4/7/2015. Welcome and Introductions. Icebreaker. Management and Supervisor Training. Quality Improvement in Public Health

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1 Management and Supervisor Training Quality Improvement in Public Health April 15, 2015 Kathy Brooks, Susan Little, Tara Lucas, Amanda Cornett 1 Welcome and Introductions Faculty Introductions Ground Rules Participation is essential Learning and sharing from one another is important Don t forget to silence cell phones 2 Icebreaker Name Job Title and Organization Choose one adjective to describe yourself - Adjective should start with the same letter of your first or last name 3 1

2 Objectives Define QI and its importance in public health Learn how to apply the Model for Improvement and Lean Use QI tools to understand your current process and identify change ideas Learn to use the Plan Do Study Act cycle to test changes Identify ways to use QI & Practice Management (PM) tools in your agency Discuss QI & PM resources available to public health agencies 4 Quality Improvement Definitions What is Quality Improvement? A continuous and ongoing effort and culture to best achieve measurable improvements in the efficiency, effectiveness, quality, performance, and outcomes of services and systems with the goal of improving the health of North Carolinians and our communities. NC DPH Management Team, 2009 Adapted from Accreditation Coalition QI Subgroup Consensus Agreement 6 2

3 Visual adapted from Marni Mason of MCPP Consulting; based on Joseph Juran s Trilogy 7 QI Principles Focus on systems, not individual Use data to clarify the problem and make decisions about what areas need improvement Identify the root cause of the problem (using data) and identify potential changes to improve the problem Customer focus: ideas/changes come from customers & front line staff Focus on testing changes using PDSA cycle Frequent, ongoing measurement and data-driven decision making QI is a never-ending process it s continuous What is Lean Thinking? A systematic approach to identifying and eliminating wasteful activity (non-value-added activities) in the pursuit of perfection through continuous improvement; providing increased value to our clients / community 9 3

4 Lean Thinking Client / customer first Our People are the most valuable resource Continuous improvement Focus on where the work is done Evidence Based = Research based outcomes Evidence Strategies = actual Evidence Based programs Quality Improvement Approach 4

5 Every system is perfectly designed to achieve the result it gets 13 Changing the System: Usual Model Traditional model for introducing change PROBLEM SOLUTION FINAL PLAN IMPLEMENT SYSTEM BARRIERS FAIL 14 QI Approach BIG, VAGUE PROBLEM Clarify problem Assess current condition Prioritize issues & set a target Define POSSIBLE Solutions Test solution s & adapt IMPROVED and SUSTAINED OUTCOMES Adapted from: Jean Vukoson s Bright Futures Presentation and Concepts from Toyota Way 5

6 Model for Improvement What are we trying to accomplish? (AIM) How will we know that changes are an improvement? (MEASURES) Act Plan Study Do What changes can we make that will result in an improvement? (IDEAS) Test Ideas & Changes with Cycles for Learning and Improvement 16 Evidence Based Strategies Practice Management Examples: EBS Screening: move to risk based screening vs universal screening focuses on risk identification & reduction vs un-necessary screening Resources: Programmatic guidance NOTE: STD requires universal screening EBS Health Communication : compliance with health recommendations is improved if there is a relationship with the provider reduce steps & messengers in the flow process and priority messages from the provider enhance communication & clients ability to apply the recommendations Resources: Programmatic Best Practice Clinic Flow Models; CDC Health Literacy strategies Improve the Health of Populations Smoking Bans Linked To Lower Hospitalizations For Heart Attacks And Lung Disease Among Medicare Beneficiaries (Weg, Rosenthal and Sarrazin) MI fell 20 21% COPD fell 11% (workplace ban) and 15% (bar smoking bans) 18 6

7 Data Driven Decisions What is Gemba? Gemba is the area in which the work is being done To truly understand a situation, you must go to the Gemba and see for yourself! This is the Gemba Walk You are performing an observational walkthru of the area you plan to improve 20 Gemba Walk View of potential problems/waste: wastes or beaver dams in the system View from the client s perspective: wait time, steps, messengers View from the worker s perspective: handoffs; standard processes; motion 21 7

8 Understand the Current Process Why is it important? Helps you to see what is actually going on: can t change what you don t see Reveals the true root cause of a problem Avoids putting a Band-Aid on the symptom Finds a real fix to prevent the problem from re-occurring 22 8 Wastes? Defects Overproduction Waiting Non Value-Added Processing Transportation Inventory Motion Employee (Underutilizing) Typically 40-60% of all lead time is non-value added. 23 Actual VSM 24 8

