HIMSS Ambulatory Davies Award: Independent Ambulatory Practice
The mission of The Wright Center is to continuously improve education and patient care in a collaborative spirit to enhance outcomes, access and affordability. Executive Leadership Linda Thomas-Hemak, MD Jignesh Sheth, MD Brian Ebersole Teresa Lacey, RN Clinical Innovation Tiffany Jaskulski Courtney Dempsey Health Information Technology and Innovation John Janosky Edward Wargo Communications/Development Maria Montoro-Edwards, PhD Jennifer Hetro Kerri Price
The Wright Center (TWC)
5 South Washington Avenue, Jermyn, PA 18433
Case Study Three
Change Management and PDSA Tracker Tool Our PDSA Tracker Tool is essentially an “idea pool� where everyone within our 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 with over 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.
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 Outcome TWC 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. Team Color
Current Status
Date Started
Expected Actual Completion Category of PDSA Completion Date Date
Purple [1] Blue [12]
2/6/2014 [3]
Resident 1
in progress [13]
5/27/2014 [14]
Resident 2
Resident 3
PDSA FLOWSHEET [16]
7/31/2014 [15]
Sponsoring Physican
Measure to Impact
Bassel [17]
Dr. Barooah [7] Dinesh [18]
Sowmya [19]
Track PDSA for a given patient [21]
Dr. Sheth [20]
Identify pts who have not had microalbumin in the past one year [29]
microablumin [27] Completed [25]
5/8/2014 [26]
5/15/2014
Bassel/Dennis [28]
Purple [33]
Identify pt's whose LDL is less than goal and ascertain whether or not they are on appropriate therapy [38]
LDL [36] Completed [34] Completed [43]
In Progress [48] Blue [60]
5/8/2014 [35] 5/8/2014 [44]
5/15/2014 5/15/2001 [45]
11/5/2014 [49]
11/21/2014 [50]
1/16/2014 [61]
[62]
A1c>9 [46]
Clinical Decision Support [51]
Bassel/Dennis [37] Bassel/Dennis [47]
QT prolongation with citalopram 40/ECG monitoring [52] IVD patients due for LDL [63]
Purple
Completed [65]
12/12/2013
1/2/2014
In Progress [74]
6/5/2014 [75]
7/5/2014 [76]
Completed [88]
12/13/2013 [89]
1/2/2014 [90]
12/12/2013
1/2/2014
1/3/2014 [66] Create PDSA triage template in MEDENT [78]
Deobrat [79]
LDL/A1C [93] 1/28/2014 [91] [92]
Blue [103]
Purple 1/2/2014
Dinesh Keerty [80]
Sowmya [81]
Jaya Nair [95]
Sowmya [96]
Rani Gollamudi [104]
Deborat [105]
sanjay/arsh [112]
Ghelani /Melad [113]
1/3/2014 [110] [111]
Ghelani
[98]
Identify patients who do not have a documented LDL in the past year or Call patients who have not had their LDL drawn in the past year A1c [99] or A1c drawn [100] To move measure by obtaining and documenting depression screening for POF [106]
Dr. Sheth
Dr. Barooah
Study
Act
Access needs and requirement Calculate risk based on new CV of patient after reviewing chart and creat PDSA phone triage for guideline for need of Statin and Identify patient needs to be on statin, requirement and list of based on BP need of ACE inhibitor, complication, ACEI, Aspirin and follow up labs for next step is to call DM and Lipid control [70] Look for BP, Contraindiaction of check for Labs and contraindication patient and address issue, if including allergy for starting Statin, LFT check, make PDSA have recent appointment, create medication [72] phone triage and call regarding a note to address it during OV needs and goal set up [71] [73] D/w Tiffany points to be included Will test the functioning & utility of the phone calls made-good To create a PDSA Phone Triage in the template. Template response.roll out to all patients template in MEDENT [83] template on 10 patients. [85] created. [84] [86]
Dr. Sheth [82]
Dr. Sheth [97]
Do
clean registry, document to do list on will call pt to assess severity if alert sheet [10] not properly documented. Will Review charts, call patients [9] arrange for PFT if needed. [11] Create a trackable flow sheet that will be added to the patient's chart [22] Improve patient compliance [23] Charts reviewed, people who did not have microalbumin in the Results documented in triage [31] Documented current past one year and did not have microalbumin in chart, those who an appt in the next 3 months need testing were informed [32] were called [30] Charts being reviewed for latest created to check lipid n = 58, age 18-85, 16 pts with LDL Alerts LDL, current pharmacotherapy, <100, or direct LDL in pt's with 41 pts with LDL >100, 1 pt with panel and triages and alerts are being hypertriglyceridemia, pts without LDL unknown [40] created [39] recent lipid panel called [41]
Evaluate number of patients with Check for +/- presence of ECG, if Document patient need for ECG, % of patients with annual active citalopram 40 mg Rx, Run list of patients on citalopram ECG, check that QTC <500. If no promote staff education at huddle on meds associated with ECGs, assessment of QTc research guidelines on how to 40, chart reviews on those ECG in past year, document patient qt prolongation and how to in patients on citalopram 40 monitor QT prolongation in patients patients to assess for presence requires ECG next visit. [58] monitor [59] [55] on high risk meds/risk factors [56] of ECG [57]
Dr. Barooah
Deobrat DM Depression Screen/SMS
12/12/2013
Ghelani / Dennis [69]
deobrat [94] DM Depression Screen/SMS
Completed [109]
Qi [68]
Dennis [67] Delivery System Design [77]
