View
3
Download
0
Category
Preview:
Citation preview
Transition Points Workshop
September 22nd 2008
Objectives
• Review the CDPM model• Provide an overview of longitudinal care• Present a completed process flow diagram (KCC
to ICHD transition point) and identify gaps and potential requirements for improvement
• Document information on 5 identified priority transition points
• Discuss required information/data and the process of information flow that would support continuum of care and seamless transition of patients from one service area to another.
‘Care for the chronically ill needs to bea collaborative, multidisciplinary process
[that supports] coordinated, seamless care across settings and clinicians and over time.
Source: Crossing the Quality Chasm, Page 11.
A CDPM systems approach has the potential to achieve:
• Fewer people with chronic diseases
• Better clinical outcomes, longer more functional life
• Increased efficiency in the system, quality care in the appropriate setting by the appropriate provider at the right time
• Reduced hospitalizations, reduced use of emergency departments and reduced duplication of services
• Increased healthy behaviours MoH-LTC, 2007
INDIVIDUALS AND FAMILIES
Improved clinical, functionaland population health outcomes
HEALTH CAREORGANIZATIONS
Informed,activated
individuals& families
Prepared, proactivepracticeteams
Activated communities &
prepared, proactivecommunity
partners
HealthyPublicPolicy
SupportiveEnvironments
CommunityAction
DeliverySystemDesign
ProviderDecisionSupport
InformationSystems
Productive interactions and relationships
PersonalSkills & Self-Management
Support
Ontario’s CDPM Framework
INDIVIDUALS AND FAMILIES
Improved clinical, functionaland population health outcomes
HEALTH CAREORGANIZATIONS
Informed,activated
individuals& families
Prepared, proactivepracticeteams
Activated communities &
prepared, proactivecommunity
partners
HealthyPublicPolicy
SupportiveEnvironments
CommunityAction
ProviderDecisionSupport
InformationSystems
Productive interactions and relationships
PersonalSkills & Self-Management
Support
Delivery SystemDesign
Ontario’s CDPM Framework
Delivery System DesignFocus on prevention and improve access, continuity
of care and flow through the system:
• Interdisciplinary Teams• Integrated Health Promotion and Disease
Prevention • Planned Interactions, active follow-up• Adjustment, innovations in practice • Information System• Outreach and population need based care
Delivery System DesignKey elements to facilitate seamless care:
• Create networks to providers delivering care to our patients (internal & external)
• Cooperation & Collaboration between providers• Primary care through to tertiary care and back to community• Coordinated care across operating units• Functional Integration• Shared policies & practices of common functions (Consistency)
• Evidence based clinical care guidelines and protocols incorporated into care delivery
• Focus on internal process re-design (across transition points)
• Define roles and responsibilities (role clarity) especially at transition points• Physician involvement• Organized system easy to access by patient• Patient has information to make decisions• Measurement of performance outcomes
INDIVIDUALS AND FAMILIES
Improved clinical, functionaland population health outcomes
HEALTH CAREORGANIZATIONS
Informed,activated
individuals& families
Prepared, proactivepracticeteams
Activated communities &
prepared, proactivecommunity
partners
HealthyPublicPolicy
SupportiveEnvironments
CommunityAction
DeliverySystemDesign
ProviderDecisionSupport
Productive interactions and relationships
PersonalSkills & Self-Management
Support
Information Systems
Ontario’s CDPM Framework
Information Systems Are essential for enhancing information for providers to provide
quality care; for patients to support them in managing their disease on a day to day basis; and for integrating services across the health
care system:• Electronic Health Records• Case Management Software• Patient Registries to identify patient subpopulations
for proactive care• Web - based support• Information for Patients• Links (internal and external)
– How and how well does information flow.
The RNS Vision
Using the Ontario CDPM framework, implement a comprehensive CDPM program for our patients, thereby preventing and/or delaying onset to dialysis, improving the QOL for renal patients throughout their lifespan and reducing health care costs.
