IPIP Kick-Off!

January 16, 2007Monroe Center Greenville, NC

WelcomeThank you for contributing to IPIPGet to know the other teamsShare senselessly and steal shamelesslyMake us work for you tonight

IntroductionsSteve Willis MDExecutive Director, Eastern AHEC

Chuck Willson MDMedical Director of Community Care Plan of Eastern Carolina (CCPEC)

Let us knowYour Practice NameAre you measuring Diabetes or Asthma?What are you looking to get out of IPIP?

Improving Performance in Practice Warren P. Newton, MD, MPHGreenville, NC January 16, 2007

ObjectivesIntroduce briefly the Improving Performance in Practice (IPIP) project, and your role in it Summarize IPIP methods and rationaleDescribe how it will work expectations, timeline and reimbursement

IPIP: Why?The Quality Chasm

About half the time, interventions that we all agree should happen dont, no matter what the problem or setting

IPIP: A National InitiativeAmerican Board of Medical SpecialtiesAmerican Academy of Family PhysiciansAmerican Academy of PediatricsAmerican Board of Family MedicineAmerican Board of Pediatrics PlusAmerican College of PhysiciansAmerican Board of Internal Medicinefunded by the Robert Wood Johnson Foundation and the CDC

IPIP: The VisionRadical transformation of office care with improvement of management of chronic disease and access to careAll Primary Care DisciplinesFamily Medicine, Pediatrics, General Internal Medicineacross the whole stateNew approach to CME and linkage to Maintenance of Certification Part IV Pilot with Asthma and Diabetes in North Carolina and Colorado

IPIP in North CarolinaFocus is providing help for doctors to transform their practicePartnership of CCNC and AHEC; other partners: NCAFP, NCPS, NC cACP and NCMS, with NC Department of Public Health, CCME (MRNC) Pilot: CCPEC/Eastern AHEC/Pitt Co HD and Access II Care/MAHEC/Henderson Co HD

IPIP Methods OverviewFocus is on providing help for doctors change their practices rapidlyQuality Improvement CoachesData Collection and ReportingLearning Networks

What is the evidence? Organized systems of care have resulted in profound improvements Northern New England Cardiovascular GroupEnd Stage Renal Disease NetworkChildrens Oncology GroupEight fold increase in survival for patients with ALLVermont Oxford Network (neonatology)NHS primary care collaborativeCystic Fibrosis Collaborative (ongoing)

Adequacy of HemodialysisSehgal A, JAMA 2003;289:1996-1000

Asthma ManagementWroth TH, Boals JC NCMJ 2005;66(3):218-220

IPIP in North CarolinaHow will it work for you?

IPIP Overall Goal

Dramatic and sustainedimprovement in quality of care of asthma and diabetes

IPIP will provide you withQIC to work with you on all aspects of practice redesignHelp with setting up data systems Tools for changing your practice Comparisons to other practices, with opportunity to learn from themCME and MOC IV creditSome financial support

What IPIP wants from youIdentification of a team from your practice to champion change Participation in kick-off meetingSubmission of baseline and regular dataFrequent small changes in your practice, with tests of changeParticipation in activities of learning network

IPIP Timeline12/06-2/07develop data systems, kick off meeting, submit baseline data3/07-10/07learning network phase 1 begins; submit regular data and record changes in practice; participate in learning network activities10/07 onwardtransition to phase 2, with new focus of interest

IPIP ReimbursementInitial $1000 after identification of clinical improvement team, attendance at kick-off meeting and beginning submission of baseline dataSecond $1000 after submission of baseline and six months of data and participation in network activities.CME will be provided for ongoing activities

IPIPA Vehicle for LeadershipHelp us learn how to help other doctors across the state to transform their practice and respond to pay for performance initiativesPilot the Governors Quality InitiativeHelp push reimbursement reform for quality and the role of the medical home

Ups and Downs of ImprovementDarren DeWalt, MDUNC General Internal Medicine

OutlineGetting startedImproving data managementInvolving the providersUsing a registry to improve careExpanding the use of the registry

UNC General Internal Medicine Practicecirca 199975 resident and faculty physicians

day per week to 5 days per week

Individual care often good, but uncoordinated

Limited access to providers

Limited diabetes education/other illness self-management support

Patient barriers often not addressed because of limited time, skills, resources

Getting StartedInterest in improving chronic illness care

Improve access to self-management education

Reduce variation in practice

Ensure adherence to guidelines

Data EntryAll manual entry in beginning

Slow transition to connect with health system information technology

Randomized Controlled Trials Planned care versus Usual careDiabetesLower A1CLower BPMore prescribing of aspirin

*Rothman et al. American Journal of Medicine 2005, 118:276-284.**DeWalt et al. BMC Health Services Research 2006, 6(1):30

