Quality Improvement in Family Practice · Quality Improvement in Family Practice: “El Camino se hace al andar” 61 Annual Scientific Assembly Alberta College of Family Physicians

Quality Improvement in Family Practice:“El Camino se hace al andar”

61 Annual Scientific Assembly Alberta College of Family Physicians

Banff AlbertaMarch 2016

Dr Rob Wedel MD CCFP FCFPFamily Physician, Taber, Alberta

Faculty/Presenter Disclosure

•Faculty/Presenter: Rob Wedel

•Relationships with commercial interests:–Grants/Research Support: Not applicable–Speakers Bureau/Honoraria: Not applicable–Consulting Fees: Not applicable– Other: This presentation has received financial

support from the Alberta College of Family Physicians in the form of a speaker fee.

Objectives:• Discuss the conditions that contribute to successful

improvement initiatives in our clinics, and our role as physicians in those initiatives

• Discuss Improvement techniques and supports that can be applied within our family practice clinic

• Discuss the elements of the PMH, and the role they can play in guiding Improvement activities in our clinics

• Describe practical examples of QI initiatives that have made a measurable difference in quality of care of a family practice clinic.

New Approach to primary medical care: Nine Point Plan for family practice

1. Practice registration (patient enrollment)2. A system of blended funding (salary, Capitation,

incentives)3. Primary care through interprofessional teams4. A balance between preventative, curative, and palliative

services5. central health records6. Computerized databases7. Use of health targets8. Local authority with fiscal responsibility for coordinating

care9. A managed system

Forster et al, “New Approach to Primary Medical Care”, Canadian Family Physician, Sept 1994 http://www.researchgate.net/publication/15279277

Framework for Surveillance of Chronic Disease

A. Identify Patient PopulationB. Multidimensional AssessmentC. Systematic, proactive MonitoringD. Consistent assessment toolsE. Patient Education in Self and Family CareF. Integration of Evidence based care/practice

guidelinesG. Coordination of careH. Rapid Response in Crisis

Dr. Ed Wagner. Chronic Care Model. 1985

“New Script, same old Play?”

• Commission on the Future of Health Care in Canada. Building on Values: The future of Health Care in Canada ( Romanow, Ottawa:2003) • Standing Senate Committee on Social Affairs, Science and Technology. The Health of Canadians – the Federal Role, Final Report on the State of the Health Care System in Canada (Kirby, Ottawa: 2003)• Alberta, Premier’s Advisory Council on Health. A Framework for Reform. (Mazenkowski, Edmonton:2001)• Saskatchewan Commission on Medicare. Caring for Medicare, Sustaining a Quality System (Fyke, Saskatoon: 2001)• Ontario Health Services Restructuring Commission. Looking Back, Looking Forward, A Legacy Report (Toronto:2000)• Quebec Study Commission on Health Services and Social Services. Emerging Solutions, Report and Recommendations (Quebec:2000)• Health Services Review Committee. Fredericton:1999

Jeffery Simpson, Globe and Mail editorial, Jan 8, 2004“New script, same old play?

Reform primary health care. (pick a model, any model)”

“New Script, same old Play?”• Commission on the Future of Health Care in Canada. Romanow, Ottawa:2003• Standing Senate Committee on Social Affairs, Science and Technology. Kirby, Ottawa: 2003• Alberta, Premier’s Advisory Council on Health. Mazenkowski, Edmonton:2001• Saskatchewan Commission on Medicare. Fyke, Saskatoon: 2001• Ontario Health Services Restructuring Commission. Toronto:2000• Quebec Study Commission on Health Services and Social Services. 2000• Health Services Review Committee. Fredericton:1999Jeffery Simpson, Globe and Mail editorial, 2004: “Reform primary health care.”

• Office of the Auditor General of Alberta 2012

• CFPC. A Vision for Family Practice. The Patients Medical Home. 2011• PCN Evolution. VISION AND FRAMEWORK. Report to the Minister of Health. AMA

Primary Care Alliance Board . 2013 • Expert Committee on Strengthening PHC in Ontario, Ontario Ministry of Health.

Patient Care Groups: A new model of population based primary health care for Ontario. Price et al. 2015

“The Evidentiary Vacuum” “Discussions of innovations in primary care invariably take

place in an evidentiary vacuum. Strong evidence is lacking to support the superiority of any one model...”Hutchison B et al. Primary care in Canada: so much innovation, so little change.

Health Affairs 2001

Evidence from recent Canadian experience is that primary health care can be transformed through a process that is voluntary and incremental. This emerging vision (Patients Medical Home) offers opportunities to those ready to embrace innovation without imposing changes on the remainder. Hutchison B et al. Primary Care in Canada: Systems in Motion.

