Session 12: Performance Improvement Tools: Gathering the Evidence

R.S. Crawford, III, MD, MBArcrawford@usuhs.mil

William Hirst, BSN, MPH, CPHQMHirst@SouthcentralFoundation.com

April 2012

Setting the Stage

Analyst Goal with Dr Crawford

• Establish a working relationship, trust and listen

What insight does he already have

• Assist in decreasing his level of uncertainty

This isn’t a research study

• Provide useful information for decision support

• Demonstrate actionable information tools for all staff

Executives

Managers

Front-end Staff

Big Picture

PreventionPopulation at Risk

Incidence of Disability or Disease

Case Management Level 1

Prevalence of Disability or Disease

Level 2Level 3Level 4

Level 5

Death

Recovery

75.2

77.5

60

65

70

75

80Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11

ER Visits / 1000 Pt EmpanelledER Visits / 1000 Pt. Empanelled

UCL 73.9

Mean 68.1

LCL 62.4

Mean 68.13

70.369.8

55

60

65

70

75

Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11

%

% ER Visits Between 0800 - 1700

UCL 67.0

Mean 63.8

LCL 60.6

40.2

10

15

20

25

30

35

40

45

Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11

ER Visits / 1000 Asthmatics

ER Visits / 1000 Asthmatics

UCL 37.2

Mean 26.8

LCL 16.5

Dec 11

Clinic ER Visits Total Empanelled

ER Visits per 1000 Empanelled

% of Total Visits

Family Practice 1,844 17,500 105.37 79.31%

Internal Med 97 2,500 38.80 4.17%

Peds 384 10,000 38.40 16.52%

Total 2,325 30,000 77.50 100.00%

Dec 10Clinic ER Visits Total

EmpanelledER Visits per 1000

Empanelled% of Total

VisitsFamily Practice 1,498 17,500 85.60 74.94%

Internal Med 103 2,500 41.20 5.15%

Peds 398 10,000 39.80 19.91%

Total 1,999 30,000 66.63 100.00%

Tricare Operations Center (TOC)

http://mytoc.tma.osd.mil

Visits with Assigned PCM(source: Tricare Operations Center)

VALHALLA Family Medicine Clinic 44%

Provider Schedule ReportDetermine Provider Availability: # Providers with Schedules

VALHALLA FMC Provider Availability 50%

Provider Schedule ReportClinic/Provider Specific with # of Appointments

Template Analysis Tool (TAT)Overall Clinic Summary Views

0

200

400

600

800

1000

1200

14004/1/2012 4/3/2012 4/5/2012 4/7/2012 4/9/2012 4/11/2012 4/13/2012 4/15/2012 4/17/2012 4/19/2012 4/21/2012 4/23/2012 4/25/2012 4/27/2012 4/29/2012 5/1/2012 5/3/2012 5/5/2012 5/7/2012 5/9/2012 5/11/2012 5/13/2012 5/15/2012 5/17/2012 5/19/2012 5/21/2012 5/23/2012 5/25/2012 5/27/2012 5/29/2012 5/31/2012

(blank) - (blank)

(blank) -

Wellness - OPEN

Wellness - FROZEN

Wellness - CANCELLED

Wellness - BOOKED

Specialty - OPEN

Specialty - FROZEN

Specialty - CANCELLED

Specialty - BOOKED

Routine - OPEN

Routine - FROZEN

Routine - CANCELLED

Routine - BOOKED

Other - OPEN

Other - FROZEN

Other - CANCELLED

Other - BOOKED

Acute - OPEN

Acute - FROZEN

Acute - CANCELLED

ATC Category

Slot Status

Appt Date

Sum of Count

Clinic Location Provider

Template Analysis Tool (TAT)ATC Category and Slot Status Dynamic Templates

0

20

40

60

80

100

120

140

160

4/2/2012 4/3/2012 4/4/2012 4/5/2012 4/6/2012 4/9/2012 4/10/2012 4/11/2012 4/12/2012 4/13/2012 4/16/2012 4/17/2012 4/18/2012 4/19/2012 4/20/2012 4/23/2012 4/24/2012 4/25/2012 4/26/2012 4/27/2012 4/30/2012 5/1/2012 5/2/2012 5/3/2012 5/4/2012 5/7/2012 5/8/2012 5/9/2012 5/10/2012 5/11/2012 5/14/2012 5/15/2012 5/16/2012 5/17/2012 5/18/2012 5/21/2012 5/22/2012 5/23/2012 5/24/2012 5/25/2012 5/29/2012 5/30/2012 5/31/2012

