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NCA - TBC - Session 1 Slides

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The Community Health Center, Inc. and its Weitzman Institute will provide education, information, and training to interested health centers in Transforming Teams and Training the Next Generation. They offer national webinars and learning collaboratives focused on advancing team-based care, post-graduate residency programs, and health professions students in Federally Qualified Health Centers. The Community Health Center has a long history, serving over 145,000 patients across 203 sites through integrated clinical care, research, and training programs.

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1

We will begin shortly… Welcome 1

2

Using Zoom Join a ZOOM meeting or webinar from your computer, iPhone or iPad Use the Q&A button to send us your questions!

3

Zoom At this time- Please use the CHAT button to tell us the name of your Health Center and how many people have joined the meeting.

4

4 Community Health Center, Inc. Foundational Pillars 1. Clinical Excellence- fully Integrated teams, fully integrated EMR, PCMH Level 3 2. Research & Development- CHC’s Weitzman Institute is the home of formal research, quality improvement, and R&D 3. Training the Next Generation: Postgraduate training programs for nurse practitioners and postdoctoral clinical psychologists as well as training for all health professions students CHC Profile: •Founding Year - 1972 •203 delivery sites •145k patients

5

The Community Health Center, Inc. and its Weitzman Institute will provide education, information, and training to interested health centers in Transforming Teams and Training the Next Generation • National Webinars on advancing team based care, implementing post- graduate residency programs, and health professions students in FQHCs. • Invited participation in Learning Collaboratives to advance team based care or implement a post-graduate residency program at your health center. CHC’s NCA on Clinical Workforce Development The National Training and Technical Assistance Cooperative Agreements (NCAs) provide free training and technical assistance that is data driven, cutting edge and focused on quality and operational improvement to support health centers and look-alikes.

6

National Webinar Series -2892 viewers attended the webinar series -Most attended webinar: Enhancing the Role of the Medical Assistant -(March 3, 2016) 373 attendees - Videos: Viewed a total of 1,102 times - Slides: Viewed a total of 6,746 times - Representation from all 50 states, US Virgin Islands, Puerto Rico and Canada.

7

The LC Teams

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147,769 1,708 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 TotalPatients Participating FQHCs Total Patients UDS 2015 Health Center Data Team-Based Care Residency Both Demographic and Population Profile Collectively, we serve over 607,884 patients

9

Demographic and Population Profile 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 %ofTotalPatients Participating FQHCs Age UDS 2015 Health Center Data Older Adults (age 65 and over) Adult (18 - 64) Children (< 18 years old)

10

Patient Characteristics Uninsured 18% Medicaid/ CHIP 57% Medicare 9% Other Third Party 16% Payor Data UDS 2015 Health Center Data

11

Almost all health centers offer Medical, Dental and Mental Health services. Staffing and Utilization: UDS Table 5 – We encourage you to look at your data!

12

Quality Improvement Education Patti Feeney Manager, Quality Improvement Education

13

Effective Meeting Skills Providing meeting and team structure for coaches I. AGENDA II. MEETING ROLES III. ACTION PLAN

14

NCA - TBC - Session 1 Slides

15

NCA - TBC - Session 1 Slides

16

NCA - TBC - Session 1 Slides

17

Define the Problem Fishbone Diagram; a useful cause & effect tool

18

Developing a Project Specific Aim

19

All tools referenced in today’s session and support material can be found by following theses links: NCA Team-Based Care Learning Collaborative NCA Post-Graduate Residency Learning Collaborative Tools and Resources >> Quality Improvement

20

We will begin shortly… Welcome 20

21

Team Based Care (TBC) Learning Collaborative Session One September 21, 2016 3:35 - 4:30 EST

22

Introductions TBC Collaborative Design, Facilitation, Faculty  Ann Marie R Hess NP, MS National Cooperative Agreement  Anna Rogers, Director  Reema Mistry, Project Assistant Mentors , Coaching Faculty  Deborah Ward, RN (1:8)  Kasey Harding (1:8) 3:35 Evaluation Faculty  Kathleen Thies, PhD, RN Improvement Science Faculty  Patti Feeney  Mark Splaine, MD

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Session 1 Objectives  Teach effective meeting skills, cause and effect diagramming, and writing specific aims to support team improvement work.  Provide an overview of the learning collaborative structure and expectations.  Help teams ‘get started’ redesigning roles.  Review Action Period 1 assignments for improving team based care.

