NTTAP Webinar Series - April 13, 2023: Quality Improvement Strategies in a Team-Based Care Environment

Quality Improvement Strategies in a
Team-Based Care Environment
April 13th, 2023
1:00-2:00pm Eastern / 10:00-11:00am Pacific
1

Continuing Education Credits
In support of improving patient care,
Community Health Center, Inc. / Weitzman
Institute is jointly accredited by the
Accreditation Council for Continuing Medical
Education (ACCME), the Accreditation Council
for Pharmacy Education (ACPE), and the
American Nurses Credentialing Center
(ANCC), to provide continuing education for
the healthcare team.
A comprehensive certificate will be available
after the end of the series, Summer 2023.
2

Disclosure
• With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship
between the party listed above (or spouse/partner) and any for-profit company in the past 12 months which would
be considered a conflict of interest.
• The views expressed in this presentation are those of the presenters and may not reflect official policy of
Community Health Center, Inc. and its Weitzman Institute.
• We are obligated to disclose any products which are off-label, unlabeled, experimental, and/or under investigation
(not FDA approved) and any limitations on the information hat we present, such as data that are preliminary or
that represent ongoing research, interim analyses, and/or unsupported opinion.
• This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of
Health and Human Services (HHS) as part of an award totaling $137,500 with 0% financed with non-governmental
sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an
endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
3

At the Weitzman Institute, we value a
culture of equity, inclusiveness,
diversity, and mutually respectful
dialogue. We want to ensure that all
feel welcome. If there is anything said
in our program that makes you feel
uncomfortable, please let us know via
email at nca@chc1.com
4

National Training and Technical Assistance Partnership
Clinical Workforce Development
Provides free training and technical assistance to health centers across the
nation through national webinars, learning collaboratives, activity sessions,
trainings, research, publications, etc.
5

Speakers
• Deborah Ward, RN
• Quality Improvement Consultant, Community Health Center, Inc.
• Raneda Porter, LMSW
• AmeriCorps Program Director, Community Health Center, Inc.
6

Objectives
• Review Team-Based Care concepts
• Define what is Quality Improvement (QI) and outline a common model for
QI
• Recognize the importance of data and how to use it
• Discuss how to establish and facilitate a QI/Performance Improvement
(PI) committee
• Describe coaching and a clinical microsystems approach to QI
• Explore CHC QI clinical microsystems strategy example
7

Introduction to Team-Based Care
• A patient-care team is a group of diverse clinicians and practice staff who
communicate with each other regularly about the care of a defined group
of patients and participate in that care.
• Rather than a lone clinician being responsible for the care of a panel of
patients, the team shares that responsibility. Everyone on the team shares
the care.
8

Why do we need to transform primary care?
• Patient access is poor and getting worse
• Continuity of care is under stress
• Panel sizes are too large because not enough clinicians choose primary
care careers
• The downward spiral of large panels and burnout
9

The 10 Building
Blocks of
High-Performing
Primary Care
Website: cepc.ucsf.edu
10 Source: Bodenheimer et al, Ann Fam Med 2014:12:166-171

What is Quality Improvement?
“Quality improvement (QI) consists of systematic and continuous actions
that lead to measurable improvement in health care services and the health
status of targeted patient groups.”1 - HRSA
To do this, teams need actionable data.
“Every system is perfectly designed to get the results it gets.”2
–Paul Batalden, MD
11
1. US Department of Health and Human Services, Health Resources and Services Administration. Quality improvement. 2011.
https://www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/qualityimprovement.pdf. Accessed March 21, 2022.
2. Nelson, E. C., Batalden, P. B., & Godfrey, M. M. (Eds.). (2011). Quality by design: a clinical microsystems approach. John Wiley & Sons.