We will achieve this through….
• Increased Self management• Strengthened Coordination• Risk Stratification Process• Enhanced IT system• Collection & Sharing of aggregate data• Increased communication• Increased Quality for patients and staff
Strengthen Coordination
• We need your help
For Today… First step……
• Give you more information about:– Continuum of care and longitudinal care– Things to look for in identifying gaps in the care
delivery process during transitions– Making improvements to existing processes
Then……
Help you to……• Identify 5 key transition points of greatest
importance.• Collect information on these transition points• Identify gaps• Identify possible solutions
Key Deliverables for the Day• Collection of required information to complete
process flow diagram for five major transition points in care with identification of gaps
• Generation and brain storming of possible solution to fill the gaps
• Identification and flow of data/information required at the transition points
• Identification of top two transition points and organization of working groups to complete work on these transition points
Roll up your sleeves. We need your help
Longitudinal CareCoordination
Helping patients through the Perilous Journey of the Healthcare System
Learning Objectives
• Define the “care continuum”.• Explain current challenges working across
the care continuum.• Understand “population” based care.• Promote “systems” thinking.• Discuss coordination of care.
Question
What is your definition of the continuum of care?
“The current health care delivery system is structured and financed to manage acute care episodes,
not to manage and support individuals with progressive
chronic disease”Crossing the Quality Chasm:
A New Health System for the 21st CenturyNational Academy Press 2001
Challenges with Coordinating Care
A study showed that no information was sent to specialists in 49% of referrals. Referring physicians received feedback from the specialist 55% of the time.
In 2005, 33% of adults hospitalized in the previous 2 yrs received information as to whether they should take their pre-hospitalization medications; 48% reported not routinely getting information about the side effects of drugs.
A study showed that 33% of physicians do not consistently notify patients about abnormal results.
28% of primary care physicians and 43% of specialists were dissatisfied with the quality of information they received from each other.
Bodenheimer, 2008
Problems with conflicting recommendations
Chronic Disease Self-Management Confusing medication regimens( high potential for error
and duplication) Lack of follow-up care Inadequate pt and caregiver preparation Poorly executed care transitions leading to greater use of
hospital and emergency services¹ Duplication of diagnostic testing²
1. Coleman et al, 2004 2. Bodenheimer 2008
Fragmented care Reactive: incident driven Patients were told what to do
Coordinated, integrated care Proactive: prevention focus Patient Self Management focus Reduced costs with home based therapies
Partner
Coordination
Mutually Aligned Incentives
Outcome Driven Care Management
HomeGP/Neph. Dialysis
Specialist Ancillary Services
Hospital
HospitalNephrologistDialysis
SpecialistAncillaryServices
Acute Care Chronic Care
Acute to Chronic
Adapted from RMS
WHO The Challenge of Chronic Conditions
Identifies 5 Core Competencies 1. Pt centered care2. Partnering3. Quality Improvement4. Information and Communication Technology5. Public Health Perspective
“Partnering with those who care for the patient across time, in different settings, from different disciplines and for different comorbid health concerns.” WHO 2005
Traditional Role Of The Health Professional
New Role Of The Health Professional
How may I help you ?
WHO The Challenge of Chronic Conditions
Identifies 5 Core Competencies 1. Pt centered care2. Partnering3. Quality Improvement4. Information and Communication Technology5. Public Health Perspective
“A public health perspective emphasizes the entire care continuum, from clinical prevention to palliative care.” WHO 2005
Population Health
Public health defined: “ The science and art of preventing disease, prolonging life, and promoting health through the efforts of society” (Acheson D. Public Health in England. London, HMSO, 1988)
Thinking from a public health perspective moves the workforce from caring for one patient at a time, to planning care for populations of patients.
Population refers to patients associated with a particular provider, clinic or health care system.
A population approach adds another dimension as individuals benefit from the information developed for populations to which they belong.
