nca tbc session 3 dec 14 2016

We will begin shortly…

Welcome

1

Using Zoom

Turn your webcam on!

Please remember to mute yourself during the presentations.

If you have a question, you may un-mute yourself and ask after each presentation, OR use the Q&A button

Advanced Team Based Care (TBC) Learning Collaborative

Welcome to Session 3December 14, 2016

3:00 - 4:30 EST

Developing core and extended team capabilities for implementing an advanced team based care model.

Introductions

TBC Collaborative Design, Facilitation, Faculty Ann Marie R Hess ANP, MS

National Cooperative Agreement Anna Rogers, Director Reema Mistry, Program Coordinator

Mentors , Coaching Faculty Deborah Ward, RN (1:8) Kasey Harding (1:8)

Evaluation Faculty Kathleen Thies, PhD, RN

Improvement Science Faculty Patti Feeney Mark Splaine, MD

Objectives Session 3

Summarize Action Period 2 Milestones (6 weeks) Learn how to use data for improvement Learn from team Specific Aims and PDSAs

→Healthcare for the Homeless→Carolina Family Health Center→The Children's Clinic

Provide path forward and resources for Action Period 3

Session 2 Feedback

88%-100% Visuals supported TBC content Session met learning needs Can apply information to our practice Learned a moderate to great amount Teaching methods were effective

Improvementso Provide more examples of PDSA cycles and fishbone diagramso Send agenda and next assignments ahead of timeo Provide more examples of what it means to create a team environmento We would like more statistics about what works and what does not worko At the time of day for us, people tired even though sessions very educational

16 Teams : most teams adjusted core and extended

93 participating Core and Extended Team Members Interact daily/weekly with patients and families Roles: MD, NP, LPN, BH, Care Coordinator, CNA, FNP, Care Manager, MA, NP,

Front Desk, RN, LVN, Radiology Tech, LCSW, PNP, Interpreter, Case Manager, Dental Coordinator, Pharmacist, Call Center Rep, Outreach Specialist, MSW

POD structure with multiple providers and dedicated MAs (4)

Other Leadership and Management : CQO, Quality Coord, Dir of Ops, Site Manager, HR Dir, Data Analyst, Ops Specialist, Clinical Support Services Manager, Compliance, COO, CMO, EMR Manager, Clinical Manager, IT, Patient Financial Coord, Dir Patient Services, BH Manager, Medical Director, Chief Clinical Officer, CMO, Referral Manager

Advanced TBD Learning Collaborative

Agenda (3:00-4:30)

3:00 5 min Welcome and IntroductionsPutting it All Together : Improvement Ramp

3:05 10 min Action Period 2 Milestones and Challenges

3:15 35 min Using Data for Improvement

3:50 30 min TBC Improvement Work -Healthcare for the Homeless Team-Carolina Family Health Center Team-The Children’s Clinic

4:20 10 min Path Forward and Resources [ Introduce Progress Check List]Action Period 3 Assignments

Improvement Science Theory Bursts (10 min)Developing Capacity for Implementing Advanced TBC Model

Session 1 : Sept 21st o Running effective team meetings using toolso Developing and using a cause and effect diagram to inform PDSAso Writing a global and specific aim statement

Session 2 : Nov 2nd

o Developing a process map or current state workflow o Applying PDSA methodology for improvement

Session 3 : Dec 14o Using data for improvement (run charts, bar graphs, sampling)

Session 4 : Jan 25o Standardizing (SDSAs) and Reliability Science

Session 5 : March 15o Spreading Change

Session 6 : April 26o Gantt Charting : 3-6 month Core Team improvement plan

Define Core and Extended Team

Achieve multiple TBC specific aims

Standardize (SDSAs) roles and key processes (Playbook, Spread Plan)

Improve team and coach skills (improvement science, team work, coaching)

Move Practice Assessment Data toward Level A

Develop a post collaborative team action plan

TBC Learning Collaborative

90 minLearningSessions

Between Session Action Periods (6 weeks)Complete AssignmentsWeekly Team Meetings , Daily HuddlesMonthly ReportingShare Your Work – TBC Website (Moodle)

Developing Effective Meeting and Improvement SkillsImplementing Team Based Care – Small Tests of ChangeLearning from Each Other

