Project ECHO QI: Communicating and Advocating Using Data June 29, 2016

Welcome to Project ECHO Quality ImprovementWe will begin momentarily.

Join the Discussion!Use #QIECHO on

TwitterSend questions via Zoom Q&A or Chat.

Welcome!Project ECHO Quality

Improvement

Presented by the Weitzman Institute, a division of Community Health Center, Inc.

Session 4: Communicating and Advocating Using DataJune 29, 2016

Faculty• Presenters

– Tierney Giannotti, MPA, QI Data Analyst

– Mark Splaine, MD, MS, Director of Education

• Panelists– Patti Feeney, MS, QI Education Manager

– Deb Ward, RN, Senior Quality Improvement Manager

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Community Health Center, Inc.

Foundational Pillars Clinical Excellence Research & Development Training the Next Generation

CHC Profile: Founding Year - 1972 200+ delivery sites 130k patients

Project ECHO QI SessionsJune 29, 2016Communicating & Advocating Using Data

July 20, 2016Plan-Do-Study-Act Cycles – Getting the Most from Your Tests of Change

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To register visit: http://weitzmaninstitute.org/clinics/qualityimprovement

• The Weitzman Institute Online Learning Network is free and available to anyone interested in the session materials

• We have posted many resources and answered questions from our previous sessions on our online site.

• Recording and slides are available after each session by clicking on the following link:

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Online Resources

http://moodle.weitzmaninstitute.org/course/view.php?id=16



• Functions we will use in this session – Chat, polling, Q & A

• Live tweet us @CHCProjectECHO and #QIECHO

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Get the Most out of Zoom

Learning Objectives• As a result of participating in this session,

attendees will be able to:– Learn multiple ways to visually display data that

tell the story of your project– Appreciate the use of different analytic tools to

display data– Describe ways to engage care team members in

understanding, accepting, and using data

1. Data Over Time with Relevant Comparisons– Uniform Data Set (UDS) Care Team Reports

2. Statistical Process Control Charts– Opioid Dashboard Data: Understanding the sources of

agency-level improvement

3. Analysis of Means– An approach to use when nothing seems to be improving

Agenda – Three Tools

Polling Question #1:

1. Data Over Time with Relevant Comparisons

Stratified Time Plot: ExplanationLines on graph:• Provider (diamonds)• Site (squares)• Agency (triangles)

Uses:• Comparisons• Annotate when events

occur• Retrospective or

prospective review

SiteProvider

Building Data Displays• Many ways to create displays – software and

statistical packages• At CHC, we use Excel for most displays

– Much of the data come from our data warehouse• Excel templates for creating all of the displays

we show today are available on our Weitzman Online Learning Network

• Let’s take a look at using a template….

Stratified Time Plot: Template

• Noted there is a lack of standardized information for care teams about their performance over time

• Idea for report by QI Department and Clinical Chiefs to provide information not currently available using a display familiar to all audiences and aligned with agency priorities

• Tested report with 8 providers • Dissemination by email with an invitation to participate in a 10 minute call

meeting to discuss the report and hear provider ideas/feedback

• After revisions based on feedback, further dissemination now in progress

Report Development & Testing

• Displays allow comparison of performance on multiple measures

• Provider results compared with site and agency results• Goal clearly referenced to assess progress over time

SiteSite

• Display provides a summary of previous graphs relative to current performance

• Annotations (color coding, asterisk) used to guide interpretation

• Frame your report with the question(s) it is trying to address

• Get feedback from your audience

• There is value in displaying data over time with relevant comparisons

• Provide actionable data

Key Points

What questions or comments do you have?

2. Statistical Process Control Charts

Control Charts: Explanation

Mar-15 Jun-15 Jul-15 Aug-15 Sep-15 Nov-15 Dec-15 Jan-16 Feb-160

102030405060708090

100Urine Toxicology Screening (past 6 months)


20

40

60

80

100

Pain Assessment (past 3 months)

statistically significant increase for one month

Lines on graphs:• Solid line = average

• Dashed lines = 3 std dev limits

Patterns to Look For:• Point(s) outside limits

• Shift (8 or more consecutive points on same side of average)

• Trend (7 or more points with consecutive increase or decrease)

Interpretation:• Pattern absent = random variation

• Pattern present = significant ∆

• CHC recognized it could do better as an organization to address the opioid crisis

• Implemented a multi-faceted intervention on the management of patients on chronic opioid therapy (COT)

• New and improved Opioid Dashboard unveiled• Didactic session (Grand Rounds)• Provider-specific Report• Panel management time to review cases on the Opioid Dashboard

• Followed results monthly over time to assess for changes in results

Background

Opioid Measures: % Patients Meeting Measure (Agency)


102030405060708090

100Opioid Agreement (ever)


20

40

60

80

100 Urine Toxicology Screening (past 6 months)


20

40

60

80

100Patients Receiving Behavioral Health

(past 3 months)


20

40

60

80

100Pain Assessment (past 3 months)

statistically significant increase for one month


20

40

60

80

100Prescription Monitoring Drug Website Queried (12 months)

statistically significant increase for two months

Sites That Have Improved Significantly (Green)

SiteRx Drug Website

Average Last ValueA 60% 76%B 43% 47%C 27% 43%D 71% 82%E 27% 54%F 50% 66%G 24% 36%H 8% 23%I 43% 52%J 23% 75%K 80% 0%L 39% 47%

Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-160%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Month

% o

f pati

ents

on

COT

who

se p

rovi

der c

heck

ed th

e CT

PM

P in

the

last

12

mon

ths

p Chart: Checking Rx Drug Website – Provider I

• Using a control chart provides a tool that can be used to evaluate the impact of a change

• Analysis at different levels (i.e., stratifying or disaggregating) is needed to understand where change is occurring

• Use of control charts must be tied to an understanding of the process producing the data

• This example also shows the importance of monitoring outcomes linked to an educational intervention

Key Points

3. Analysis of Means

Site D Site C Site F Site B Site J Site K Site A Site I Site H Site L Site E Site G0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

6% 6% 6% 6% 6% 8% 8% 10%

11%15% 15%

28%

Calendar Year 2015

percent upper limit lower limit

Analysis of Means: Explanation

Sites

Percent meeting UDS measure

x-and y-axis cross at Agency average

1% limits; width varies with denominator size

Significant difference from average when

bar crosses limit

Uniform Data Set: Hypertension Control Rates at CHC

2015 2014 2013 2012 20110%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Goal: 75%

Analysis of Means: Hypertension Rates by Site

Site A Site B Site C Site D Site E Site F Site G Site H Site I Site J Site K Site L0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

55% 56%60% 61% 62% 63% 64%

65% 65% 66% 68% 70%

Calendar Year 2015

percent upper limit lower limit

UDS Measure: Hypertension Control (<140/90) by Site

SiteJan-Dec

2015Jul 2014-Jun 2015

Jan-Dec 2014

Jul 2013-Jun 2014

G 60.5 % 63% 59% 62%H 70.1 % 71% 70% 73%I 62.5 % 62% 63% 65%

statistically significant higher than the average (p<.01) statistically significant lower than the average (p<.01)

• Site H consistently higher than the agency average in all 4 periods

• Analyzed data by provider for each time period and saw no differences

Digging Deeper• Visited the Site H Microsystem to share the

results and ask about their process• What the team shared as hypotheses for why

their rates were highUsing nursing visits regularly for HTN patientsScheduling nursing visits in between visits with PCPReferring to HTN patients to nutritionist (RD)Prescribing home blood pressure monitoring cuffs

ANOM: Nursing Visits for Uncontrolled HTN Patients by Site

E B F J K L G A I D H C0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

4%

16% 19% 19% 19% 20% 20%

31% 33% 33%

55%61%

Calendar Year 2015

Site

• Site H significantly different than agency average• Same result found for Site H related to RD visits and BP cuff

prescriptions

• Use of analysis of means provides a way to identify a site (or other stratum) on which to focus deeper process understanding

• Engaging the people who do the work provides ideas (hypotheses) that may be tested using existing data

• Findings from an analysis of means may represent best practices and thus could be considered for adoption by others throughout the organization

Key Points

References• Data Display

George ML, Rowlands D, Price M, and Maxley J. The Lean Six Sigma Pocket Toolbook. New York, NY: McGraw-Hill, 2005. Chapters 6 and 7, pp 104-118.

Tufte ER. The Visual Display of Quantitative Information. Cheshire, CT: Graphics Press, 1983. Introduction and Chapter 1, pp 9-53.

• Control Charts Amin SG. Control charts 101: a guide to health care applications. Quality

Management in Health Care. 2001; 9:1-28. Benneyan JC, Lloyd RC, Plsek PE. Statistical process control as a tool for research and

healthcare improvement. Qual Saf Health Care. 2003; 12:458-464.• Analysis of Means

Balestracci D, Barlow JL. Statistical stratification: analysis of means. In Quality Improvement: Practical Applications for Medical Group Practice (2nd Ed). Center for Research in Ambul Health Care Administration: Englewood, CO, 1996; pp. 151-189.

Homa K. Analysis of means used to compare providers' referral patterns. Qual Manag Health Care. 2007;16(3):256-64.

Additional Resources

Weitzman Institute offers a range of additional QI training resources and opportunities. If you’d like to learn more, please contact [email protected]

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Slides and recording of today’s session:http://moodle.weitzmaninstitute.org/course/view.php?id=16


Project ECHO Clinics

RemindersSign up for our next session in this series:

Plan-Do-Study-Act Cycles – Getting the Most from Your Tests of Change

Wednesday, July 20th from 12-1p.m. EDT

Complete our post-session survey!

Sign up at http://weitzmaninstitute.org/clinics/qualityimprovement

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Project ECHO QI: Communicating and Advocating Using Data June 29, 2016

Healthcare

Transcript of Project ECHO QI: Communicating and Advocating Using Data June 29, 2016