.

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References

• www.improvingchroniccare.org

• http://www.med.unc.edu/medicine/generalm/documents/DiabetesResearch.pdf

• www.ihi/org/extranet.

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• http://www.med.unc.edu/medicine/generalm/documents/DiabetesResearch.pdf