Action Period 3

Core and Extended Team Refinements – challenges

TBC Webinars

Effective Meetings and Daily Huddles

Readiness Survey

Role Activity and Cycle Time Data - deeper

Global, Specific Aims

Fishbone : Defining Problem and PDSAs

Process Mapping : Workflow and Roles

Brainstorming and Benchmarking

PDSAs

SDSAs

Between Session Mentoring and Faculty SupportMoodle Resources and Discussion Board

7

Sept 21 Dec 14 Jan 25 Mar 15 Apr 26 June 14Nov 2

Mentors HelpingWeekly Coach : Mentor Group Meetings, Individual as Needed

Teaching skills, reviewing tools (more skill building needed from theory bursts, struggling with tools)

Addressing Online Learning Network Site (Moodle) challenges

Advising difficulties getting meetings off the ground (no time to meet), using roles (resistance)

Clarifying assignments, how to use assessment tools

Providing advice for managing : ‘turmoil’, ‘overwhelming assignments’, ‘team and leadership engagement issues’ , ‘team vs coach ownership’, ‘worried management will roadblock us’

Reminding : Start Where you Are, Use What you Have, Do What you Can….

Weekly Meetings : Action Period 3*no meeting tomorrow 3pm

Rate the Meetings On average 8-9 (scale of 1 -10) .

Most helpful:

hearing report outs from other teams and progress they are making,reinforcing and learning new skills to help our teams, learning from how others are overcoming challenges, staying on track with assignments and getting help with how to completegetting help with how to use data

Action Period 2

Milestones More than half the teams have been: Refining their core and extended team structures Defining roles and communication – both within

core team, and between core and extended team

Challenges:• Keeping same staff in Core Team or a POD• Staff pulled for coverage other shifts or sites• Significant turnover (Providers, MAs, RNs)• RNs more attracted to extended team role• Other team members who cover us do not know

what we are doing…

Action Period 2 : Give Teams Time to Meet (webinar 1)Challenges: Time to meet. Getting time when ‘necessary people’ can get there. Team members not engaged Turnover – significant. Staff pulled for coverage other sites, departments Provider not willing to delegate, when ultimately responsible if does not get done Leadership support (e.g.’buy in’ to the process, communication about the work)

10 Teams (overcoming challenges) working hard at sustaining 3 meetings/month, some 4-5/ month), 45-60 min finding a good time to meet after trials of different times learning who is required to attend – those needed to do the work, invite others when needed meeting even if a few people (discipline and rhythm), start on time and do not wait for people getting leadership support for protected time sending meeting reminders (e.g. text 15 min ahead of meeting) engaging team members

o using fishbone and process mapping (‘have stake in it’)o rotating roles, assigning timekeeper for easy roleo posting work on the wall for input between meetings

6 Teams : meeting 2 or fewer times/month, working on unique challenges, different pace

Assignments : Improvement Ramp for Implementing TBC

Define Team Stru

cture, M

eeting

1

Action Period 6

4-5

2-3

SPECIFIC AIMS AND PDSAs

Aim: Reduce waiting room time from 25 min to 14 min By Dec 30

Weekly Data 5 Patients To Date: 19 min from 25 min Adding observation by Coach: MA Rooming

PDSAs : Redesign and standardize MA Rooming Process – more time with MA (value added)

Team Engagement

Peach Tree Healthcare

Action Period 2Example : Data, Mapping, Aims, PDSAs

Early Stages of Change MA Role, RN Just Getting Started (Use Your Data)

Peach Tree Healthcare

Holyoke Health Center

MA Role

RN Role

Insights 8 hours of Tracking Significant Duplication of Efforts Double Documentation (paper, EHR) No Standards and Protocols for activities

‘Insufficient’ RN Care Management and Coordination time – 16 min

Challenging Questions

What is ideal time for advanced activity? All roles at once? How do you narrow down roles and

activity to work on?

Healthcare for Homeless

Role Activity Challenges (Action Period 3)

Common Challenges

Provider Completion of Role Activity More differences than we anticipated

between what we are ‘currently doing’ and what we identified as ‘ideal’

Fears about giving things up, adding new

Lack of role delineation between LPN and RN – and Provider duplication

Variation between same roles (2-3 MAs) So many inefficiencies to tackle

Some Opportunities

Shadowing provider half day - activity tracking. Shorter periods over days.

Activity analyses helping improve job descriptions, role delineation, optimization

Transparency of work opportunity to ask – We are doing ‘what’? We are putting it ‘where’? Why are we doing ‘that’?

