management and supervision fall 2014 - unc gillings school ...sph.unc.edu › files › 2014 › 11...

Management and Supervision Fall 2014

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Quality Improvement in Public Health

November 19, 2014

Management and Supervisor Training

Kathy Brooks, Jean Vukoson,

Tara Lucas, Pamela Cochran

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Welcome and Introductions• Faculty Introductions

• Ground Rules• Participation is essential

• Learning and sharing from one another is important

• Don’t forget to silence cell phones

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Icebreaker

• Name

• Job Title and Organization

• Choose one adjective to describe yourself - Adjective should start with the same letter of

your first or last name


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Objectives

– Define QI and its importance in public health– Learn how to apply the Model for Improvement

and Lean– Use QI tools to understand your current process

and identify change ideas– Learn to use the Plan‐Do‐Study‐Act cycle to test

changes– Discuss QI resources available to public health

agencies

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The Center for Public Health Quality

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Mission:Create an infrastructure to foster and supportcontinuous quality improvement and learning among allpublic health professionals in North Carolina.

Vision: All local and state public health agencies will have anembedded culture of continuous quality improvement thatwill help North Carolina become the healthiest state in thenation.

Creating 10,000 public health problem solversin North Carolina


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The Team

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PH QI 101 Program

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The overall objectives of the course are to help participants:

• Understand, select, and use QI methods and tools in their daily activities to improve the efficiency of services within their agency as well as health outcomes

• Coach others within their local setting to use QI methods and tools

• Develop a plan to incorporate QI methods and tools within their local agency so that it becomes “the way we do business”

CPHQ Experience

NC Division of Public Health• Children & Youth Branch• Chronic Disease & Injury Section• Food Protection & Facilities Branch• Heart Disease & Stroke Prevention

Branch• Nutrition Services Branch• Tobacco Prevention & Control Branch• Vital Records• Women’s Health Branch

Partners• NC Institute for Public Health• Eastern AHEC• Office of Rural Health & Community Care


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Model for ImprovementWhat are we trying to accomplish?

(AIM)

How will we know that changes are an improvement?

(MEASURES)

What changes can wemake that will result in

an improvement?(IDEAS)

Act Plan

Study Do

Test Ideas & Changes with Cycles for Learning and Improvement

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Tests of Change

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Ideas

Changes that result in

improvement

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What is Lean Thinking?

A systematic approach to

identifying and eliminating wasteful activity (non-value-added activities)

in the pursuit of perfection

through continuous improvement;

providing increased value to

our clients / community


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Lean Thinking

• Client / customer first

• Our People are the most valuable

resource

• Continuous improvement

• Focus on where the work is done

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What is Quality Improvement?

“A continuous and ongoing effort and culture

to best achieve measurable improvements

in the efficiency, effectiveness, quality, performance, and outcomes of services and

systems

with the goal of improving the health

of North Carolinians and our communities.”

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NC DPH Management Team, 2009Adapted from Accreditation Coalition QI Subgroup Consensus Agreement

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Some Key Features of QI

• Focus on systems, not individuals• Ideas/changes from customers & front line

staff– The “intervention” is designed iteratively,

through testing of ideas/changes• Frequent, ongoing measurement and data

driven decision making• Never ending process (never “done”)


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“Every system is perfectly designed to achieve the

result it gets”

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“FINAL” PLAN

IMPLEMENT

PROBLEM

SOLUTION

Traditional model for introducing

change

FAIL

SYSTEM BARRIERS

Changing the System: Usual Model

Adapted from: Jean Vukoson’s Bright Futures Presentation and Concepts from Toyota Way

QI Approach

IMPROVED and SUSTAINED OUTCOMES

Define POSSIBLESolutions

Test solution

s & adapt

Assess current condition

Prioritize issues & set a target

Clarify problem

BIG, VAGUE PROBLEM


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Visual adapted from Marni Mason of MCPP Consulting; based on Joseph Juran’s Trilogy

2020

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DPH Clinical Services Practice Management Project


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Broad Application of Improvement Strategies

• The business principles used in the Practice Management Project are applicable

across all public health programs & services

• To be successful you must understand: – your customer needs (demand)

– your ability to provide the services (capacity or supply)

– your profit profile (revenue vs. cost & profit margin)

– How to link business model to services for all stakeholders

– understand your customer values (customer satisfaction) 22

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Practice Management Kaizen• Requested by local health directors based

on current public health context for clinical services:– Reduced number of clients =

reduced revenue

– Reduction in Medicaid Cost Study funding

– Reduction in Block Grant funding

– Continued staffing and facility costs

• Kaizen Team includes local DONs and Nursing Supervisors, DPH Consultants and Joy Reed

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Practice Management Kaizen• Objectives:

– Improve health outcomes by improving clinic efficiency and cost effective services

– Develop and test productivity benchmarks and practice models• Provider/Nurse productivity: average

20/visits/day

• Consensus staffing model for public health

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Practice Management Kaizen

• Objectives:– Develop tools and skills training to

support

• Balance-Supply and Demand for services

• Optimize staffing resources

• Improve revenue

• Decrease cost of care

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What are we Trying to Accomplish with Practice

Management Project?