The Milbank Quarterly. 2011

The Science of ImprovementThe Evidentiary Vacuum…?

– The RCT-The ‘gold standard’ of Best Evidence in clinical practice – Quality Assurance-The establishment of Best Standards in care– Quality Improvement -A focus on the Best Quality of care

• A ‘new’ science…• Interventions (process, idea) made within a unique social context (clinics,

teams, systems) to produce the multidimensional changes required for improvement

– implementation of guideline based medicine –CPGs– processes of care- timely access, efficiency, patient safety– Integration of care- teams/systems that work

• Multiple models –LEAN, Six Sigma, etc – alone or combined (AlbertaAIM)-all intended to provide us easier and better ways of getting improvement faster.

Donald Berwick. The Science of Improvement. JAMA. 2008

The Science of Improvement

AIMSMART-Specific, Measurable, Achievable, Realistic, Timely

TEAM“The people that do the work have to change the work”

MAPMEASURE

Access (TNA), Continuity/Panel, Quality of Care

CHANGEPDSAsSUSTAINDonald Berwick. The Science of Improvement. JAMA. 2008

The Science of Improvement: Quality Improvement is not Quality Assurance

Quality Improvement Proactive Focuses on all aspects of

care Improves processes to

improve outcomes• Focuses on system

performance; non-judgmental culture; developing best practices

Quality Assurance Reactive Focuses on defects and

activities below target Accreditation = pass/fail

of minimum standard

12

No one wants to talk M%@$~#*!*^&(Measurement)

Measurement is about improving patient experience and outcomes by changing and refining the health care system rather than judging it.

– At the clinic level, measurement is about identifying problems, and recognizing opportunities for improvement.

– At the PCN level, aggregated data can inform the sharing of successful improvement strategies across clinics within the network.

– At the provincial level, aggregate data monitors the performance of the health system and ensures transparency and accountability to Albertans.

• Multiple supports available to us in our province. – PCNs, PMO, HQCA, AIM, etc

Primary Care News. PCN PMO. Dec 2015

The Concern...While once Canada was seen in middle of

the pack in primary care (Starfield 2002), other countries of similar wealth and health systems have advanced and left us behind. 2015 Commonwealth Fund Survey Naylor Report. Health Canada Oct 2015 (www.healthycanadians.gc.ca)

“Canada seems to have stalled in its commitment to strengthening primary care...In this regard, Canada is probably at least 10 years behind.”

Barbara Starfield, 2008

Elements of the Commonwealth Fund Survey

Dimension of Care Grade

Access to care

Timeliness of Care

Cost as a barrier to health care access

Coordination of care

With specialists and hospitals

Between primary care visits

With home care and social services

IT adoption

Computerized care decision support

Electronic communication with patients

Performance Measurement

Measuring patient outcomes and experience

Monitoring preventive care

How Canada Compares• Timely access remains the lowest of the OECD countries.• ER visits per capita are the highest of any other country.• Coordination of care between primary care doctors and other home care

and social services is lower.• Use of EMRs to support decisions of care is not standard practice in

Canada. • Canadian primary care doctors are considerably less likely

– To assess/measure performance, and to track progress (17% versus 37%).

– To routinely review surveys on patient satisfaction and experiences (17% versus 47%)

• However, Canadian physicians working in primary care models (PCNs, FHNs, FHTs) had better overall results than their Canadian peers.

How Canada Compares: Results from the 2015 Commonwealth Fund Survey. CIHR. CIHI. Jan 2016

Most provinces are below the international average in use of performance measurement.

How do the provinces compare?

18

B.C. Alta. Sask. Man. Ont. Que. N.B. N.S. N.L. Can. CMWF avg.

Have reviewed their own clinical performance against targets at least annually

45% 29% 42% 43% 65% 13% 38% 38% 33% 41% 52%

Routinely receive information on how the clinical performance of their practice compares with that of other practices

24% 8% 15% 20% 31% 1% 8% 17% 6% 17% 37%

Proportion of primary care doctors who

Quality Improvement in “small office settings”

• Benefits identified-– More appropriate, effective patient care– Greater practice efficiency and safety – Improved timeliness of care– Improved patient outcomes– Improved revenue – Clinic staff and patient satisfaction/retention– Improved practice reputation with patients and community

Woflson et al. Quality Improvement in small office settings: an examination of successful practices. BMC Family Practice. 2009, 10:14

Quality Improvement in “small office settings” • Internal Facilitators

– Intrinsic professional motivation to provide better care

• a “Physician champion” – an Idea and Improvement champion• (vs. Financial incentives)

– “teamness’ of the practice• An office culture that values and supports improvement work• A sense of empowerment within the team

– “Success breeds success- QI gains momentum with each new effort”


The “Physician Champion”• The physician champion:

– is committed to improving care they provide to their patients– willing to change personally in order to do so– Actively supports the team, through encouragement,

empowerment to suggest and make improvements, visibility, participation

– Is a respected physician, a strong listener and negotiator, able and willing to take initiative as needed.

