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Lori Pigeon, NPAssociate Medical Director
for Quality
Pam Azar, OT
Objectives
Introduction to Improvement Science
Learn how to create an AIM Statement
Learn how to set up Measures and use of run charts to measure change over time
Learn Quality Tools and when to use them
Review of improvement Science Examples at Harbor Health
WHAT IS MEANT BY QUALITY IMPROVEMENT IN HEALTH CARE?
Systematic, data-guided activities designed to bring about immediate improvement in a health care setting.
What Do you mean by systematic?
Systematic – it is not simply the introduction of a new change
• Guided by data – it is not just implementing changes and assuming things get better
• Emphasizes immediate action – it is about testing new ways to do things and making changes right away (huddle/PDSA)
5 FUNDAMENTAL PRINCIPLES OF IMPROVEMENT
1. Know why you need to improve2. Have a way to tell if the improvement is
happening 3. Develop an effective change that will result in an improvement 4. Test changes well before trying to implement 5. Know when and how to make the change permanent
Change and Improvement in a system is complex. Takes TIME and a lot of work.
In a system, everything affects everything else. A change in one area may result in improvement in some ways, but could also cause harm in other parts of the system.
When thinking about making changes, it is important to consider all the interdependencies within a system and both the positive and negative potential results.
Culture Influences success.
The status quo is preserved by prevailing and existing mindsets. -Shift the status quo.
Understanding culture and complexity is key to doing improvement work
Assembling a good team for an improvement project promotes success and sustainability. Everyone works toward improvement.
Where Do We Start?
Problem Statement
Aim Statement
Where to Start:
WHAT ARE WE TRYING TO ACCOMPLISH? Problem Statement & Aim Statement Outlines the general problem and purpose of your project.
There are 4 parts to a precise aim statement:
• What will improve?
• Where?
• By how much?
• By when?
We Start With the Basics. Shift the Status quo
UseUse data and transparency to drive quality improvement
• Educate all staff on quality goals
• Show staff progress towards goals via dashboards
EngageEngage entire staff in quality improvement activities
• Empower all staff to identify areas for improvement
• Use the expertise of front-line staff to identify solutions
DevelopDevelop a culture of continuous improvement
• Shift away from a culture of blame
• Incorporate improvement into daily activities
Culture Change for 2018
Aim Statement
95% of ESP staff will complete 2 training sessions on the introduction of quality science in 2018.
Aim Provide all ESP staff with a basic understanding of quality improvement. Educate staff on our quality goals and how, with their help, we plan to achieve them.
Problem: Many ESP staff have limited or no training in quality improvement methods and tools. It is difficult to achieve quality without everyone being part of the team and understanding quality goals.
Driver Diagram
A driver diagram serves as a tool for building the testable hypothesis.
It consists of a team’s shared theory of knowledge—and includes relevant beliefs of team members about what must change and which ideas may result in improved outcomes.
AIM
Primary Drivers Secondary Drivers Projects who goal date
To Implement
Quality Improvement
utilizing measurable goals across organization
in 2018
Develop Infrastructure/leadership
support
Leadership makes safety and Quality primary goal
communicates commitment to staff ED to send monthly emails. Incorporate into monthly all staff
restructure Quality roles Review current data collection and quality projects and align with new quality goals/infrastructure
Align incentives with accountability-each manager/project lead reports progress to Quality
Set department level goals. Implement aims/measures/
implement standardized reporting infrastructure Mangers to utilize standard reporting infrastructure to report monthly/quarterly to QAPI depending on Tier.
implement standardized support structure by Quality leads(LP/SH)
Lori/Susan to work with individual project to help set up standards of work/Aim/Measures/PDSA cycles at departmental level.
Planning align with regulatory needs. UDS, CMS audit, encounter, HPMS, coding
align with finance Tier projects; set priorities according to tier/include FD
align with organizational goals Growth sustainability safety, quality
strategy establish measuring capabilities Priority matrix with EMR of outlined projects/FTE to conduct data analysis monthly/create dashboard of measures/eliminate manual data retrieval chart audits. .
prioritize projects focus on vital few with most impact.
focus on vital few with most impact.
