Cross‐fertilizing Our Team’s Knowledge and Ability to Improve Quality through the PPRNet Model

A PPRNet Powered Patient-Centered Family Medicine Home

Tim Tobolic MDByron Center Family Medicine

ttobolic@bfmpc.com

Auigust 22, 2014

PPRNET History

Solo > Small group (5 FP, 30+ staff) > paper chart 1999 New EMR designed Office > PPARTc. 2004 PPRNET4/2009 “Sold out” - “captured” - “sold again”.

Raised in captivity - “Epic” diet Secretly making plans to escape

“It is not necessary to change. Survival is not mandatory.”

...W. Edwards Deming

PPRNET History

•9/2010 “Escaped” captivity > solo > paper chart

•12/2010 Chose PPART because of PPRNET

•2012 PCMH Designation

PPRNet Early days• Champion in our office manager - embraced PPRNet

Model.

• Participation agreed on by Drs, but lackluster participation

• PPRNET Quality Improvement Team, Project leaders. Office projects focused on HTN, DM, Aspirin, Mammograms

• Invited PH - a mistake since they stole Office Manager but better for her.

• Newsletter, QI and Patient satisfaction info for large group.

• Steve Proposal for “distribution of wealth” (Steve = Obama visionary)

Fertilizing BCFM with PPRNet - TRIP

Model• Prioritize Performance• Involve All Staff• Delivery System Redesign• Patient Activation• Population-based Medicine• EMR Tools

Byron Center Family Medicine

Strategic PlanMISSIONTo provide a innovative patient centered family medicine home that exceeds patient expectations and improves the quality of life of our patients and the community.

Strategic Plan Incorporates PPRNet model and strategies

Health Maintenance • In “Cross Fertilzing” Terms - HM = the ultimate fertilizer

spreader.

• PPRNet gave meaning to Health Maintenance

• “Get the Red Out”

• “Need to look at date”

• Constant updating, tweaking, rule making.

• Helps with Independent / Team thinking.

• Chronic Disease (Cross Ferilization) relationships are better understood!

• 11 months is the new 12

• 5 months is the new 6

• Patient Activation @ POC Staff Educate patients on the what and why of HM needs in real time.

EMR / HM ToolsMultiple simple embedded QT to help push and pull information and identify needed HM

PPRNet Site visits & Best Practices Push Result it to

HM

Here for acute problem, check on HM needed

<<CKD

Tool>>

EMR Tools•Multiple simple QT reminders embedded in Progress Note, PC-Refill, PC-Problem, Lab Result Templates

Calling for Refill

Open related Lab

HM, OV, Lab Needed? Get it done !

“Hi Mr Jones, Rx called in, only gave 30 day supply until you get

Bp and A1c checked.”

     

We should work on our process, not the outcome of our processes.

...W. Edwards Deming

TRIP - PROJECTS

C-TRIPColorectal Screening

• Our First experience with TRIP Project

• Multifaceted - PPRNet TRIP Model• Focus on Preventive Screening• Staff Involved• Engaging patients• Meaningful use of PPART• Practical use of HM, Dot Codes

• Cross Fertilize team ability and knowledge -put us ahead of the curve on quality incentives for payors

C-TRIPColorectal Screening

Results of project

2007 2008 2009

Power of th

e Chart

• Bring in ALL medications to each visit.

• Keep medication in original labeled bottle

• Dispose of outdated, not used meds.

• Bring All meds to consultants, hospitals, ER, UC

MS-TRIPMedication Safety

MS-TRIPMedication Safe Sack

Project

CKD-TRIPChronic Kidney Disease• Evaluation group

• Knowledge base and knowledge need - higher

• Understand CKD relationships to medication

• Understand CKD relationship to other chronic disease, labs - HTN, Lipids, CBC, GFR, ACE/ARB, NSAIDS

• “CKD Tool” - complicated but so far very helpful - (thanks Cara Litvin)

• Higher level of patient ed. - NKDEP information

• One of our payors just introduced CKD as a quality measure - fertilizer is working !

• COLORECTAL• MEDICATION SAFETY• CKD• Requests for Project Support• AAFP TOBACCO• AAFP IMMUNIZATION• STAY INVOLVED • YES DEMANDING BUT NEVER LET UP• CROSS FERTILIZE EDUCATION

• We don’t have time to do it all• The Professors from MUSC

PPRNet TRIP Projects

PPRNet TRIP Projects

Benefits • Focus on important Quality Initiatives - Preventive care & Chronic disease management.

• Staff - Not researchers or statisticians but better idea about research, process. evidence-based care.

• Skills transferable (cross-fertilize) other projects and office processes

• PPRNET Projects cross fertilizes many PCMH domains and many payor quality initiatives + incentives

• Staff better understand the multiple links between chronic diseases -eg: Working on DM “cross-fertilizes quality improvement in HTN, CV disease, Immunizations, Lipids.

PPRNet TRIP Projects

Benefits

•Staff develop desire and refine their ability to provide care that improves quality of life for our patients

PPRNet in Community

It is not enough to do your best; you must know what to do, and then do your best.

...W. Edwards Deming

KNOWLEDGE

TRIP Projects = Value• Involvement Investment in PPRNET

projects

•Site Visits

• Individual and Team project focused training

•HM tools - enhancements

•PPRNet Webinars

•“Best Practices” discussed

PPRNET Meetings = Value

Involvement in PPRNET Meetings

•Educational

•Networking with “experts”

•Carry back (“fertilize”) other team members

•HM tools - enhancements

•Realize they are not alone !