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Learning Session 1 Agenda Team Based Care Participants 3:35 10 min Introductions 3:45 10 min Collaborative Goal, Structure and Expectations, Resources 3:55 15 min Getting Started Tools : Role Activity Assessment , Cycle Time 4:10 10 min Action Period 1 Assignments 4:20 10 min Brief Team Meeting Break Out

25

NCA - TBC - Session 1 Slides

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Interviews : General Impressions  Many asked for clarification of team and coach definitions  Lots of recent growth and change in many organizations  Many reported EHR challenges re: data, documentation, duplication, and getting actionable reports  Few have depth of experience with primary care redesign models and QI methods (e.g Wagner, Bodenheimer, Nuka Alaska, PCMH, IHI)  Most are familiar with term PDSA  Most not meeting weekly to focus on QI, ‘fit into’ day of back to back visits  All have been evolving their team based model of care over time, multiple starts, looking for “refresh”  Many working on PCMH certification, recertification  Few practices have experience with coaching model Introductions

27

Interviews : Goals and Expectations  Want structure, guidance, resources from the Collaborative: how-to’s vs concepts  Learn from others’ and their mistakes  Common Goals | Global Aims • better efficiency, improved workflows • staff working at top of license, includes standing orders and protocols • team role clarity and standardization (care management, documentation) • improve quality outcome measures (e.g. UDS outcomes) • improve patient and team satisfaction  Reduce stress and “put the joy back into practice, need “relief from the chaos”  We have a cohesive, good team but we “all work in our silos to get the work done” Introductions

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Introductions Name of FQHC Coach Team Carolina Family Health Centers , Inc. Chasity Godwin 1 MD, 1 NP, 2 LPN, 1 Care Coordinator, 1 Front Desk, 1 Interpreter, 1 CNA Community Health Initiatives Zlata Vainstein 1 Medical Director, 1 Physician, 2 MA, 1 Front Desk Daughters of Charity Grace Mena 1 Area Practice Manager, 1 MD, 3 FNP, 2 Care Coordinator, 4 MA Healthcare for the Homeless Carlie Brown Need new team Holyoke Health Center Megan T. Wechsler (Primary) 1 Director of Quality and Compliance, 1 Physician, 3 RN, 1 MA, 1 Front Desk Johnson City Community Health Center Flo Weierbach 1 front Desk, 1 PNP, 1 LCSW, 1 RN, 1 Interpreter Sumter Family Health Center Sandra Sturkie 1 Director of Patient Services, 1 Clinical Manager, 1 BH Clinical Manager, 1 BH RN, 1 Physician, 2 Case Managers, 1 MA, 1 Dental Services Coordinator, 1 Patient Financial Coordinator, 1 Clinical IT, 1 Pharmacist, 1 Call Center Rep, 1 Referrals Manager Syracuse Community Health Center, Inc. Cathy Brigden 1 Physician, 1 FNP, 1 LPN, 2 RN, 3 MA, 1 Office Manager Tyler Family Circle of Care Sherri Gould 1 CMO, 1 COO, 1 LVN, 1 OA, 1 PNP, 1 Process Improvement Manager

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Name of FQHC Coach Team Avenal Community Health Center John Kalfayan 1 BH, 1 Physician, 1 MA, 1 Medical Director, 1 Front Desk Educational Health Center of Wyoming Brenda Burnett 1 Provider, 2 RN, 1 Radiologic Technologist, 1 EMR Manager, 1 MA, 1 Clinical Manager El Rio Santa Cruz Josh Carzoli 1 MA, 1 RN, 1 BH, 1 Chief Clinical Officer, 1 LPN, 2 Physician, 1 Front Desk, 1 COO, 3 RN Clinic Manager, 1 IT Peach Tree Healthcare Ruben Ruiz 1 Chief Quality Officer, 1 Quality Coordinator, 1 Dir of Operations, 1 Site Manager, 1 Dir of HR, 1 NP, 3 MA, 1 Data Analyst, 1 Ops Specialist, 1 Clinical Support Services Manager Pecos Valley Medical Center L. David Young 2 RN, 1 NP, 1 MA The Children’s Clinic Karla Rodriguez 1 Provider, 1 MA, 1 Care Team Rep Via Care Community Health Center Kimberly McFerguson 1 FNP, 1 MA, 1 Outreach & Enrollment Specialist, 1 MSW, 1 Front Office Lead MA Introductions

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Team Skills Assessment Summary (N=51) Percentage Strongly Agree or Agree are Competent % Strongly Agree or Agree 60 60 65 85 65 0 10 20 30 40 50 60 70 80 90 100 Gathering and Using Data Skills Using Effective Meeting Skills Implementing Daily Huddles Applying Teamwork Skills Using Improvement Skills

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Coach Skills Assessment Summary (N=16) Percentage who rated themselves Competent, Proficient, or Expert 35 65 47 47 59 0 10 20 30 40 50 60 70 80 90 100 Data and Information Systems Meeting and Interpersonal Skills Improvement Skills Technical Skills (excel, webinar) Art of Coaching Skills %

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Level D: Just Getting Started Level C: Early Stages of Change Level B: Implemented Basic Changes Level A: Achieved Most or All of the Important Change Required Team Based Practice Assessment (LEAP)

