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Welcome

1

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4

Community Health Center, Inc.

Foundational Pillars

1. Clinical Excellence- fully Integrated teams, fully integrated EMR, PCMH Level 3

2. Research & Development- CHC’s Weitzman Institute is the home of formal research, quality improvement, and R&D 3. Training the Next Generation: Postgraduate training programs for nurse practitioners and postdoctoral clinical psychologists as well as training for all health professions students

CHC Profile: •Founding Year - 1972 •203 delivery sites •145k patients

The Community Health Center, Inc. and its Weitzman Institute will provide education, information, and training to interested health centers in Transforming

Teams and Training the Next Generation

• National Webinars on advancing team based care, implementing post-graduate residency programs, and health professions students in FQHCs.

• Invited participation in Learning Collaboratives to advance team based care or implement a post-graduate residency program at your health center.

CHC’s NCA on Clinical Workforce Development The National Training and Technical Assistance Cooperative Agreements (NCAs) provide free training and technical assistance that is data driven, cutting edge and focused on quality and operational improvement to support health centers and look-alikes.

National Webinar Series -2892 viewers attended the webinar series -Most attended webinar: Enhancing the Role of the Medical Assistant -(March 3, 2016) 373 attendees - Videos: Viewed a total of 1,102 times - Slides: Viewed a total of 6,746 times - Representation from all 50 states, US Virgin Islands, Puerto Rico and

Canada.

The LC Teams

147,769

1,708 0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Tota

l Pat

ien

ts

Participating FQHCs

Total Patients UDS 2015 Health Center Data

Team-Based Care

Residency

Both

Demographic and Population Profile

Collectively, we serve over 607,884 patients

Demographic and Population Profile

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

% o

f To

tal P

atie

nts

Participating FQHCs

Age UDS 2015 Health Center Data

Older Adults (age 65 and over)

Adult (18 - 64)

Children (< 18 years old)

Patient Characteristics

Uninsured 18%

Medicaid/CHIP 57%

Medicare 9%

Other Third Party

16%

Payor Data UDS 2015 Health

Center Data

Almost all health centers offer Medical, Dental and Mental Health services.

Staffing and Utilization: UDS Table 5 – We encourage you to look at your data!

Quality Improvement Education Patti Feeney

Manager, Quality Improvement Education

Effective Meeting Skills

Providing meeting and team structure for coaches

I. AGENDA II. MEETING ROLES III. ACTION PLAN

Define the Problem Fishbone Diagram; a useful cause & effect tool

Developing a Project Specific Aim

All tools referenced in today’s session and support material can be found by following theses links:

NCA Team-Based Care Learning Collaborative

NCA Post-Graduate Residency Learning Collaborative

Tools and Resources >> Quality Improvement

We will begin shortly…

Welcome

20

Team Based Care (TBC)

Learning Collaborative

Session One

September 21, 2016

3:35 - 4:30 EST

Introductions

TBC Collaborative Design, Facilitation, Faculty

Ann Marie R Hess NP, MS

National Cooperative Agreement

Anna Rogers, Director

Reema Mistry, Project Assistant

Mentors , Coaching Faculty

Deborah Ward, RN (1:8)

Kasey Harding (1:8)

3:35

Evaluation Faculty

Kathleen Thies, PhD, RN

Improvement Science Faculty

Patti Feeney

Mark Splaine, MD

Session 1 Objectives

Teach effective meeting skills, cause and effect diagramming, and writing specific aims to support team improvement work.

Provide an overview of the learning collaborative structure and expectations.

Help teams ‘get started’ redesigning roles.

Review Action Period 1 assignments for improving team based care.

Learning Session 1 Agenda

Team Based Care Participants

3:35 10 min Introductions

3:45 10 min Collaborative Goal, Structure and Expectations, Resources

3:55 15 min Getting Started Tools : Role Activity Assessment , Cycle Time

4:10 10 min Action Period 1 Assignments

4:20 10 min Brief Team Meeting Break Out

Interviews : General Impressions

Many asked for clarification of team and coach definitions

Lots of recent growth and change in many organizations

Many reported EHR challenges re: data, documentation, duplication, and getting actionable reports

Few have depth of experience with primary care redesign models and QI methods (e.g Wagner, Bodenheimer, Nuka Alaska, PCMH, IHI)

Most are familiar with term PDSA

Most not meeting weekly to focus on QI, ‘fit into’ day of back to back visits

All have been evolving their team based model of care over time, multiple starts, looking for “refresh”

Many working on PCMH certification, recertification

Few practices have experience with coaching model

Introductions

Interviews : Goals and Expectations

Want structure, guidance, resources from the Collaborative: how-to’s vs concepts

Learn from others’ and their mistakes

Common Goals | Global Aims

• better efficiency, improved workflows

• staff working at top of license, includes standing orders and protocols

• team role clarity and standardization (care management, documentation)

• improve quality outcome measures (e.g. UDS outcomes)

• improve patient and team satisfaction

Reduce stress and “put the joy back into practice, need “relief from the chaos”

We have a cohesive, good team but we “all work in our silos to get the work done”

Introductions

Introductions

Name of FQHC Coach Team

Carolina Family Health Centers , Inc.