Establish 1 year and 5 year goals.
focus on never events; those that can cause most harm.
Prioritize patient safety
Develop improvement capability and culture
introduction of improvement science to all create visual teaching tools/establish a training schedule. (2, 1 hr sessions in year 2018 to all staff) Establish space.
all managers complete learning module on improvement methodology
create visual teaching tools/establish a training schedule. (2 1 hr sessions in year 2018 to all staff) Establish space.
Implement at least one front line project in each department. Each project charted by standard method
Adopt IHI improvement methodology to guide projects.
profile improvement work with boards and monthly communication.
Establish improvement boards in each department
Sustainability use transparency as lever Use of dash boards
standardize process and accountability . Review of progress at departmental level weekly.
Score cards at department levels
visual management/process boards/huddles in each department.
Incorporate huddles to communicate clear goal oriented with front line staff. Understand barriers and problem solve
problem solving at local levels daily. Encourage tier 3 projects in each department.
Pillar Goal level of reporting and project
lead
Quality 95% of staff will complete initial training on improvement science by May 2018 Tier I: Lori completed 2
sessions
People/service Improve participant service request/grievances compliance. 100% compliance with
CMS regulations.
Tier I: reported monthly to
quality by CC.
Quality 80% compliance with immunizations by September 2018 Tier I: goal 95% of initials have
immunizations by month 4. Lori
/Mardi /Janene
Quality 95% of new enrollees will have HCP scanned into chart within 1 week of enrollment. Tier I: Suz/Julie project
complete;tracking
Finance Decrease LOS in short term acute by % by X Tier II: Maureen/Lori
Quality 95 % compliance with wound risk assessments via scanned Braden. Tier II: Mardi/Janene
Quality EMR compliance and maximize use of EMR for communication completed Relias training
Quality 95% of clients will have Molst within 6 months of enrollement Tier III: Christine tracking
Finance 4 net enrollment per month or more Tier III Julie
Finance HCC capture trends will increase and maintain to minimum of 2.5 risk score by Jan
2017
Tier III Maureen
Quality Improve accurate DX of malnutrition by 50% by July 2018 Tier III Ann
Quality 100% compliance with weekly On call universe compliance edits Tier III; CC tracking
Problem Statement
In December clinicians recognized that clients did not have HCP in charts after enrollment. Review of data identified as of August 2017 we had a significant decline in HCP compliance. Only about 45% of HCP were obtained and scanned into charts. This was a 55 % decline.
0%
20%
40%
60%
80%
100%
120%
% HCP 1 month post enrollment
Mattapan
Brockton
Aim Statement
Improve the compliance with capturing HCP upon enrollment to a goal of 100% by May 2018.
Improve compliance of HCP scanned into EMR within 1 week post enrollment to a goal of 100% by May 2019.
PDSA cycles: Plan – Do –Study – Act.
• This is about testing your idea in a small way.
• Learn what will be most effective in making improvements before you implement on a full scale.
• Involve front line staff to try out the change before it is implemented- help reduce barriers to change.
HOW WILL WE KNOW A CHANGE IS AN IMPROVEMENT?
Measures: Not all changes are going to lead to improvement. You need data to inform the team whether the changes are working.
Sharing and transparency of data helps drive change.
CHARTER
A documented plan to guide the work of the team.
Clarify purpose
Limit the tendency to get off track
Outline roles of various team members
Show where to start
Determine when project is finished
Goal: 95% of New Enrollees will have HCP Scanned into Chart within 1 week of enrollment.
80%
100% 100% 100% 100% 100% 100% 100%
80%
93%
100% 100% 100%
89%
100% 100%
0%
20%
40%
60%
80%
100%
120%
Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18
% HCP Obtained and Scanned into EMR within one week of Enrollment
% scanned % obtained
80%
100% 100% 100% 100% 100% 100% 100%
80%
93%
100% 100% 100%
89%
100% 100% 100%
0%
20%
40%
60%
80%
100%
120%
Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18
% HCP Obtained and Scanned into EMR within one week of Enrollment
% scanned % obtained
Background REHAB LOS
AIM: Decrease Sub –acute LOS to
average of 14 days by January 2019
2017 avg LOS is 17.6 days per 1000 member months. PDAC: Short Term NF days PM/PM
2017 Q1 Harbor Peer Average
0.65 0.60
2017 Q2 0.76 0. 58
Financial impact:
Gap analysis/RCA revealed :
lack of clearly identified team member who's responsibility it was to outline the functional goals for discharge
lack of standard process to document/communicate goals with SNF staff or IDT.
lack of tracking of progress and barriers to discharge on routine basis.
Knowledge gap of contracted SNFs
Overall there was lack of standardization, and lack of processes.
Fishbone or Cause and Effect Diagram
Tool that helps teams explore and display the many causes contributing to a certain effect or outcome.
Graphically displays the relationship of the causes to the effect and to each other, helping teams identify areas for improvement
Staff/Facility interviews current state 2017/July
Type of visit when do you use how oftenHow do you define change in status.
Where do you document it?,
what is documentation process for client admitted to Sub-acute?
How do you receive information/how do you send?
What do you find helpful in the tools?
PDSA
Educate the SNF Administration and PACE staff of PACE model and basic expectations of return to community for continued care.
Educate
Standard template to all IDT meetings to address daily SNF clients and barriers to discharge.
EMR builds to standardize communication and documentation/Allow reporting
Add
Therapy to set discharge goals and expected timelines to meet goals within 48 hrs of admission. Weekly Progress Notes
Standard template in EMR created utilized to communicate to facilities and families
Standardize
Where are We now?
After 4 months of testing paper form we moved to EMR template.
Used EMR tools to simplify documentation.
Create Standard for documentation
Create a SOP procedure so all are clear on expectations
PLOF and weekly progress Notes will be documented in chart. Built in capability to fax to each rehab directly from EMR. Notes also to be tasked to IDT.
Changed format of IDT to facilitate discussion and help with cultural barriers.
Updated EMR with all SNF rehab fax numbers with specific cover sheet.
Have had several RCA meetings with providers and Provider education to help decrease the cultural barriers
Included EMR builds to run reports for tracking and make notes easy to find on SNF documentation.
Next Steps
All staff have been educated on standards and EMR tools
Continue Weekly tracking of process measures
Continue RCA on outliers to identify themes driving LOS
Education plan for contracted SNFs
Explore alternative levels of payment for non skilled restorative program.
Monitor impact of increase in home care and cost benefit ratios
Explore creation of a utilization role to support LOS decrease goal and to act as liaison between facilities/families and clinical staff.
Goal: : Decrease LOS in SNF to an Average of 14 days by January 2019.
50%
60%
70%
80%
90%
100%
110%
Weekly SNF Documentation
0%
20%
40%
60%
80%
100%
120%
% Compliance with PLOF Documentation
Series3
0
100
200
300
400
500
600
700
800
900
Jan
-16
Feb
-16
Mar
-16
Ap
r-1
6
May
-16
Jun
-16
Jul-
16
Au
g-1
6
Sep
-16
Oct
-16
No
v-1
6
Dec
-16
Jan
-17
Feb
-17
Mar
-17
Ap
r-1
7
May
-17
Jun
-17
Jul-
17
Au
g-1
7
Sep
-17
Oct
-17
No
v-1
7
Dec
-17
Jan
-18
Feb
-18
Mar
-18
Ap
r-1
8
May
-18
Jun
-18
Jul-
18
Au
g-1
8
SNF Admits days/1000
Series1 Series2
Background: HCC AIM: Improve HCC score to 2.5 by Jan 2017Improve Compliance risk to < 5%
In 2016 we identified that our existing clinical documentation was not accurately reflecting medical diagnosis.