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(AIM)


(MEASURES)



Act Plan

Study Do



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Aim Statement

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What is an aim statement?

– An explicit statement of the desired outcome that is time specific and measurable

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AIM Practice Management ProjectWe aim to develop the benchmarks, data dashboards and training to support local health departments in better managing their clinical services to improve outcomes and reduce cost of care. We will complete this project by end June 2014. This is important to ensure that we optimize local resources to sustain critical clinical services. We will achieve this by using QI principles and tools. Our specific goals include:•Prior to March 2014, develop and test and finalize recommendations for a public health staffing model;

•Prior to March 2014, develop and test productivity benchmarks for clinical providers and staff;

•Prior to March 2014, develop and test data dashboards to support management of clinical services, including fiscal and clinical measures.

•Prior to May 2014, develop & implement training content and options for local health departments with a goal of 80% of participants rating the content as “very helpful”.

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Practice Management Trainingfor Local Health Departments

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CLAY

POLK

CATAWBAROWAN

IREDELL

STANLY

DAVID-SON

MONT-GOMERY

RANDOLPH

MOORE

ANSONRICH-

MOND HOKE

CHATHAM

LEEHARNETT

CUMBER-LAND

ROBESON

SCOT-LAND

BLADEN

SAMPSON

COLUMBUS

BRUNSWICK

NEWHANOVER

PENDER

ALA-MANCE

ORANGE

CASWELLPERSON GRAN-

VILLE

WARREN

FRANKLIN

DURHAM

WAKE

NASH

JOHNSTON

WAYNE

DUPLIN

GREENE

LENOIR

PITT

JONES

ONSLOW CARTERET

PAM-LICO

BEAU-FORT

CRAVEN

HYDE

DARETYRELLWASH-INGTON

BERTIE

MARTIN

HERT-FORD

CAM-DEN

PER-QUIMANS

CURRITUCKNORTH-AMPTON

GATES

HALIFAX

EDGE-COMBE

ROCKING-HAM

STOKESSURRY

FORSYTHGUILFORD

YADKIN

DAVIE

WILKES

ALEX-ANDER

GASTONCHEROKEE

SWAIN

MACON

GRAHAMJACKSON

HAY-WOOD

HENDERSONTRAN-

SYLVANIA

RUTHER-FORD

BUN-COMBE

MADISONYAN-CEY

AVERY

CLEVE-LAND

LINCOLN

BURKE

MECKLEN-BURG

UNION

CABARRUS

ASHE

WATAUGA

ALLE-GHANY

CALDWELL

McDOWELLWILSON

VANCE PASQUO-TANK

CHO-WANMITCHELL

70/85 Health Departments (82%)


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Key components of an aim statement

–What are we trying to accomplish?

–Why is it important?

–Who is the specific target population?

–When will this be completed?

–How will this be carried out?

–What is our measurable goal(s)?

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How Will We Know that a Change

is Improvement?

“All improvement is change, but not all change is an improvement.”

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(AIM)


(MEASURES)



Act Plan

Study Do



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How Will We Know? (MEASURES)

• Measurement is the voice of the process

• Accurately tells you how well the process is working

• Any process that can be mapped can be measured

• Measures are linked to the goals in your project aim statement

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Measurement• Brings rationality to the process

• Replaces subjectivity with objectivity

• Focuses on process, not individuals

How Will We Know? (MEASURES)

“ The nurse practitioners never•complete the encounter forms!”

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Types of Project Measures

• Outcome – Ultimate results we are trying to

achieve

• Process– What we do to achieve the outcome

• Balancing– What we could “mess up” while trying

to improve process & outcome


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Examples of Project Measures • Outcome

– Increase provider productivity to 100% benchmark

• Process– Decrease lead time for preventative service by 25%

in next quarter

• Balancing– 80% of clients will rate wait time in clinic as “very

good”– 80% of clients will rate their understanding of health

information shared by the provider as “clear understanding”

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Practice Management Measures

• Budgeted vs. actual revenue

• Payer source by program

• Productivity benchmarks: capacity vs. actual seen

• No show rate

• Demand for services by program

• Revenue compared to costs

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Practice Management Data

What are your questions regarding this fiscal picture?