Source: World Health Organization, 2005
www.health.gov.on.ca/transformation/fht/guides/fht_chronic_disease
1-31 --9/20/2010
Seamless Integration of Patient Care
Pre-Dialysis PD/HHD ICHDIn Patient
Unit
Seamless Transition throughout Renal Lifespan from GP to Nephrologist to CKD to ESRD to Transplant to End of Life
care.
Transplant
Nephrologists
Primary CareProviders
SpecialistsCommunity
Agencies
Pharmacies
Dialysis ProgramUnits
Acute CareHospital
MDT Team
CCAC
Coordination Across the System
Care Coordination
“The deliberate integration of patient care activities between two or more participants involved in a patient’s care to facilitate the
appropriate delivery of health care services”
Bodenheimer 2008 ( from Agency for Health care research and quality 2007)
Fragmented Care
Continuity of Care
5 C’s of Longitudinal Care
Communication Collaboration Co-ordination Community Change
Communication
Is the essential element in successful partnering.
Requires special skills, the ability to:– Negotiate– Share decisions– Identify strengths and weaknesses– Clarify roles and responsibilities– Evaluate progress
WHO 2005
Collaboration
To be competent in collaborating with each other, providers need skills that promote cooperation, communication, and the integration of careMust work interdependently while
demonstrating mutual respect, trust, support and appreciation of each discipline’s unique contribution
WHO 2005
Co-ordination
“Break down the silos”Financial, regulatory, and professional
barriers serve to further reinforce these silos of care such that care coordination across different setting is often lacking.Operating independently with no common
care plan may adversely affect patients.
Coleman et al, 2004
Community
Community partners can be as diverse as employers, academic institutions, civil society groups, media, government, pt advocacy groups and faith-based organizationsPromote development of pt referral
pathways between healthcare and community.
WHO 2005
Change – Emotional Intelligence © HayGroup
Social Skills• Leadership• Developing Others• Influence• Communication• Change Catalyst• Conflict Management• Building Bonds• Teamwork &
Collaboration
SocialAwareness
• Organizational Awareness• Service Orientation• Empathy
Self-Management
• Self-Control• Trustworthiness• Conscientiousness• Adaptability• Achievement Orientation• Initiative
Self Awareness
• Emotional Self-Awareness
• Accurate Self-Assessment
• Self-Confidence
RENAL Continuum of Care
Transplant/End of LifeTransition planning to TransplantCoordination of Palliative Care
COORDINATIONTo assist patients in navigating the health care system,
providing caregiver consistency as they transition through the Renal lifespan. To communicate & collaborate as a patient advocate with the Interdisciplinary team
CKDChronic Kidney Disease (CKD)
Home visits according to risk assessmentInitial assessment for multidisciplinary care planning
Communication of Care Plan with GP's.Promotion of patient self management.
Reinforcement of CKD teachingRigorous monthly data collection
Dialysis Home visits according to Risk Assessment
Facilitate transition from CKDAttend first Dialysis (HD and PD)
Patient visits at all regional hospitalsFocus on Co-morbid management
Discharge planning & follow-upRigorous monthly data collection
Reinforcement of modality education forunplanned starts
Introduce useof systematic tools
and processes.
Proactively managehigh risk caseload.
Function of Coordinating Role
ImprovingCare
Coordination
Provide focusedtraining/education
and follow up monitoring
Extend GP role through collaborative
partnershipswith qualified nurses.
Facilitate appropriate fast track care inCommunity &
hospital.
Monitor Outcomes
Identify highrisk population
Blue = Data interventionGreen = Role re-engineering
Purple = Process re-engineering
ESRD Newly-diagnosed CKD
Acute Starts
GPs, Nephrologist ReferralCKD.
EmergencyPreviously unknown to
the program
PD, HHD, ICHD
1. INTAKE 2. CDM introduction 3. Key Worker identification
Assessment: inc. Risk Screening, PHQ9Baseline Evaluation
Allocate to Key worker
Individualised Care Plan:5 A’s Goal Setting & Evidence Based Pathways
Follow-up: Telephone coaching or individual consults (frequency based on
High, Medium, Low status.)
Individual servicesDental, Physio, OT, Podiatry,
Psychology, CounsellingDiabetes Ed
Community linkagesPhysical Activity, Socialisation support,
Lifestyle management, Psychosocial support, Self-help groups
Group programsStanford course, rehab, Diabetes education,
Falls prevention, Tai-Chi for arthritis, CVD Phase 3, etc.
Psychologist case reviewand treat directly or extra support to key worker
Scheduled Recall and Review & 6-monthly evaluation surveys
GP: Intro & Clinical data for
evaluation
GP: Detail Care Plan
Patient-held record
GP:Revisions to Care
Plan or 6 months
Targ
et G
roup
s &
Ref
erra
l Sou
rces
Review assessmentsalready completed to avoid duplication
CDM Pathway
Mental health
conditionidentified
Evaluating Longitudinal Care
• Demonstrated reduction in subsequent postdischarge hospital use¹– “Half as likely to return to hospital than those without
transition coach”• QOL-
– “Pt’s report high levels of confidence in managing their condition..”¹
• Rehospitalizations, deaths and total costs significantly lower²
1. Coleman et al, 2004 2. Bodenheimer 2008
“Nephrotopia” Chronic Care Model*
Patient
Family
(CDPM)
Primary Care
Providers
Specialist
Referral
Hospital In-Patient Unit
Local CDM Team/CenterPre-Dialysis
Hospital Community Integration
ESRD
Full Family Practices provide ongoing chronic disease prevention and management according to standards with guidelines at point of patient care.Provincial eGFR for early referral.Health Risk Questionnaire – Health Coaches for Diabetes and HPT. DATA
Specialist support the diagnosis and episodic treatment of chronic illness with information following continuum of care.Shared Decision Making for Modality choice –based on patient’s core values & lifestyle.Pre-emptive Transplant. DATA
CC Health Coaches & MDT in shared care model. Home visits – Initial assessment. Patient risk stratification. Proactive Case management for patients with complex co-morbidities. Questionnaire patient activation levels, - Education & self management support. Patient Life PlansNative access in situ before dialysis. DATA
Multidisciplinary Team coordinates care across the continuum acting as a navigator for complex patients. Health Coaches straddle hospital/community/home care. Proactive care based on risk stratification. Telephonic DM. LTC facilities/Home Assist programs.DATA
Support programs.CC &Multidisciplinary Team coordinate care between hospital, community and home.End of Life care.Family supports.Discharge with home visit F/U.DATA
Resources intensify according to patient needs
Prevention & Promotion work through all sectors
*(E-HealthTechnology TBA)
“Nephrotopia”- Goals & Outcomes
Patient
Family
(CDPM)
Primary Care
Providers
Specialist
Referral
Hospital-
In patient unit
Local CDM Team/CenterPre-Dialysis
In – Center
Community Integration
ESRD
Goal: Decrease or halt progression of Diabetes and HPT thereby decreasing progression to renal failure and increasing patient QOL..Diabetics = 65% with Hgb A1C <7HPT = 80% with BP <130/80Decrease need for Nephrologist referral.Decrease % of “parachutes” to renal program.
Goal: Increase patient QOL/Prevent or delay onset to dialysis through co-morbid management.Shared Decision Making for Modality choice –based on patient’s core values & lifestyle.50% Choose Home TherapiesIncrease % of Pre-emptive Transplant.
Goal: Increase QOL/Prevent or delay onset to dialysis through co-morbid management.Modality – 50/50 – Clinical – BP, A1C, Anemia Mgt.Self-Management – 80% of patients have self management goal.Delay of onset, reduced hospital utilizationDialysis Access – Incidence >50% native access
Goal: Increase patient QOL Co-morbid management.QOL/Patient Satisfaction QuestionnairesCVC – < 10% CSN KDOQI AVF>60%Decrease in Hospital Utilization/”Drop Ins”“Parachute” 50/50 re-capture rate.% Reduction in parachute rate.
Goal: Increase QOLReduced ALOS, Reduced hospital visits.Reduced re-admission rates.Reduced Renal occupancy rate.Increased % of home visits within 7 days of discharge.
Program
Targets
Evidence
Based
Guidelines
Continuum of care…..what can you add to this vision?
References1. Coleman, E. et al ( 2004). Preparing Patients and Caregivers to Participate
in Care Delivered Across Settings: The Care Transitions Intervention, JAGS52: 1817-1825.
2. Bodenheimer, T. ( 2008). Coordinating Care- A Perilous Journey through the Health Care System. N Engl J Med, 358; 10.
3. World Health Organization ( 2005). The Challenge of Chronic Conditions; Preparing a Health Care Workforce for the 21st Century. Geneva, World Health Organization.
4. Wagner EH, (1998). Chronic Disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2-4
5. Nielsen, J. (2000). Disease Management Coordinates “Care”- Not “cases”-To Improve ESRD Patient Outcomes. Nephrology News and Issues,Sept. 67-70.
Process Flow DiagramsKCC to ICHD
Process Flow Diagrams
Snap shot of processes carried out within RNS service areas/programs.
Outlines general flow of tasks by service providers.
Identifies: Common processes & data used by service areas Areas of potential efficiencies & improvements Possible explanations of outcomes
Transition Points in care
A point at which there is a service change within the health care system
5 C’s of Longitudinal Care
Communication Collaboration Co-ordination Community Change
Ideal Outcomes
Seamless patient transition and continuum of care
Want to prevent…
Patient anxiety Break in coordination of care Loss of patient information Loss of patient confidence Overall risks to patients &
staff
KCC to ICHD transition point
Understand the processes carried out within each service area
Associate tasks to team members ID data collected ID what works well within the existing
process What processes should be consistent
throughout the program ID gaps and potential solutions
Process Flow DiagramKCC to ICHD
Referral to KCC KCC on-going visit KCC post clinic KCC transition to ICHD Transitioned to ICHD
Initial thoughts …
What are your initial thoughts about this process flow?
What works well?
KCC ICHD
Nephrologist
RN
Dietitian
Pharmacist
Social Worker
Vascular Access Nurse
Front Unit Clerk
Back Unit Clerk
External Lab
Volunteer
Nephrologist
RN
Dietitian
Pharmacist
Social Worker
Vascular Access Nurse
Unit Clerks
Resource Nurse
Educator Leader
KCC LeaderICHD Leader
Initial Analysis
5 C’s of Longitudinal Care
Communication Collaboration Co-ordination Community Change
Ideal Outcomes
Seamless patient transition and continuum of care
Findings: Gaps and potential solutions
KCC Referral process--Gaps
Referral to KCC not consistent Patient reminder done by volunteer and if no
volunteer patient reminder not done In patients need to be booked when out patients.
Currently manually tracked by unit clerk Patients who do not show up sometimes fall through
the cracks. No follow up MDT must review patient info from chart. Very little
info accessible in Meditech
KCC Referral process—Potential Solutions
Automated referral process set up in Meditech (for pts with Unique number)
Look into increasing automation in Meditech i.e. automating generated letter that reminds patient of KCC initial appointment (date driven), notification of d/c inpatients referred to KCC, flag patients after a certain number of months who have not been seen, etc.