Common Models that Require Special Training
Six Sigma/DMAIC Lean/Six Sigma
12
1. https://www.qualitymag.com/articles/94429-back-to-basics-six-sigma
2. https://www.greycampus.com/blog/quality-management/a-brief-introduction-to-lean-and-six-sigma-and-lean-six-sigma

Team &
Roles Defined
Assessment
And
Baseline Data
Global Aim
Problem
Statement
Change
ideas/
solution
storming
Specific Aims
and
measures
PDSA
SDSA
Spread
Measure
and
Monitor
CHC’s Stages of Improvement
On-Going Data Collection & Review
Not a linear process: iterative
These stages overlap with and are an adaptation of several models, e.g., the IHI
model (PDSA) and DMAIC (Define/Measure/Analyze/Improve).
Source: Thies, K., Schiessl, A., Khalid, N., Hess, A. M., Harding, K., & Ward, D. (2020). Evaluation of a learning collaborative to advance team-based care in
Federally Qualified Health Centers. BMJ Open Quality, 9(3), e000794.
13

CHCI Quality Improvement
How QI works at CHC
• Data
• Performance Improvement
Committee
• Teams and Coaching
14

Data is used to:
Track the health of an individual patient
Track the health status of populations of patients, disparities
Track cycle time, no show rates
Predict trends in utilization of care
Track costs associated with care
Reimburse care
Benefit from value-based contracts
Continuously improve care to justify further investments in care
15

Infrastructure for Data: Business Intelligence
• BI systems combine data gathering, data storage, and knowledge
management with analytical tools to present actionable information to
planners and decision makers.
• BI provides actionable data structured so that it is meaningful and can be
acted on by staff: dashboards, reports, graphics, etc.
• Without the right data in the right hands at the right time in the right
format, you cannot improve performance or measure performance.
16

CHC uses the Clinical Microsystems approach to QI
• A clinical microsystem in health care is “a small group of people who work
together on a regular basis to provide care to discrete subpopulations of
patients. It has clinical and business aims, linked processes, and a shared
information environment, and it produces performance outcomes.”
• Built on the premise that the people who do the work know how the work
can be improved.
Source: Nelson, E. C., Batalden, P. B., & Godfrey, M. M. (Eds.) (2011). Quality by design: a clinical microsystems approach. John Wiley & Sons.
17

Microsystems and Team-Based Care
• Clinical Microsystems improvement team is “a small group of people who work
together on a regular basis…,” also the principle of team-based care
• Consistent with the foundations and functions of team-based primary care:
systems-oriented, data-driven, team-based.
• Built on a team culture of “Share the Care,” not “my patients” but “our patients”
 culture of “share the outcomes”  “share the process of improving the care”
• Begins with the team doing an assessment of their own practice (data), not PDSA
cycles or proposing solutions.
Source: Ghorob, A., & Bodenheimer, T. (2012). Sharing the care to improve access to primary care. The New England Journal of Medicine, 366(21), 1955-
1957. doi:10.1056/NEJMp1202775
18

CHC’s Performance
Improvement Structure
19

Category Goal topic Specific Goal Source 2020 Rate
Current rate
(11/21)
Current Goal
Recommended
Goal
Chronic disease care
Diabetes control
Increase the number of patients with an A1c
(HbA1c) less than 9.0 percent
UDS 57.97% 65.39% 70% 70%
A1C testing
Reduce the number of patients with diabetes
who have not had an A1c completed in the last
12 mo.
CHC 22.00% 13.54% 5% 5%
HTN control
Increase the number of patients with
hypertension whose BP is controlled (less than
140/90)
UDS 46.82% 51.47% 70% 60%
BP documentation
Reduce the number of patients with
hypertension who have NOT had a BP
documented in the last 12 months
CHC 26.30% 17.00% 10%
Home BP cuff use
Increase the number of patients with HTN who
have a home BP cuff
CHC
0.7% (last 12
mo)
11%
New goal:
input from
Team
1. Category
2. Goal topic
3. Define Specific goal
4. Source
5. 2020 Rate
6. Current rate
7. Current Goal (2021)
8. Recommended Goal
• Chronic Disease
• Screening
• Behavioral Health
• Preventative Care
• Population Health
• Dental
• Medical and Dental
• Prenatal
Performance
Improvement Goals
20

Coach Training within Health Centers
• Identification of the new coach
• Communication with leaders
• Commitment from the coach in training and supervisor
• Training (six to seven didactic sessions)
• Mentor program
• Monthly Coach meeting
• Reports to Performance Improvement/Steering committee
22

