pfcc. breakout 1. helga avila. use of lean tools to advance pfcc

Use of Lean Tools to

Advance PFCC

Quality Forum Presentation

By Helga Avila

Manager Process Improvement

February 27, 2013

MoH KRA 3

• Implement an integrated model of primary and community care to more effectively meet the needs of British Columbians, especially frail seniors and patients with chronic and mental health and substance use conditions.

VIHA Guiding Principles

• Comprehensive Services Across the Care Continuum

• Person/Patient Focus • Geographic Coverage and Population Served • Standardized Care Delivery through Inter-

Professional Teams • Quality Improvement

VIHA Guiding Principles

• Information Systems • Organizational Culture and

Leadership • Physician Integration • Governance Structure • Financial Management

Complexity of Need Triangle

Source: Kaiser and MOHS HCC Care Management Strategy

Level 1 Well Population

No Risk but may have socioeconomic risk factors

Level 2 Supported Self Care & Management

Low Risk

Level 3 Chronic Disease

Management Care High Risk

Level 4 Complex Care

High Risk Complex

Complexity of N

eed

Individual Based

Population Based

↓ Disability & Complication

Maintain Health & ↓ incidence of

disease

Support respectful end

of life

Stay Healthy

Goals of Care

Nuka System - summary

Cultural Foundations

We

Are our own healing

Move as a people/tribe

where they we want to go

Know our identity/

uniqueness

Are the pure descendents

Walk along side and allow

choice

Healing the spirit world

wide is about relationship

Source: Southcentral Foundation Nuka Model

• 1999 –redefined Vision, Mission, Key Points, Operational Principles – Mission: Working together with the Native Community to

achieve wellness through health and related services

– Vision: A Native Community that enjoys physical, mental, emotional and spiritual wellness

• Since –continual principle driven design

Organization


Cornerstones • Value working together with the individual, the family, and the

community. • Honor the dignity of every individual. • Journey to wellness being traveled in shared responsibility

and partnership with those for whom we provide services.

Shared Responsibility

• Strive to provide the best services for the Native Community. • Employ fully qualified staff in all positions and we commit

ourselves to recruiting and training Native staff to meet this need.

• Structure our organization to optimize the skills and contributions of our staff.

Commitment to Quality

• Value the family as the heart of the Native Community. • Work to promote wellness that goes beyond absence of

illness and prevention of disease. • Encourage physical, mental, social, spiritual and economic

wellness

Family Wellness


Decision Making Model

100 Patient/Family

“Control”

The “System” 0

Low

Acuity High

1. Control - who makes the final decision influencing outcome? 2. Influences - family, friends, co-workers, religion, values, money 3. Real opportunity to influence health costs/outcomes – influence

on the choices made - behavioural change 4. Current model - tests, diagnosis, treatment (meds or procedures)


• If the goal is population health over time • The major variables we can affect relate to

chronic conditions, habits, choices, optimizing impact of treatments

• Then…the backbone MUST be effective, longitudinal, personal coaching, teaching, supporting, coordinating relationship

• Office visits, procedures, hospitalization become episodes of care only

Rethinking the basic platform


Evidence-Based Health System

Consultants

Hospital Services

Social Services

Individual/Family

Medical Home/Care Team

Community Resources

Public Health

Note: The “Medical Home” is likely not the “primary care” that we currently have. Source: Southcentral Foundation Nuka Model

• Defining the purpose – relationship over time • Understanding complexity science -principles • Moving from product to service as the

fundamental base of entire system • Optimized primary care with redefined entire

system on that ‘new’ backbone/platform • Customer driven design –reallocation of power

and control at every level • Optimizing messy human relationships

The SCF Nuka Model


Parallel Work Flow Redesign

Integrated Care Team

Medication refill

Chronic disease Monitoring

Management of study / test results Info

Undiagnosed or Changing new

Consumer concern

Preventive med Intervention

In clinic Point of care

testing

Chronic Disease Compliance

Barriers

Acute Mental Health

Concern

Customer

Customer

Customer

Customer

Customer

Customer

Customer

Customer

Customer

Customer

Customer

Customer

Behavioural Health

Consultant

Certified Medical

Assistant Clinical

Pharmacist PCP

Provider Dietician Case Manager


Voice of the Customer – ‘Deep listening

• Multiple geographic advisory councils • Focus Groups • Comment cards • Customer Satisfaction surveys • SCF internet • Annual Gathering • Individual in depth interviews