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0 1 2 3 4 5 6 7 Level A Level B Level C Level D Self-Management Support Planned Care Care Management Medication Management Care Activities Assessment (N=11) Number of sites reporting level of performance implementing key processes Just getting started Early stages of change Implemented basic changes Achieved most or all of the important changes required

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0 1 2 3 4 5 6 7 Level A Level B Level C Level D Medical Assistant (MA) Registered Nurse (RN) Laypersons Pharmacist Role Activities Assessment (N=11) Number of sites reporting by level of performance by role Just getting started Early stages of change Implemented basic changes Achieved most or all of the important changes required

35

Transformational Team Based Care Improves Outcomes

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Learning Session 1 Agenda Team Based Care Participants 3:35 10 min Introductions 3:45 10 min Collaborative Goal, Structure and Expectations, Resources 3:55 15 min Getting Started Tools : Role Activity Assessment , Cycle Time 4:10 10 min Action Period 1 Assignments 4:20 10 min Brief Team Meeting (break out)

37

Goal The Team-Based Care Learning Collaborative is designed to provide transformational* strategies and mentored coaching support, to help a core team implement an advanced model of team- based care over 12 months. *Transformation can take up to 18-24 months 3:45

38

 Achieve multiple TBC specific aims  Standardize (SDSAs) roles and key processes (Playbook, Spread Plan)  Improve team and coach skills (improvement science, team work, coaching)  Develop a post collaborative team action plan How is the Collaborative Structured? 90 min Learning Sessions Between Session Action Periods (6 weeks) Complete Assignments Weekly Team Meetings (5-6), Daily Huddles Monthly Reporting Implementation Tools and Skills Change Concept Resources Learning From Each Other Team Based Care Webinars (8) Core Team Team Based Practice Assessment (LEAP) Coach and Team Skills Assessment Practice Outcomes Data (UDS, Other) Interviews Coach Prep Session Technology Session Between Session Mentoring and Faculty Support 7 Sept 21 Nov 2 Dec 14 Jan 25 Mar 15 Apr 26 June 14

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Improvement Science Theory Bursts (10 min) Developing Skills Session 1 : Sept 21st o Running effective team meetings using tools o Developing and using a cause and effect diagram to inform PDSAs o Writing a 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 14 o Using data for improvement (run charts, control charts) Session 4 : Jan 25 o Standardizing (SDSAs) and Reliability Science Session 5 : March 15 o Spreading Change Session 6 : April 26 o Gantt Charting : 3-6 month Core Team improvement plan

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Mentor and Coach Roles Coaches (posted role descriptions)  Help and support teams in learning new skills and achieving their aims  Help teams complete action period assignments, monthly reports, evaluation  Meet weekly with Mentor and other coaches, 1:1 as needed  Participate in 7 learning sessions  Support weekly team meetings, and between meeting assignments, session prep Mentors (posted role descriptions)  Provide support and resources for developing coaching skills  Facilitate weekly debriefs with Coaches  Provide individual support as needed

41

NCA Online Learning Network Find material for download, TBC webinars, and team folders for sharing your work... Improvingprimarycare.org Discussion Board Ask questions or make requests of teams, faculty….

42

Any Questions? Before “Getting Started”…. 3:55

43

Implementing Team Based Care (Webinar #1) Webinar 1

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Defining Structure and Staff Responsibilities Practice Managers and Leaders : must stay involved, engaged in your work

45

Start with Core Team, Then Expanded Team Current State Examples: 8 Participating Teams  1 MD, 1 NP, 2 LPN, 1 Care Coordinator, 1 Front Desk, 1 Interpreter, 1 CNA  1 MD, 2 MA, 1 Front Desk  1 PNP, 1 LCSW, 1 RN, 1 Interpreter, 1 front Desk,  1 MD, 3 FNP, 2 Care Coordinator, 4 MA  1 MD, 1 FNP, 1 LPN, 2 RN, 3 MA, 1 Office Manager  1 FNP, 1 MA, 1 Outreach Specialist, 1 MSW, 1 Front Office, Lead MA  1 BH, 1 MD, 1 MA, 1 Front Desk  1 Provider, 2 RN, 1 Radiologic Tech, 1 MA

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TBC Concept Resource (webinar #1 and #2) Principle  Patients want to receive their care from smaller teams (PODS) and know them personally Physical  Wall colors differentiate pods in practice , match business cards  Central open area surrounded by exam rooms  Co location of pod members, all carry laptops  3 exam rooms per provider – all care comes to patient  2 pods share procedure room - standardized TBC Structure  Break down large systems into PODS (care teams)  4 “Empaneled” Providers (3FTEs), 3 MAs dedicated to provider (dyad)  1 BH, 1 RN, 1 Case Coordinator (navigator, health coach), 1 front desk,  Patient empaneled both to a pod and to a Dyad  Flow Coordinator and Team Manager rotating roles (RN, MA)  Medical Records staff – input electronic data Roles and Responsibilities  Defining and Training, Standing Orders and Protocols Standardizing Workflows • Making ‘hundreds’ accessible to all Teams Need to Meet • Daily Huddles : 8am and 2pm • Weekly Meetings : Improvement Work, Population Health Management