Team &
Roles Defined
Assessment
And
Baseline Data
Global Aim
Problem
Statement
Specific
Aims
And
Measures
Change Idea
Solution-
Storming
PDSA
SDSA
Spread
Measure
and
Monitor
 6. SOLUTION STORMING for CHANGE
IDEA
What could we try?
Realistic ideas, Manager|Leader involvement.
TOOLS/SKILLS/PROCESS:
Idea Tree
Parking Lot
Force Field Analysis
Impact Effort
Multi-Voting
 7. PDSA
Aim, test, who, when, where.
PLAN Tasks: How will we do it? What, Who,
When, Where. Predictions, Measures
DO: Lets try it out. Results
STUDY: How is it working out? ACT: Lets try it
again with modifications?
PDSA Template
Keep test SMALL
Only one PDSA at a time
Measures
On-Going Data Collection & Review
 1. TEAM AND ROLES DEFINED
Coach Assigned, Identify Core and Extended
Team Members, Define Roles, Schedule Team
Meetings, Communication Plan
Effective Meeting Tools
Forming/Storming/Norming/
Performing
 2. ASSESSMENT AND
BASELINE DATA
What is our current state? Describe population
of interest, Identify data sources, Drill down to
specific areas of focus. Related to other
projects?
Tick & Tally & other data collection
Process Mapping
Role Assessment
Team Practice Assessment
 3. GLOBAL AIM
What is our overall goal for advancing TBC
Model? Theme, Name process, location,
Start/End of Process, Benefits/Imperatives
Build Consensus
Fishbone Diagram (cause & effect diagram)
 4. PROBLEM STATEMENT/THEME
Problem Statement, Importance, Goals/
Objectives, Deliverables, KPIs
QI Charters as agenda items
Brainstorming/ Brain writing
Multi-Voting
Impact/ Effort Grid
Fishbone Diagram
Five Whys
Process Map
Build consensus
 5. SPECIFIC AIMs and MEASURES
What do we want to accomplish in days and weeks
? What will change, by how much & when , How
will we know that we accomplished it?
Specific Aim Tool
Build Consensus
Fishbone Diagram (cause & effect)
Tick & Tally & other data collection
 8. SDSA
Standardize the test that was successful. Will it
work the same in every day routine? Document.
Involve all team members
Communication Plan
Playbook – Influence Spread
 9. SPREAD, MEASURE & MONITOR
Implement spread strategy and track how it is
working.
Communication Skills
Spread Strategy
Big Picture View
Connecting the dots
QI Process
1
2
3
4
5
6
7
8
9
23

Clarifying Terms
• Plan-Do-Study-Act (PDSA) Cycle – an approach to testing a change and
learning from the experience
• Standardize – the effort to make something reliable and defect-free
• Standardize-Do-Study-Act (SDSA) Cycle – an approach to standardizing a
process and learning from the experience
• Sustain – the ability to maintain an effort (process) without or with
minimal vulnerability over time
• Spread – the movement of an idea or process from one setting to another
setting
24

Spread Can Occur at
Different Levels
Testing
Changes
(PDSAs)
Try change in
another site,
then spread to
another
Standardizing
SDSAs &
Documentation
Use and improve
Playbook
Broad
Spread
and
Sustainability
(A BIG
Deal!)
25

Team &
Roles Defined
Assessment
And
Baseline Data
Global Aim
Problem
Statement
Change
ideas/
solution
storming
Specific Aims
and
measures
PDSA
SDSA
Spread
Measure
and
Monitor
CHC QI Strategy Example
26

