the wright center (twc) case study three - amazon...

Our PDSA Tracker Tool is essentially an “idea pool” where everyone withinour organization is not only enabled, but expected to contribute to quality

improvement efforts and a learning culture. The PDSA Tracker Tool provides a team-based IT framework to organize stackable, deliberate, constructive

improvements driven by reflective practice and PACE Card metrics.

The successful implementation of our PDSA Tracker Tool has advanced a culture of universal employee engagement and continuous learning for system

improvement. Within the last two years, 799 PDSAs have been initiated withover 550 completed. Four PDSA examples are highlighted in this case study. We encourage any practice in its current state to introduce the replicable and

scalable models outlined in this TWC case study compilation.

Case Study ThreeChange Management and PDSA Tracker Tool

The mission of The Wright Centeris to continuously improveeducation and patient care

in a collaborative spiritto enhance outcomes,

access and affordability.

The Wright Center (TWC)5 South Washington Avenue, Jermyn, PA 18433

HIMSS Ambulatory Davies Award:Independent Ambulatory Practice

Executive LeadershipLinda Thomas-Hemak, MD

Jignesh Sheth, MDBrian Ebersole

Teresa Lacey, RN

Clinical InnovationTiffany Jaskulski

Courtney Dempsey

Health InformationTechnology and Innovation

John JanoskyEdward Wargo

Communications/DevelopmentMaria Montoro-Edwards, PhD

Jennifer HetroKerri Price

Organizationally, TWC is highly invested in developing stackable continuous quality improvement projects to improve clinical and educational operations, patient care delivery processes and health outcome measures. Each resident is contractually responsible for six “Plan. Do. Study. Act.” (PDSA) system improvements, three in the in-patient and three in the out-patient settings each year. Annually, all staff are also expected to participate in six PDSAs within their daily work environment to realize all levels of their performance-based bonuses. TWC developed an interface called the PDSA Tracker Tool to monitor all process improvement changes across all areas of operations and by users engaged in the system improvements.

Local Problem Identified and Intended OutcomeTWC outpatient clinics began assigning quality improvement projects on a weekly basis depending on the status of our quality measures for that month. As PDSAs were being assigned to residents, there was not consistent hand-off of the project if the assigned resident was leaving for another rotation. TWC lacked infrastructure to manage, track, ensure compliance and validate value add of all ongoing QI projects.

In early stages of tracking PDSAs, a Google Document was created and shared with the entire organization (below). Residents accessed the document, updated their PDSAs accordingly and were expected to sign out to another team member when necessary to ensure continuity and completion of the project. This Google Document quickly became cumbersome and difficult to manage. TWC needed a seamless and reliable way to track ongoing and completed, venue specific PDSAs for each resident and employee and to gauge whether or not the PDSAs were successful and spreadable.

Design and ImplementationAlthough data is fairly easy to update in Excel, the amount of data was becoming cumbersome to edit manually. The IT department devised a plan to address this challenge and programmed a proprietary PDSA Tracker Tool. At TWC, all clinical staff members, includ-ing medical assistants, LPNs, RNs, residents and providers, are assigned to an empanelment team categorized by team color; PDSAs are also categorized by team color. To standardize the information, the following elements needed to be included:

1. Title2. Location3. Status4. Category5. Sponsor6. Team Color7. Start Date8. Completion Date9. Lessons Learned

© 2015 | The Wright Center | HIMSS Ambulatory Davies AwardChange Management and PDSA Tracker Tool

Team Color Current Status Date Started ExpectedCompletion Date

Actual CompletionDate Category of PDSA Title Resident 1 Resident 2 Resident 3 Sponsoring Physican Measure to Impact Plan Do Study Act

Purple [1]In Progress [2] 2/6/2014 [3]

Asthma patients on appropriate meds[4]Arsh [5]

Zin [6]Dr. Barooah [7]

To clean Registry, To assureapproriate asthma severity

designation and appropriatemedication managment [8] Review charts, call patients [9]

clean registry, document to do list onalert sheet [10]

will call pt to assess severity ifnot properly documented. Willarrange for PFT if needed. [11]

Blue [12]in progress [13] 5/27/2014 [14] 7/31/2014 [15]

PDSA FLOWSHEET [16]Bassel [17]

Dinesh [18] Sowmya [19]Dr. Sheth [20]

Track PDSA for a given patient [21]Create a trackable flow sheet thatwill be added to the patient'schart [22] Improve patient compliance [23]

Purple [24]

Completed [25] 5/8/2014 [26] 5/15/2014

microablumin [27]

Bassel/Dennis [28]