9 What is it? Value Stream Map Used to visually represent the steps in a process Shows complexity, handoffs, unnecessary loops in the process Identifies data points Provides context for consensus building regarding what we do and what we think we do 25 Value Stream Map How do you create one? 1. Define process to examine and set limits 2. Observe the work processes first hand and document observations 3. Document each of the process steps 4. Arrange steps in order of sequence, including when things go wrong, corrections, decisions 5. Get input from outside group 26 Results: Decrease Lead Time VSM identified beaver dams & extra steps Wilson VSM 27 9

10 Try It! Identify the wastes of this meeting process Identify gaps & areas for improvement in the process Think about how you could use a Value Stream Map for your meeting process 28 Fishbone Diagram What it is? A visual display that allows teams to organize information and identify multiple causes of a problem Why use it? Provides structure during brainstorming Enables team to think through all potential causes Creates a snapshot of the team s collective knowledge Breaks problem into smaller pieces Focuses on causes rather than symptoms Helps prioritize and focus on specific areas 29 Fishbone Diagram Procedures Methods Cause Cause Cause Materials Policies Cause Cause Problem Cause Cause Cause Cause Place/Technology Machine Manpower People Root Cause 30 10

11 Fishbone Example 32 5 Whys What it is? A question asking method Used to quickly determine the root cause of a problem

12 Fishbone and 5 Whys Example 1. ~100 apps/consultant at one time 2. Most agencies send apps at the last minute 3. Apps are mistakenly thrown away 4. Agencies don t realize that the app is an important document No indication of important document on mailing envelope Try It! Review the identified problem Use the Fishbone and identify potential causes of the problem Use the 5 Whys to drill down to the root cause 35 Aim Statement What is an aim statement? An explicit statement of the desired outcome that is time specific and measurable 36 12

13 Key components of an aim statement What are we trying to accomplish? Why is it important? Who is the specific target population? When will this be completed? How will this be carried out? What is our measurable goal(s)? 37 What Changes Can We Make? 39 13

14 Brainwriting What it is? Alternative form of brainstorming Why use it? Everyone contributes ideas Reduces threat of ideas being blocked by others Quick way to generate many innovative ideas 40 Idea 1 Idea 2 Idea 3 Brainwriting 1 AAA BBB CCC 2 3 Idea 1 Idea 2 Idea AAA BBB CCC 5 2 DDD EEE FFF Idea 1 Idea 2 Idea AAA BBB CCC 6 2 DDD EEE FFF 3 GGG HHH III Method (6 people, 3 ideas, 5 minutes) 41 Brainwriting Example 42 14

15 Alternative Brainwriting Methods Gallery Brainwriting Write problem statements on flip charts Each person selects a flip chart, reviews problem statement & writes 3 ideas on post-it notes (1 idea/post-it) Rotate to the flip chart on the right, review problem statement, read the ideas, add 3 new ideas and/or enhance the other ideas Continue until everyone has visited each flip chart Review ideas and group them into themes Index card Display the problem statement at the front of the room Each person writes 3 ideas on an index card & passes it to person on their right Each person reviews ideas on card, adds 3 new ones or enhances the other ideas Continue process for minutes 43 Gallery Brainwriting Example 1. Problem Statement 2. Each person has a different colored adhesive note 3. Ideas reviewed and grouped into themes 44 Try It! Review the identified problem Use the Brainwriting template Write 3 ideas in Row A When we call Time pass your paper to the right Review the 3 ideas and add your own ideas on Row B 45 15

16 Evidence Based Strategies Practice Management Examples: EBS : compliance with health recommendations improved if relationship with provider reduce steps & messengers in process Examples: best practices tested by other agencies: Streamlined clinic flow processes Organization of clinics (integrated vs. stand alone) Team approach and huddles Practice management dashboards 46 How Will We Know? (MEASURES) Measurement Brings rationality to the process Replaces subjectivity with objectivity Focuses on process, not individuals The nurse practitioners never complete the encounter forms! 47 How Will We Know? (MEASURES) Measurement is the voice of the process Accurately tells you how well the process is working Any process that can be mapped can be measured Measures are linked to the goals in your project aim statement 48 16