Problem Statement • CHC has patients with uncontrolled hypertension (HTN) who may not be on evidence
based maximized therapy.
Team Members
•Planning Team: Agi Erickson, Tierney Giannotti, Veena Channamsetty, Mary Blankson, Lynn
Giuffrida, Brent Jacobs, Maria Tarantello
•Implementation Team: Agi Erickson, Tierney Giannotti, Lynn Giuffrida, Brent Jacobs, Maria
Tarantello, Claudine Lee, Laina Cross, Beth Dmowski, Mary Blankson
•Champions: Veena Channamsetty and Mary Blankson
•QI Coach: Raneda Porter; QI Coaching Support: Aubrey Roscoe
Research
Question/ Why
work on this now?
• In light of the pandemic, increased challenges have been experienced by patients with
chronic disease including a reduction in the number of patients with controlled
hypertension.
• Across the agency, the number of patients with controlled hypertension has plateaued.
• This goal is a PI priority and UDS measure that when met improves patient outcomes and
increases agency revenue for higher number of patients with controlled hypertension.
• By leveraging more resources that are available to combat uncontrolled hypertension in
patients, the collaboration of this team and eConsult will aid in provider satisfaction,
improved communication between telehealth nurses and patient’s care teams, and
increased capacity to provide more specialized care.
Measures
• As of November 2021 across all sites, XX% of patients with hypertension have controlled
BP (less than 140/90) and there is a goal to reach 70% by December 2022.
• As of December 2021, the 2 designated providers at one of our sites had XXX patients
with hypertension whose BP is uncontrolled and treated with 2 or more medications.
Goal Statement
• Increase the number of patients with improved blood pressure.
• Increase the number of patients with hypertension who move from uncontrolled to
controlled blood pressure.
Milestones/ Dates
• First Planning meeting and Project Charter created April 5, 2022.
• Pilot utilizing eConsult as intervention will take place at one of our sites for 3-6 months.
Scope
• Patients receiving care with 2 designated providers at one of our sites who have
uncontrolled hypertension that is being treated with 2 or more medications, but do not
have complex BH, SUD, and end stage renal disease.
HTN eConsult
Project Charter
04/05/2022
27

We aim to improve • The number of patients with hypertension whose BP is controlled
In • One CHC site for 2 designated providers in 1 Pod
The process begins
with
• Identifying those patients with hypertension whose BP is
uncontrolled and do not meet the exclusion criteria.
The process ends
with
• Patients having a documented BP reading in eCW for pre and post
treatment.
Working on this
now we expect
• To increase the number of patients with hypertension that show
any level of improvement in their BP.
• To improve provider experience and overall satisfaction with
eConsult that will increase its utilization to combat uncontrolled
hypertension.
• To improve communication between telehealth nurses and
patient’s care teams.
It is important to
work on this now
because
• There are patients with hypertension whose BP is uncontrolled
that may not be receiving appropriate treatment and may benefit
from specialty advice.
HTN eConsult
Global Aim
28

We will • Decrease
The • Average Systolic and the Average Diastolic BP
(Process) • Readings of patients with a BP that is not in control
By • XX% of patients (XX of XXX patients)
OR/ From
• Average Systolic BP of 150
• Average Diastolic BP of 86
To
• Average Systolic BP of 140
• Average Diastolic BP of 80
By • September 30, 2022.
HTN eConsult
Specific Aim
29

Pop Health creates report of
patients to receive eConsult
Telehealth RN initiates referral in
eCW by selecting specialty:
eCardiology Pop Health from
referral and documents in notes
reason for referral and questions
for specialist.
PCP timestamps TE approving
eConsult referral.
ConferMed receives eConsult and
confirms all documents provided
for completeness.
ConferMed routes eConsult to
specialist for review and
comments.
ConferMed sends response from
specialist back to CHC via P2P
within 2-4 days.
Indexing Team reviews and uploads
consult note to patient chart within
2 days and tags as eCardiology Pop
Health. and assigns to Telehealth
RN.
Referral team receives referral for
eConsult and reviews, sends
referral to ConferMed via P2P
attaching all relevant information
to include medical summary and
BP flowsheet from ehr within 2
days.
PCP completes 2 week in-person
visit with patient discussing
eConsult recommendations, any
results, and BP check.
Telehealth RN schedules patient
for in-person appt. with PCP 2
weeks out with reason: F/U
eConsult recommendations.
PCP reviews TE, acknowledges
receipt in message section and
closes TE.
PCP
Referral Team
ConferMed
Indexing Team
Telehealth RN
Pop Health
KEY:
Telehealth RN reviews
recommendations and executes
specialist recommendations based
upon their scope.
Telehealth RN sends TE to provider
for approval to reach out to patient
and initiate eConsult referral
Telehealth RN conducts telehealth
visit with patient to discuss
initiation of eConsult referral and
assess for bluetooth BP device.
Telehealth RN creates TE for
provider in eCW with message
regarding status of executed
eConsult recommendations
including note of patient s
upcoming appt. with provider.
PCP completes 4 week follow
up appt. with patient for BP
check.
PCP creates recall for 4 week follow
up (in-person).
PDSA #1: Plan for HTN eConsult Workflow
31