– has the networks necessary to identify experts and consultants with experience in QI to help facilitate the changes.

– acts as a liaison between their practice and the health care system


• Internal Facilitators– Intrinsic professional motivation to provide better care –“teamness” of the practice

• collective values and shared vision• office culture that values and supports improvement work• generates a sense of empowerment within the team• clear delineation of shared responsibilities• routine interaction between doctors and staff. • Cooperation/commitment of physicians and other

clinical/support staff


Outcomes: Access(Time to Next Available Appt.)

Delay

Delay

Data Entry Instructions: At the SAME TIME EACH WEEK, calculate the time to third next appointment for each provider and enter it into the corresponding field. Enter the name of the provider or service in the cells labelled "Provider X"

Graph Instructions: A delay chart for the clinic (average wait) will be automatically created on the next tab.

Week beginning:Clinic Average

8/1/0533.7777777778

8/8/0534.6666666667

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Delay Chart

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Clinic Average

33.7777777778

34.6666666667

28.9

28.1

33.6

31.1

28.2

25.1

32.3

31.3

31.5

30.3

29.8

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33

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35.8

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32.4

30

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26.6

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11.7

8.6

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15.3

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15.7

15.8

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5.6

12.8

10.5

11.2

10.6

13

10.8

11.4

13

18.5

15.8

13.2

14

14.6363636364

15.6363636364

8.4545454545

13.3636363636

10

14.5454545455

13.6363636364

10.1818181818

7.7272727273

7.3636363636

6.9090909091

7.3636363636

2.8181818182

8.3076923077

6.6153846154

9.25

8.0833333333

11.4166666667

7.5

6.9166666667

14.9

13.2

10.5

11.3

13.4

9.8

12.1

14.3

15.9

12.8

12.9090909091

12.5454545455

12.8181818182

6

7.7272727273

8.5454545455

7.6363636364

7.6363636364

6.8181818182

10.7272727273

11.2727272727

13.0909090909

9.7272727273

8.2222222222

12.5555555556

11.3333333333

9.4444444444

9.1111111111

17.6666666667

14.2222222222

6.7777777778

5.3333333333

5.4444444444

8.4444444444

8

8.1111111111

12.3333333333

12.2222222222

12.5555555556

10.8888888889

11.5555555556

6.8888888889

3.4444444444

8.2222222222

3.5555555556

3.5555555556


• External Facilitators– Available external resources, like Learning

Collaboratives, facilitators– committed internal resources, including the staff time

needed to engineer new office practices– Decision support, including systems to initiate

performance assessment and track progress– Support from national and provincial professional

organizationsWoflson et al. Quality Improvement in small office settings: an examination of successful practices. BMC Family Practice. 2009, 10:14

Quality Improvement in “small office settings” • Barriers

– Time constraints– Internal cost (staff time, equipment)– Resistance of clinical staff– External pressure

• loss of autonomy• increasing responsibility with heightened expectations from

patients, payers, insurers, and regulators.• changing remuneration arrangements


Time Constraints

• Most physicians report overall career satisfaction, but perceive themselves on a treadmill, with increased expectations and erosion of autonomy. – Suggested Strategies to ease practice burdens and

empower physicians include • increased use and enhanced scope of non-physician clinicians, • adoption of IT and disease management programs to safety and

effectiveness • thoughtful practice design to improve efficiency and quality.

Mechanic D. Physician Discontent: New Demands and the importance of Time. Organizational Modifications and Chronic Disease Models. JAMA. 2003Gillette R. Turtles and Rabbits: Family Physicians Under Time Pressure.FamPracManag. 1999.