Problem of Scale-UpDiabetes trial had 230 patients

We care for ~1600 patients with diabetes

Needed to engage all staff of clinic

Needed InnovationsDecision support (case management not available on scale-up)

Automation of guidelines (ordering needed tests)

Managing Information at the VisitPatient profileall the information needed for a given patientUseful for the nurse or other care assistant

Decision support tool for cliniciansAddresses specific concerns the physician should address

Patient Profile

Patient Profile

Patient Profile

Patient Profile

Patient Profile

Decision Support

Re-implement automatedFront desk fidelity

Chart1

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% Total Cholesterol Tested

Percent of patients with Total Cholesterol Tested Yearly

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1-Jan62

Feb-0561

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Front Desk ProcessList of patients with diabetesWhether or not labs need to be drawn

I had patients that needed labs that were not getting triaged appropriately

Looked at front desk logs

Front Desk LogsAbout 60 patients with diabetes/week30 needed a lab drawn

Only 15 had it drawn (50%)

Pizza for 90% Fidelity25/33 = 75% No pizza34/36 = 94% PIZZA

Re-implement automatedFront desk fidelity

Chart1

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% Total Cholesterol Tested

Percent of patients with Total Cholesterol Tested Yearly

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1-Jan62

Feb-0561

Mar-0562

Apr-0562

May-0566

Jun-0564

Jul-0565

Aug-0564

Sep-0562

Oct-0575

Nov-0576

Dec-0577

Jan-0679

Feb-0682

Mar-0684

Apr-0683

May-0686

Jun-0686

Jul-0686

Aug-0687

Sep-0686

Oct-0687

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Continue to EvolveMonthly review of run charts and PDSAsQuarterly all-hands meetingWorking on several different projects (diabetes, advanced access, anticoagulation, chronic pain management, colon cancer screening)Giving out awards to clinicians

SummaryImprovement work different from researchNeed to engage all members of staffWhen results slow, examine parts of the processWe continue to make changes and to take on new projectsImprovement isnt about arriving, it is about changing and optimizing

What Now?Improving total cholesterol measurement, but how do we get LDL measurement up?

Another Example If Needed

Measurement and ImprovementDarren DeWalt, MDUNC General Internal Medicine

IPIP MeasuresStarting with diabetes and asthmaAvoid creating new measures, adopt nationally endorsed measuresUse national goals when availableIPIP charter expects that practices will reach all goals within 3 yearsClose gap between performance and goal by 33% per year.

Asthma Measures

MeasureGoalEndorsementsAssessment Symptom assessment>90%NQF, PC, BPHC Severity Classification>90%CCNCAnti-inflammatory Persistent asthma on anti-inflammatory>90%AQA, NQF, CCNCPrevention Influenza vaccination>90%AQA, NQF, CCNC Smoking counseling>90%AQA, NQFComposite Measure Receive all 3 key strategies for asthma care (classification, anti-inflammatory, vaccination)>75%Utilization ED visit

Diabetes Measures

MeasureGoalEndorsementsA1C A1C documented >90%AQA, NCQA, NQF, CCNC Most recent A1C level greater than 9.0% 40%1NCQABlood Pressure BP documented in the last year 65%1AQA, NCQA, NQF BP documented in the last year 35%NCQACholesterol At least one LDL>85%1AQA, NCQA, NQF, CCNC LDL Control 63%1NCQA, NQF LDL Control 36%1NCQA, NQF

Diabetes Measures Contd

MeasureGoalEndorsementsEye Exam Received a dilated eye exam>60%1AQA, NCQA, NQF, CCNCFoot Exam Foot exam>80%1NCQA, NQF, CCNCNephropathy Tested for nephropathy or already under treatment >80%1NCQA, NQFPrevention Influenza vaccination >60%AQA, NCQA, NQF, CCNC Smoking counseling >80%1AQA, NCQA, NQF, CCNC

Using Data for ImprovementChoose evidence-based process or outcome measures for goals

Create meaningful measures as needed for smaller PDSA cycles (lab order example)

To improve, measurement does not need to be perfect (small samples ok)

Measurement for ImprovementIS:Designed to help your team and other teams learnLike a growth curve: its not where you are, but where you are going

IS NOT:Designed for criticism or punishmentSupposed to end (it should be sustainable)

You cant fatten a cow by weighing it. --Palestinian Proverb

Using Measurement

What are we trying toaccomplish?How will we know that achange is an improvement?What changes can we make thatwill result in improvement?Model for ImprovementActPlanStudyDoFrom: Associates in Process Improvement

Model for ImprovementAIM: What are we trying to accomplish?

MEASURES: How will we know that the change is an improvement?

IDEAS: What changes can we make that will result in an improvement?

