Connecting All the Connecting All the Pieces – How Close Pieces – How Close

Are We?Are We?

Mike Davies MD, FACPMike Davies MD, FACPMark Murray and AssociatesMark Murray and AssociatesChinook Learning Session 5Chinook Learning Session 5

September 27, 2006 1300-1415September 27, 2006 1300-1415

Current StateCurrent State

Patients wait FOR appointmentsPatients wait FOR appointments Patients wait AT appointmentsPatients wait AT appointments A single patients’ care is A single patients’ care is

fragmented among many providersfragmented among many providers Much prevention and chronic Much prevention and chronic

disease care has gone undonedisease care has gone undone Regional teams and others have Regional teams and others have

tried to fill the gaptried to fill the gap

ResultsResults

Many patients don’t have a providerMany patients don’t have a provider Patients shop for provider with soonest Patients shop for provider with soonest

accessaccess Providers may churn visitsProviders may churn visits Some patient problems go unaddressedSome patient problems go unaddressed Chronic disease care and prevention are Chronic disease care and prevention are

an afterthoughtan afterthought Patients may not get as good of care as Patients may not get as good of care as

they needthey need

Every System is Perfectly Every System is Perfectly Designed to Get the Results Designed to Get the Results

it Getsit GetsPaul BataldinPaul Bataldin

Patient Needs

PreventionAcute

Out-patientChronic DiseaseL

ifestyle Screen

ing*

Alcoh

ol/Dru

g Use S

creen

Imm

un

izations (m

ultip

le)

Can

cer Screen

ing m

ale/female

Men

tal Health

Screen

Acu

te Illnesses

Acu

te Illnesses

Acu

te Illnesses

Med

ication R

x

Exam

& D

iagnostic T

ests

Diagn

osis/Treatm

ent

Acu

te Exacerb

ation O

ut-p

t. Rx

Mon

itoring

Ed

ucation

Self-C

are

Preven

tion of h

ospitalization

s

PreventionAcute

Out-patientChronic DiseaseL

ifestyle Screen

ing*

Alcoh

ol/Dru

g Use S

creen

Imm

un

izations (m

ultip

le)

Can

cer Screen

ing m

ale/female

Men

tal Health

Screen

Acu

te Illnesses

Acu

te Illnesses

Acu

te Illnesses

Med

ication R

x

Exam

& D

iagnostic T

ests

Diagn

osis/Treatm

ent

Acu

te Exacerb

ation O

ut-p

t. Rx

Mon

itoring

Ed

ucation

Self-C

are

Preven

tion of h

ospitalization

s

System Flow MapSystem Flow Map

PCN Physician Patient

Dyad

Patient

Specialty Services: Physicians

Diagnostics:Lab & Medical

Imaging

Acute Care Services

Mental Health

Family Health: Women’sChildren’s

Seniors Health: Access Centre (Living Options) Community Care Palliative Care

Wellness (Public Health): Health PromotionHealth Protection

Legend:Direction of arrow denotes flow of work/patient/demandDemand at each stepSupply at each stepVariation at each stepWait time at each stepProcess time at each step

Diagnostics:Lab & Medical

Imaging

Result?Result?

Multiple venues to go for careMultiple venues to go for care ConfusionConfusion

Where do I go for what?Where do I go for what? Incomplete informationIncomplete information

What was done….where was it done?What was done….where was it done? Very expensive supplyVery expensive supply

DuplicationDuplication Poor performance of tasks for populationPoor performance of tasks for population

““everybody” & “nobody” responsibleeverybody” & “nobody” responsible Relatively poorer health levelsRelatively poorer health levels

Care ExpenseCare Expense

Most to Least ExpensiveMost to Least Expensive O.R.O.R. ICUICU In-Patient CareIn-Patient Care Emergency RoomEmergency Room Specialty CareSpecialty Care Out-Patient Primary CareOut-Patient Primary Care PreventionPrevention

Hospital Care

Results continued….Results continued…. Patient FactorsPatient Factors

Multiple appointments: need to fit into Multiple appointments: need to fit into scheduleschedule

Multiple appointments: gas and timeMultiple appointments: gas and time Multiple appointments: no-showMultiple appointments: no-show

Provider FactorsProvider Factors Not responsible for prevention/chronic careNot responsible for prevention/chronic care Unsure what has been done or not doneUnsure what has been done or not done

System factorsSystem factors Provide staff, buildings, gas, cars, information Provide staff, buildings, gas, cars, information

for each chronic disease and prevention areafor each chronic disease and prevention area Patient illness at higher ratePatient illness at higher rate Patient death at higher ratePatient death at higher rate

Reputation, Mission, Expense

OptionsOptions

Design a system where each patient Design a system where each patient need is met by a different provider?need is met by a different provider?

Are there alternative Are there alternative designs?designs?

Faced with the choice of changing one’s mindOr proving there is no need to do so, almost everyone gets busy on the proof.

-John Kenneth Galbraith

Patient Needs

Primary Care Team “Responsible for providing

or Coordinating themajority of the patient’s

Care”

SpecialtyCare

Home Care Tests

AndServices

Improvement Project Improvement Project ChecklistChecklist

The improvement project is an iterative The improvement project is an iterative process but also has some foundational process but also has some foundational principles. (ie. For good clinical care we principles. (ie. For good clinical care we must have good access and efficiency)must have good access and efficiency)

The following checklist is meant to help The following checklist is meant to help the teams assess where they are at the teams assess where they are at and help them focus their improvement and help them focus their improvement energyenergy

Improvement Project Improvement Project ChecklistChecklist

For each of the 7 categories rate your For each of the 7 categories rate your improvement progress to dateimprovement progress to date 1.0 No Activity1.0 No Activity 2.0 Activity; No Changes2.0 Activity; No Changes 2.5 Began testing; no measurable progress2.5 Began testing; no measurable progress 3.0 Testing; initial measurable progress3.0 Testing; initial measurable progress 3.5 Testing multiple changes; measurable 3.5 Testing multiple changes; measurable

progress in at least 2 itemsprogress in at least 2 items 4.0 Reached goals4.0 Reached goals 4.5 Surpassed goals; spread to wider area4.5 Surpassed goals; spread to wider area 5.0 Results are leading edge nationally5.0 Results are leading edge nationally

Pre-WorkPre-Work

Create an Improvement TeamCreate an Improvement Team RepresentationRepresentation

Clinic Management, Provider Expertise, Day Clinic Management, Provider Expertise, Day to day Leaderto day Leader

Leaders/Change AgentsLeaders/Change Agents Leaders/Team has enough clout to institute Leaders/Team has enough clout to institute

changechange Authority to trial changes and Authority to trial changes and

implement successimplement success Ability to allocate necessary resourcesAbility to allocate necessary resources

Pre-WorkPre-Work

Regular meeting scheduleRegular meeting schedule Planned time for an regular attendance Planned time for an regular attendance

of:of: Improvement team meetingsImprovement team meetings Practice/Business meetingsPractice/Business meetings Clinic-wide meetingsClinic-wide meetings

Pre-WorkPre-Work

Ensure adequate resources support Ensure adequate resources support are available for improvement are available for improvement projectproject Time to collect measuresTime to collect measures Administrative timeAdministrative time Resources to support the improvement Resources to support the improvement

processprocess

Pre-WorkPre-Work

Mechanism for sharing learningsMechanism for sharing learnings StoryboardsStoryboards Oral reportsOral reports Measurements posted in common areaMeasurements posted in common area Others?Others?

Pre-WorkPre-Work

Understand and commit to rapid Understand and commit to rapid learning cycleslearning cycles Aim, Measure, ChangeAim, Measure, Change Plan, Do, Study, ActPlan, Do, Study, Act

Pre-WorkPre-Work On the supplied checklist, provide your On the supplied checklist, provide your

rating on your teams Pre-Work activities to rating on your teams Pre-Work activities to date:date: 1.0 No Activity1.0 No Activity 2.0 Activity; No Changes2.0 Activity; No Changes 2.5 Began testing; no measurable progress2.5 Began testing; no measurable progress 3.0 Testing; initial measurable progress3.0 Testing; initial measurable progress 3.5 Testing multiple changes; measurable 3.5 Testing multiple changes; measurable

progress in at least 2 itemsprogress in at least 2 items 4.0 Reached goals4.0 Reached goals 4.5 Surpassed goals; spread to wider area4.5 Surpassed goals; spread to wider area 5.0 Results are leading edge nationally5.0 Results are leading edge nationally

Access - AimAccess - Aim

Provider patient relationship Provider patient relationship sacrosanctsacrosanct Care delivery model supports the Care delivery model supports the

physician patient dyadphysician patient dyad

Access - AimAccess - Aim

Commitment to PanelCommitment to Panel Committed to managing Committed to managing allall the care the care

needsneeds of their panel of their panel Doing today’s work todayDoing today’s work today

Access - MeasuresAccess - Measures

Measures collected to support access Measures collected to support access aimsaims Time to third next / Future open Time to third next / Future open

capacitycapacity Panel sizePanel size Demand/supply/supply usedDemand/supply/supply used Fail to keep appointmentFail to keep appointment ContinuityContinuity

Access - ChangesAccess - Changes

Advanced AccessAdvanced Access Balance supply and demandBalance supply and demand Eliminate bad backlogEliminate bad backlog Offer of same day visitOffer of same day visit Anticipate changes in demand and Anticipate changes in demand and

supplysupply Develop contingency plansDevelop contingency plans

Access - ChangesAccess - Changes

Use of measures to inform and shape Use of measures to inform and shape practicepractice Share measures broadlyShare measures broadly Interpret measures to inform practiceInterpret measures to inform practice Record and report failed trials as well as Record and report failed trials as well as

successful trialssuccessful trials

AccessAccess

On the supplied checklist, provide your On the supplied checklist, provide your rating on your teams Access activities to rating on your teams Access activities to date:date: 1.0 No Activity1.0 No Activity 2.0 Activity; No Changes2.0 Activity; No Changes 2.5 Began testing; no measurable progress2.5 Began testing; no measurable progress 3.0 Testing; initial measurable progress3.0 Testing; initial measurable progress 3.5 Testing multiple changes; measurable 3.5 Testing multiple changes; measurable

progress in at least 2 itemsprogress in at least 2 items 4.0 Reached goals4.0 Reached goals 4.5 Surpassed goals; spread to wider area4.5 Surpassed goals; spread to wider area 5.0 Results are leading edge nationally5.0 Results are leading edge nationally

Efficiency - AimEfficiency - Aim

No unnecessary wait at the No unnecessary wait at the appointmentappointment

Check in

MA to Room

MD Enters

MD Leaves

Check out

Efficiency - AimEfficiency - Aim

Keep/increase value added timeKeep/increase value added time Greatest constraint is the providerGreatest constraint is the provider Optimized ‘Red Zone’ timeOptimized ‘Red Zone’ time

Efficiency - MeasuresEfficiency - Measures

Measures collected to support Measures collected to support efficiency aimefficiency aim Cycle timeCycle time Flow mapsFlow maps Number of interruptionsNumber of interruptions

Efficiency - ChangesEfficiency - Changes

Optimized office environmentOptimized office environment Balance supply/demand for non-Balance supply/demand for non-

appointment workappointment work Synchronize patient, provider and Synchronize patient, provider and

informationinformation Predict and anticipate patient needsPredict and anticipate patient needs Optimize rooms, staff and equipmentOptimize rooms, staff and equipment

EfficiencyEfficiency

On the supplied checklist, provide your On the supplied checklist, provide your rating on your teams Efficiency activities to rating on your teams Efficiency activities to date:date: 1.0 No Activity1.0 No Activity 2.0 Activity; No Changes2.0 Activity; No Changes 2.5 Began testing; no measurable progress2.5 Began testing; no measurable progress 3.0 Testing; initial measurable progress3.0 Testing; initial measurable progress 3.5 Testing multiple changes; measurable 3.5 Testing multiple changes; measurable

progress in at least 2 itemsprogress in at least 2 items 4.0 Reached goals4.0 Reached goals 4.5 Surpassed goals; spread to wider area4.5 Surpassed goals; spread to wider area 5.0 Results are leading edge nationally5.0 Results are leading edge nationally

Teamwork - AimTeamwork - Aim

Clear goal or Mission Statement Clear goal or Mission Statement

(What are we trying to accomplish?)(What are we trying to accomplish?) As an operational teamAs an operational team As a clinical teamAs a clinical team As an improvement teamAs an improvement team

Teamwork - AimTeamwork - Aim

Defined/Measurable Objectives Defined/Measurable Objectives

(How will we know we accomplished (How will we know we accomplished it?)it?) As an operational teamAs an operational team As a clinical teamAs a clinical team As an improvement teamAs an improvement team

Teamwork - MeasuresTeamwork - Measures

Measures to support teamwork aimsMeasures to support teamwork aims ““Vital signs”Vital signs” Provider/staff satisfaction surveysProvider/staff satisfaction surveys Activity analysisActivity analysis

Teamwork - ChangesTeamwork - Changes

Optimized TeamOptimized Team Leadership committed to improvementLeadership committed to improvement Service agreementsService agreements Job descriptions (functions)Job descriptions (functions) Signals, hand-offs and huddlesSignals, hand-offs and huddles Reduce interruptions and distractionsReduce interruptions and distractions

TeamworkTeamwork

On the supplied checklist, provide your On the supplied checklist, provide your rating on your Teamwork activities to date:rating on your Teamwork activities to date: 1.0 No Activity1.0 No Activity 2.0 Activity; No Changes2.0 Activity; No Changes 2.5 Began testing; no measurable progress2.5 Began testing; no measurable progress 3.0 Testing; initial measurable progress3.0 Testing; initial measurable progress 3.5 Testing multiple changes; measurable 3.5 Testing multiple changes; measurable

progress in at least 2 itemsprogress in at least 2 items 4.0 Reached goals4.0 Reached goals 4.5 Surpassed goals; spread to wider area4.5 Surpassed goals; spread to wider area 5.0 Results are leading edge nationally5.0 Results are leading edge nationally

Clinical Care - AimClinical Care - Aim

Deliver consistent reliable care Deliver consistent reliable care (planned care)(planned care)

Clinical Care - AimClinical Care - Aim

Deliver best possible care for Deliver best possible care for patients with chronic conditionspatients with chronic conditions

Clinical CareClinical Care

Deliver best possible care for Deliver best possible care for preventable diseasepreventable disease

Clinical Care - MeasuresClinical Care - Measures

Measures to support Clinical Care Measures to support Clinical Care aimsaims Use of protocolsUse of protocols Number of patients at clinical goalNumber of patients at clinical goal Number of patients/population receiving Number of patients/population receiving

prevention careprevention care

Clinical CareClinical Care

Optimized Clinical CareOptimized Clinical Care Know which patients should be receiving Know which patients should be receiving

what carewhat care Opportunistic care deliveryOpportunistic care delivery Patient involvement in decision makingPatient involvement in decision making

Clinical CareClinical Care

Defined linkage to specialist/RHA Defined linkage to specialist/RHA programsprograms