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Poll Question Would you say that you have ‘significant’ work to do defining your “core” and “extended” team structure? Yes No

48

Role Activity Assessment Who Does What Now? 4:08

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Why analyze your team’s roles?  Have the right person doing the right thing at highest level of training and licensure  Eliminate duplication or unnecessary work  Reduce interruptions  Challenge assumptions about what staff are doing  Increase capacity to take on new activities  Develop specific aims for improvement

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Implementing Team Based Care (Webinar #1) Webinar 1

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Role Assessment of ‘the work’: Webinars 1-8

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Role Activity Assessment (customizable)

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Role Tracking Worksheet Consider Tracking Interruptions Role Activity Analysis Position: Tic Marks (each time activity done, may add AM, PM) Total Tic Marks Estimated Time per Activity in minutes Total Time Access and Communication Processes Activity 1. Schedules patients with a personal clinician for continuity of care ||||| ||||| ||||| 15 4 min 60 min 2. Coordinates visits with multiple clinicians and/or diagnostic tests and procedures 3. Triages how soon a patient needs to be seen including a process for after-hours care 4. Monitors access to appointment, backlog and wait time using telephone and email requests 5. Monitors and triages secure patient portal messages 6. Provides advice on clinical issues via telephone or portal messaging 7. Identifies and arranges for language services 8. Collects patient demographic and insurance information, including preferred method of communication 9. Helps patients activate their Personal Health Record by signing up during office visit 10. Identifies and refers patients who might benefit from care management support, other practice resources, community services Population Health Management Activity 1. Uses population registries and clinical quality reports to monitor a panel of patient’s health and risk status and close care gaps. 2. Communicates with many patients at once via bulk outreach letters and portal messaging (e.g. reminders for preventive care visits ,testing, screening gaps) 3. Provides outreach services to patients overdue for visit to follow up management of chronic

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SampleData.Hess.2009 Worksheet.clinicalmicrosystem.org IHI.org Poster 25% 75% RN Activity [planned care registry, triage level 2, nurse visits, self management support] Sampling of a Typical Day RN Role Ticks and Tally

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55 33% 67% Non-Physician Tasks Physician Tasks Non-Physician Tasks -immunizations -obtaining consults -obtaining MR -setting up room -filling out clerical fms -finding interpreter -bringing pt to room -data entry -finding information

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Webinar #1

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Receptionists Telephone Encounters: Significant # of calls were within 3 days after a visit Printing All AVSs (thought they had to) : 50% patients did not want paper, shred.

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Poll Question Have you ever participated in any type of analysis of what you do every day (tasks and functions)? YES NO

59

Using Cycle Time to Improve Efficiency and Office Flow

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15 Patients (1-2 weeks) Use Clipboard with Clock Select One Appointment Type Random Selection Patients AM and PM Target 1.5 X Appt Time 15 min Appt = 23 min cycle time 20 min Appt = 35 min cycle time 30 min Appt = 45 min cycle time 45 min Appt = 68 min cycle time SampleData.Hess.2009 Worksheet.clinicalmicrosystem.org Note: scheduled appoint time What if early arrival?

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Data Collection Worksheet

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Efficiency and Role Optimization 3 4 5 15 1 28 2 2 6 16 2 30 1 4 8 14 1 30 2 3 6 17 1 31 2 3 4 15 1 27 0 5 10 15 20 25 30 35 Waiting Room Time w/Clinical Staff Pre-Exam Waiting Active Exam Check Out Avg Length of Visit Minutes 12-Feb 20-May 20-Jun 15-Jul 26-Aug Family Practice : 9 min non value added time , active exam time and waste

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Hess.CPM.2010 Example: Assessment data (long cycle time) is analyzed using Fishbone Diagram Problems that have high leverage for improving results, inform your PDSAs (session 2). Top of the Ramp – Specific Aim Putting It Together for Action Period 1

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Action Period 1 Assignments 1. Meet weekly (50 min) as a Core Team  Practice effective meeting skills and use tools with coaching support 2. Continue Daily Huddles (5-10 min) | Starting is Optional 3. Complete and share the following by uploading to TBC website: - Within 4 weeks a) What is your global aim? – the broad objective you want to achieve in the longer run b) Role Activity Assessment (who does what now) c) Role Activity Tracking Data (1-3 days, all roles, coach inputs data)  Fishbone diagram with drivers of role problem(s)  Document any ‘quick hits’, insights  Write a specific aim for improvement using role data d) Cycle Time Assessment (15 )  Fishbone diagram with drivers of cycle time problem  Document any ‘quick hits’, insights  Write a specific aim for improvement using cycle time data 4. Upload monthly progress report to inform Session 2 Planning. 5. Upload all missing assessments.