HCC ceased if documentation was not found to support.
We had significant drop in risk scores
Gap Analysis/RCA revealed:
Documentation process was complicated
Providers lacked knowledge
Documentation workflows did not support maximum capture of HCC
Interventions/PDSA
Implemented a standardized documentation process and improved charting hygiene (discrete data fields)
Developed policy and standard operating procedure, educated providers on expectations and worked on barriers
Implemented Bi-annual training sessions
Implemented a missed opportunity tool, reporting tools
Implemented EMR build and workflows to ease documentation and reminders. (favorites, problem lists, printed sheets with visits
Next Steps
Continued tracking of process measures
Incorporate other disciplines in HCC capture
Continued Education
Documentation completed within 7 days
40%
50%
60%
70%
80%
90%
100%
110%
Jan '17 Feb '17Mar '17Apr '17May '17Jun '17 Jul '17 Aug '17Sep '17 Oct '17Nov '17Dec '17 Jan '18 Feb '18Mar '18Apr '18May'18 Jun'18 Jul'18
Compliance with Documentation
2016-2018
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
Jan
Fe
b
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Se
p
Oc
t
No
v
De
c
Jan
Fe
b
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Se
p
Oc
t
No
v
De
c
Jan
Fe
b
Ma
r
Ap
r
Ma
y
20161 20162 20171 20172 20181
HCCPMPM
HCC PMPM
5
3
0
1
4
0 0
3
1
0
2
0 0
7
0
1
0 0
1
0
1
3
1% 0% 0% 1% 0% 0% 0% 1% 0% 0% 1% 0% 0% 2% 0% 0% 0% 0% 0% 0% 0% 1%
Documentation Compliance
unsupported Codes that would not pass audit %
6162 Codes audited19 Incorrect November 2016-August 2018
Background: Immunizations
In 2017 it was identified that we had only met 33% of mandated immunization rate for Pneumovax
GAP ANALYSIS/RCA Revealed:
70% of clients live in ALF and do not come to clinic
Immunization requires temperature control
Brockton clients did not have a process to capture immunizations on clinic visits.
Interventions to Date
Developed a protocol for safe transport of vaccine ordered equipment and set up geographical vaccine clinics in community.
Re-educated Mattapan staff on goal to capture on initial and annuals. Weekly huddles to review.
SOP with visual steps
Incorporated EMR alerts
Next Steps
Implement process to capture immunizations in Brockton on clinic visits.
Set Set process to obtain vaccine records from outside facilities and update our EMR
ContinueContinue to track ALF clients and run quarterly immunization clinics in community
Staff review of SOP bi-annually
Goal: 80% Compliance with Immunizations
50%
100%
50%
80%
100% 100%
66%
80% 80%
100% 100% 100%
50%
80%
50%
55%
100% 100% 100%
0%
20%
40%
60%
80%
100%
120%
% PCV Compliance Both Sites Initial
% compliance Mattapan % compliance Brockton
Background: wound Risk
In 2017 we had increase incidents of Level II wounds
CMS requested a corrective action plan
Gap Analysis/RCA revealed:
We did not have a standardized process to assess, document, communicate wound risk.
Interventions
Implemented a standardized tool to assess wound risk
Developed policy and standard operating procedure
Educated all nursing staff to goal
Tested in paper format
Transitioned to EMR build with reporting capabilities
Next Steps
Continued tracking of process measures
Review data to identify our high risk clients now that we have reporting capability
Develop a standardized treatment and care plan protocol
Goal: 95% compliance with wound risk assessments via scanned Braden in EMR by initial POC
33%
83%
100% 100% 100%
70%
80%
86%89%
46%
58%
66%
100%
83%
0%
20%
40%
60%
80%
100%
120%
Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18
% Compliance Braden Scores
