Using Data to Proactively Organize the day, Eliminate Future Work and Drive Improvement

Kirsten Meisinger, MD

The presenters have

nothing to disclose.

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After this session, participants will be able to:

Plan a local approach to implementing a Quality

Improvement infrastructure

Understand the importance of empanelment

Understand how to start and use registries with

teams

Plan a sustainable daily huddle with team based

pre-visit work

Objectives

Areas to Organize

Data

Patients

Providers and Staff

– Teams (outreach)

– Day of the visit (in-reach)

– Culture Change

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OK, Data Usually Bores People, Right?

Even doctors, who SAY they like data, fall asleep more often in data meetings than any other kind of meeting (P<.0000000001)

Things We do with Data at Union

Square

Baby showersCollect clothes for patients in needForms workflow (we kept losing them!)Diabetes perfect careDepression screening

(You get the idea)

Use the Right Chart for the Right Purpose

� Run Charts and Statistical Process Control � Often best for QI Projects

� Bar and Column Charts � Categorical Data During A Single Period

� Comparison Of The Actual Versus The Reference

Amount

� Bars For Long Labels

� Pie Charts

� Scatter Plots

� Radar Chart/Spider Graph

Different Kinds of Visuals

Avoid These Common Visualization Mistakes

� Wrong Visualization for the

Data (wrong tool)

� LABELS!

� Missing

� Unclear

� Misleading

� Numbers Don’t Add Up

� Axis

� Crop/Scale

� Reverse

� Not in order

� Too much data

� Correlation and Causation

� Impossible Comparisons

� Missing Annotations

Watch Out for These:

Measure Q1 Q2 Q3 Q4 Q1 Q2

A1c Control 75 76 77 90 91 93

LDL Control 70 80 90 80 85 83

BP Control 78 81 85 87 92 96

70

75

80

85

90

95

100

Q4 2015 Q2 Q3 Q4 Q1 Q2

A1cControl

LDLControl

0

20

40

60

80

100

120

Q1 Q2 Q3 Q4 Q1 Q2

A1cControl

LDLControl

0

20

40

60

80

100

Q1 Q2 Q3 Q4 Q1 Q2

A1c

LDL

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Measure Q4 2015National 90th%

A1c Control 75 78

LDL Control 90 89

BP Control 95 85

Eye Exam 35 65

Nephropathy 68 78

0

20

40

60

80

100A1c Control

LDL Control

BP ControlEye Exam

Nephropathy

Diabetes Composite Performance Relative to National 90th% Cohort 1

Q4 2015 National 90th%

What do You Think About This?

Pulling It All Together:

Interpret and Communicate Your Results

o Begin with the End in Mind

o Understand and Acknowledge Data Limitations

o Keep Your Analysis as Simple as Possible, but Not

Simpler

o “Not me!”

o Most Importantly – a good tool creates HAPPINESS

In Short

Organizing Your Patients

How many patients in your practice?

How do you organize who needs to come in and when?

Are you doing this now? – Or do patients just show up and get care?

Are you HAPPY in your current state of Population Health?

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How Can We Improve the Health of our

Population of 120,000 Patients?

One panel at a time.

PanelPanel Panel

Panel Panel

Panel

Panel

Panel

Empanelment

Panels are groups of patients small enough that

a single team can work on them and not get

terminally depressed by never seeing any

change

Seriously – it’s that simple

How do we do it?

– PCP (since that is who the patient has to identify in

the US)

Then build the team around that…

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Registries

A registry is a list of patients that you want to

impact with outreach, or care that occurs when

the patient is NOT in your office

It is a list – it can be fancy, but it is still just a list

Examples of registries we have used:

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Reporting Workbench in EPIC (outreach)Example: Diabetes Registry

The Power of Data

Earthquake in Nepal

– Able to identify and outreach all our families

using the registry

– Everyone was OK thankfully, only one family had

an extended family member perish

Individual-Care to

Population-Based Care

Instead of: “what can I do to maximize the

care of the 30 patients on my schedule

today?”

Monday Patients

8:00AM Ms. Ngo

8:15AM Mr. Sven

8:30AM Ms. Reilly

8:45AM Mr. Padilla

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The future: “what can we do

today to maximize the care

of the 2500 patients in our

panel?”

Organize Yourselves!

Make Meetings for Teams!

• Meeting Objective: provide care at a panel level

• Meetings are meant to review a list of patients, not 1-2 patients

• Coordinated development of action plans by care teams for targeted patient

cohorts; some actions include:

– Remind a team member to schedule a patient visit with a nurse,

pharmacist, social worker etc.

– Perform a change in medications

– Update preventive care list, problem list, etc.

– Perform a referral (Specialty, community resources, etc.)

• Meetings occur weekly and last 30 minutes

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Week 1 Week 2 Week 3 Week 4

Cancer Screening & Follow

Up

Diabetes & Hypertension Depression Complex Care

Sample Meeting Workflow: Diabetes

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At Meeting After MeetingBefore Meeting

• MAs review patients

who need tests or

screenings

• RNs review patients not

at goal

• Providers review

patients not at goal and

who require care plans

• Care team meets to

review patient list

• Team agrees on patients

who require outreach for

tests, A1c follow ups, or

care plans

• Charts and registry

updated as needed

• Team reviews quality

dashboard

• Teams do what was

agreed on during the

meeting

o Schedule a visit

o Phone encounter to

update a care plan

o Change medications

o Process referrals

• Coordinator monitors

and supports team

A Dashboard

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Sharing the Work

ALL staff at the site have a panel of patients they

are responsible for

This shares the care, allows for accountability

and keeps a patient centered focus for everyone

I highly recommend this!

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How Does this Align with Daily Work?

Pre-visit work and huddles (in-reach)

Organize the work of the day– Best practice: have the team review the chart ahead of the visit

– Meet briefly the day of the visit to review and communicate the plan

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Date

MA: (prevention list)

LPN: (immunizations)

RN: (chronic disease patients)

Provider: (provider specific tasks)

Timestamp (date and who started the list)

Workflow and Staff Meetings

• Workflow & Staff meetings allow for different care teams to learn from one another

• These are NOT the same kind of meeting as team meetings

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Staff MeetingsWorkflow Meetings

• Develop and pilot clinic

specific workflows to pursue

specific quality metrics

• Provide pilot feedback to site

leadership

• Enable standardization of

workflows that have been

piloted successfully

• Review sites overall Quality

Performance

• Highlight teams that have

perform exceptionally well

• Discuss ways to leverage

tactics across all other care

teams

The Population Health Strategy55

Dept. PI Projects

Outreach Reports

Bringing it Back Around…

Culture change

How does this new work become “the norm”?

– Hard work for leadership

– Pilot teams

– Celebrate successes

– Make it all about the patients

Teams mean less hierarchy

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Questions?57