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Monthly Reporting Tool

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Improvement Ramp

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Wrap Up and Questions Set Up Brief Team Meeting

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10 Minute Meeting

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Thank Your Colleagues

More Related Content

NCA - TBC - Session 1 Slides

  • 1. We will begin shortly… Welcome 1
  • 2. Using Zoom Join a ZOOM meeting or webinar from your computer, iPhone or iPad Use the Q&A button to send us your questions!
  • 3. Zoom At this time- Please use the CHAT button to tell us the name of your Health Center and how many people have joined the meeting.
  • 4. 4 Community Health Center, Inc. Foundational Pillars 1. Clinical Excellence- fully Integrated teams, fully integrated EMR, PCMH Level 3 2. Research & Development- CHC’s Weitzman Institute is the home of formal research, quality improvement, and R&D 3. Training the Next Generation: Postgraduate training programs for nurse practitioners and postdoctoral clinical psychologists as well as training for all health professions students CHC Profile: •Founding Year - 1972 •203 delivery sites •145k patients
  • 5. The Community Health Center, Inc. and its Weitzman Institute will provide education, information, and training to interested health centers in Transforming Teams and Training the Next Generation • National Webinars on advancing team based care, implementing post- graduate residency programs, and health professions students in FQHCs. • Invited participation in Learning Collaboratives to advance team based care or implement a post-graduate residency program at your health center. CHC’s NCA on Clinical Workforce Development The National Training and Technical Assistance Cooperative Agreements (NCAs) provide free training and technical assistance that is data driven, cutting edge and focused on quality and operational improvement to support health centers and look-alikes.
  • 6. National Webinar Series -2892 viewers attended the webinar series -Most attended webinar: Enhancing the Role of the Medical Assistant -(March 3, 2016) 373 attendees - Videos: Viewed a total of 1,102 times - Slides: Viewed a total of 6,746 times - Representation from all 50 states, US Virgin Islands, Puerto Rico and Canada.
  • 8. 147,769 1,708 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 TotalPatients Participating FQHCs Total Patients UDS 2015 Health Center Data Team-Based Care Residency Both Demographic and Population Profile Collectively, we serve over 607,884 patients
  • 9. Demographic and Population Profile 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 %ofTotalPatients Participating FQHCs Age UDS 2015 Health Center Data Older Adults (age 65 and over) Adult (18 - 64) Children (< 18 years old)
  • 11. Almost all health centers offer Medical, Dental and Mental Health services. Staffing and Utilization: UDS Table 5 – We encourage you to look at your data!
  • 12. Quality Improvement Education Patti Feeney Manager, Quality Improvement Education
  • 13. Effective Meeting Skills Providing meeting and team structure for coaches I. AGENDA II. MEETING ROLES III. ACTION PLAN
  • 17. Define the Problem Fishbone Diagram; a useful cause & effect tool
  • 18. Developing a Project Specific Aim
  • 19. All tools referenced in today’s session and support material can be found by following theses links: NCA Team-Based Care Learning Collaborative NCA Post-Graduate Residency Learning Collaborative Tools and Resources >> Quality Improvement
  • 20. We will begin shortly… Welcome 20
  • 21. Team Based Care (TBC) Learning Collaborative Session One September 21, 2016 3:35 - 4:30 EST
  • 22. Introductions TBC Collaborative Design, Facilitation, Faculty  Ann Marie R Hess NP, MS National Cooperative Agreement  Anna Rogers, Director  Reema Mistry, Project Assistant Mentors , Coaching Faculty  Deborah Ward, RN (1:8)  Kasey Harding (1:8) 3:35 Evaluation Faculty  Kathleen Thies, PhD, RN Improvement Science Faculty  Patti Feeney  Mark Splaine, MD
  • 23. Session 1 Objectives  Teach effective meeting skills, cause and effect diagramming, and writing specific aims to support team improvement work.  Provide an overview of the learning collaborative structure and expectations.  Help teams ‘get started’ redesigning roles.  Review Action Period 1 assignments for improving team based care.
  • 24. Learning Session 1 Agenda Team Based Care Participants 3:35 10 min Introductions 3:45 10 min Collaborative Goal, Structure and Expectations, Resources 3:55 15 min Getting Started Tools : Role Activity Assessment , Cycle Time 4:10 10 min Action Period 1 Assignments 4:20 10 min Brief Team Meeting Break Out