Identify pts who have not hadmicroalbumin in the past one year

[29]

Charts reviewed, people who didnot have microalbumin in thepast one year and did not havean appt in the next 3 monthswere called [30]

Results documented in triage [31] Documented currentmicroalbumin in chart, those whoneed testing were informed [32]

Purple [33]Completed [34] 5/8/2014 [35] 5/15/2014

LDL [36]Bassel/Dennis [37]

Identify pt's whose LDL is less thangoal and ascertain whether or not

they are on appropriate therapy [38]

Charts being reviewed for latestLDL, current pharmacotherapy,and triages and alerts are beingcreated [39]

n = 58, age 18-85, 16 pts with LDL<100, 41 pts with LDL >100, 1 pt with

LDL unknown [40]

Alerts created to check lipidpanel or direct LDL in pt's withhypertriglyceridemia, pts withoutrecent lipid panel called [41]

Purple [42] Completed [43] 5/8/2014 [44] 5/15/2001 [45] A1c>9 [46] Bassel/Dennis [47]

In Progress [48] 11/5/2014 [49] 11/21/2014 [50]Clinical DecisionSupport [51]

QT prolongation with citalopram40/ECG monitoring [52]

Bo Jiang [53]Jen Malinowski, PharmD[54]

% of patients with annualECGs, assessment of QTcin patients on citalopram 40[55]

Evaluate number of patients withactive citalopram 40 mg Rx,

research guidelines on how tomonitor QT prolongation in patientson high risk meds/risk factors [56]

Run list of patients on citalopram40, chart reviews on thosepatients to assess for presenceof ECG [57]

Check for +/- presence of ECG, ifECG, check that QTC <500. If no

ECG in past year, document patientrequires ECG next visit. [58]

Document patient need for ECG,promote staff education athuddle on meds associated withqt prolongation and how tomonitor [59]

Blue [60] 1/16/2014 [61] [62] IVD patients due for LDL [63] Christina/Brittany/Lida[64]

Purple

Completed [65] 12/12/2013 1/2/2014 1/3/2014 [66]

ASA/ACE/ARB/Statin/vaccines

Dennis [67]

Qi [68] Ghelani / Dennis[69]

Dr. Barooah

Identify patient needs to be on statin,ACEI, Aspirin and follow up labs for

DM and Lipid control [70] Look for BP, Contraindiaction ofStatin, LFT check, make PDSAphone triage and call regardingneeds and goal set up [71]

Calculate risk based on new CVguideline for need of Statin and

based on BP need of ACE inhibitor,check for Labs and contraindication

including allergy for startingmedication [72]

Access needs and requirementof patient after reviewing chartand creat PDSA phone triage forrequirement and list ofcomplication, next step is to callpatient and address issue, ifhave recent appointment, createa note to address it during OV[73]

In Progress [74] 6/5/2014 [75] 7/5/2014 [76]Delivery SystemDesign [77]

Create PDSA triage template inMEDENT [78] Deobrat [79]

Dinesh Keerty [80] Sowmya [81]Dr. Sheth [82]

To create a PDSA Phone Triagetemplate in MEDENT [83]

D/w Tiffany points to be includedin the template. Templatecreated. [84]

Will test the functioning & utility of thetemplate on 10 patients. [85]

phone calls made-goodresponse.roll out to all patients[86]

Blue [87]Completed [88] 12/13/2013 [89] 1/2/2014 [90] 1/28/2014 [91] [92]

LDL/A1C [93]deobrat [94]

Jaya Nair [95] Sowmya [96]Dr. Sheth [97] [98]

Identify patients who do not have adocumented LDL in the past year or

A1c [99]Call patients who have not hadtheir LDL drawn in the past yearor A1c drawn [100]

Status documented via PDSA triagtype and alert put in chart to get

patients testing [101]

Residents and MA's shouldcheck alert and address all if ptcomes in for appt or POC testing.[102]

Blue

In Progress 12/12/2013 1/2/2014 [103]

DM Depression Screen/SMS

Deobrat

Rani Gollamudi[104] Deborat [105]

Dr. Sheth

To move measure by obtaining anddocumenting depression screening

for POF [106]

Resident team identified patients thatactually had depression screen done

vie BHS and was not reported.Identified error was adding to report

and was rerun showing improvement.[107]

SMS Goal need a Status [108]

PurpleCompleted [109] 12/12/2013 1/2/2014 1/3/2014 [110] [111]

DM Depression Screen/SMSGhelani

sanjay/arsh [112] Ghelani /Melad[113]