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Practice Management Data

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18%

8%

58%

16%

Medicaid

Other

Local 101

State Funds

All Revenue Sourceswithout Cost Settlement

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Practice Management DataReview the data for Standard County Health Department (Handout) at each of your tables•What are your questions regarding the data?

•What additional information would you request?

•How would you prioritize further assessment based on the data?

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What is Return on Investment?


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Terminology/Formula

ROI (return on investment): A performance measure used to evaluate the efficiency of an investment

ROI = (Benefits-Costs)/Costs

EI (economic impact): Refers to costs and benefits of an activity.

EI = Benefits-Costs

*

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ROI/EI – Why do it?

• Earns the respect of Stakeholders and Leaders

– Justification for implementing an intervention/project

• View public health as an investment vs. expense

– Helps to “sell” the concept of public health

• Part of evaluation…accurate, credible, and widely used process

– Based on facts or evidence so it’s believable

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Preliminary ROIs from QI Projects

Improvements in STD ClinicAnnualized savings to the community with the

prevention of Pelvic Inflammatory Disease~$119,000/year.

Increased Referrals to QuitlineAnnualized savings to the community

of $92,142/year.


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ROI: Triple AIM in US Health Care(Berwick, Nolan and Whittington, IHI)

AIM = What Are We Trying to Accomplish?• Improve the experience of care• Improve the health of populations• Reduce per capita costs of health care

How do we Accomplish the AIM• Partnerships with individuals and families• Redesign of primary care• Population health management• Financial management• Macro-system Integration

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Improve the Health of Populations

Smoking Bans Linked To Lower Hospitalizations For Heart Attacks And

Lung Disease Among Medicare Beneficiaries

(Weg, Rosenthal and Sarrazin)

• MI fell 20 – 21%

• COPD fell 11% (workplace ban)

and 15% (bar smoking bans)

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Reduction per capita Cost of Health Care

Public Health Productivity Benchmarks

• Provider productivity benchmark:Average 20 visits/day x 5 days/week x 48 weeks =

4,800/year

• Nurse Clinic productivity benchmark:Average 20 visits/day x 5 days/week x 48 weeks =

4,800/year

• Child Health Enhanced Role Nurse (with support) benchmark:

Average 6 visits/day x 5 days/week x 48 weeks = 1,440/year


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Billing Codes as Determinants of Provider Capacity

• RN: 99211, NB/PPHV, HIV CTS, Pregnancy Tests, T Codes for TB, LU Codes, Immunization Administration codes for Immunization Only Visits, TB skin tests (free if related to PH), DEPO, pill supply, treatment only services (wart destruction), Dental Varnishing if stand alone.

• MD/NP/PA: 99212 – 99215, 99201 – 99205, Prevention Codes, Maternity Care Package Codes

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Billing Codes –Determinants of Capacity

• Rostered CH RN: 99211 and Prevention Codes with CH modifiers

• Enhanced Role STD RN: T Codes for Medicaid and 99211 for Third Party, Free to Patient

• Enhanced Role Maternal Health RN: 99211

• Enhanced Role FP RN: 99211 and Prevention Codes with FP modifier

Public Health Staffing Model

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Note: projected revenue based on 100% reimbursement for services

$315,120 divided by 4,800 visits = $65.65 per visit cost

Revenue minus staffing cost“in the black” or positive number


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Impact of Schedules on Revenue

CLINIC CAPACITY• Total NP Visits/Week = 100 ($7,800 based on a 99213 at

$78.00) • Total RN Visits/Week = 100 ($3800 based on a 99211 at

$38.00)• Total CH Visits/Week = 30 ($2700.00 based on

prevention visits code billed by age at $90.00)• Total STD Visits/Week = 40 (Varies based on % of

population that has Medicaid or 3rd Party Insurance) • Total HV Visits/Week = 25 ($1500.00 based on PP/NB

HV at $60.00)• Total All Visits/Week = 295 ($15,800)• Total Revenue/Year = $758,400.00

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What Changes Can We Make that will Result in

Improvement?