Resistance and Cooperation of physicians and other clinical staff

Taber - Phase 1 Clinic with AVG TTTN data by quarter for 10 physicians

0

5

10

15

20

25

30

35

40

45

50

55

60

65

70

last q

uarte

r 05

1st q

uarte

r 06

2nd

quar

ter 0

6

3rd

quar

ter 0

6

4th

quar

ter 0

6

1st q

uarte

r 07

2nd

quar

ter 0

7

3rd

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ter 0

7

4th

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ter 0

7

1st q

uarte

r 08

2nd

quar

ter 0

8

3rd

quar

ter 0

8

4th

quar

ter 0

8

2005 to end of 2008

TTTN

Day

s

Chart1

last quarter 05last quarter 05last quarter 05last quarter 05last quarter 05last quarter 05last quarter 05last quarter 05last quarter 05last quarter 05

1st quarter 061st quarter 061st quarter 061st quarter 061st quarter 061st quarter 061st quarter 061st quarter 061st quarter 061st quarter 06

2nd quarter 062nd quarter 062nd quarter 062nd quarter 062nd quarter 062nd quarter 062nd quarter 062nd quarter 062nd quarter 062nd quarter 06

3rd quarter 063rd quarter 063rd quarter 063rd quarter 063rd quarter 063rd quarter 063rd quarter 063rd quarter 063rd quarter 063rd quarter 06

4th quarter 064th quarter 064th quarter 064th quarter 064th quarter 064th quarter 064th quarter 064th quarter 064th quarter 064th quarter 06









Beckie

Bester

Christensen

Chychota

Demontigny

WadeSteed

Torrie

Wesley Steed

Wedel

Yamabe

2005 to end of 2008

TTTN Days

Taber - Phase 1 Clinic with AVG TTTN data by quarter for 10 physicians

45.2941176471

44.7647058824

27.1764705882

29.1764705882

14.5294117647

15

47.3529411765

63.1176470588

24.2307692308

23.3076923077

0

12.0769230769

8.0769230769

9.1538461538

23.6153846154

24.2307692308

18

17.4615384615

7.9230769231

8.1538461538

5.6153846154

6.6923076923

15.9230769231

15

19.9230769231

20.1538461538

7.7692307692

10.8461538462

7.3846153846

13.6666666667

7.4615384615

18.0769230769

19.8461538462

25

8.4

5

3.3

3.8

8.2

11.1

10.8

8.3

22.1538461538

20.1538461538

9.0769230769

5.3076923077

15.9230769231

6

18.3076923077

14

23.9230769231

16.4615384615

6.5

5.5384615385

3.7692307692

16.8461538462

7.1538461538

16.2307692308

9.3076923077

22.2307692308

11.6923076923

8.6153846154

11.1538461538

2.8461538462

13.6153846154

3.6153846154

10

5.1538461538

9.7857142857

16.7857142857

1.4285714286

7.7142857143

2

13.6428571429

3.4285714286

12.2857142857

3.7142857143

14.8461538462

0

15.1538461538

0

0.3846153846

1.1538461538

8.0769230769

4.0769230769

14.2307692308

6

8.9

0

13.1

5.4

0.1

1

2.7

1.7

9.6

1.5

11.8461538462

1.0769230769

9.3846153846

3.4615384615

0

1.1538461538

4.5384615385

3.6923076923

7.4615384615

4.5384615385

6.75

14

9.1818181818

0.6363636364

2.0909090909

1.8181818182

4

1.6363636364

9.5454545455

4.8181818182

Sheet2

If starting a new practise. Take TTTN 1st average 2 months after they have been practising for 6 months.

NotesAverageaverage

PhaseClinicPhysicianfor March 20091st 2 months/1st 8 measurementslast 2 monthsdifference20052006200720082009

1pincherGelber9.385.004.389

1pincherCameron5.755.500.255

1pincherIrving11.131.389.7512

1pincherRottger28.2520.387.8830

1pincherScrimshaw27.7516.0011.7528

1pincherdeWet7.387.75-0.389

1pincherBrunner28.1325.632.5033

1pincherJacksonLeft practise15

1pincherParkerLeft practise9

1pincherTBurton

What we Know Works…“The Medical Home”• The greater the range of services provided by primary care clinic,

along with a family physician providing a continuous care relationship to a defined patient population had one third lower overall costs and were 19% less likely to die

• “Attachment to a practice” was more significant than all other variables, such as age.

• For most aspects of care and health outcomes, identification of a particular practitioner provides even better services than mere identification of a particular place”.

Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy. 2002;603:201–218The Future of Family Medicine. Annals of Family Medicine, 2004 Hollander, MJ, et al. Increasing Value for Money in the Canadian Healthcare System: New Findings on the Contribution of Primary Care Services. Healthcare Quarterly Vol.12 No.4 2009

The Patient’s Medical HomeThe Pillars

The Patients Medical HomePatients receive care that is centered on their needs from a

team that knows their story

http://www.patientsmedicalhome.ca




Clinical Supports provided by the Medical HomeTimely Access to care and information Team based Care

Continuity to personal family doctor Comprehensive, Coordinated care




System Supports for the Medical HomeProvincial Support Programs Integrated Information Systems/EvaluationSupportive Payment Structures Workforce Development

Patient Centered Medical Home:Impact on Cost and QualityAggregated outcomes from 28 Peer reviewed articles and government program evaluations

Statistically significant improvements in:

SatisfactionAccessQualityCostutilization

What do we know works in Canada…Practices that provide the best, most effective care...• Enhance capacity through effective patient flow processes, focusing

on eliminating delays for appointments and at appointments.

• have a sound knowledge of patient population, and of their community resources. (Four Principles of Family Medicine)

• Have pre – planned and prepared for patient encounters, using protocols and guidelines to support collaborative team-based care, whether co-located or not

• Have a strong emphasis on self management

• Use and share sophisticated electronic medical records that include clinical decision support, prompts, reminders, registries, communication tools for other providers, etc

• Use continuous measurement and evaluation to inform changeKatz, Glasier et al. “Applying what works in Canada: Closing the Gap”. CHSRF Working Group. Jan 2008

What do our patients value?• The single most important

issue for Canadians is poor access to health services. (p>0.01)– Access to primary care (for appts)– Timeliness at the appointment– Respect and empathy– Time available in the consultation– Medication and Treatment costs

• Delay in seeing a doctor and getting treatment is the longest among the seven developed countries.

(2015 Commonwealth Fund Survey)

• Physicians prioritize:– ER visits– Self efficacy– Multidisciplinary teams– Collaboration between

healthcare organizations– Self care support– Technical quality of Chronic

disease management– Physical activity counselling

Boivin et al. Implementation Science 2014, 9:24. http://www.implementationscience.com/content/9/1/24

Patients Medical Home-Links to Resources:

– CFPC ‘Best Advice’: www.patientsmedicalhome.ca– Compilation of Resource Tools:

• http://www.topalbertadoctors.org/file/pmh-implementation-field-kit.docx– Compilation of PMH Evidence:

• http://www.topalbertadoctors.org/file/top--evidence-summary--benefits-of-pmh.pdf– Advanced Access, Measurement Tools:

www.albertaaim.ca/index.php/resources– Panel Management, Team based care:

• www.pcnevolution.ca; www.pcnpmo.ca• http://www.albertaaim.ca/index.php/resources/• https://www.youtube.com/watch?v=cqGsHB3vvj0&feature=youtu.be

– McMaster U: Quality Book of Tools. 2010• http://qualitybookoftools.ca/wp-login.php

http://www.topalbertadoctors.org/file/pmh-implementation-field-kit.docxhttp://www.albertaaim.ca/index.php/resourceshttp://www.pcnevolution.cahttp://www.pcnpmo.cahttps://www.youtube.com/watch?v=cqGsHB3vvj0&feature=youtu.be

Take the leap…. we will build our wings on the way down.

Donald Berwick

“El Camino Se hace al andar”

“wanderer, there is no path,the path is made by walking.”

Antonio Machoda 1939

Quality Improvement in Family Practice:�“El Camino se hace al andar”�Faculty/Presenter DisclosureObjectives:Slide Number 4New Approach to primary medical care: Nine Point Plan for family practice Framework for Surveillance of Chronic Disease“New Script, same old Play?” “New Script, same old Play?” “The Evidentiary Vacuum” The Science of ImprovementThe Science of Improvement The Science of Improvement: �Quality Improvement is not Quality AssuranceNo one wants to talk M%@$~#*!*^&�(Measurement)�The Concern...Slide Number 15Elements of the Commonwealth Fund SurveyHow Canada ComparesHow do the provinces compare?Quality Improvement in “small office settings” Quality Improvement in “small office settings” The “Physician Champion”Quality Improvement in “small office settings” Outcomes: Access� (Time to Next Available Appt.)Slide Number 24Quality Improvement in “small office settings” Quality Improvement in “small office settings” Time ConstraintsResistance and Cooperation of physicians and other clinical staff�What we Know Works…The Patient’s Medical Home�The PillarsThe Patient’s Medical Home�The PillarsThe Patient’s Medical Home�The PillarsPatient Centered Medical Home:�Impact on Cost and QualityWhat do we know works in Canada…What do our patients value?Patients Medical Home-�Links to Resources:�

Documents

Quality Improvement in Family Practice · Quality Improvement in Family Practice: “El Camino se hace al andar” 61 Annual Scientific Assembly Alberta College of Family Physicians