Chasity Godwin 1 MD, 1 NP, 2 LPN, 1 Care Coordinator, 1 Front Desk, 1 Interpreter,

1 CNA

Community Health Initiatives Zlata Vainstein 1 Medical Director, 1 Physician, 2 MA, 1 Front Desk

Daughters of Charity Grace Mena 1 Area Practice Manager, 1 MD, 3 FNP, 2 Care Coordinator, 4 MA

Healthcare for the Homeless Carlie Brown Need new team

Holyoke Health Center Megan T. Wechsler (Primary) 1 Director of Quality and Compliance, 1 Physician, 3 RN, 1 MA, 1

Front Desk

Johnson City Community Health Center

Flo Weierbach 1 front Desk, 1 PNP, 1 LCSW, 1 RN, 1 Interpreter

Sumter Family Health Center Sandra Sturkie

1 Director of Patient Services, 1 Clinical Manager, 1 BH Clinical Manager, 1 BH RN, 1 Physician, 2 Case Managers, 1 MA, 1 Dental Services Coordinator, 1 Patient Financial Coordinator, 1 Clinical IT,

1 Pharmacist, 1 Call Center Rep, 1 Referrals Manager

Syracuse Community Health Center, Inc.

Cathy Brigden

1 Physician, 1 FNP, 1 LPN, 2 RN, 3 MA, 1 Office Manager

Tyler Family Circle of Care Sherri Gould 1 CMO, 1 COO, 1 LVN, 1 OA, 1 PNP, 1 Process Improvement

Manager

Name of FQHC Coach Team

Avenal Community Health Center John Kalfayan 1 BH, 1 Physician, 1 MA, 1 Medical Director, 1 Front Desk

Educational Health Center of Wyoming Brenda Burnett 1 Provider, 2 RN, 1 Radiologic Technologist, 1 EMR Manager, 1

MA, 1 Clinical Manager

El Rio Santa Cruz Josh Carzoli 1 MA, 1 RN, 1 BH, 1 Chief Clinical Officer, 1 LPN, 2 Physician, 1

Front Desk, 1 COO, 3 RN Clinic Manager, 1 IT

Peach Tree Healthcare Ruben Ruiz 1 Chief Quality Officer, 1 Quality Coordinator, 1 Dir of

Operations, 1 Site Manager, 1 Dir of HR, 1 NP, 3 MA, 1 Data Analyst, 1 Ops Specialist, 1 Clinical Support Services Manager

Pecos Valley Medical Center L. David Young 2 RN, 1 NP, 1 MA

The Children’s Clinic Karla Rodriguez 1 Provider, 1 MA, 1 Care Team Rep

Via Care Community Health Center Kimberly McFerguson 1 FNP, 1 MA, 1 Outreach & Enrollment Specialist, 1 MSW, 1

Front Office Lead MA

Introductions

Team Skills Assessment Summary (N=51) Percentage Strongly Agree or Agree are Competent

% Strongly Agree or Agree

60 60 65

85

65

0

10

20

30

40

50

60

70

80

90

100

Gathering andUsing Data Skills

Using EffectiveMeeting Skills

ImplementingDaily Huddles

ApplyingTeamwork Skills

UsingImprovement

Skills

Coach Skills Assessment Summary (N=16)

Percentage who rated themselves Competent, Proficient, or Expert

35

65

47 47

59

0

10

20

30

40

50

60

70

80

90

100

Data andInformation

Systems

Meeting andInterpersonal Skills

Improvement Skills Technical Skills(excel, webinar)

Art of CoachingSkills

%

Level D: Just Getting Started Level C: Early Stages of Change Level B: Implemented Basic Changes Level A: Achieved Most or All of the Important Change Required

Team Based Practice Assessment (LEAP)

0

1

2

3

4

5

6

7

Level A Level B Level C Level D

Self-Management Support

Planned Care

Care Management

Medication Management

Care Activities Assessment (N=11) Number of sites reporting level of performance implementing key processes

Just getting started

Early stages of change

Implemented basic changes

Achieved most or all of the

important changes required

0

1

2

3

4

5

6

7

Level A Level B Level C Level D

Medical Assistant (MA)

Registered Nurse (RN)

Laypersons

Pharmacist

Role Activities Assessment (N=11) Number of sites reporting by level of performance by role

Just getting started

Early stages of change

Implemented basic changes

Achieved most or all of the

important changes required

Transformational Team Based Care Improves Outcomes

Learning Session 1 Agenda

Team Based Care Participants

3:35 10 min Introductions

3:45 10 min Collaborative Goal, Structure and Expectations, Resources

3:55 15 min Getting Started Tools : Role Activity Assessment , Cycle Time

4:10 10 min Action Period 1 Assignments

4:20 10 min Brief Team Meeting (break out)

Goal

The Team-Based Care Learning Collaborative is designed to provide transformational* strategies and mentored coaching support,

to help a core team implement an advanced model of team-based care over 12 months.

*Transformation can take up to 18-24 months

3:45

Achieve multiple TBC specific aims

Standardize (SDSAs)

roles and key processes (Playbook, Spread Plan)

Improve team and coach

skills (improvement science, team work, coaching)

Develop a post

collaborative team action plan

How is the Collaborative Structured?

90 min

Learning

Sessions

Between Session Action Periods (6 weeks)

Complete Assignments

Weekly Team Meetings (5-6), Daily Huddles

Monthly Reporting

Implementation Tools and Skills Change Concept Resources Learning From Each Other

Team Based Care Webinars (8)

Core Team Team Based Practice Assessment (LEAP) Coach and Team Skills Assessment Practice Outcomes Data (UDS, Other) Interviews Coach Prep Session Technology Session

Between Session Mentoring and Faculty Support

7

Sept 21 Nov 2 Dec 14 Jan 25 Mar 15 Apr 26 June 14

Improvement Science Theory Bursts (10 min) Developing Skills

Session 1 : Sept 21st

o Running effective team meetings using tools

o Developing and using a cause and effect diagram to inform PDSAs

o Writing a specific aim statement

Session 2 : Nov 2nd

o Developing a process map or current state workflow

o Applying PDSA methodology for improvement

Session 3 : Dec 14

o Using data for improvement (run charts, control charts)

Session 4 : Jan 25

o Standardizing (SDSAs) and Reliability Science

Session 5 : March 15

o Spreading Change

Session 6 : April 26

o Gantt Charting : 3-6 month Core Team improvement plan

Mentor and Coach Roles

Coaches (posted role descriptions)

Help and support teams in learning new skills and achieving their aims

Help teams complete action period assignments, monthly reports, evaluation

Meet weekly with Mentor and other coaches, 1:1 as needed

Participate in 7 learning sessions

Support weekly team meetings, and between meeting assignments, session prep

Mentors (posted role descriptions)

Provide support and resources for developing coaching skills

Facilitate weekly debriefs with Coaches

Provide individual support as needed

NCA Online Learning Network Find material for download, TBC webinars, and team folders for sharing your work... Improvingprimarycare.org

Discussion Board Ask questions or make requests of teams, faculty….

Any Questions?

Before “Getting Started”….

3:55

Implementing Team Based Care (Webinar #1)

Webinar 1

Defining Structure and Staff Responsibilities

Practice Managers and Leaders : must stay involved, engaged in your work

Start with Core Team, Then Expanded Team

Current State Examples: 8 Participating Teams

1 MD, 1 NP, 2 LPN, 1 Care Coordinator, 1 Front Desk, 1 Interpreter, 1 CNA

1 MD, 2 MA, 1 Front Desk

1 PNP, 1 LCSW, 1 RN, 1 Interpreter, 1 front Desk,

1 MD, 3 FNP, 2 Care Coordinator, 4 MA

1 MD, 1 FNP, 1 LPN, 2 RN, 3 MA, 1 Office Manager

1 FNP, 1 MA, 1 Outreach Specialist, 1 MSW, 1 Front Office, Lead MA

1 BH, 1 MD, 1 MA, 1 Front Desk

1 Provider, 2 RN, 1 Radiologic Tech, 1 MA

TBC Concept Resource (webinar #1 and #2) Principle

Patients want to receive their care from smaller teams (PODS) and know them personally Physical

Wall colors differentiate pods in practice , match business cards Central open area surrounded by exam rooms Co location of pod members, all carry laptops 3 exam rooms per provider – all care comes to patient 2 pods share procedure room - standardized

TBC Structure Break down large systems into PODS (care teams) 4 “Empaneled” Providers (3FTEs), 3 MAs dedicated to provider (dyad) 1 BH, 1 RN, 1 Case Coordinator (navigator, health coach), 1 front desk, Patient empaneled both to a pod and to a Dyad Flow Coordinator and Team Manager rotating roles (RN, MA) Medical Records staff – input electronic data

Roles and Responsibilities Defining and Training, Standing Orders and Protocols

Standardizing Workflows • Making ‘hundreds’ accessible to all

Teams Need to Meet • Daily Huddles : 8am and 2pm • Weekly Meetings : Improvement Work, Population Health Management

Poll Question

Would you say that you have ‘significant’ work to do defining your “core” and “extended” team structure?

Yes

No

Role Activity Assessment

Who Does What Now?

4:08

Why analyze your team’s roles?

Have the right person doing the right thing at highest level of training and licensure

Eliminate duplication or unnecessary work

Reduce interruptions

Challenge assumptions about what staff are doing

Increase capacity to take on new activities

Develop specific aims for improvement

Implementing Team Based Care (Webinar #1)

Webinar 1

Role Assessment of ‘the work’: Webinars 1-8

Role Activity Assessment (customizable)

Role Tracking Worksheet

Consider Tracking

Interruptions

Role Activity Analysis

Position:

Tic Marks (each time

activity done, may add AM,

PM)

Total Tic Marks

Estimated Time per Activity in minutes

Total Time

Access and Communication Processes Activity

1. Schedules patients with a personal clinician for continuity of care

||||| ||||| |||||

15

4 min 60 min

2. Coordinates visits with multiple clinicians and/or diagnostic tests and procedures

3. Triages how soon a patient needs to be seen including a process for after-hours care

4. Monitors access to appointment, backlog and wait time using telephone and email requests

5. Monitors and triages secure patient portal messages

6. Provides advice on clinical issues via telephone or

portal messaging

7. Identifies and arranges for language services

8. Collects patient demographic and insurance information, including preferred method of communication

9. Helps patients activate their Personal Health Record by signing up during office visit

10. Identifies and refers patients who might benefit from care management support, other practice resources, community services

Population Health Management Activity

1. Uses population registries and clinical quality reports to monitor a panel of patient’s health and risk status and close care gaps.

2. Communicates with many patients at once via bulk outreach letters and portal messaging (e.g. reminders for preventive care visits ,testing, screening gaps)

3. Provides outreach services to patients overdue for visit to follow up management of chronic

SampleData.Hess.2009

Worksheet.clinicalmicrosystem.org

IHI.org Poster

25%

75%

RN Activity[planned careregistry, triagelevel 2, nursevisits, selfmanagementsupport]

Sampling of a Typical Day RN Role

Ticks and Tally

55

33%

67%

Non-Physician Tasks Physician Tasks

Non-Physician Tasks

-immunizations

-obtaining consults

-obtaining MR

-setting up room

-filling out clerical fms

-finding interpreter

-bringing pt to room

-data entry

-finding information

Webinar #1

Receptionists

Telephone Encounters: Significant # of calls were within 3 days after a visit Printing All AVSs (thought they had to) : 50% patients did not want paper, shred.

Poll Question

Have you ever participated in any type of analysis of what you do every day (tasks and functions)?

YES

NO

Using Cycle Time to Improve Efficiency

and Office Flow

15 Patients (1-2 weeks) Use Clipboard with Clock

Select One Appointment Type

Random Selection Patients AM and PM

Target 1.5 X Appt Time

15 min Appt = 23 min cycle time 20 min Appt = 35 min cycle time 30 min Appt = 45 min cycle time 45 min Appt = 68 min cycle time

SampleData.Hess.2009 Worksheet.clinicalmicrosystem.org

Note: scheduled appoint time What if early arrival?

Data Collection Worksheet

Efficiency and Role Optimization

34

5

15

1

28

2 2

6

16

2

30

1

4

8

14

1

30

23

6

17

1

31

23

4

15

1

27

0

5

10

15

20

25

30

35

Waiting

Room

Time

w/Clinical

Staff

Pre-Exam

Waiting

Active Exam Check Out Avg Length

of Visit

Min

ute

s

12-Feb

20-May

20-Jun

15-Jul

26-Aug

Family Practice : 9 min non value added time , active exam time and waste

Hess.CPM.2010

Example: Assessment data (long cycle time) is analyzed using Fishbone Diagram Problems that have high leverage for improving results, inform your PDSAs (session 2). Top of the Ramp – Specific Aim

Putting It Together for Action Period 1

Action Period 1 Assignments

1. Meet weekly (50 min) as a Core Team

Practice effective meeting skills and use tools with coaching support

2. Continue Daily Huddles (5-10 min) | Starting is Optional

3. Complete and share the following by uploading to TBC website: - Within 4 weeks

a) What is your global aim? – the broad objective you want to achieve in the longer run

b) Role Activity Assessment (who does what now)

c) Role Activity Tracking Data (1-3 days, all roles, coach inputs data)

Fishbone diagram with drivers of role problem(s)

Document any ‘quick hits’, insights

Write a specific aim for improvement using role data

d) Cycle Time Assessment (15 )

Fishbone diagram with drivers of cycle time problem

Document any ‘quick hits’, insights

Write a specific aim for improvement using cycle time data

4. Upload monthly progress report to inform Session 2 Planning.

5. Upload all missing assessments.

Monthly Reporting

Tool

Improvement Ramp

Wrap Up and Questions

Set Up Brief Team Meeting

10 Minute Meeting

Thank Your Colleagues