Lincoln Intermediate Unit 12 August 11, 2014 Differentiated Supervision: The Danielson Framework.
Management and Supervision Fall 2014 - UNC Gillings School ...sph.unc.edu › files › 2014 › 11...
Transcript of Management and Supervision Fall 2014 - UNC Gillings School ...sph.unc.edu › files › 2014 › 11...
Management and Supervision Fall 2014
1
1
Quality Improvement in Public Health
November 19, 2014
Management and Supervisor Training
Kathy Brooks, Jean Vukoson,
Tara Lucas, Pamela Cochran
2
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
3
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
Management and Supervision Fall 2014
2
4
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
5
The Center for Public Health Quality
6
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
Management and Supervision Fall 2014
3
7
The Team
8
PH QI 101 Program
8
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
Management and Supervision Fall 2014
4
10
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
11
Tests of Change
11
Ideas
Changes that result in
improvement
1212
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
Management and Supervision Fall 2014
5
1313
Lean Thinking
• Client / customer first
• Our People are the most valuable
resource
• Continuous improvement
• Focus on where the work is done
14
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.”
14
NC DPH Management Team, 2009Adapted from Accreditation Coalition QI Subgroup Consensus Agreement
1515
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”)
Management and Supervision Fall 2014
6
16
“Every system is perfectly designed to achieve the
result it gets”
17
“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
Management and Supervision Fall 2014
7
1919
Visual adapted from Marni Mason of MCPP Consulting; based on Joseph Juran’s Trilogy
2020
21
DPH Clinical Services Practice Management Project
Management and Supervision Fall 2014
8
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
23
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
23
24
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
24
Management and Supervision Fall 2014
9
25
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
25
26
What are we Trying to Accomplish with Practice
Management Project?
26
27
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
Management and Supervision Fall 2014
10
28
Aim Statement
28
What is an aim statement?
– An explicit statement of the desired outcome that is time specific and measurable
29
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”.
29
Practice Management Trainingfor Local Health Departments
30
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%)
Management and Supervision Fall 2014
11
31
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)?
31
32
How Will We Know that a Change
is Improvement?
“All improvement is change, but not all change is an improvement.”
32
33
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
Management and Supervision Fall 2014
12
34
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
35
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!”
36
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
Management and Supervision Fall 2014
13
37
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”
38
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
38
Practice Management Data
What are your questions regarding this fiscal picture?
39
Management and Supervision Fall 2014
14
Practice Management Data
40
18%
8%
58%
16%
Medicaid
Other
Local 101
State Funds
All Revenue Sourceswithout Cost Settlement
41
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?
41
42
What is Return on Investment?
Management and Supervision Fall 2014
15
43
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
*
44
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
44
45
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.
Management and Supervision Fall 2014
16
46
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
47
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)
48
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
Management and Supervision Fall 2014
17
49
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
50
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
51
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
Management and Supervision Fall 2014
18
52
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
53
What Changes Can We Make that will Result in
Improvement?
53
54
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
Management and Supervision Fall 2014
19
5555
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
5656
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
57
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
57
Management and Supervision Fall 2014
20
58
• 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
5959
8 Wastes ?• Defects• Overproduction• Waiting• Non Value-Added Processing• Transportation• Inventory• Motion• Employee (Underutilizing)
59
Typically 40-60% of all lead time is non-value added.Typically 40-60% of all lead time is non-value added.
60
Apply it!
At your tables, identify possible wastes in the processes you received and record on the Wastes Worksheet
Management and Supervision Fall 2014
21
61
“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
62
63
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
Management and Supervision Fall 2014
22
64
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
65
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
66
Results: Decrease Lead Time
VSM identified “beaver dams” & extra steps
Wilson VSM
Management and Supervision Fall 2014
23
67
67
Let’s Try it Together!!
---
Customer Process Step Waits Between
Info./Software Flow
Starburst/ Idea Data Box
VALUE STREAM MAP LEGEND
6868
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
69
Brainstorming
69
• 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
Management and Supervision Fall 2014
24
70
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
71
72
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
Management and Supervision Fall 2014
25
73
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
74
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
75
5 WHYS
WHY?
WHY?
WHY?
WHY?
WHY?
PROBLEM
75
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.
Management and Supervision Fall 2014
26
76
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
77
Testing our Change Ideas
77
78
Model for Improvement
What 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)
Test Ideas & Changes with Cycles for Learning and Improvement
Act Plan
Study Do
Management and Supervision Fall 2014
27
79
Testing Changes
79
Ideas
Changes that result in
improvement
80
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
81
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.
Management and Supervision Fall 2014
28
82
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.
83
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)
84
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
Management and Supervision Fall 2014
29
85
PDSA Tip #1: Scale Down
• Years
• Quarters
• Months
• Weeks
• Days
• Hours
• Minutes
• Number of clients
“Drop 2”
85
86
PDSA Tip #2: “Oneness”
86
87
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”)
Management and Supervision Fall 2014
30
88
Apply It!
How can you use PDAS cycles to test changes in your agency?
89
Where do you go from here?
89
90
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”
90
Management and Supervision Fall 2014
31
91
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.
92
Change Management Process
92
93
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
93
Management and Supervision Fall 2014
32
94
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
94
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
96
Management and Supervision Fall 2014
33
97
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
97
98
Contact InfoJean VukosonPhone: [email protected]
Pamela CochranPhone: [email protected]
98
Kathy BrooksPhone: [email protected]
Tara LucasPhone: [email protected]