17 Types of Project Measures Outcome Ultimate results we are trying to achieve Process What we do to achieve the outcome Balancing What we could mess up while trying to improve process & outcome 49 Examples of Project Measures Outcome Increase provider productivity to 100% benchmark Process Decrease lead time for preventative service by 25% in next quarter Balancing 80% of clients will rate wait time in clinic as very good 80% of clients will rate their understanding of health information shared by the provider as clear understanding 50 Practice Management Measures Budgeted vs. actual revenue Payer source by program Productivity benchmarks: capacity vs. actual seen No show rate Demand for services by program Revenue compared to costs 51 17

18 PM Data Dashboard Service County by Practitioner Summary Practice Management Data Dashboard Service Count by Practitioner Summary Report 1/1/2013 Through 12/31/2013 RSC County Number Practitioner Medicaid Units Non-Medicaid Units Total Units Medicaid Services Non-Medicaid Services Total Services , ,734 1, , ,180 1, ,180 1, , ,808 5,502 8,310 2,514 4,603 7,117 PM Data Dashboard Service Count by Program Summary RSC County Non-Medicaid Number RRG Practitioner Medicaid Units Units Total Units Medicaid Services Total Services Non-Medicaid Services AH AH AH AH AH AH AH AH AH AH AH AH CH CH PM Data Dashboard Service County by Practitioner and CPT Code Practitioner = (Name of Practitioner will appear here) Procedure Code Procedure Description Medicaid Units Non-Medicaid Units Total Units Medicaid Services Non-Medicaid Services Total Services OFFICE/OUTPATIENT VISIT NEW OFFICE/OUTPATIENT VISIT EST OFFICE/OUTPATIENT VISIT EST PREV VISIT NEW AGE PREV VISIT NEW AGE PREV VISIT EST AGE PREV VISIT EST AGE Practitioner Totals:

19 PM Data Dashboard Exporting Instructions To export the report, at the top of the page click the Export icon (circled in red below) Then select the method the report should be exported. Export Document As will export all report tabs. Export Current Report As will export the report tab that is currently open. The report can be exported as a PDF, Excel, or Text Document (exporting to Excel limits the report to 65K rows, Excel 2007 does not). Reduction per capita Cost of Health Care Public Health Productivity Benchmarks Provider productivity benchmark: Average 20 visits/day x 5 days/week x 48 weeks = 4,800/year Nurse Clinic productivity benchmark: Average 20 visits/day x 5 days/week x 48 weeks = 4,800/year Child Health Enhanced Role Nurse (with support) benchmark: Average 6 visits/day x 5 days/week x 48 weeks = 1,440/year 56 Practice Management Data What are your questions regarding this fiscal picture? 57 19

20 Practice Management Data All Revenue Sources without Cost Settlement 16% 18% Medicaid Other 58% 8% Local 101 State Funds 58 Focus on Customers & Stakeholders How do our customers experience our product or services? 20

21 Customer Focus Who are our customers? WIC clients, community builders or homeowners, clinical services patients What do our customers value in our product or service? Friendliness, efficiency, accuracy? How do we know? Customer Focus Are we developing solutions with customer values in mind? Are schedules or hours of operations convenient to our clients or meet staff needs Does our product or service meet our customer needs? How do we know? How do we involve patients in developing solutions or services? How do organizational stakeholders experience improvement? 63 21

22 Stakeholder Input To make real improvements we must understand the processes from the people who do them: stakeholders are the frontline staff who actually do the work Managers think they understand the issues or processes but do not always have stakeholder perspectives: assumptions should be validated with stakeholders What s the problem? Stakeholder Engagement Stakeholders hold the keys to successful solutions if engaged in the change process Stakeholder engagement facilitates adoption and embedding of improvement strategies Engagement requires continuous feedback & reinforcement What s the solution? Systems Change 22

23 Testing our Change Ideas 67 PDSA Cycle Use the PDSA cycle to test changes Act What changes are to be made? Adapt? Or Abandon? Next cycle? Study Complete the analysis of data Compare data to predictions Summarize what was learned Plan Objective of cycle Questions/predictions Plan to carry out the cycle (who, what, where, when) Do Carry out the plan Document problems/unexpected observations Begin analysis of data 68 Another Example PDSA Cycle Aim: By December 1, 2013, we aim to increase the number of patient visits per staff discipline (see below) over 2012 capacity. MD/NP/PA = 20 patient visits/day (2012 = 12) ¹RN (General Clinic/Mandated Services) = 20 patient visits/day (2012 = 6) Rostered CH RN = 6 patient visits/day (2012 = 3) PP/NB HV = 5 patient visits/day (2012 = 3) ¹If STD service visits are not included in the RN (General Clinic/Mandated Services) numbers, then the benchmark would be 8 patient visits/day