Eliminating duplication of documentation Reducing interruptions by optimizing EHR

messaging, workflows

Using Fishbone Long Cycle Timeto Identify Aims and PDSAs (Action Period 3)

Key Drivers Pre Registered vs Not On site lab delays Early and late arrivals (team on time?)

AIM : Increase Percentage of Patients that are Pre Registered from 26% to 29% by Dec 31st

Team Engagement

High Leverage PDSAs(Action Period 3)

Efficiency, Role Optimization

AM , PM Start Times Rooming Standards Daily Huddles (6 Teams) Pre Visit Planning

Sumter Family Health Center

PDSA Discipline (Action Period 3)

Increase Complexity of Change- Start Small Test, days –weeks- Small Wins- Each PDSA can have a measure

Increase number of patients- Have standards and protocols- Have standard workflows- Hard to implement

Get it right , Fewer Patients- before scaling up to a defined population

Daughters of Charity

October 20160

10

20

30

40

50

60

70

80

90

80

Total Cycle Time - Check In to Check Out

Use Your Data (Cycle Time) Track Over Time (Action Period 3)(5 / week, 15/ month)

How long do we track it? Achieving results you wanted, sustaining results due to standardization and process reliability, new habits in daily work

Check In Time

Waiting Room Time

Support Staff Time

Exam Room Wait

Time

Time with Provider

Check out Time

0

5

10

15

20

25

30

Break Down of Cycle TimeSpecific Aims

Goal: 30 min for 20 min appt type

Using Data for Improvement (Action Period 3)

Gathering an

d Using Data

Skills

Using Eff

ective

Mee

ting Skills

Implemen

ting Daily Huddles

Using Im

provement S

kills

Applying Tea

mwork Skills

020406080

10066

86 76 6891

Team Skills Self-Assessment Summary (N=68)Percentage Strongly Agree or Agree are Competent

% S

tron

gly

Agre

e or

Agr

ee

October 2016

Using Data for Improvement

Mark Splaine, MD3:15 – 3:50

Session on Data & Samplingfor the Team-Based Care Collaborative

Mark E. Splaine, MD, MS

December 14, 2016

Displaying Data & Sampling• Three theory bursts

– Displaying data over time (5 minutes)– Types of variation (5 minutes)– Overview of run charts (5 minutes)

• Application exercise– Interpreting a run chart example (10 minutes)

• Sampling for improvement work (5 mins)• Questions and discussion (5 mins)

31


Check In Time Waiting Room Time

Support Staff Time

Exam Room Wait Time

Time with Provider

Check out Time0

5

10

15

20

25

30

Series1

Time 1 October 26, 2016 33

total time in office

check in time waiting room time

time with the nurse

exam room wait time

time with provider

check out time

0

20

40

60

80

100

120

140

160

180

Mean Minimum Maximum

Cycle Time: Johnson City CHC

Holyoke

MA Role Activity Tracking RN Role Activity Tracking

Diabetics & Flu Shots

35

2012 201346.2

46.4

46.6

46.8

47.0

47.2

47.4

47.6

Year

% R

ecei

ving

Vac

cine

Jan-Mar Apr-Jun Jul-Sep Oct-Dec20253035404550556065

20122013

Quarter

% R

ecei

ving

Vac

cine

Jan-1

2

Mar-12

May-12

Jul-1

2

Sep-12

Nov-12

Jan-1

3

Mar-13

May-13

Jul-1

3

Sep-13

Nov-13

20253035404550556065

Month

% R

ecei

ving

Vac

cine

2012 201320253035404550556065

Year

% R

ecei

ving

Vac

cine

Diabetes MonitoringB

lood

Sug

ar

Days 1-15

36

Days 1-15 Days 16-310

20

40

60

80

100

120

140

160

180

200

> 140< or = 140

> 140< or = 140

Days 16-31Intervention to change diet began on Day 16

Proportion of High

Readings

Time Plot• A graph of data in time order

• Often kept to identify if and when problems appear (proactive)

• Also used to see trends over time (reflection)

• Especially helpful when you implement a change to follow the result

37

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

6080

100120140160180200 Diabetes Stratified Time Plot

Days

Blo

od S

ugar

(mg/

dl)

Morning ReadingsBefore Bed Readings

38

Goal


October 20160

10

20

30

40

50

60

70

80

90



Two Types of Variation

• Random (common cause) variation

• Non-random (special cause) variation

40

Random Variation• Typically due to a large number of small

sources of variation – Example: Variation in arrival time of a patient

might include: weather, vehicle problems, parking issues

• Usually requires a deep understanding of the process to change

41

Non-Random Variation• Are not part of the process all the time.