New Meditech screens being designed/redesigned to facilitate data entry and automation of reports and data retrieval
KCC On-Going Visit--Gaps
Not always the same MD who sees/follows patient KCC secretaries multi-tasking, other duties i.e. filing
falls behind. All disciplines must compete with chart to access
patient info Wait times for patients to see disciplines sometimes
long No Patient acuity rating. Difficult to judge who is a
“heavy patient” vs. “light patient” (for operational time management in clinic)
KCC On-Going Visit–Potential Solutions
Explore MD model in clinics to support more consistent care of patients
Explore more even workload model for KCC secretaries
Continue to facilitate data entry into Meditech Explore more efficient operational tactics to minimize
patients’ wait times in clinic
KCC Post Clinic--Gaps
MDT rounds at end of clinic sometimes generates over-time
Tasks required to finish clinic spills over to next day
For Initial Visit patients, MD does not see
KCC Post Clinic—Potential Solutions
Explore more efficient means of enabling patient reviews
Consider alternative model where MD sees new KCC patients
KCC Transition to ICHD—Gaps
Routine orders written in KCC may not be implemented until weeks later in ICHD
Notification of new ICHD starts done manually and is dependent on Resource Nurse
No formal “hand off” from KCC to ICHD
KCC Transition to ICHD—Potential Solutions
Need to build in process to have routine orders verified by MD if > 3 weeks (?) implementation
Automate referral to ICHD Explore incorporating a more formal ‘hand off’
from KCC to ICHD
Patient transitioned to ICHD--Gaps
No formal orientation or information provided to patient
Routine orders needing review/verification may be written by a different MD than the MD who is now on for ICHD
Inconsistent management of first HD treatment by ICHD RNs
Patient transitioned to ICHD—Potential Solutions
Incorporate formal orientation and provision of information to new ICHD patients
Discuss alternative MD model that enables consistency of care
Creation of 1st ICHD treatment curriculum for staff to follow
Accountabilities
Collection of datasets that enable measurement
Performance Indicator development Team commitment and understanding of
needed changes for improvement Desire for improved patient care and
outcomes
Working Groups
• From the 5 identified transition points• Break into working groups
Transition point gap identified
What is the level of risk associated with the gap?
Risk to patient safety or
working out of scope of practice
Increased work load for staff/ unnecessary
delay for patients
A nuisance, easily completed but
should be eliminated through
automation
High priority
This gap significantly increases workload and make patients wait
Effects my workload and delays patients but only for a limited amount of time
Medium priority
Frequently occurs
Rarely occurs
Low priority
Prioritizing identified gaps
Key principles to consider when documenting process flow
Step 1• Identify team members involved in the process• Write down actions/activities of each team member that they carry
out within the process.• Indicate at process points what information is collected and/or
documented (electronic and/or paper).
• Identify any policies or standards that guide practice (if any).
Step 2• Identify what works well in the process (does not need any changes and should
remain part of the process).Step 3 • Identify gaps throughout the process and categorize the gap based on
the following:The gap poses:– Patient risk or causes staff to work out of their scope of practice– Increase workload or makes patients wait– A nuisance, easily completed but should be eliminated through automation
Solutions
Questions are never indiscreet, answers sometimes are.
Oscar Wilde
Flow of Information
Computers are useless. They can only g ive you answers.
Pablo Picasso
Input of data
Data Accuracy Clear definition and understanding of
datasets Simple and efficient process of data
entry Accessible resources that enable data
entry
Meditech Screens enable data input
Other enables of data entry
Accessing the data
Requires datasets to reside in Meditech in order to:
Input
Access
Analysis and reporting of data
“Front end” populated from data that resides in the Meditech repository
Med
itec
h
• Regardless of what Nephrology data management system (software) is purchased, requires access to Meditech data.
Patient clinical datasetsDemographics Clinical History
Patient Name MD Health Card Number DOB Address Phone Number (s) Allergies Family MD Nephrologist (refer)
Lab values Weight Vital Signs Medications Diagnostic Test results Dialysis Modality (if applicable) Dialysis Access (if applicable) Dialysis Prescription (if applicable) Immunization
Medical Social Work Dietitian Pharmacy Nursing
Overview: Current data being collected within RNS
RNS Process Flow DiagramPh
arm
Tec
hSo
cial
Wor
kDi
etPh
arm
Exte
rnal
La
bPa
tient
Secr
etar
yNu
rse
Neph
Phones pt and sets up initial visit.