Blue [87]
In Progress
Jen Malinowski, PharmD [54]
Bo Jiang [53] Christina/Brittany/Lida [64]
ASA/ACE/ARB/Statin/vaccines
Plan To clean Registry, To assure approriate asthma severity designation and appropriate medication managment [8]
Zin [6] Arsh [5]
Purple [24]
Purple [42]
Title Asthma patients on appropriate meds[4]
In Progress [2]
To move measure by obtaining and documenting SMS goals [114]
call patients to set goals [115]
Status documented via PDSA triag Residents and MA's should check alert and address all if pt type and alert put in chart to get comes in for appt or POC testing. patients testing [101] [102] Resident team identified patients that actually had depression screen done vie BHS and was not reported. Identified error was adding to report SMS Goal need a Status [108] and was rerun showing improvement. [107] People who responded to their measure willingness of patients to set calls were found willing to set goals over phone [116] goals over a phone conversation [117]
Design and Implementation Although 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, including 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. Title 2. Location 3. Status 4. Category 5. Sponsor 6. Team Color 7. Start Date 8. Completion Date 9. Lessons Learned
© 2015 | The Wright Center | HIMSS Ambulatory Davies Award Change Management and PDSA Tracker Tool
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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 Health IT 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/Outcomes Currently 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.
© 2015 | The Wright Center | HIMSS Ambulatory Davies Award Change Management and PDSA Tracker Tool
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PDSA #1 Mammograms Alerts 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 information 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, meaning 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.
Practice 50th Percentile Measure Target 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.
Number of Female Patients Between Ages 40-85 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.
© 2015 | The Wright Center | HIMSS Ambulatory Davies Award Change Management and PDSA Tracker Tool
Partnership with Lackawanna Mobile X-ray Almost 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. Page 4
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.
Practice 50th Percentile Measure Target 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.
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
Š 2015 | The Wright Center | HIMSS Ambulatory Davies Award Change Management and PDSA Tracker Tool
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PDSA #2 Diabetes Mellitus Self-Management Support (SMS) Goals
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 providers 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
Practice 50th Percentile Measure Target 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.
© 2015 | The Wright Center | HIMSS Ambulatory Davies Award Change Management and PDSA Tracker Tool
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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. 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.
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.
© 2015 | The Wright Center | HIMSS Ambulatory Davies Award Change Management and PDSA Tracker Tool
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PDSA #4 Tobacco Cessation “Moving beyond office visit-based goal setting and motivational interviewing” 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 behavior change. If the patient’s relevance and readiness for change are high, providers 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 implemented 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. 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.
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. © 2015 | The Wright Center | HIMSS Ambulatory Davies Award Change Management and PDSA Tracker Tool
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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.
TWC and Tobacco Free Northeast Partnership Referrals and Revenue
Tobacco Cessation Participants
53%
Number of orders created internally for smoking cessation counselors.
Total Enrolled: 213 Total Completed: 113
47% Completed Program
Did Not Complete
Total Patients Who Quit Completely or Significantly Cut Down* Revenue generated solely through the Tobacco Free Northeast PA grant for expanded tobacco cessation counseling service.
18%
82% Receipts received per month for the smoking counseling done by our provider care teams.
Total Program Enrollment (6 Month Increments) 140 120 100
Total Did Not Quit Total Behavior Change *After Fully Completing the Program
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.
80
Lessons Learned
60
• 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.
40 20 0
January 2014 - June 2014 July 2014 - December 2014 January 2015 - June 2015
Financial Implications TWC’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. © 2015 | The Wright Center | HIMSS Ambulatory Davies Award Change Management and PDSA Tracker Tool
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