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(AIM)


(MEASURES)



Act Plan

Study Do



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What Changes Can We Make? (IDEAS)

Data needed to develop change ideas includes

• Fiscal: revenue vs. cost• Productivity data• Understand your current process

– Observational “Gemba” Walk– Process Map/Value Stream Map– Staff/Client Feedback

• Identify change ideas/solutions

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Understand the Current Process

• Why is it important?– Helps you to see what is actually going on:

“can’t change what you don’t see”

– Reveals the true “root cause” of a problem

– Avoids putting a Band-Aid on the symptom

– Finds a real fix to prevent the problem from re-occurring

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What is Gemba?• Gemba is the area in which the work is

being done

• To truly understand a situation, you must go to the Gemba and see for yourself! This is the Gemba Walk

• You are performing an observational walk-thru of the area you plan to improve

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• View of potential problems/waste: wastes or beaver dams in the system

• View from the client’s perspective:wait time, steps, messengers

• View from the worker’s perspective:handoffs; standard processes; motion

Gemba Walk

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8 Wastes ?• Defects• Overproduction• Waiting• Non Value-Added Processing• Transportation• Inventory• Motion• Employee (Underutilizing)

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Typically 40-60% of all lead time is non-value added.Typically 40-60% of all lead time is non-value added.

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Apply it!

At your tables, identify possible wastes in the processes you received and record on the Wastes Worksheet


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“If you can't describe what you are doing as a process, you don't know what you're doing.”

-W. Edwards Deming

Map the Process

Actual VSM

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Value Stream MapWhat is it?

• Used to visually represent the steps in a process

• Shows complexity, handoffs, unnecessary loops in the process

• Identifies data points

• Provides context for consensus building regarding what we do and what we think we do


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Value Stream MapHow do you create one?1. Define process to examine and set limits2. Observe the work processes first hand and

document observations3. Document each of the process steps4. Arrange steps in order of sequence, including

when things go wrong, corrections, decisions5. Get input from outside group

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Value Stream MapHow do you create one?● Use icons to draw current state

● Draw by hand and with pencil

● Capture actual times, not standards

● Used to highlight improvement opportunities vs. document process

● 70% accurate rule

● Map both the information flow and the process flow

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Results: Decrease Lead Time

VSM identified “beaver dams” & extra steps

Wilson VSM


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Let’s Try it Together!!

---

Customer Process Step Waits Between

Info./Software Flow

Starburst/ Idea Data Box

VALUE STREAM MAP LEGEND

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What Changes Can We Make? (IDEAS)

• Understand your current process– Observational “Gemba” Walk– Process Map/Value Stream Map– Staff/Client Feedback

• Identify change ideas/solutions– Brainstorm– Use Evidence Based Strategies– 5Whys

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Brainstorming

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• The ability to generate a large number of ideas around one area of interest

• Allows all participants an opportunity to express their ideas

Effective Brainstorming requires• Assembling the right people• Getting everyone to contribute ideas• Stating the issues to be discussed• Setting a time limit• Recording all ideas


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Evidence Based Strategies

Practice Management Examples:•EBS : compliance with health recommendations improved if relationship with provider reduce steps & messengers in process

•Examples: best practices tested by other agencies:

– Streamlined clinic flow processes

– Organization of clinics (integrated vs. stand alone)

• Team approach and huddles

– Practice management dashboards 70

Child Health Best Practice FlowPreventative Visit

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Practice Management Strategies

• Inventory = set up a tracking system in order to minimize costs and standardize location in stock room and clinic (relates back to standardization)

• Testing = PDSA• Measuring No Show Rates = a prescheduled

appointment slot that was not used• Types of Wastes = appointments, supplies, staff

time, staff skills, space, etc. • Demand for Appointments• Third Available Appointment


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Practice Management Strategies

• Flow Analysis = objective assessment of how patients and staff flow through the system

• Scheduling Design = how time slots are arranged and utilized

• Capacity = how many patients can be seen in a day based on numbers of staff, their skill level and practice model they work in

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5 Whys

What is the 5 Whys?• Gets to the real root cause of the

problem– “treat the disease vs. the symptom”

• Removes layers of assumptions

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5 WHYS

WHY?

WHY?

WHY?

WHY?

WHY?

PROBLEM

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Duplication of effort RN & FNP increases lead time for visit.

RN & FNP review the history at each visit

“We’ve always done it this way” to avoid providers missing something that will result in ding on the audit

Corrective Action previous audits found providers missed a documentation components”

Providers are not part of the audit process or nursing staff meetings where findings are reviewed

Not sure, our previous DON set it up that way.


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Try It!

• From the list of improvement areas you identified from the VSM & Gemba Walk, choose a different area/problem and drill down to the root cause

• Ask Why 5 times

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Testing our Change Ideas

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Model for Improvement

What are we trying to accomplish?(AIM)


(MEASURES)




Act Plan

Study Do


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Testing Changes

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Ideas

Changes that result in

improvement

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PDSA Cycle

Act Plan

Study Do

• Objective of cycle • Questions/predictions• Plan to carry out the cycle

(who, what, where, when)

• Carry out the plan• Document

problems/unexpected observations

• Begin analysis of data

• Complete the analysis of data

• Compare data to predictions

• Summarize what was learned

• What changes are to be made?