Key Points for PDSA CyclesOften the study is specific to the PDSAUsually not one of core measures Usually ends with PDSA cycleOften qualitative Do cycles on smallest scale possibleThink baby stepsFailed cycles are learning when small (trial and learning)

Example: Lumberton Childrens ClinicAim: Improve asthma outcomes (reduce ED and hospital visits by 50% and improve patient well-being) by:improving care process in office improving patient self-management skillsFirst step: Identify asthma patients (so they can rate severity and improve management)

Improve Severity Classification: Cycle One PlanFind and label charts of all asthma patientsTheory: we can feasibly label charts of all asthmaticsDoComputer run of all asthma diagnosesStudyN = 3500Too many patients to labelActNew cycle: focus on sickest patients

Plan Start with sicker patients Theory: we can feasibly label charts of our sickest asthmatics (seen in ED or practice recently)DoAsthmatics seen in ED and in practice in last 2 months identified by computerAsthma patients identified as they come into officeStudyN= 75, easy to accomplishActBegin labeling these chartsImprove Severity Classification: Cycle Two

Tests of ChangeIdeasChanges that result inimprovementLearningLearning

Resources (Learn QI and Get Ideas)Quality Improvement Consultant (QIC)

Extranet

Improvement network--sharing of ideas

EMBED Pagis.Document

_953455813.tiff

What Now?Where will you begin your improvement?

What global measure will you start with?

What can you do this week? (PDSA)

What measure will you use in the PDSA?

Report OutTeams report their results of the exercise

Wrap UP!The 1st Stipend Payment Please turn in your signed Letter of Intent tonight. Payment will be sent to you from NC Academy of Family Physicians once requirements are met

Conference CallsPlease return your survey tonightOnce compiled, a day and time will be emailed to you for our first conference call.

Thank you for coming tonight -- We are looking forward to working with you and your practice!

Contact InformationBobbie Bonnet RN, BSNQuality Improvement ConsultantEastern AHEC(919) 277-bonnetr@mail.ecu.edu

Ann Lefebvre MSW, CPHQProject Director(919) 833-2110alefebvre@ncafp.com

***Drilling down into aggregate data will hopefully give us clues for changes we may make to get an improvementImprovement involves a changeWhat we learn from drilling down into aggregate data will hopefully lead to changes to test - this is our model for testing**The aim is what brings the group together. Aim is the QI term for answering the questionWhat are you trying to accomplish? Even though this test run or PDSA cycle occurred in 2000, it illustrates several key points about PDSAs.

This was a very large practice and one of the first things in improving care for patients with chronic conditions such as asthma, is knowing your population. Identifying your population can assist you in targeting new approaches and you can target strategies for different groups an The improvement team for Lumberton thought that by classifying/staging patients with asthma they could then start using management plans with at least their persistent population. (cant do everything at once) They had this idea to label all the charts with a benign stickergreen dot so that when those charts were pulled for future visits, staff would know to put a blank management plan and it would prompt providers to classify severity.

This group wanted to classify and had already tested the management plans. They were ready to implement part of their system.

*So here is how they designed their first test for labeling charts. Generate a report from billing system for all patients seen in the last 18 months with asthma dx. But the test failed. They had a list of 3500 patients! Labels are expensiveand who would do all this

At first they were very discouraged and wondered what should they do. we can never label all these patients, we dont even have the money for the stickers! much less the forms all at once.

So they talked about it and decided to focus on the sickest patients first if they could find them. One of the ways was to ask some of the nurses and providers to name 5 children each with asthma. They could pull those charts and put the labels on etc. That was manageable.

They met with staff

*Another way to find patients with asthma that were not managing well was to look for patients seen in the ED in the previous 2 months. At this time they had an appointment type for ED follow-up and asked for ED f-u and asthma.

[This was before they had done open access. Now they only have 1 appt type}

They decided to generate another report, this time just looking for pts seen in ED and/or in practice in the previous 2 months with asthma diagnosis.

A 3rd way was to identify patients in the future. They looked at the schedule on Thursday for the following week and tagged kids with asthma. A couple of nurses could quickly look at the print out.

These 3 methods came up with about 75 patients. They pulled these charts in batches of 25 over a week and put the labels on and started inserting the blank plans.

The medical records folks were glad that they didnt have to pull 3500 charts and got involved with the new forms and prompts quickly when they learned how they could be helpful. From there, they continued to build their system and over time, everyone knew how to assess for asthma, what new tools/forms to look for and use.

Perhaps you could pause here and ask if what people think. Remind them that this is still too big a test for them.(n of 75) Remember that they had been working a couple of months on asthma. [end of example]

**Sometimes if were moving fast and something works - we dont remember how we did it a week later!