Continuous Quality Improvement is the Driving

Force for Change in Community & Practice

Karly Saez, Senior Consultant

Ohio Association of Community

Health Centers Fall Operations Conference

October 19, 2017

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Our Mission: To simplify the delivery of efficient,

high-quality health care

3Value Driven. Health Care. Solutions.

Who I Am

Why We Care

Plan, Do, Study, Act (PDSA)

Change Driver Diagrams

What Medical Advantage Group is Doing

Why it Matters

Benefits and Challenges of Change

Objectives

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Practice Transformation ServicesBring quality info focus by building high-performing practices

Local experts. Personal. Proven Tools. Results

>> Health care consulting and

solutions company

>> Help physicians maximize success

in value-based contracting

>> Participation in federal grants

>> Focus on the Triple Aim

– Improve quality

– Improve the patient experience

– Decrease costs

>> Telehealth initiatives

>> Practice transformation objective

support

5Value Driven. Health Care. Solutions.

Shift from fee-for-service to fee-for-value

Emphasis from acute care to preventive population health

Patients expect providers to stay up-to-date

Increasing access to care, to get busy patients prompt

care

Health Care Change is Accelerating

6Value Driven. Health Care. Solutions.

Identify who your change agent is

Determine, as a team, “why?”

Clearly identify and delegate

Ask for feedback

Plan on using PDSA and driver diagrams

Next Step for Transitioning to Fee-for-Value

7Value Driven. Health Care. Solutions.

How will you determine if the change is successful?

Focus Question

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What am I/are we trying to accomplish?

How will I/we know if the change is an improvement?

What change can I/we make that will result in an

improvement?

Four steps to focus on for continual process

improvements:– Plan

– Do

– Study

– Act

Plan, Do, Study, Act

9Value Driven. Health Care. Solutions.

PDSA Example

What am I trying to accomplish? – Read more non-professional books

How will I know if the change is an improvement? – Read one book in the month of August

What change can I make that will result in improvement? – Set aside 30 minutes each

weekday for reading

10Value Driven. Health Care. Solutions.

Plan, Do

Plan– Set a reminder on my phone at 9 pm

to go to bed, so I can read for 30

minutes

Do– Set the phone reminder successfully

– Twenty-three weeknights in August

• Eight nights were successful

• Fifteen nights were not

11Value Driven. Health Care. Solutions.

Study– I did not meet my goal, but I did read on 35% of available

weeknights

– Reading on the living room couch or in bed is very distracting

Act– Readjust my goal to focus on the number of days I am reading

– Readjust to read on 50% of weeknights

– Read in a quiet place, away from distractions

Plan– Continue phone reminder, but add reading to my daily calendar

on two to three days with less extracurricular activities

– Will read in home office, without the dog

Study, Act, Plan

12Value Driven. Health Care. Solutions.

In my example, other things should be considered as

my PDSA cycles continue

The same can be applied in your organization

Do Not Forget External, Uncontrolled Forces

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Patient satisfaction survey completion rate

Waiting room time or perceived waiting time

Improve medication adherence

Promotion of group visits or healthcare access

Patient portal utilization

Potential Health Care Examples

14Value Driven. Health Care. Solutions.

Change Driver Diagram

PrimaryAim

PrimaryDriver

SecondaryDriver

ChangeConcept

SecondaryDriver

ChangeConcept

PrimaryDriver

SecondaryDriver

ChangeConcept

PDSA

Cycle

s

15Value Driven. Health Care. Solutions.

Change Driver Diagram Example

PrimaryAimImprove

VaccinationRatesinMedicaid

Childrenfrom50%to75%within12

Months

PrimaryDriverLackofperceived

importance

SecondaryDriverLackofknowledgearound

vaccinationschedule

ChangeConceptProvideremindercallswithenoughadvancednoticetoensuretimeliness,providereminder

callsorletters

SecondaryDriverBeliefthatvaccinationsareharmful,

causeotherdiseases,etc

ChangeConceptCreateadvertisementsormaterialsthatinclude

factsanddebunkmyths

PrimaryDriverChronicno-showsorhighcancellation

rates

SecondaryDriverLackoftransportation

ChangeConceptAssistwithtransportationarrangements

ChangeConceptArrangefreepublictransitforhealthdepartment

visits

SecondaryDriverNoknowledgeofappointment,

whereittakesplace,etcChangeConcept

Schedulingreminders,provideappointmentreminders,handoutswithlocationandhowto

getto/from

16Value Driven. Health Care. Solutions.

Improvement in quality is a primary aim

The primary drivers are the things hindering improvement

and better quality

Common primary drivers in health care– Lack of compliance or adherence to medical or care plan

– Lack of crucial resources

– Chronic no-shows or cancellations

– Physician shortage

– Limited physician access

It is All About Quality

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Practice transformation objectives– Advancing infrastructure within (or access to) PCMH practice

environments1

– Expanding access to care = improving quality of care

Examples– Group visit implementation

– Medication management

– Patient portal access

– Telehealth

Overcoming Primary Drivers

18Value Driven. Health Care. Solutions.

Education and training for patient self-management

by a non-physician professional using a standardized

curriculum, face-to-face with the patient or caregiver

Proven effectiveness– Improving clinical status of chronic conditions2-3

– Advance care planning (ACP)4

– Patient acceptance5

– Decreasing high ED utilization6-7

Group Visits

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Group Visits in Action

Adult and pediatric diabetes classes

General healthy living group visits

Support groups

Programs for new parents

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Integrating a pharmacist into a portion of the patient’s

care in a non-hospital based or pharmacy environment

Proving effectiveness– Improved error rates8

– Expanding access8

– Improving clinical outcomes9

– Reducing readmissions10

Medication Management

21Value Driven. Health Care. Solutions.