  • 26. Interviews : General Impressions  Many asked for clarification of team and coach definitions  Lots of recent growth and change in many organizations  Many reported EHR challenges re: data, documentation, duplication, and getting actionable reports  Few have depth of experience with primary care redesign models and QI methods (e.g Wagner, Bodenheimer, Nuka Alaska, PCMH, IHI)  Most are familiar with term PDSA  Most not meeting weekly to focus on QI, ‘fit into’ day of back to back visits  All have been evolving their team based model of care over time, multiple starts, looking for “refresh”  Many working on PCMH certification, recertification  Few practices have experience with coaching model Introductions
  • 27. Interviews : Goals and Expectations  Want structure, guidance, resources from the Collaborative: how-to’s vs concepts  Learn from others’ and their mistakes  Common Goals | Global Aims • better efficiency, improved workflows • staff working at top of license, includes standing orders and protocols • team role clarity and standardization (care management, documentation) • improve quality outcome measures (e.g. UDS outcomes) • improve patient and team satisfaction  Reduce stress and “put the joy back into practice, need “relief from the chaos”  We have a cohesive, good team but we “all work in our silos to get the work done” Introductions
  • 28. Introductions Name of FQHC Coach Team Carolina Family Health Centers , Inc. Chasity Godwin 1 MD, 1 NP, 2 LPN, 1 Care Coordinator, 1 Front Desk, 1 Interpreter, 1 CNA Community Health Initiatives Zlata Vainstein 1 Medical Director, 1 Physician, 2 MA, 1 Front Desk Daughters of Charity Grace Mena 1 Area Practice Manager, 1 MD, 3 FNP, 2 Care Coordinator, 4 MA Healthcare for the Homeless Carlie Brown Need new team Holyoke Health Center Megan T. Wechsler (Primary) 1 Director of Quality and Compliance, 1 Physician, 3 RN, 1 MA, 1 Front Desk Johnson City Community Health Center Flo Weierbach 1 front Desk, 1 PNP, 1 LCSW, 1 RN, 1 Interpreter Sumter Family Health Center Sandra Sturkie 1 Director of Patient Services, 1 Clinical Manager, 1 BH Clinical Manager, 1 BH RN, 1 Physician, 2 Case Managers, 1 MA, 1 Dental Services Coordinator, 1 Patient Financial Coordinator, 1 Clinical IT, 1 Pharmacist, 1 Call Center Rep, 1 Referrals Manager Syracuse Community Health Center, Inc. Cathy Brigden 1 Physician, 1 FNP, 1 LPN, 2 RN, 3 MA, 1 Office Manager Tyler Family Circle of Care Sherri Gould 1 CMO, 1 COO, 1 LVN, 1 OA, 1 PNP, 1 Process Improvement Manager
  • 29. Name of FQHC Coach Team Avenal Community Health Center John Kalfayan 1 BH, 1 Physician, 1 MA, 1 Medical Director, 1 Front Desk Educational Health Center of Wyoming Brenda Burnett 1 Provider, 2 RN, 1 Radiologic Technologist, 1 EMR Manager, 1 MA, 1 Clinical Manager El Rio Santa Cruz Josh Carzoli 1 MA, 1 RN, 1 BH, 1 Chief Clinical Officer, 1 LPN, 2 Physician, 1 Front Desk, 1 COO, 3 RN Clinic Manager, 1 IT Peach Tree Healthcare Ruben Ruiz 1 Chief Quality Officer, 1 Quality Coordinator, 1 Dir of Operations, 1 Site Manager, 1 Dir of HR, 1 NP, 3 MA, 1 Data Analyst, 1 Ops Specialist, 1 Clinical Support Services Manager Pecos Valley Medical Center L. David Young 2 RN, 1 NP, 1 MA The Children’s Clinic Karla Rodriguez 1 Provider, 1 MA, 1 Care Team Rep Via Care Community Health Center Kimberly McFerguson 1 FNP, 1 MA, 1 Outreach & Enrollment Specialist, 1 MSW, 1 Front Office Lead MA Introductions
  • 30. Team Skills Assessment Summary (N=51) Percentage Strongly Agree or Agree are Competent % Strongly Agree or Agree 60 60 65 85 65 0 10 20 30 40 50 60 70 80 90 100 Gathering and Using Data Skills Using Effective Meeting Skills Implementing Daily Huddles Applying Teamwork Skills Using Improvement Skills
  • 31. Coach Skills Assessment Summary (N=16) Percentage who rated themselves Competent, Proficient, or Expert 35 65 47 47 59 0 10 20 30 40 50 60 70 80 90 100 Data and Information Systems Meeting and Interpersonal Skills Improvement Skills Technical Skills (excel, webinar) Art of Coaching Skills %
  • 32. Level D: Just Getting Started Level C: Early Stages of Change Level B: Implemented Basic Changes Level A: Achieved Most or All of the Important Change Required Team Based Practice Assessment (LEAP)
  • 33. 0 1 2 3 4 5 6 7 Level A Level B Level C Level D Self-Management Support Planned Care Care Management Medication Management Care Activities Assessment (N=11) Number of sites reporting level of performance implementing key processes Just getting started Early stages of change Implemented basic changes Achieved most or all of the important changes required
  • 34. 0 1 2 3 4 5 6 7 Level A Level B Level C Level D Medical Assistant (MA) Registered Nurse (RN) Laypersons Pharmacist Role Activities Assessment (N=11) Number of sites reporting by level of performance by role Just getting started Early stages of change Implemented basic changes Achieved most or all of the important changes required