24 PDSA Cycle Example: Schedule Act Change flows to decrease non-value added processes (hand-offs, stops, etc.) and try again. Study Current clinic flows didn t support additional patient load. Was able to see more patients but didn t achieve Aim. Plan If we set the staff schedules up to accommodate the increase in patient visits, will staff be able to sustain the load? Do Design schedules to reflect target and test for one day in clinic. 70 PDSA Practice Management Example PDSA Cycles: Improve Health Outcomes by Improving Clinic Efficiency and Cost Effective Services. 1. Test new schedule which supports desired benchmark of patient visits/provider. (PDSA #1) 2. Test Flow (PDSA #2) 3. Test staffing model (PDSA # 3) 71 Testing Changes Changes that result in improvement Ideas 72 24

25 How Have You Used PDSAs? What was the aim of your project? What change did you test using a PDSA cycle? What did you learn from the first PDSA cycle? What were the benefits of using a PDSA cycle 73 PDSA Tip #1: Scale Down Years Quarters Months Weeks Days Hours Minutes Number of clients Drop 2 74 PDSA Tip #2: Oneness 75 25

26 Key Points for PDSA Cycles Successful tests As move to implementation, test under as many conditions as possible Special situations (e.g., busy days) Factors that could lead to breakdowns (e.g., different staff involved) Things naysayers worry about (e.g., It will not work on Wednesdays ) 76 Try It! Think about a change you want to test to improve the meeting process Use the PDSA cycle template to develop a plan for how you would test the change 77 Small Group Work Applying what you have learned 26

27 Ongoing Measurement Continuous Quality Improvement Why Should we Continue to Monitor? Practice Management Ongoing monitoring of trends in productivity & revenue & data-based response Joint performance objectives & data dashboards provide structure & information to identify issues and make appropriate improvement decisions Improvement opportunities: Strategies to optimize revenue: Billing & coding audit training & monitoring of practice s coding Maintain current billing & follow-up of denials Accept credit & debit cards 81 27

28 What is Return on Investment? 82 Terminology/Formula EI (economic impact): Refers to costs and benefits of an activity. EI = Benefits-Costs ROI (return on investment): A performance measure used to evaluate the efficiency of an investment ROI = (Benefits-Costs)/Costs 83* ROI/EI Why do it? Earns the respect of Stakeholders and Leaders Justification for implementing an intervention/project View public health as an investment vs. expense Helps to sell the concept of public health Part of evaluation accurate, credible, and widely used process Based on facts or evidence so it s believable 84 28

29 Change Planning & Communication Planning for Implementation of Change Clear AIM and measures Leadership sponsor which can articulate the change imperative and AIM & secure resources Practice Management Team with clear joint performance objectives Implementation plan which includes detailed steps, resource requirements, accountabilities, and monitoring data set Build change capacity on early successes or low hanging fruit 86 Organizational Structure & Change Leaders = point the managers towards the vision and mission of the agency and leverages the funds to make it happen Managers = plan for, designs and controls factors that affect work Supervisors = over-sees or directs people at work Line of Sight Supervision = supervisors can see employee performance in the work flows Standardize = policies, procedures, environment, work flows, job description, work plans

30 Change Management Process 88 Change Communication Communication must Clearly define impetus for change Clearly define assessment process & change process Be consistent from health director to middle managers to front line Communication structure: all staff meetings, team meetings, huddles, data reports re: progress toward objectives 89 Change Communication Communication must: Recognize change process & implications for and concerns of all stakeholders: Example: the goal of the clinic efficiency is to optimum use of resources: staffing resources freed by reducing duplication & increasing efficiency & productivity will be redeployed to other value added services Address resistance and anxiety with multiple changes in status quo 90 30

31 Where do you go from here? 91 Next Steps How will you use what you ve learned in the next 2 weeks? AIM Team Identify specific agency strengths Identify and address barriers Develop a plan & work the plan Questions, Comments Debriefing 93 31

32 Resources Available Center for Public Health Quality ( Institute for Healthcare Improvement (ihi.org) The Public Health Foundation DPH Practice Management Resources ( DPH Administrative & Nurse Consultants 94 Contact Info Susan Little Phone: Kathy Brooks Phone: Tara Lucas Phone: Amanda Cornett Phone: