1 hivqual-us funded by hrsa hiv/aids bureau hivqual-us in+care campaign, developing process...
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1 HIVQUAL-US Funded by HRSAHIV/AIDS BureauHIVQUAL-US
In+Care Campaign,Developing Process Diagrams, and
Tests of Change/PDSAs
Nanette Brey Magnani, EdD, HIVQUAL USApril 4, 2012
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• Participants– Benjamin Harris – Erie FHS– Mandy Kastner – ARC/W– Shelton Kay – Crusader Health Center– Bessie Akuomah - CDOH– Alice Wightman – Heartland Health Outreach
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Check-in and Next StepsWhat can you do by our May 7th meeting?Bessie – start with data; and enter it; 75%Mandy – working on VL suppressionBenjamin – meet with case managers at
monthly meeting; Outreach worker and care coordinator; identify reasons; fine tune how to link back in to care;
Alice – pull team together; share/discuss data; develop initial draft of process diagram
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• Shelton – meet eCW consultant; access to data; enter data into In+Care– MH screening QI Project - Develop Mental health
screening process diagram– Then when eCW data is ready; review results and
select QI focus
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AgendaWelcome: Unmute lines, interactive webinar with discussion,
Q&AUpdates:
Next regional group meeting – Monday, May 7th; 9:30-12:30at Erie Family Health Center; North Ave/ California (NE
corner of park)In+Care Campaign progress
Review and discuss examples of process diagramsShare some tests of change and team management tools
Next Steps
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Site Visits – week of May 7th
• Near North – OA; 2-4
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QI Project Steps
Step 1: Collect and Analyze Data.Step 2: Convene QI Project Team. Step 3. Investigate the ProcessStep 4: Implement PDSA(s)Step 5: Evaluate ResultsStep 6: Systematize Change
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Step 1: Performance Measures and DataIn+Care Campaign Measures
• Gap in Care –% who did not have a medical visit with a provider w prescribing privileges in the last 180 days
• Medical Frequency: % who had a medical visit w a provider w prescribing privileges in each 6-month period of the 24-month measurement period w/ a min. of 60 days between visits
• Patients Newly Enrolled in Care: % who were newly enrolled with a medical provider w/ prescribing privileges and had a medical visit in each of the 4-month periods of the measurement year
• Viral Load Suppression: % of patients with a viral load less than 200 copies/ml at last VL test during the measurement year
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In+ Care Campaign Data Update March 15, 2012
• 11 Part C/D grantees are members of Greater Chicago QM Group
• 4 submitted data for February, 2012• 2 registered, no data entry• 5 not registered in database
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Initial Data for 4 Submitting Programs: Validate Data – Is it accurate?
Program Gap in Care Visit freq over two years
Newly enrolled in care
VL suppression
#1 CCHCPatient total
15.7%223
53%218 ?
71%267
#2 EFHSPatient total
1.62%185
92.7%151
87.5%8
84%185
#3 HBPatient total
18.6%1590
58.5%1538
59.8%157
73.7%1933
#4 Open DoorPatient total
3%361
Not submitted 83.3%12
76%423
16.12%103,259 – 163 org
3.6% - 3,852 -17 org5.4%--11,755-41 org
*Nat’l -urban
Top 10%Top 25%
67.4%58,364 – 96 org
95.9%-7,928 –10org 90.4%-10,651-24org
59.4%8,795 – 157 org
99.2%-154-16 org89.8%-1847-40 org
69%119,656 – 157 org
87.7% -5,371-16 org83.1%-17,478- 40 org
ARC/W: gap: 3% new pts: 83% retention: 63% VL supp: 74%
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February Data for 4 Submitting ProgramsMASSACHUSETTS – Part C
Program Gap in Care Visit freq over two years
Newly enrolled in care
VL suppression
#1Patient total
10.3%146
90%146 (15 ?)
80.4%163
#2Patient total
4%270
89.5%239
87.5%8
94%299
#3Patient total
14.7%157
#4Patient total
10.9%55
49.4%77
100%1
83%71
*Nat’l –programs <500
Top 10%Top 25%
16.1%103,760 – 166 org
3.7% - 3,852 -17 org5.5%--12,057-42 org
66.6%58,990 – 99 org
96% - 7,978 -10 org90.1%--10,792- 25 org
59.62%8,823 – 160 org
100% - 91 -16 org 91%--1738-40 org
69%120,577 – 160 org
88.5% - 5,588 -16 org83.7%--17,499-40 org
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QI Project Steps
Step 1: Collect and report data. (QM Committee report on performance measures.) (if no data, then develop a process diagram; work flow)
Step 2: Convene QI Project Team (sub group), review data and set improvement goal
Step 3: Investigate the cause: understand the process and causal analysis (Flow chart/process diagram; drill down data)
Step 4: QI Project (PDSA)Step 5: Evaluate with QM Committee and Stakeholders.Step 6: Systematize changes.
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Step 2: Team Formation
Who is on your QI Project Team?
Do they need training? If so, can they be available for team training and commit to the schedule?
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Step 3: Investigate the Process and Causal Analysis
• Causal analysis tool– Drill down your data– Find out who is not meeting the measure– Find out why
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Step 3: Investigate the Process
• Process Diagrams– More deeply understand process improvement
• PDSA – change isolated vs clearly connected to process – Promotes better decision making
• Helps you to see your work at as a system, a whole• Gathers team’s thinking• Creates buy-in and consensus• Functions as a procedure and thus can be used to create
protocols and evaluate current ones• Promotes wider understanding of process
Resources : HIVQUAL Workbook – flow chart NQC: National Quality Academy Tutorials – flow chart
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Types of Processes in Health Care
Flowcharts
Patient flow Information flow
Material flow Clinical practice
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What does a processdiagram look like?
Also called flow chart; work flow (Six Sigma)
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Process Diagram Definition
A process diagram or flow chart is a picture of the steps of a process to: – Understand the process– Identify potential sources of problems – id underlying
causes– Outline the ideal process steps and address the causes– Enable communications with others
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Creating a Process Diagram and Next Steps in Implementing PDSA
1. Agree on use and level of detail2. Define starting and ending points3. Document each step 4. Follow each branch to the end 5. Review and agree on the steps and diagram6. Identify problem steps and list underlying
causes next to the step7. Discuss tests of change (interventions) to
address key causes.8. Develop a PDSA plan and implement.
Flowcharts
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Most Commonly Used Process Diagrams/Flowchart Symbols
Activity/step
Start, end
Decision yes, no
Wait symbol
Connecting lines
Flowcharts
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Improving Patient Retention • Delta Regional Medical Center – Greenville,
MS• Wright Primary Care Center – Scranton, PA
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DeD
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Improving VL Suppression Rates
• Arnot Ogden Medical Center, Elmira, NY• St. Elizabeth’s, Utica, NY• Brockton Neighborhood Health Center,
Brockton, MA
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Model of Hotspotters team activities – test new process
Patients on HAART with HIV viroload over 100 Patients not seen in 6 months
CM follows up with CBOCM follows up with the patient
□ Schedule medical appointment with the provider □ Schedule case management review with CM (if needed, to follow up on patient’s issues)
Review most recent clinic and adherence data for the client Identify individual retention problems
Contact the patient with lab results (NP)
□ Schedule f/u bloodwork□ Schedule visit with NP to discuss
the lab results□ Schedule appointment with
Treatment Adherence Counselor
Collection of Data by QI Coordinator(based on Excell spreadsheets, eMD and AIRS reporting)
□ Review outcome of interventions at the end of the month.□ Update viroload information and follow up on scheduled appointments□ Review client’s chart in eMD for possible coordination of care needs.
Meeting of the Team (second Friday of the month), review of the data
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Treatment Adherence for people with VL
Self-AssessmentDo they know which meds to take, how many, and
when?
Review Missed DosesAre they missing doses of their medication?
Medication Education
Provide medication and treatment education.
Identify BarriersFigure out how many doses missing and why?
Review Medication GuidelinesAre they taking it appropriately (i.e., with food,
without splitting, with other meds)?
Develop Care PlanSet client-focused goals to overcome adherence
barriers (if client is agreeable).
Resistance TestingDetermine if resistance has occurred and if a med
change needs to happen.
Reassess for ReadinessDetermine if client is ready to take medications
(confidence and importance).
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Overall Findings• Start of the project – November 2011
- 60 clients on the list
- 25% no-shows
- 75% VL over 100
- 23% female/77% male
• Current data - March 2012- 54 clients- 13% no-shows- 13% new clients- 73% VL over 100- 26% female/74%male
• 22 patient from November list remain on it in March
• 18%(4) no-shows/82%(18) VL over 100
• 32% female/68% male (note: higher number of women remaining on list for longer time)
• All of the clients remaining on the list were outreached to schedule an appointment, repeat VL, run a resistance test and/or see Treatment Adherence Counselor.
• Patients with VL over 100: 61%(11) VL down, 28% (5) VL up, 2 – no change
• 2 clients restarted medications recently
• 5 clients with severe mental health problems – 4 enrolled in MH care
• 1 client refusing care, 1 about to be closed (MIA).
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Team: Task/Next Steps to complete Step 3. Investigate the Process
• Draw a process diagram of your current process.• Use flip chart paper, 8 ½ x 11” paper for each step• Tape to a wall for others to see • Could make it participatory by discussing with others to get
their input• Circle key problem steps.• Write causes of the problems next to each
problem step.• Discuss and select interventions that can address
the key causes.• Share with other members of team/clinic for
feedback.
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Step 4: PDSA
• What changes address key causes?• Develop a plan.• Try it out.• Measure. Did the change make a difference?• Why? Or why not?• Is there a need for another change?
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PDSA Examples
• HIV Patient Alert System (Arnot Ogden, St. Elizabeth’s)
• Self management goal setting form (in conjunction with individualized care plans)
• New Patient visit form (BHNC)• Teach back tool for understanding importance
of taking medication (BMHC, St. Elizabeth’s)
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HIV Patient Alert System with TeamIn combination with pt goal setting and individualized care plans
Red Yellow Green
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Lawndale Christian Health Center - Sonji
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36 HIVQUAL-US Funded by HRSAHIV/AIDS BureauHIVQUAL-US
Take Your HIV Medicine On Time and Every Day
Educator name:
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CD4-T
The CD4 T cells in your body are your friends.
They are like a factory, making things that protect you from infection.
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HIV
CD4-T
But HIV is a clever virus.
It hijacks your good CD4 T cells, and turns them into an HIV factory.
Then you get a lot of HIV (a big Viral Load).38
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Your HIV medicines stop that HIV factory!
When you swallow HIV pills, they go from your mouth to your stomach, then into your blood to defend your CD4-T cells.
HIV HIV Medicine
CD4-T
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If you take your medicine ON TIME and EVERY DAY, you keep enough medicine in your blood to defend you, and you will usually feel better.
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Additional PDSAs
Wright Primary Care Center• Improved review lists (measured by comparing
list of weekly scheduled appointments)• Scheduling appointments for patients by the
nurse and NP and given a cardDelta Regional Medical Center• Involve District Social Worker after the first
letter is sent
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Team Management Tools
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Lancaster General Hospital. Comprehensive Care Center.