  • 35. Transformational Team Based Care Improves Outcomes
  • 36. Learning Session 1 Agenda Team Based Care Participants 3:35 10 min Introductions 3:45 10 min Collaborative Goal, Structure and Expectations, Resources 3:55 15 min Getting Started Tools : Role Activity Assessment , Cycle Time 4:10 10 min Action Period 1 Assignments 4:20 10 min Brief Team Meeting (break out)
  • 37. Goal The Team-Based Care Learning Collaborative is designed to provide transformational* strategies and mentored coaching support, to help a core team implement an advanced model of team- based care over 12 months. *Transformation can take up to 18-24 months 3:45
  • 38.  Achieve multiple TBC specific aims  Standardize (SDSAs) roles and key processes (Playbook, Spread Plan)  Improve team and coach skills (improvement science, team work, coaching)  Develop a post collaborative team action plan How is the Collaborative Structured? 90 min Learning Sessions Between Session Action Periods (6 weeks) Complete Assignments Weekly Team Meetings (5-6), Daily Huddles Monthly Reporting Implementation Tools and Skills Change Concept Resources Learning From Each Other Team Based Care Webinars (8) Core Team Team Based Practice Assessment (LEAP) Coach and Team Skills Assessment Practice Outcomes Data (UDS, Other) Interviews Coach Prep Session Technology Session Between Session Mentoring and Faculty Support 7 Sept 21 Nov 2 Dec 14 Jan 25 Mar 15 Apr 26 June 14
  • 39. Improvement Science Theory Bursts (10 min) Developing Skills Session 1 : Sept 21st o Running effective team meetings using tools o Developing and using a cause and effect diagram to inform PDSAs o Writing a 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 14 o Using data for improvement (run charts, control charts) Session 4 : Jan 25 o Standardizing (SDSAs) and Reliability Science Session 5 : March 15 o Spreading Change Session 6 : April 26 o Gantt Charting : 3-6 month Core Team improvement plan
  • 40. Mentor and Coach Roles Coaches (posted role descriptions)  Help and support teams in learning new skills and achieving their aims  Help teams complete action period assignments, monthly reports, evaluation  Meet weekly with Mentor and other coaches, 1:1 as needed  Participate in 7 learning sessions  Support weekly team meetings, and between meeting assignments, session prep Mentors (posted role descriptions)  Provide support and resources for developing coaching skills  Facilitate weekly debriefs with Coaches  Provide individual support as needed
  • 41. NCA Online Learning Network Find material for download, TBC webinars, and team folders for sharing your work... Improvingprimarycare.org Discussion Board Ask questions or make requests of teams, faculty….
  • 42. Any Questions? Before “Getting Started”…. 3:55
  • 43. Implementing Team Based Care (Webinar #1) Webinar 1
  • 44. Defining Structure and Staff Responsibilities Practice Managers and Leaders : must stay involved, engaged in your work
  • 45. Start with Core Team, Then Expanded Team Current State Examples: 8 Participating Teams  1 MD, 1 NP, 2 LPN, 1 Care Coordinator, 1 Front Desk, 1 Interpreter, 1 CNA  1 MD, 2 MA, 1 Front Desk  1 PNP, 1 LCSW, 1 RN, 1 Interpreter, 1 front Desk,  1 MD, 3 FNP, 2 Care Coordinator, 4 MA  1 MD, 1 FNP, 1 LPN, 2 RN, 3 MA, 1 Office Manager  1 FNP, 1 MA, 1 Outreach Specialist, 1 MSW, 1 Front Office, Lead MA  1 BH, 1 MD, 1 MA, 1 Front Desk  1 Provider, 2 RN, 1 Radiologic Tech, 1 MA
  • 46. TBC Concept Resource (webinar #1 and #2) Principle  Patients want to receive their care from smaller teams (PODS) and know them personally Physical  Wall colors differentiate pods in practice , match business cards  Central open area surrounded by exam rooms  Co location of pod members, all carry laptops  3 exam rooms per provider – all care comes to patient  2 pods share procedure room - standardized TBC Structure  Break down large systems into PODS (care teams)  4 “Empaneled” Providers (3FTEs), 3 MAs dedicated to provider (dyad)  1 BH, 1 RN, 1 Case Coordinator (navigator, health coach), 1 front desk,  Patient empaneled both to a pod and to a Dyad  Flow Coordinator and Team Manager rotating roles (RN, MA)  Medical Records staff – input electronic data Roles and Responsibilities  Defining and Training, Standing Orders and Protocols Standardizing Workflows • Making ‘hundreds’ accessible to all Teams Need to Meet • Daily Huddles : 8am and 2pm • Weekly Meetings : Improvement Work, Population Health Management
  • 47. Poll Question Would you say that you have ‘significant’ work to do defining your “core” and “extended” team structure? Yes No
  • 48. Role Activity Assessment Who Does What Now? 4:08
