Transformation

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• Transformation
• Practice Metrics
• Practice Improvement
• Collaborative Learning
• David V. Garrett, MHA and Randall Oates, MD
• April 17, 2008

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Presentation Outline

• A. Practice Transformation
• Continuous Practice Quality Improvement
• Practice Metrics
• Collaborative Learning
• E. Early Learning of TransforMED

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Brief TransforMED History

• Fall of 2005 RFP Process
• Spring of 2006 Practices Picked, Staff Hired
• Randomized in Facilitated Self Directed
• Study Began in Earnest Summer of 2006
• Independently Evaluated

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NDP Multiple Interventions

Patient Centered Care
Health Information Technology
Access to Information Care
Quality and Safety
Point of Care Services
Practice Management
Team-Based Care
NDP Medical Practice
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Practice Transformation
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Practice Transformation
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TransforMED Mission

• The mission of TransforMED is to lead and
  empower medical practices in implementing a new
  model of patient-centered care thereby
  improving health care for their patients, as well
  as the success of their practices

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Practice Transformation

• Examples of Key Changes
• Update their Use of Technology
• Electronic Records (Interoperable)
• E-Lab Results and Prescription Generation
• Vibrant Websites
• Point of Care Reminders around Best Practices
• Begin to Manage Populations

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Practice Transformation

• Examples of Key Changes (continued)
• Provide Timely Access
• Same Day Appointments
• Supply and Demand
• Provide Alternative Types of Visits

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Practice Transformation

• Examples of Key Changes (continued)
• Discipline Financial Management
• Personnel Management
• Team-Based Care
• Evidence Based Care
• Establish A Quality Improvement Process

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Practice Transformation

• Transform (verb) 1 a to change in composition
  or structure b to change the outward form or
  appearance of c to change in character or
  condition

Source Webster Dictionary, 2007
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Sir Edmund Hillary
Practice Transformation
Mt. Everest
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Practice Change Sherpa
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Practice Metrics Improvement Can Only Be
Proven when Its Measured
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Curent Heathcare MetricsPay for Performance

• Rewarding practices for the reporting of a set of
  clinical outcome data results in practices having
  a focus on being able to perform well reporting a
  set of clinical outcome data.
• P4P Pay for Reporting

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P4P Heathcare Metrics lack in areas delivering
value

• Do they
• ___ focus on what patients want?
• ___ decrease cost?
• ___ increase satisfaction or well-being?
• ___ provide evidence of higher quality?
• Does Reporting Performance Quality?

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Metric Tools of National Demonstration Project

• Clinical
• NCQA
• AQA
• Also
• PEC Practice Environment Checklist
• CSQ Clinical Staff Questionnaire
• POS Patient Outcome Survey

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National Clinical Measures
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AQA Quality Metrics
NDA - Includes a subset from AQA. Below is the
first of 16 AQA elements
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NDP Operational Metrics

• Cycle Time Analysis
• Patient Pathways
• Examining Flow Bottlenecks
• Financial Metrics
• Supply and Demand Evaluation
• Example Same Day Scheduling

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Core Ingredients

• To succeed in change, practices need
• Strong Leadership
• Teamwork
• Effective Communication channels
• Manageable Units of Change
• Recognition of Small Gains
• These are largely outside of traditional metrics.

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What has been learned about the Medical Home
Approach?

• Thinking inside the box first typical
  business principles DO apply
• Eliminating the operational inefficiencies in a
  practice translates into revenue
• Practicing good evidence based medicine generates
  revenue from more volume and Pay for Performance
  Programs
• Group visits are not a cash cow but can pay for
  themselves.
• Midlevel providers are poorly utilized in
  practices
• .Physicians often lack basic leadership and
  change management skills.