Clinical CareClinical Care

On the supplied checklist, provide your On the supplied checklist, provide your rating on your teams Clinical Care activities rating on your teams Clinical Care activities to date:to date: 1.0 No Activity1.0 No Activity 2.0 Activity; No Changes2.0 Activity; No Changes 2.5 Began testing; no measurable progress2.5 Began testing; no measurable progress 3.0 Testing; initial measurable progress3.0 Testing; initial measurable progress 3.5 Testing multiple changes; measurable 3.5 Testing multiple changes; measurable

progress in at least 2 itemsprogress in at least 2 items 4.0 Reached goals4.0 Reached goals 4.5 Surpassed goals; spread to wider area4.5 Surpassed goals; spread to wider area 5.0 Results are leading edge nationally5.0 Results are leading edge nationally

Delivery System - AimsDelivery System - Aims

Increase reliabilityIncrease reliability Decrease redundancyDecrease redundancy Manage variationManage variation

Delivery System – AimsDelivery System – Aims

EMR supports clinical and operational EMR supports clinical and operational systemssystems Reminder systemReminder system Panel profilePanel profile Identification of patients with selected Identification of patients with selected

conditionsconditions Measurement of clinical Measurement of clinical

indicators/outcomesindicators/outcomes

Delivery System - MeasuresDelivery System - Measures

Measures to support Delivery System Measures to support Delivery System aimsaims Chart auditsChart audits System and process flow mappingSystem and process flow mapping

Delivery System - ChangesDelivery System - Changes

Standardized processesStandardized processes Streamlined processesStreamlined processes Just-in-time informationJust-in-time information Contingency plansContingency plans Office automationOffice automation

Delivery SystemDelivery System

On the supplied checklist, provide your On the supplied checklist, provide your rating on your teams Delivery System rating on your teams Delivery System activities to date:activities to date: 1.0 No Activity1.0 No Activity 2.0 Activity; No Changes2.0 Activity; No Changes 2.5 Began testing; no measurable progress2.5 Began testing; no measurable progress 3.0 Testing; initial measurable progress3.0 Testing; initial measurable progress 3.5 Testing multiple changes; measurable 3.5 Testing multiple changes; measurable

progress in at least 2 itemsprogress in at least 2 items 4.0 Reached goals4.0 Reached goals 4.5 Surpassed goals; spread to wider area4.5 Surpassed goals; spread to wider area 5.0 Results are leading edge nationally5.0 Results are leading edge nationally

Sustainability/SpreadSustainability/Spread

Strategies to maintain momentumStrategies to maintain momentum

Sustainability / SpreadSustainability / Spread

On the supplied checklist, provide your On the supplied checklist, provide your rating on your teams Clinical Care activities rating on your teams Clinical Care activities to date:to date: 1.0 No Activity1.0 No Activity 2.0 Activity; No Changes2.0 Activity; No Changes 2.5 Began testing; no measurable progress2.5 Began testing; no measurable progress 3.0 Testing; initial measurable progress3.0 Testing; initial measurable progress 3.5 Testing multiple changes; measurable 3.5 Testing multiple changes; measurable

progress in at least 2 itemsprogress in at least 2 items 4.0 Reached goals4.0 Reached goals 4.5 Surpassed goals; spread to wider area4.5 Surpassed goals; spread to wider area 5.0 Results are leading edge nationally5.0 Results are leading edge nationally

Interpreting ScoresInterpreting Scores

““There is no quality without access.”There is no quality without access.” If you don’t have an access score of If you don’t have an access score of

“4”, then priority is to work on access“4”, then priority is to work on access If access score is 4, then work on If access score is 4, then work on

office efficiency.office efficiency.

Access Score 4.0?

YES

NOPriority work on

Access

Efficiency Score 4.0?

Teamwork Score 4.0?

NO

Priority work on Efficiency

YES

Clinical Care Score 4.0?

Ongoing maintenance and spread of Access and EfficiencyOngoing work on Teamwork and Clinical Care

Summary ViewSummary View

Team MeetingTeam Meeting

Discuss your individual assessments Discuss your individual assessments of your teams improvement progressof your teams improvement progress

Review/create an action plan for your Review/create an action plan for your high leverage change areashigh leverage change areas

? Other activities? Other activities