Dr. Barooah

To move measure by obtaining anddocumenting SMS goals [114]

call patients to set goals [115]

measure willingness of patients to setgoals over phone [116]

People who responded to theircalls were found willing to setgoals over a phone conversation[117]

The PDSA Tracker Tool is Internet-based and accessible at all resident training locations (i.e., inpatient, outpatient, specialty clinic, etc.). The category section includes the areas in the organization that this quality improvement is aimed to impact (i.e., delivery system design, EHR enhancement, healthcare disparity, etc.). Each PDSA must have a “sponsor,” an attending faculty member who acknowledges they will oversee this project from start to finish and can attest that the PDSA is complete. Once the general information is input into the PDSA Tracker Tool, members involved in the quality improvement project can begin adding themselves and updating their narratives and contributions. It is expected if a resident is leaving their block rotation for another site, he or she will communicate the PDSA plan with another team member who will continue the PDSA within the clinical environment. The Tracker Tool allows for each section of the PDSA to be described and each PDSA assigned a category of quality improvement. Attachments can be added for further illustration and tracking of progress, completion and lessons learned. Employee pictures, phone numbers and emails are included for easy access and recognition of each team member. Team members receive an email if there is an update within PDSAs to which they are assigned. Managers track the total number of PDSAs going on in the clinic at any time and overall PDSA metrics feed the corporate Balanced Scorecard, providing testimony of a culture of learning and continuous improvement. The PDSA Tracker Tool (right) is a part of our web-based employee portal and is password protected. PDSA Tracker Tool education is integrated into residents’ and employees’ orientation and ongoing education.

How Was HealthIT Utilized?EHR-generated fluid registries, exception reports and PACE Cards at empanelment team and clinic levels provide the platform to identify PDSAs that align with clinical quality measures needing attention. Expectations for creation of PDSAs fosters the engagement of faculty, residents and staff in quality improvement of patient care and education, providing the platforms for individual and team-based incentives.

TWC recognizes authentic practice transformation is not possible without integrated Health IT to mandate trackable and measurable outcomes that can ultimately be replicated at other care venues. Any practice in its current state can introduce the replicable and scalable model outlined in this case study to improve the health outcomes of their patient populations and promote accountability. These metrics inspire value driven deliverables from care team members. Once a PDSA has been deemed successful, other care teams follow suit and replicate the actions within their own workflow, leading to organic practice transformation. These successes are integrated into the Clinical Workflow Document.

Value Derived/OutcomesCurrently teams use a quality improvement infrastructure to stack PDSAs for rapid cycle-driven practice transformation. The creation of the PDSA Tracker Tool to document implemented improvement cycles and hold practice team members accountable was an important advancement within TWC. By integrating this tool with the rollout of provider team and individual report cards to show specific performance data and health metrics, TWC became one of the most innovative, outcomes-focused primary care practices in the country. The informatics platform continues to drive innovation and the developments and outcomes are being increasingly recognized in the local and national community for current and future potential impact on care delivery, public health and medical education. In the following pages, we highlight four PDSAs created to respond to specific care delivery and health metrics identified as necessary by clinical staff.


PDSA #1 MammogramsAlerts were added to charts for all women between the ages of 40-85 who had not had a mammogram documented within the last two years. If the mammogram report is not present in the chart, the alert remains red, calling the patient’s provider’s attention to address the importance of mammography with the patient at all points of contact.

Even with chart alerts, the overall percentage of women with a mammogram documented in the chart was historically not improving. Reports from radiology departments were not being sent back to our primary care office. A TWC physician led PDSA #1 and engaged two large, local hospital systems to secure remote access to their EHR so our nursing staff could retrieve mammography reports for patients without relying on the hospital to fax the informa-tion to our data management department. After TWC’s nursing staff gained access, the percentage of women within the practice with documented mammograms increased from November 2013 until February 2014 (below).

The graph (right) demonstrates that TWC’s registries are fluid, mean-ing patients are not excluded from reporting if they are a new patient in the reporting period. As our population of women in the age range to receive a mammogram continuously grows, our trending mammogram performance may concordantly drop or plateau (below). We transparently acknowledge the challenges of fluid registry functionality with all providers, stressing intentional focus on controllable factors and continuous improvement. The green arrow shows where PDSA #1, described above, began and the yellow arrow shows progress plateauing due to practice influx of new female patients in that timeframe.

Number of Female Patients Between Ages 40-85

Partnership with Lackawanna Mobile X-rayAlmost a year later, a community-based service agency, Lackawanna Mobile X-ray approached TWC to see if we would be interested in offering mammograms onsite at the office. A PDSA was developed to describe how we trained one of their staff members to proactively run the exception report of all women due for mammograms (left). The staff member was trained to call and schedule interested patients for onsite mammography within our EHR. We saw a spike in the number of completed mammograms within a month and successfully completed a total of 169 on site mammograms for TWC patients.