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Practice Transformation

• Medical Home Vitals a quick educational tool is
  on the website today!
• Thorough on-line assessment tool for TransforMED
  Medical Home model of care that will translate to
  the NCQA recognition process
• Web pagepositioned to be the ultimate medical
  home resource
• Planning collaborative meetings
• Planning practice products
• Planning practice services

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Continuous PracticeQuality Improvement

• PDSA Cycles

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Evaluation Team Validated Tools

• Patient Outcome Survey (POS Q105)
• Measures Patient Satisfaction
• Clinical Staff Questionnaire (CSQ - Q90)
• Measures Physician and Staff Satisfaction
• Practice Environmental Checklist (PEC - Q100)
• Measures the Facilitators Thoughts

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Evaluation Team Validated Tools

• Patient Outcome Survey (POS)
• 105 Questions to get at that Patient Centered
  Relationship
• Q9 The doctor knows a lot about my family
  history.
• Q 11 The doctor always takes my beliefs and
  values under consideration when caring
  for me.
• Q 20 The doctor/practice always explains things
  to my
• satisfaction

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NDP Operational Metrics

• Cycle Time Analysis
• Patient Experience Questionnaires
• Patient Pathways Examining Flow Bottlenecks
• Financial Metrics
• Supply and Demand Evaluation (Same Day
  Scheduling)

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NDP Operational Metrics

• Cycle Time Analysis
• Scheduled appointment time___________ AM PM
  (Circle one)
• Provider_________________________________________
  ___________
• Type Of Appointment (Check one)
  
• 10 min_____ 15 min_____ 20 min_____ 30 min_____
  40 min_____ 60 min_____
• Time patient checked in _________________________
  __ AM PM (Circle one)
• Time patient entered exam room___________________
  ________________
• Time provider entered exam room__________________
  ________________
• Time provider left examroom______________________
  ________________
• Time patient checked out_________________________
  _____________

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NDP Operational Metrics

• PATIENT EXPIERENCE
• Provider Name _______________________
• How would you rate length of time waiting during
  todays visit?
• Excessively long Long A little slow
  Right on Time Ahead of Schedule
• 1 2 3
  4 5
• How satisfied were you with length of time spent
  with your doctor?
• Very Disappointed Disappointed Just OK
  Satisfied Very Satisfied
• 1 2 3
  4 5
• How would you rate the overall experience of your
  visit today?
• Poor Fair Good
  Very Good Excellent
  1 2 3
  4 5
• What would make it better?

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Potential Practice Changes

• Start your day on time.
• Limit the number of types of clinic appts.
• Dont try to do it all.
• Educate your patients.
• Review practice processes
• Standardize exam rooms

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Common Practice Benchmarks

• Cycle Standards Benchmarks
• Patient Cycle Time 1.5 X Touch Time
• Touch Time lt 20 Min
• Avg. Patient Wait Time lt 15 Min.
• Appointment No Show Rate lt 2 3
• Financial Standards
• Cost of Office Space 7 8 of practice
  revenue
• Overhead 57 61 Total revenue
• (salary, utilities, etc.)
• Source Medical Group Management Assoc. (MGMA)

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Collaborative Learning
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Collaborative Learning

• 4 Learning Sessions in Kansas City
• Facilitated Practices Share Experiences
• Change Management Techniques
• National Presenters

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Collaborative Learning

• Practice Presentations/Break Out Sessions
• Q and A and Demonstrations (Group Visits)
• Technology Vendors
• Observation by External Evaluators

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What are the NDP Learnings?

• Population based registries work and are a
  critical success factor for chronic disease
  management and patient centered care
• Practice and Quality outcome metrics modify
  behavior
• Teambuilding concepts really do work and lead to
  higher quality, greater productivity and improved
  job satisfaction with providers and staff

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Learning and Challenges
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What are the NDP Learnings?

• The entire model of care CAN be implemented, but
  there are critical prerequisites for success
• Point of care evidence based reminders improve
  quality and provider satisfaction
• The components of the new model are
  interdependent
• There is an inverse correlation between the time
  the provider spends with a patient and patient
  satisfaction

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What are the NDP Learnings?

• Practice Web sites are popular with practices and
  patients
• E-visits work but patients need to be better
  educated and incentives need to change for
  patients and providers
• Patients and providers like group visits
• Same Day scheduling really works

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Challenges Identified from the NDP

• Practice are Not Prepared to Change
• Practice Level Leadership is Lacking
• Communication is Poor
• E-Communication is Slow to Gain Acceptance
• Access Is Primary to Patients

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Challenges Identified from the NDP (Continued)

• Electronic Health Records Are Not Interoperable
• Quality Can Only Be Proven when Its Measured
• Safety at the Practice Level is Inadequate
• Practice Level Business Expertise is Lacking
• Same Day Scheduling is Difficult and Requires
  Maintenance
• Team Care is Not Taught and Difficult for the
  Practice Staff to Grasp

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