•Elder Council •Listening Conference •Governing board •Staff Interactions •Service agreements •Individual complaints •Relatives and friends of staff •Customer Service staff


Current State Mapping

• Integrated Health Network • Adult Mental Health • Child Youth & family • Senior’s Health • Diabetes Education • Heart Health

Time consuming finding communication pathLack of details

Hospital

Paris

Oceanside Health Centre – Home & Community Care - Current State Detailed Map – April 26, 2012 – FINAL Version

C

Hospital Liaison/EST or Acute

determine if client known to HCC

Client Known? Fax Referral to Dr. Fax?Hospital Liaison/

EST or AcuteFax/Phone/Email

YesYes

External ReferralClient Update

form Paris

- St Hoes- RJH

Home Support?

Discuss Service- Resume - Change

Yes YesPhone

Case Manager- HNC

- OT?PT

Does not always receive notifications

May not get picked up if directed to a ClinicianC

Note Pads

Admin Determines who to forward fax

to

GPCommunity

Family

Central IntakePhone or Fax

Paris

Eligibility Screen(High Level)

BC Resident0 MVA, 3RD PartyCanadian Citizen

Criteria Met? Determine PriorityYesLogs in Paris/

Opens Encounter in Cerner

Cerner

No

Complete Home Support Details

FormEnter into Paris

Client Update form Paris

- St Hoes- RJH

Inform Admin Photocopy

Change in Service Hours

Home Support Procura

End

Distributes Fax

Open Intake Assessment

Paris

Yes

No

Clinician Assesses Over Phone/

Decides Discipline & Urgency

Logs Referral to Appropriate Discipline

Paris

Send to Geographic Team

Fax Collateral Info to Geographic

Team

Paris

Admin Receives & Disseminates to

Appropriate Discipline

Admin Prints Outstanding Call

List

Creates New or Adds to Existing

Chart

Paris DocumentsFaxed Collateral

Blank DocumentsLabels (Paris)

Kardex

Case Management?

Nursing?

Social Work

Admin Places in Basket on Desk

No

No

No

Does not refer to Home Support

Why?C

Admin Delivers Paper Info into

Route Box

Route RN Checks Box in am and pm

(8am – 2-4pm)Yes Filter Updates

Yes Sort New Referrals into OT and PT

If an Update Uses Rolodex to Determine Therapist

Records Name on Update Paper

Admin Delivers to Therapist MailboxStamp & Date

Sort into Geographic

Region

Access Paris to Allocate via Geographic

Region

OT(Rehab)/PT

Home Support

No

Check Off Names from Outstanding

Referral ListDocument in Paris

Paris

Allocate Charts for HCN

Case Management? Yes

Place Charts on Shelf & Signed

Out by Appropriate Clinician

No

Admin Delivers to Baskets on Wall Outside Office

Client Known?Close Encounter

(Cerner)Close Paris

End

Create Master File

Log Referral(Central Intake)

Fax paperwork to Geographic Office

File Paper in Existing File

Provide info via phone

A

Update?

New Referral?

Changes to Service?

HSDFHome

Support Details Form

No

No

No

Human Resources (Staff)

New Referral?

OT/PT ActionUpdates?