Changing the scale helps justify our speculation that as more women between the ages of 40-85 come into the practice without a mammography report, our mammogram measures would plateau.


KEY: The blue line depicts TWC practice screening mammography performance; the red line depicts the HEDIS 50 percentile; the yellow line depicts the target set by the collaborative in which TWC participates.

Practice50th PercentileMeasure Target

As the Lackawanna Mobile X-Ray staff member was engaging patients, she encountered and reported patient frustrations from women who had bilateral mastectomies, making a mammogram unnecessary. TWC recognized this as a significant source of patient frustration so a patient-centered Registry Clean-up PDSA was led by a concerned resident to avoid any further mammogram promotion outreach to women with a history of bilateral mastectomies. This project required the resident to do manual chart reviews for 574 patients to determine if there was mention of bilateral mastectomies that were not clearly marked in the patients’ charts. At the end of his chart review, he found a total of 17 additional patients who should be excluded from our mammogram exception report. His efforts triggered a subsequent, impactful Mammogram Registry and Exception Report PDSA (below). This PDSA, focused on office-wide education regarding appropriate diagnostic documentation of breast disorders within the EHR, led to a significant improvement in practice level screening mammography performance metrics.

Mammogram Registry and Exception Report Clean-up PDSA

The yellow arrow represents timing of the

partnership with Lackawanna Mobile X-ray

for co-located services. The green arrow represents

timing of a registry clean-up PDSA.


KEY: The blue line depicts TWC practice screening mammography performance; the red line depicts the HEDIS 50 percentile; the yellow line depicts the target set by the collaborative in which TWC participates.


A template for Self-Management Support (SMS) Goal tracking (right) was added to the EHR system by the vendor to document problem specific goals. This trackable process is consistent with Medical Home Accreditation and Meaningful Use Attestation standards.

After using the new problems and goals section for a period of time, we observed a slow decrease in the number of our diabetics who had a documented SMS Goal in the last 12 months on our population health reports. Physician leaders were confident the measured outcomes were not capturing patient-care delivery processes for SMS Goal setting, so providers led PDSA #2 (right). They focused on re-evaluating patients identified as a “no” for SMS Goal setting in the exception reports and quickly discovered that residents and provid-ers were free texting the SMS Goal setting details and not actually documenting within the new problem specific trackable template. As a result, our percentage of diabetic patients with an active SMS Goal was decreasing.

After the creation and completion of this Diabetes SMS Goal Setting PDSA #2 (right), we quickly saw an increase in our performance graph; with on-going education of the provider teams, we have maintained our progress. To demonstrate success, all diabetic population measures, including number of hospitalizations shown in the line graph below, were compared over a timeframe in relation to the Diabetes SMS Goal Setting PDSA #2. This PDSA took place in October and the number of hospitalizations decreased the next month and also within the following six month timeframe. Hospitalizations for patients with an A1c >9 began to decrease as well. We concluded that our efforts to focus on Diabetes SMS Goal setting with patients in the clinics had a positive correlation with improving several outcome measures, especially for highest risk diabetics.

Diabetic Bundle Measures

Diabetic Hospitalizations

PDSA #2 Diabetes MellitusSelf-Management Support (SMS) Goals


KEY: The blue line depicts TWC as a practice; the red line depicts the HEDIS 50 percentile; the yellow line depicts the target set by the collaborative in which TWC participates.


PDSA #3 Meaningful Use e-Prescribing Formulary Check When our EHR updated to become certified for Stage II of Meaningful Use, we immediately identified that our providers were grossly deficient in one particular measure: checking the drug formula with each Electronic Prescription Request Refill (eRx). After research, we learned that for all prescriptions refilled over the phone or through a Triage message, the nursing/provider staff needs to manually select a “Get Coverage” button in order to get reporting credit for checking the formulary. We approached the EHR vendor and explained why this could not be an automatic function. In the interim of our request going to programming, we needed a solution to increase Electronic Prescription Request Refill formulary check compliance.

This screenshot is an example of the dashboard programmed in our EHR created for the providers to verify that they are meeting thresholds for Stage II of Meaningful Use. The highlighted box in this example shows this provider’s eRx percentage is 82%. This comparison graph is sent out monthly to all providers participating in Meaningful Use for comparison of their measures to other providers in the organization to promote healthy competition and bring awareness to this metric, which is a semi-annual performance evaluation focus.

