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DRVS: UDS Colorectal Cancer Screening Quality Improvement Initiative
September 17,
2015
Quality Initiative Framework
• Pilot Six Federally Qualified Health Centers Four urban, two rural FQHCs UDS measure
• Selection Process Applicants Criteria Interest Capability
• Four EMRs: NextGen, Epic, Athena, Centricity
Project Structure
• Learning community Monthly virtual learning sessions: 90 minutes Agreement to share un-blinded aggregated data Peer-peer sharing DRVS and non-DRVS centers
• QI coach in-person and virtual meetings Monthly reports looking at trailing year and
recent months UDS data o Site and provider level
Encourage use of registries in QI setting Utilize patient visit planning reports
Project Milestones
• Six month modular format: Kick off Process mapping Sett the aim and select targets Develop an improvement strategy and start
tests of change Pilot reliable standard process of care Implement new standard process Spread new standard process
Resource Commitments
Executive Sponsor
2 hours
Leadership level sponsor
of project
Sign off upon project
completion
Project Team Lead
20 hours
Champion of QI Project
CHC resource
coordinator
Escalation point for
issues/risks
Network Admin/IT
2 hours
Provide access to
CHC Network/
EHR
DRVS connectivity
and performance
support
EHR Expert
16 hours
Review current state and
identify missing data
Workflow mapping
Participate in PDSA cycle
Participate in learning
community
QI Specialist
16 hours
Identify process measure
Complete workflow mapping
Execute PDSA cycles
Document results
Participate in learning
community
Provider Rep/Clinical
Support
8 hours
Identify data capture
workflow
Design and execute
PDSA cycles
Participate in learning
community
Colorectal Cancer Screening CrosswalkJuly 2015
Footnotes *2014 Mass average is MLCHC reported as 2014 UDS data not yet available through HRSA. **TY = Trailing year to date for DRVS data
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Colorectal Cancer Screening (2013UDS)
Colorectal Cancer Screening (2014UDS)
Colorectal Cancer Screening (2013DRVS)
Colorectal Cancer Screening (2014DRVS)
Colorectal Cancer Screening (TY**June 2014-June 2015 DRVS)
Participant Health CenterColorectal Cancer Screening
HOLYOKE HEALTH CENTER 2014 Mass average (UDS)* 2013 Mass average (UDS)
2013 National average (UDS) National HEDIS Healthy People 2020
UDS Averages Benchmarks Colorectal Cancer Screening (2013 UDS)
Colorectal Cancer Screening (2014 UDS)
Colorectal Cancer Screening (2013 DRVS)
Colorectal Cancer Screening (2014 DRVS)
Colorectal Cancer Screening (TY** June 2014-June 2015 DRVS)
2014 Mass average (UDS)*
2013 Mass average (UDS)
2013 National average (UDS)
National HEDIS
Healthy People 2020
Participant HEALTH CENTER 46.9% 48.6% 32.6% 64.0% 70.5% 54.3% 43.0% 44.0% 52.0% 51.0%
DRVS Comparison Report
Clinical Registry
Data Management & Daily Practice
Tools, Templates, and Resources
Examples of recommended tools, templates and resources:» Developing an AIM Statement» Quality Improvement Project – Implementation
Guidance» PDSA Model for Improvement & PDSA Example» Improvement Project Planning Form» A3 Instructions & A3 Blank Template» Cause & Effect Diagram» PDSA Planning Worksheet» PDSA Testing For Change» Project Charter Instructions & Blank Worksheet» Prioritization/Ranking Variation» Elevator Speech» Stakeholder Analysis & Resistance Tool» Action Plan (WWW)» Communication Plan» Developing a Storyboard
Change is hard
• Importance of senior leadership and other stakeholder support
• What do you do with the registries?• Work flow mapping• QI structure• AIM statement tool • PDSA cycles• Who has responsibility for new processes?• Project versus work sustainable change
mentality
Recommended Resources
www.ihi.org Institute for Healthcare Improvement
DRVS Learning Series: Maximize use of Visit Planning Report DRVS Training: Setting Measure Targets Baltimore Medical System/Azara DRVS presentation at NACHC CHI 2014
Azara YouTube Channel
Integrated Work Solutions QI Forum
Questions & Next Steps?
Diana EraniDirector of HCCN
Jennifer KincaidProject Coordinator