  • 49. Why analyze your team’s roles?  Have the right person doing the right thing at highest level of training and licensure  Eliminate duplication or unnecessary work  Reduce interruptions  Challenge assumptions about what staff are doing  Increase capacity to take on new activities  Develop specific aims for improvement
  • 50. Implementing Team Based Care (Webinar #1) Webinar 1
  • 51. Role Assessment of ‘the work’: Webinars 1-8
  • 52. Role Activity Assessment (customizable)
  • 53. Role Tracking Worksheet Consider Tracking Interruptions Role Activity Analysis Position: Tic Marks (each time activity done, may add AM, PM) Total Tic Marks Estimated Time per Activity in minutes Total Time Access and Communication Processes Activity 1. Schedules patients with a personal clinician for continuity of care ||||| ||||| ||||| 15 4 min 60 min 2. Coordinates visits with multiple clinicians and/or diagnostic tests and procedures 3. Triages how soon a patient needs to be seen including a process for after-hours care 4. Monitors access to appointment, backlog and wait time using telephone and email requests 5. Monitors and triages secure patient portal messages 6. Provides advice on clinical issues via telephone or portal messaging 7. Identifies and arranges for language services 8. Collects patient demographic and insurance information, including preferred method of communication 9. Helps patients activate their Personal Health Record by signing up during office visit 10. Identifies and refers patients who might benefit from care management support, other practice resources, community services Population Health Management Activity 1. Uses population registries and clinical quality reports to monitor a panel of patient’s health and risk status and close care gaps. 2. Communicates with many patients at once via bulk outreach letters and portal messaging (e.g. reminders for preventive care visits ,testing, screening gaps) 3. Provides outreach services to patients overdue for visit to follow up management of chronic
  • 54. SampleData.Hess.2009 Worksheet.clinicalmicrosystem.org IHI.org Poster 25% 75% RN Activity [planned care registry, triage level 2, nurse visits, self management support] Sampling of a Typical Day RN Role Ticks and Tally
  • 55. 55 33% 67% Non-Physician Tasks Physician Tasks Non-Physician Tasks -immunizations -obtaining consults -obtaining MR -setting up room -filling out clerical fms -finding interpreter -bringing pt to room -data entry -finding information
  • 57. Receptionists Telephone Encounters: Significant # of calls were within 3 days after a visit Printing All AVSs (thought they had to) : 50% patients did not want paper, shred.
  • 58. Poll Question Have you ever participated in any type of analysis of what you do every day (tasks and functions)? YES NO
  • 59. Using Cycle Time to Improve Efficiency and Office Flow
  • 60. 15 Patients (1-2 weeks) Use Clipboard with Clock Select One Appointment Type Random Selection Patients AM and PM Target 1.5 X Appt Time 15 min Appt = 23 min cycle time 20 min Appt = 35 min cycle time 30 min Appt = 45 min cycle time 45 min Appt = 68 min cycle time SampleData.Hess.2009 Worksheet.clinicalmicrosystem.org Note: scheduled appoint time What if early arrival?
  • 62. Efficiency and Role Optimization 3 4 5 15 1 28 2 2 6 16 2 30 1 4 8 14 1 30 2 3 6 17 1 31 2 3 4 15 1 27 0 5 10 15 20 25 30 35 Waiting Room Time w/Clinical Staff Pre-Exam Waiting Active Exam Check Out Avg Length of Visit Minutes 12-Feb 20-May 20-Jun 15-Jul 26-Aug Family Practice : 9 min non value added time , active exam time and waste
  • 63. Hess.CPM.2010 Example: Assessment data (long cycle time) is analyzed using Fishbone Diagram Problems that have high leverage for improving results, inform your PDSAs (session 2). Top of the Ramp – Specific Aim Putting It Together for Action Period 1
  • 64. Action Period 1 Assignments 1. Meet weekly (50 min) as a Core Team  Practice effective meeting skills and use tools with coaching support 2. Continue Daily Huddles (5-10 min) | Starting is Optional 3. Complete and share the following by uploading to TBC website: - Within 4 weeks a) What is your global aim? – the broad objective you want to achieve in the longer run b) Role Activity Assessment (who does what now) c) Role Activity Tracking Data (1-3 days, all roles, coach inputs data)  Fishbone diagram with drivers of role problem(s)  Document any ‘quick hits’, insights  Write a specific aim for improvement using role data d) Cycle Time Assessment (15 )  Fishbone diagram with drivers of cycle time problem  Document any ‘quick hits’, insights  Write a specific aim for improvement using cycle time data 4. Upload monthly progress report to inform Session 2 Planning. 5. Upload all missing assessments.
  • 67. Wrap Up and Questions Set Up Brief Team Meeting