• Adapt? Or Abandon?• Next cycle?

Use the PDSA cycle to test changes

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Another Example PDSA CycleAim:

By December 1, 2013, we aim to increase the number of patient visits per staff discipline (see below) over 2012 capacity.

MD/NP/PA = 20 patient visits/day (2012 = 12)¹RN (General Clinic/Mandated Services) = 20 patient visits/day (2012

= 6)Rostered CH RN = 6 patient visits/day (2012 = 3)PP/NB HV = 5 patient visits/day (2012 = 3)

¹If STD service visits are not included in the RN (General Clinic/Mandated Services) numbers, then the benchmark would be 8 patient visits/day.


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PDSA Cycle Example: Schedule

Act Plan

Study Do

• If we set the staff schedules up to accommodate the increase in patient visits, will staff be able to sustain the load?

• Design schedules to reflect target and test for one day in clinic.

• Current clinic flows didn’t support additional patient load.

• Was able to see more patients but didn’t achieve Aim.

• Change flows to decrease non-value added processes (hand-offs, stops, etc.) and try again.

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PDSA Practice Management Example

PDSA Cycles:Improve Health Outcomes by Improving

Clinic Efficiency and Cost Effective Services.

1. Test new schedule which supports desired benchmark of patient visits/provider. (PDSA #1)

2. Test Flow (PDSA #2)

3. Test staffing model (PDSA # 3)

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How Have You Used PDSAs?

• What was the aim of your project?

• What change did you test using a PDSA cycle?

• What did you learn from the first PDSA cycle?

• What were the benefits of using a PDSA cycle


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PDSA Tip #1: Scale Down

• Years

• Quarters

• Months

• Weeks

• Days

• Hours

• Minutes

• Number of clients

“Drop 2”

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PDSA Tip #2: “Oneness”

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Key Points for PDSA Cycles• Successful tests

– As move to implementation, test under as many conditions as possible

– Special situations (e.g., busy days)

– Factors that could lead to breakdowns (e.g., different staff involved)

– Things “naysayers” worry about (e.g., “It will not work on Wednesdays”)


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Apply It!

How can you use PDAS cycles to test changes in your agency?

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Where do you go from here?

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Planning for Implementation of Change

• Clear AIM and measures

• Leadership sponsor which can articulate the change imperative and AIM & secure resources

• Practice Management Team with clear joint performance objectives

• Implementation plan which includes detailed steps, resource requirements, accountabilities, and monitoring data set

• Build change capacity on early successes or “low hanging fruit”

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Organizational Structure & Change

• Leaders = point the managers towards the vision and mission of the agency and leverages the funds to make it happen

• Managers = plan for, designs and controls factors that affect work

• Supervisors = over-sees or directs people at work– Line of Sight Supervision = supervisors can see

employee performance in the work flows– Standardize = policies, procedures, environment,

work flows, job description, work plans.

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Change Management Process

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Change CommunicationCommunication must •Clearly define impetus for change

•Clearly define assessment process & change process

•Be consistent from health director to middle managers to front line

– Communication structure: all staff meetings, team meetings, huddles, data reports re: progress toward objectives

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Change CommunicationCommunication must: •Recognize change process & implications for and concerns of all stakeholders:

– Example: the goal of the clinic efficiency is to optimum use of resources: staffing resources “freed” by reducing duplication & increasing efficiency & productivity will be redeployed to other value added services

– Address resistance and anxiety with multiple changes in status quo

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Next Steps

How will you use what you’ve learned in the next 2 weeks?

• AIM

• Team

• Identify specific agency strengths

• Identify and address barriers

• Develop a plan & work the plan

Questions, CommentsDebriefing

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Resources Available• Center for Public Health Quality

(http://centerforpublichealthquality.org/)• Institute for Healthcare Improvement

(ihi.org) • The Public Health Foundation• DPH Practice Management Resources

http://sgiz.mobi/s3/Public-Health-Practice-Management-Resources

• DPH Administrative & Nurse Consultants

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Contact InfoJean VukosonPhone: [email protected]

Pamela CochranPhone: [email protected]

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Kathy BrooksPhone: [email protected]

Tara LucasPhone: [email protected]

management and supervision fall 2014 - unc gillings school ...sph.unc.edu › files › 2014 › 11...

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