Arise from special circumstances – Example: Patients arrive late for appointments

due to a bus strike

• Usually best uncovered when monitoring data in real time (or close to that)

42

How to React to VariationActionProcess result

Process with only random variation

Not satisfied with result: redesign process to get a better result

Reduce variation: make the process even more predictable or reliable

Process with non-random variation

Identify the cause: If positive, then can it be replicated or standardized.

If negative, then cause needs to be eliminated

Target the special causes - to get the process predictable

43

Run ChartsDetecting non-random (special cause) variation

44

45

Anatomy of a Run Chart

Variable “y”

Time

Center line is MEDIAN

Run Chart Example

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

6080

100120140160180200

Days

Fast

ing

Blo

od S

ugar

(mg/

dl)

Median

46

Non-Random Patternson Run Charts

• The presence of a shift in the process– A “run” is one or more consecutive points on the same

side of the median– A run that is too long (6 or more consecutive points on

one side of the median)• The presence of a trend

– A run with consecutive increases or decreases in data (5 or more consecutive points)

• The presence of too much or too little variability – Too few or too many runs (depends on number of

points on the chart)

47Perla, Provost, and Murray. BMJ Qual Saf. 2011;20:46-51

Source: Perla, Provost, and Murray. BMJ Qual Saf. 2011;20:46-5148

Table. Runs Rule Guidance

Number of observations excluding points on the median

Lower limit for the number of runs

Upper limit for the number of runs

13 4 1114 4 1215 5 1216 5 1317 5 1318 6 1419 6 1520 6 1621 7 1622 7 1723 7 1724 8 1825 8 1826 9 1927 10 1928 10 2029 10 2030 11 2131 11 22

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

6080

100120140160180200

A Run is a point or group of consecutive points that fall on one side of the median

Days

How to Count Runs

49

Fast

ing

Blo

od S

ugar

(mg/

dl)

Questions1. What does the blue line on the graph

represent?2. How many runs are there?3. How many shifts do you see?4. How many trends are in the data?5. How many non-random patterns (special cause

signals) are met in this run chart?6. What is your interpretation of the chart?

50

Discussion of Answers to QuestionsWhat did you decide?

51

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

6080

100120140160180200

Q1. What does the blue line represent?

Days

Run charts use the Median as the central tendency measure

The Median

52

Fast

ing

Blo

od S

ugar

(mg/

dl)

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

6080

100120140160180200 There are 14 Runs

Days

Q2. How many runs are there?

53

Fast

ing

Blo

od S

ugar

(mg/

dl)

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

6080

100120140160180200

There is ONE Shift

Days

Q3. How many shifts do you see?

54

Fast

ing

Blo

od S

ugar

(mg/

dl)

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

6080

100120140160180200

There are NO Trends

Days

Q4. How many trends are in the data?

55

Fast

ing

Blo

od S

ugar

(mg/

dl)

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

6080

100120140160180200

Runs = 14 Shifts = 1 Trends = 0

There is ONE Signal

Days

Non-random pattern (Shift)

Q5. How many non-random patterns?

56

Fast

ing

Blo

od S

ugar

(mg/

dl)

1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627282930316080

100120140160180200

• There is non-random (special cause) variation present. One would need to investigate why this occurred. Since the cause is in the wrong direction, one would ideally like to eliminate this cause from the system.

• Note: upon talking to the patient, the special cause was related to him eating dessert every night while on vacation. Some education about diet could then eliminate the cause.

Days

Non-random pattern (Shift)

Q6. What is your interpretation of the chart?

57

Fast

ing

Blo

od S

ugar

(mg/

dl)

Thoughts on SamplingFramed for Improvement Work

58

Two Type of SamplingRandom (Probability)

Samples

• Think of a pond or lake• Water stays in place

Judgment Samples

• Think of a stream or river• Water constantly moving

59

Improvement Work• Benefits from judgment sampling• What is judgment sampling?