Acute - OPEN

Acute - FROZEN

Acute - BOOKED

ATC Category

Slot Status

Appt Date

Sum of Count

Clinic Location Provider

Template Analysis Tool (TAT)Provider Specific Templates

0

2

4

6

8

10

12

14

16

18

20

4/2/2012 4/3/2012 4/4/2012 4/5/2012 4/6/2012 4/9/2012 4/10/2012 4/11/2012 4/12/2012 4/13/2012 4/16/2012 4/23/2012 4/24/2012 4/25/2012 4/26/2012 4/27/2012 4/30/2012 5/1/2012 5/2/2012 5/3/2012 5/4/2012 5/7/2012 5/8/2012 5/9/2012 5/10/2012 5/11/2012 5/14/2012 5/15/2012 5/21/2012 5/22/2012 5/23/2012 5/24/2012 5/29/2012 5/30/2012 5/31/2012

Wellness - OPEN

Wellness - BOOKED

Routine - OPEN

Routine - BOOKED

Acute - OPEN

Acute - BOOKED

ATC Category

Slot Status

Appt Date

Sum of Count

Clinic Location Provider

Access Management Report

VALHALLA Family Medicine No Shows 11%

No Show Appointments by Day

# No-Show Appointments by Day (1 Jun 06 - 31 May 07) Family Med

514572

858

1659

2117

91%

81%

66%

37%

0

715

1430

2145

2860

3575

4290

5005

5720

Monday Friday Thursday Wednesday Tuesday

Num

ber

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

n=5720 (11% of 52,000 appts)

CY 2011

No Shows by Day and Hr

Monday No-Shows Family Med (1 June 06 - 31 May 07)

42446484105127169212

1270

98%96%

93%89%

84%

78%

70%

60%

0

500

1000

1500

2000

0800-0859 0900-0959 1700-1759 1300-1359 1500-1559 1400-1459 1000-1059 1600-1659 1100-1159

Time of Day

Num

ber

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

n=2117

CY 2011

No Shows by Day and Hr

Friday No-Shows Family Med (1 June 06 - 31 May 07)

3134495066100165

500

664

98%96%

93%90%

86%

80%

70%

40%

0

500

1000

1500

1700-1759 0800-0859 0900-0959 1300-1359 1400-1459 1000-1059 1100-1159 1600-1659 1500-1559

Time of Day

Num

ber

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

n=1659

CY 2011

Tricare Operations Center (TOC)

Many More Reports

• 3rd Next Available – under beta testing

• Appointment Utilization• Access to Care Reports

• Enrollment & Population Reports

• Booked Management Report

• Length of Stay

Valhalla Findings

• Provider availability ~ 50% last 12 mo• % of Appt with PCM is low (44%)• % of 3rd Next Available Acute Appointments meeting

Access Standards (24hrs) is low in Family Medicine• Decrease in team continuity• Low appointment availability on peak days

• Deployment in 6 months• No-show rates of 11%• Training during peak hours

Potential Items Affecting Capacity

• Provider availability / schedules / templates• Team experience and continuity• Provider specialties & manpower issues• No-show rates• Leave, TDY, Holiday’s

• Additional duty, provider call• Procedures• Facility layout & Support services• Technology • Service level agreements with referrals • Don’t rely on historic utilization patterns

MHS Population Health Model

Population Questions

• Who are my patients?• What are their preventive service needs?• What conditions do they have?• Who are my high utilizers that may need case

management?• How well am I doing in the management of their

care?• HEDIS• Primary Care Medical Home

• How do I forecast & manage the demand for services?

Population Identification

https://carepoint.afms.mil

MHSPHP Data Sources

DEERS M2 CHCS

Direct CareInpt and

Outpt

Purchased Care/NetworkInpt and Outpt

PDTS

TRICARE Enrollment

AdHocs

MammographyPap Smears

Clinical ChemistryEnrollment

MHS Population Health Portal

Population Identification

Population Identification

Population Identification

MHSPHP Action List

MHSPHP Patient Detail

•Last 3 B/P’s (currently from Clinical Data Repository)•Last 6 Labs (note labs in network have no values)

MHSPHP Local Exclusions

•Exclusions automatically expire after 1 year•Exclusions follow pt (new facility can validate or delete)•30 day flag before they expire•Different icon if exclusion was at other facility•Apply to Medical Home and Action Lists, not HEDIS

MHSPHP Local Entered Notes

•Notes are NOT MEDICAL RECORD•Stay forever unless deleted by user•System flags not when pt changes facility, new facility can validate it or delete it•Default is current list, can choose more than 1

MHSPHP HEDIS & Medical Home

•Score = Completed/Total as percentage•Score as compared to All HEDIS® measured health plans Green=Score is greater than 90th percentile Yellow= Score is between 50th and 90th percentile Red= score less than 50th percentile

•Medical Home Completed/Medical Home Total•No benchmark for comparing medical home scores•Can be same, higher or even lower than HEDIS® score

MHSPHP HEDIS & Medical Home

Putting Carepoint to Work: Demand Forecasting

Demand Forecasting

• Daily Demand Forecasting:• Team huddles with integrated care team• Same reasons as inpatient report

• Planning, Coordination, Safety

• Demand Forecasting and Planning:• Deployment coming up in 6 months in which 6 of the 20

providers will be deployed. • If we decided to contract out Well Women Exams to

include pap smears. How many would we need to contract out for?

• School physical demand what can we expect? Do we need to adjust schedules?

Population Identification

Demand Forecasting and Planning

• Women 18 and older = 9231

9231/ @ least one Pap q3 yrs = ~3077/yr

• Women 40 and older

2632/ @ least one Mammogram q 2 yrs = ~1316/yr

• Children 5 years old ready to start school

256 School Physicals

• 1 Jan 11 – 31 Dec 11 ~ 52,000 FMC Appts

Putting Carepoint to Work: Demand Management

High Utilizer Identification

FICTITIOUS DATA

Evaluation:How did we do?

75.2

77.5

64.0

60

65

70

75

80

Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12

ER Visits / 1000 Pt Empanelled

ER Visits / 1000 Pt. Empanelled

UCL 73.9

Mean 68.1

LCL 62.4

UCL 73.9

Mean 68.1

LCL 62.4

Mean 65.3

MEAN 68.13

70.369.8

64.1

55

60

65

70

75

Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12

%

% ER Visits Between 0800 - 1700

UCL 67.0

Mean 63.8

LCL 60.6

Mean 62.7

40.2

22.8

10

15

20

25

30

35

40

45

Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12

ER Visits / 1000 Asthmatics

ER Visits / 1000 Asthmatics

UCL 37.2

Mean 26.8

LCL 16.5

Mean 24.1

Mar 12

Clinic ER Visits Total Empanelled ER Visits per 1000 Empanelled

% of Total Visits

Family Practice 1,450 17,500 82.86 75.40%

Internal Med 100 2,500 40.00 5.20%

Peds 373 10,000 37.30 19.40%

Total 1,923 30,000 64.10 100.00%

Dec 11

Clinic ER Visits Total Empanelled ER Visits per 1000 Empanelled

% of Total Visits

Family Practice 1,844 17,500 105.37 79.31%

Internal Med 97 2,500 38.80 4.17%

Peds 384 10,000 38.40 16.52%

Total 2,325 30,000 77.50 100.00%

Dec 10

Clinic ER Visits Total Empanelled ER Visits per 1000 Empanelled

% of Total Visits

Family Practice 1,498 17,500 85.60 74.94%

Internal Med 103 2,500 41.20 5.15%

Peds 398 10,000 39.80 19.91%

Total 1,999 30,000 66.63 100.00%

Patient Appointments with PCM(Goal 70%)

Valhalla Medical Center (Jan – Mar 2012)Source: Tricare Operations Center

MEPRS Clinic % with PCM

Family Practice Clinic A (BGAB) 70.1

Family Practice Clinic B (BGAC) 67.5

Family Practice Clinic C (BGAD) 68.7

Access to Care 3rd Next Available (Acute) - Goal 80%)

Valhalla Medical Center (Jan – Mar 2012)Source: Tricare Operations Center

MEPRS Clinic % @ Std

Family Practice Clinic A (BGAB) 83.3

Family Practice Clinic B (BGAC) 87.2

Family Practice Clinic C (BGAD) 91.2

Questions

?