Faxes from Dr’s

Lab Results

Home Support Info/Client Info/Client Charts

Nursing via paperC

i.e.: Do not resuscitate

Palliative BenefitsPharmacy

BPMHMed Hx

No

No

No

No

Review/Validate/PrioritizeYes

Yes

Yes

ReviewCommunicate to

Dr(fax or phone)

Prioritize by Urgency

Review

Action Dr. Orders

Action

Action Dr. Orders

Action

Entered into Procura

ProcuraCharting/

Scheduling

Primary Clinician(MRC)

Internal Referrals

Determine Need for Other Service

Log New Referral In Paris

Existing? Yes Revise Care Plan

No

Create New Care Plan

Document In Procura

(Scheduling Components)

ProcuraDated Note

PrintCare PlanInfo SummaryDOT & ListRespite Info Sheet

Documents place in Home By

Community Health Workers

Action

HCW come into office 60-70 per

day

ProcuraDated Note

Home Support?

CompleteHSDFAllergy

Delegation of Task

Forward to Admin (if Urgent – Verbal)

Enter Details into Procura

Forward to Home Support

ProcuraDated Note

Yes

Complete Client Update Form

ProcuraDated Note

Copy Relevant Info from Chart to

New Clinician Chart

Create File Forward to Case Management

No

HS

CM

HS

CM

Case Manager

Home Support

Nursing

OT/PT/SW

Ambulatory Clinic

Contact Client to Schedule Visit Determine Need

Workflow Sheet

Clipboard

Home Visit Determine Other Services Required

Schedule Next Visit

Review Inbox on Wall

Pull Referrals for Area

Screen & Determine Priority

Window

Valid OT/PT Referral?

Contact Client to Determine and/or

Arrange Visit(phone)

Change in Paris to Appropriate

Clinician OT or PT

No

Yes

Place in Appropriate Priority Slot

Financials require 2 visits

Home Visit(1 – 1.5 Hr)

Complete Home Assessment

Take Actions from Visit

SSRI (Paris)

Funding LettersMedical

EquipmentJustification

ReportsPre-

Discharge

FileUpdate CareplansUpdate Progress

Notes Complete Flow

Sheets

Update Paris

ParisSSRI

FinancialHome

Support Service Audit

Document Scheduled Next

VisitWorkflow/Chart/

Kardex

OT/PT record next visit on day

planners (paper)

V

V

View Schedule via Computer

Pull Charts for Clients to be Seen

Gather Supplies & Set Up Room

See Clients in Clinic Clean Equipment

Charting & Referrals (External

or Internal)

Retrieve Basket – Prioritize Issues

for Action

Schedule Home Visits

New? Quick Response Person (QRP)

Brain Injury ClientPriority 1/2

New?Case Management

Other Priorities

Create Chart

Gather Info for Visit

Red BookFile

Resource Info

Home Visit w Laptop

Use Smart Form (CM Only)2-3 Hr visitRAI to Paris

Complete Paperwork

Review Voicemail and Action V

HSCLReferral from

CLBL 19+

Central Intake(Nanaimo)

Create Chart Mail to Parksville

Received by Community Nurse

Schedule Appointment

(Self Managed)Visit Assessment Create Care PlanDetermine Needs

simple vs. complex

Provide Education i.e Diabetes

Test Blood SugarYearly Visit to test

MS Word

Create Referrals to Other Services

Paris

Update Activity in Paris

Update CLBCPhone (Complex) or Fax (Simple)

Ongoing Monitoring

Darcie Wolfe – Home & Community CareElaine Collison-Baker – Home & Community CareKatherine Zimmer – Home & Community CareDonna Hay – Home & Community CareDeb Bonora – Home & Community CareTerrie Wright – OHC Project TeamParker Gauld – VIHA Process Improvement

Julia Wilson – Home & Community CareAna Maria Gidofalvi – Home & Community CareBarb Duncan – Home & Community CareCathie Beddoes – Home & Community CareCathleen Hansen – Home & Community CareAlisha Pauling – Home & Community CareShirley Quesnel – Home & Community Care

Patient Journey Mapping

• Patients and Caregivers • Complex • Multi-diagnosis

Future State Mapping

• Registering and Intake • Assessing • Initiating • Optimizing • Transitioning

Thank-you! Helga Avila, Manager Process Improvement

Vancouver Island Health Authority