– A nonprobability sample that is selected on the basis of knowledge of the process or a subject matter expert

• Is there a trade-off to using judgment sampling?– “We trade the ability to quantify the precision of estimation

and control the bias of selection of a defined population for learning about variation in the fragments of experience we are most interested in learning about – most often with an eye toward efficiency and getting ‘just enough’ data to guide our learning and subsequent testing”

60

Some Examples

61

Example Situation Probability Sample Judgment Sample

5

Nurse leader wants to test impact of new pressure ulcer bundle

• Obtain list of all units• Randomly select 50%• Assess all patients on

selected units before and once after intervention

• Sample 5 patients each week who are at highest risk on the unit with the highest risk patients

• Track data over time

6

Oncology manager wants to know whether patients get proper education after flowsheet initiation

• Simple random sample of all patients in last 3 months

• Charts reviewed by manager

• Select the most recent patients

• Perform chart review

Summary• Variation over time is intrinsic to all health care &

other work processes.• Displaying data over time can help visualize the

variation present.• Understanding that variation can help monitor,

adjust and improve processes.• Studying variation with run charts can offer insights

about possible cause of that variation and offer clues to the design of change.

62

What haven’t we figured out yet?

Questions or issues that remain unclear?

63

References• Perla RJ, Provost LP, and Murray SK. The run chart: a simple

analytical tool for learning from variation in healthcare processes. BMJ Qual Saf. 2011;20:46-51.

• Perla RJ and Provost LP. Judgment sampling: a healthcare improvement perspective. Qual Manage Health Care. 2012;21(3):169-175.

• George ML, Rowlands D, Price M, and Maxley J. The Lean Six Sigma Pocket Toolbook. New York, NY: McGraw-Hill, 2005. Chapters 6 and 7, pp 104-118.

Agenda (3:00-4:30)





4:20 10 min Path Forward and Resources [ Introduce Progress Check List]Action Period 3 Assignments

Healthcare For The Homeless

Specific Aim and PDSAsReferral Process : RN Role

Optimization Extended Team

Manages Referrals to specialists and community resources, ensuring relevant clinical information is provided

B C

Referral Process Redesign

http://online.ideasontario.ca/wp-content/uploads/2015/10/Slide1.png

Carolina Family Health Centers

Specific Aim : Cycle Time Pre Visit Planning Daily Huddles

Total

Cycle T

ime -

Check In

to Check

Out

Check In

Time

Waiting R

oom Time

Support

Staff Ti

me

Exam Room W

ait Tim

e

Time w

ith Pro

vider

Time a

t Lab

Time a

t Refe

rrals

Check out T

ime

0102030405060708090

Oct-16

Oct-16

Cycle Time : Average 78 minutes

Fishbone

Process Map

The Children’s Clinic

Daily Huddles

Huddles• What time of day, and how long are your huddles?• What is the focus of your huddles?• Are you using a tool?• How are you including your Care Coordinator?• How are you thinking about including your Patient

Service Representative?

Agenda (3:00-4:30)





4:20 10 min Path Forward and Resources [ Introduce Progress Check List]

Action Period 3 Assignments

Improvement Ramp for Implementing TBC

1

Action Period 6

4-5

2-3


1. Meet weekly as a Core Team Problem solve ‘time to meet’ Practice effective meeting skills using tools, with coaching support Define core and extended care team (members and roles)

2. Implement Daily Huddles Work on improving (PDSAs) and standardizing (SDSAs) Align Huddle intervention with a specific aim (e.g. reduce cycle time, increase screening)

3. Write specific aim(s) statements , using data and knowledge of problem Continue Assessments (role activity, cycle time, other) Complete Fishbone diagrams and process mapping


4. Implement PDSAs (small, measurable, rapid) Share your work by uploading TBC website, discussion board Use brainstorming and benchmarking to inform changes

5. Complete readiness survey ( 50 % ), data will be posted on TBD WebsitePurpose : To assess whether an organization is ready and committed to the

implementation of a specific change, from the perspective of care team members.

Still time to complete Team Skills Assessment survey (50%)

6. Post Monthly Reports : Next Due January 10th , 2017

7. Watch Webinars (1-4)

8. Introduce Coaches to Progress Check List for tracking implementation, leadership reporting

Progress Check List

Improvingprimarycare.org

Discussion Board Ask questions or make requests of teams, faculty….

Resources

Improvingprimarycare.orgTBC Website (Moodle)

Thank You All

Survey Post Session

Thank you for your participation today and feedback : Session Evaluation