The trending in the line graphs (below) shows that the PDSA improved two providers’ measures in the first month.

Resistance to changing habitual workflow is common. True behavior change is a result of understanding rationale for change and then actively engaging because the value of the change is apparent. Health IT can provide visual management tools for coaching and supporting behavior change. In this Meaningful Use e-Prescribing Formulary Check PDSA #3, a daily report listing refills sent out without clicking the “Get Coverage” button was provided to and reviewed with the nursing staff by physician leaders to promote accountability for formulary check through “Get Coverage” compliance. After a few weeks of coaching and utilizing this report, nursing staff engaged to take the extra step.

This exception report (right) shows the list of patients given to nursing staff at the end of the day to verify Meaningful Use e-Prescribing Formulary Check compliance.


PDSA #4 Tobacco Cessation

TWC physicians knew smoking cessation counseling was a valuable tool for patients and also a billable service. Once CPT coding processes were verified and staff educated, we created DM/HM reports to alert providers of patients who are smokers that did not have a documented tobacco use and relevance/readiness for behavior change assessment and counseling session in a designated time frame. The figure on the right shows the CPT is also included in the title to prompt providers of the correct code to use, depending on the patient’s insurance.

To gauge patients’ smoking cessation readiness, we placed “Readiness Rulers” (left) in all patient rooms. Medical assistants use this tool to ask patients how important quitting smoking is to them today and how ready they are for behav-ior change. If the patient’s relevance and readiness for change are high, provid-ers direct the conversations during the visit to cessation counseling. If their readiness is low, providers know not to spend significant time on the topic. The

medical assistant documents the patient’s response in the intake note. Relevance or readiness below “5” demonstrates quitting smoking is not a top priority at

TWC built a partnership with Tobacco Free Northeast PA. Providers, residents, and staff were trained in readiness and relevance, assessment and motivational interviewing. TWC intensified training for several staff as Certified Smoking Cessation Counselors and imple-mented the referral process from the providers to the counselors while billing for smoking cessation counseling. TWC captured ancillary expanded services income from the partnership beyond CPT level billing. TWC also received nicotine replacement therapy.

The graphs (above) show the improvement of processes of tobacco assessments and CPT billable counseling from April 2014 to May 2014, after the providers and staff were trained.

“Moving beyond office visit-based goal setting and motivational interviewing”

TWC invested the time to train counselors within outpatient clinics and added counselors to our orders process within the EHR. Counselors were also trained on how to link triages and documents to the orders before they close them so the providers can reference materials associated with their counseling sessions and track services delivered.


Financial ImplicationsTWC’s VP of Information Technology and Innovation led and developed the PDSA Tracker Tool. He spent about 56 hours creating the Tool at $57.69/hour for a total cost of $3,230.64. After the PDSA Tracker Tool was developed, staff and residents were trained and held accountable to utilize this tool for continuous learning and system improvement.

The graph (left) depicts the number of patients that the cessation counselors reported to Tobacco Free Northeast PA from 2014 - 2015. The lull in July 2014 - December 2014 was a result of state funding delays and staff transition.

Number of orders created internally for smoking cessation counselors.

Lessons Learned• Improvements need to be system wide for change to occur.• In order to improve outcomes, a trackable method for outcomes and improvements is necessary.• There is great power in emerging community partnerships to enhance care delivery and health outcome metrics.

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The expanded Tobacco Cessation Support Services intake assessment was added to the EHR for cessation counselors to document their initial visit with the patients. Once the initial intake was completed, it is faxed back to Tobacco Free Northeast PA for tracking and grant funding purposes. This intake assessment is the only document that could be used to close an order for expanded tobacco cessation counseling. All orders remain in an “open” status until there is clear documentation that the patient isn’t ready to quit yet or the visit already took place with the counselor. Counselors utilize the problems and goals section in the patient’s chart to document the goal setting discussed during the visit to improve tobacco cessation SMS Goal setting metrics.

Revenue generated solely through the Tobacco Free Northeast PA grant for expanded tobacco cessation counseling service.

Receipts received per month for the smoking counseling done by our provider care teams.

Tobacco Cessation Participants

Completed Program Did Not Complete

Total Patients Who Quit Completelyor Significantly Cut Down*

Total Behavior Change Total Did Not Quit

0

20

40

60

80

100

120

140

January 2014 - June 2014 July 2014 - December 2014 January 2015 - June 2015

Total Program Enrollment (6 Month Increments)

47%

18%

53%

82%

*After Fully Completing the Program


Total Enrolled: 213Total Completed: 113

the wright center (twc) case study three - amazon...

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