Part-time pharmacist who spends a dedicated portion of

time embedded in individual practices

Shadows physician and observes workflow

Works with physician to develop focus population– Non-compliant diabetics

– Children with ADHD

– Anti-depressant combination adjustments

– Adjustment and weaning of pain medications

Medication Management in Action

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Freestanding or integrated into the electronic medical

record (EMR)– Expanding to bi-directional communication and submission of

patient-gathered information

Recognized success– Increased access to care11

– Improved patient satisfaction12

– Facilitated participation in care

– Improvements in CAHPS11

Patient Portal Access

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Patient Portal Access in Action

Expand patient portals to include– Bi-directional communication

– Submission of patient-collected data

Improve perception of care

Streamline access to care

Adjustment in workflow

24Value Driven. Health Care. Solutions.

Using digital technology to deliver remote medical,

health, and educational services to a population

– Real-time or recorded• Point-of-care consultations with providers or between providers

– Integration of patient portal• Educational videos or trainings

• Entering self-obtained results

– Remote monitoring• Measure and automatically transmit data

• Home monitoring devices

Telehealth and Telemedicine

25Value Driven. Health Care. Solutions.

Point-of-care consultations with the physician (in-home or

bedside)

Immediate, on-the-go via smart phone or laptop

Upward acceptance and reimbursement from health plans

Pilots, workgroups, and payer conversations

Telehealth and Telemedicine in Action

26Value Driven. Health Care. Solutions.

Up-front investments– Technology

– Office space

– Potential new staff

– Time commitment

Shifting workflows with new “providers”– Care managers

Moving expectations

Resistance to change

So Why Is It So Difficult?

27Value Driven. Health Care. Solutions.

Be a role model

Believe in the “why”

Remain flexible

Share the patient impact

Share the practice impact

Influencing Change

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Remain flexible

Grow professionally and organizationally

Break monotony

Embrace opportunities

Exceed expectations

Benefits of Change

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Greatest Challenge of Change

30Value Driven. Health Care. Solutions.

How Will You Determine if the Change is Successful?

Always Revisit…Always Have An Answer

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Progress is impossible without

change, and those who cannot

change their minds cannot

change anything.

– George Bernard Shaw

32Value Driven. Health Care. Solutions.

Identify a change agent and identify the desired change

Set realistic goals

Utilize change diagrams and PDSA cycles to achieve

your organization’s goals

Push outside comfort zones

Be prepared for challenges and setbacks

Share successes!

Summary

Karly Saez, Senior Consultantksaez@medadvgrp.com

(517) 231-2896

34Value Driven. Health Care. Solutions.

1. MDHHS “2017 PCMH Initiative Participant Guide”

http://www.michigan.gov/documents/mdhhs/2017_PCMH_Initiative_Participant_Guide_Draft_v1_1-9-16_547757_7.pdf

2. Housden L, Wong ST, Dawes M. Effectiveness of group medical visits for improving diabetes care: a systematic review

and meta-analysis. CMAJ. 2013;185(13):E635-644.

3. Lum HD, Sudore RL, Matlock DD, et al. A group visit initiative improves advance care planning documentation among

older adults in primary care. JABFM. 2017;30(4):480-490.

4. Miller D, Zantop V, Hammer H, Faust S, Grumbach K. Group medical visits for low-income women with chronic disease:

a feasibility study. J of Women’s Health. 2004;13(2):217-225.

5. Geller JS, Dube ET, Cruz GA, Stevens J, Bench KK. Pediatric obesity empowerment model group medical visits

(POEM-GMV) as treatment for pediatric obesity in an underserved community. Childhood Obesity. 2015;11(5):638-646.

6. Beck A, Scott J, Williams P, et al. A randomized trial of group outpatient visits for chronically ill older HMO members:

the cooperative health care clinic. J Am Geriatr Soc. 1997;45:543-549.

7. Wagner E, Grothaus L, Sandhu N. Chronic care clinics for diabetes in primary care. Diabetes Care. 2001;25:695-700.

8. Haas-Gehres A, Sebastian S, Lamberjack K. Impact of pharmacist integration in a pediatric primary care clinic on

vaccination errors: a retrospective review. J Am Pharm Assoc. 2014;54(4):415-418.

9. Davis CS, Ross LAR, Bloodworth LS. The impact of clinical pharmacist integration on a collaborative multidisciplinary

diabetes management team. J Pharm Pract. 2017;30(3):286-290.

10. De Oliveira GS Jr, Castro-Alves LK, Kendall MC, McCarthy R. Errors and health-care resources utilization after transitions

of care: a meta-analysis of randomized controlled trials. J Patient Saf. 2017;DOI10.1097

11. Schnipper J, Gandhi T, Wald J, et al. Design and implementation of a web-based patient portal linked to an electronic

health record designed to improve medication safety: the Patient Gateway mediations module. Inform Prim Care.

2008;16(2):147-155.

12. Nagykaldi Z, Aspy CB, Chou A, Mold JW. Impact of a wellness portal on the delivery of patient-centered preventive care.

J Am Board Fam Med. 2012;25(2):158-167.

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