PDSA #1 Findings
DO:
•July 27 thru September 2
•Test of Change: Telehealth RN support
•Ended early as challenges encountered
caused insufficient amount of data to be
collected
STUDY:
•XXX pilot patients
•XX patients contacts/TE created
•XX patients Provider approved eConsult
•XX patients Provider declined
•X patients declined eConsult
•X patients approved eConsult
•X eConsult referrals sent
•X eConsult recommendation received
•As of 9/20/22
STUDY:
•Only 2 telehealth nurses were available and had little
time to work on pilot.
•Pilot patient list was outdated resulting in many
provider declines for eConsult
•Unclear consent needed from patients; needed for
telehealth visit not the eConsult referral
•No eConsult was completed, if unable to reach patient
•Specific Aim not met
ACT:
• Staffing – leverage staff nurse, remove telehealth
nurse from workflow
• Data – HTN eConsult Dashboard is active and
maintains updated patient data
• Clarify in workflow patient consent only required
for telehealth visit
• When provider approves eConsult, it will be
completed whether or not able to reach patient.
32

PDSA #2 HTN eConsult
Workflow Revisions
PCP
Referral Team
KEY:
Patient
RN
PCP/RN views HTN eConsult
dashboard during panel
management and care
coordination to address pilot
patients
Nurse initiates referral in eCW by
selecting specialty: eCardiology
Pop Health from referral and
documents in notes reason for
referral and questions for
specialist.
PCP/RN creates unControlled HTN
TE and timestamps TE
Referral team receives referral for
eConsult and reviews, sends
referral to ConferMed via P2P
attaching all relevant information
to include recent labs (BMP/CMP),
last consult note with history of BP
and EKG from ehr within 2 days.
RN contacts patient for verbal
consent for telehealth visit.
Able to speak with patient?
RN informs patient of referral
ordered by provider and seeks
consent for telehealth visit.
Patient declines telehealth visit?
RN attempts to contact patient 2
separate days at 2 different times
Able to speak with patient?
RN, if time permits, discuss
medication reconciliation, assess
for BP device and any other
challenges to BP control completes
eConsult for patient.
NO
NO
NO
YES
YES
Provider approves eConsult
referral?
Provider assigns TE to RN to
contact patient and complete
uncontrolled HTN template.
NO YES
RN conducts telehealth visit to
discuss medication reconciliation,
assess for BP device, and any other
challenges to BP control.
YES
Provider assigns TE to RN for
completion of uncontrolled HTN
template, TE closure and any
additional follow up provider
indicates for patient.
HTN eConsult cannot be
made. RN ensures that patient
has active recall.
RN completes eConsult for patient.
33

PDSA #2 Findings
PLAN/DO:
•October 19 thru December 30, 2022
•Test of Change: Provider/Provider Team (RN)
initiate eConsult referral based on identified patient
list during care coordination and panel management
time
STUDY:
•XXX pilot patients
•XX patients contacts/TE created
•X patients Provider approved eConsult
•XX patients Provider declined
•X patients declined eConsult
•X patients approved eConsult
•X eConsult referrals sent
•X eConsult recommendation received
•As of 2/21/2023
STUDY:
•Staff shortage/turnover: Only 1 nurse at site.
•Pilot patient list consisted of many patients who
haven’t been seen recently (8mos. +)
•Unable to reach patient
•Problems with eConsult referral process
•Specific Aim not met
ACT:
• Complete chart review of uncontrolled HTN TEs to
determine overall effectiveness of eConsult
strategy on patient outcomes.
• Evaluate if the difference in patient outcomes that
received HTN eConsult versus those proceeded
only with Provider’s own treatment plan.
34

Next Steps
• Reporting to CHC Performance Improvement Committee to share
work and discuss to gain insights and suggestions for next steps.
• Convene meeting with Planning Team to discuss next steps based on
previous PDSA findings.
35

Contact Information
37
For information on future webinars, activity
sessions, and learning collaboratives:
please reach out to nca@chc1.com or visit
https://www.chc1.com/nca
Deborah Ward: wardd@chc1.com

NTTAP Webinar Series - April 13, 2023: Quality Improvement Strategies in a Team-Based Care Environment

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