Cross Fertilizing = Cross Training

“Quality is everyone's responsibility.”

...W. Edwards Deming

OLD Staff = MA + Front Desk + Billing + Chart people + Office

Mgr.• Greet Patient• Bp, Ht, Wt. -

occasionally• Put patient in room• Call in Refills• Answered Problem

Calls• Give Labs to Doctor• Made Next

Appointment• Arranged Referrals• Billed

OLD Office VisitPre-PPRNet

• “Why are you here” - “Let me put you in a room and doctor will go over everything.”

• “I don’t know, you’ll have to ask the doctor”

• “The Doctor will tell you what you need.”

• “You better talk to the doctor, he will order the colonoscopy if he thinks you need it”

• Patient: “Who’s that person working at the front desk”

• “The doctor will be in to tell you why you need those tests”

NEW (PPRNet Powered) Staff = Team

Office Visits•Greet / Triage•BP, Ht, Wt, BMI - every time•Review Medications• Review Medication

Safety• Review all meds each

visit• Recommend meds - eg.

Aspirin Use• Better Knowledge of

drugs & interactions.

Health Maintenance•Understand / Explain /Discuss needed HM• Better Understanding

HM time tables• Patient Education • Prevention / Chronic

Disease Guidelines

Standing Orders• Order needed labs• Order and Do

Immunization • Order preventive:

Colorectal screen / Pap / Mammogram

• POC Testing - A1c, Spirometry

System Redesign•Order Previsit labs•Reminder calls (Human vs Electronic)•Follow up No Shows

•Cross Trained

Phone Calls• Now More Comprehensive• Order needed screening• Lab Result Discussion and

follow up ordered

EMR• Deal with Interface• Order Entry

•Data Entry, Tracking• Previsit Planning

•Labs, Paperwork•TCV Visit

• WebView (anticipated)

NEW (PPRNet Powered) Staff = Team

New (PPRNet Powered) Office Visit

When I walk into exam room• “Yes I know I need a colonoscopy, Mary already ordered it.”

• “Jackie already took my urine to check my kidneys”

• “They wouldn’t give me any more medication till I came in to get my blood pressure (or my A1c, or my lipids, etc) checked.”

• “Nikki caught me and told me I need to be back here in October for my labs and she scheduled a diabetic eye exam and a colonoscopy“

• “I know, I was already told I need to bring in all my medications at the next visit.”

• “I almost forgot my visit till Shannon called to remind me.”

• “I’ll just talk to Shannon - “When I Check out” - “When I call in next time” - “If I Need anything”

• “Don’t worry Doc, They will let me know when I need ........”

• New Office Visit - a different level of patient understanding, empowerment, expectations, complexity and time.

Staff (on PPRNet) has Evolved

• Intense• Involved• Aggressive• Empowered• Persistent• Comprehensive• LOOK AT THE BIG

PICTURE!• Confident and

Convincing. • Knowledgable • More Accurate!• Better Communicators

• Caring• Patient Experience • PPRNET and PCMH savy

• Better “Team” Culture• Better at creative

thinking• Better and more

comfortable patient educators

• Better at getting needed data.

• Attitude of Excellence• Show Passion for what

they do

REWARD

“Show Me the Money!”

“Defects are not free. Somebody makes them, and gets paid for making them.”

...W. Edwards Deming

PPRNet = PCMH = P4P

•PPRNet Model made PCMH process easier

•PPRNet Background reduced learning curve

Share the WealthOrnstein Effect• Staff play significant role in meeting quality

guidelines.

• PPRNET education has been significant part of that . I could never do it alone.

• Team Knowledge + Patient Activation + Quality Improvement = Enhanced Incentive Payments with several payors.

• Staff should share in those enhanced payments

• Approx 15-20% of income in 2013 estimated to be incentives.

• PPRNet “Best Practice” is worth something!

WEPWage Enhancement Program

OLD METHOD

•Come to work, put individual patient in room, answer physician messages, do refills, go home, get paid.

•“Bonus” based on personal characteristics and individual performance.

NEW METHOD

•Value in independent thinkers who are team players, innovation, understanding of data, registries, quality parameters, patient education, recommended prevention & community based care.

•“Wage” based on outcome, team activity, quality incentives.

Employee Incentive Review•Review Work in PCMH and PPRNet

environment

•Educational - review PCMH & PPRNet elements

•Review accomplishments & set goals

•Team based & Individual

Priority HealthExample of Cross Fertilizing Incentives - Motivations

One of larger payors• Incentives• Disease

Management• Preventive Health• Infrastructure

• Info Shared with staff• Received Quality

Award

PPRNet Motivation

“Best Practice” / “High Performance” Awards - OF COURSE

PPRNet = Why It Works• Goals - clarify, focus, prioritize

• Intensity• Continue to improve Skill• Continue to Improve the Processes• Consistency in process• Every Encounter, Every Time =

Opportunity• Teamwork - Challenging / Rewarding• Develop a better understanding of the

knowledge we gain • Yes its hard, time-consuming, but

rewarding

“The job can't be finished only improved to please the

customer.” ...W. Edwards Deming