Refers pt. to clinic
Pt Info
Receives info, pre registers pt and starts chart. Leaves in RN
mailbox
Speaks with MD re: pt
Pt. Edn
Faxes info to KCC clinic
Sends MOX to MDT re: pt
Letter
Calls KCC RN Neph Secretary faxes pt info to KCC
Office sends letter to pt & KF book & video
Letter
Pt receives letter and goes for blood work
Receives MOX
Receives info from MD
Reviews pt’s chart
Receives MOX
Pt Info
Receives MOX and enters appointment into black book & scheduler
Receives MOX
Ref
Sends next steps letter re: blood work
and map to KCC
Pt Info
Pt. agrees to date. Asks questions
Pt. Info
Reviews chart
Receives blood work and adds
to chart
Reviews chart
Reviews chart
Arrives for initial assessment
Point of data entry
Overview: Collection of current datasets
Datasets collected through use of paper forms
Other members of RNS MDT do not have access to paper data unless chart is accessible
Datasets Manually inputted into system
KCC Indicators & Reports
Reported at RNS Program Council
Some datasets tracked manually
Manual data collection and analysis
Lakeridge Health Whitby Kidney Care Clinic
Date of Report:______ ###### Report Period: From _ Third QuartOct 1/07 To Dec 31 2007
Population Demographics Frequency of Report every month
1 Current number of Patients enrolled in ARIC: Number: 5752 Number of new patients referred during report period: Number: 63 As Percentage of Total Patients: 11.00%3 Distribution of new patient referrals according to KDOQI Stage: This is the new referrals that were seen
Stage Number % Quarterly Trends: Q1 Q2 Q3 Q4 Yearly60-89% Stage 2 0 0 Stage 2 % 0 0 0 0 0.00%30-59% Stage 3 9 21.00% Stage 3 % 16.00% 16.60% 21.00%15-29% Stage 4 32 74.40% Stage 4 % 75.00% 69.00% 74.40%<15% Stage 5 2 4.60% Stage 5 % 8.90% 14.30% 4.60%
434 Distribution of total patients enrolled in ARIC according to KDOQI Stage:
Stage Number % Quarterly Trends: Q1 Q2 Q3 Q4 YearlyStage 2 0 0 Stage 2 % 0 0 0 0 0.00%Stage 3 129 24.20% Stage 3 % 25.20% 22.30% 24.20%Stage 4 371 69.60% Stage 4 % 68.10% 71.80% 69.60%Stage 5 33 6.20% Stage 5 % 6.60% 5.90% 6.20%
5335 Distribution of total patients discharged from ARIC by reason:
Reason Number %Start on PD 11 20.00%Start on HHD 1 1.80%Start on ICHD 12 21.80%Transplant 0 0.00%Transfer to Other Program 6 10.90%Transfer back to Nephrologist Office 1 1.80%Expired /never seen 23 41.90%Patient refuse to return to ARIC 1 1.80%
TOTAL 55
Catheter Associated Blood Stream Infection Rate
00.20.40.60.8
11.21.41.6
04/05
- Q1
Q2 Q3 Q4
05/06
Q1 Q2 Q3 Q4
06/07
Q1 Q2 Q3 Q4
07/08
Q1 Q2 Q3 Q4
CABSI/1000 line daysbenchmark/1000 line days
CQI Implementation
Number of Months Between Episodes of Peritonitis
0.010.020.030.040.050.060.070.080.0
Q1 Q2 Q3 Q4 FY Q1 Q2 Q3 Q4 FY Q1 Q2 Q3 Q4 FY Q1 Q2 Q3 Q4
04/'05 04/'05 05/'06 05/'06 06/'07 06/'07 07/'08
Patient Months
CQI Completed
CWPDIG benchmark
Taking things to the next level…
Prioritize data sets and indicators to be collected and reported for KCC.
Establish a more efficient data collection process
Establish reporting of meaningful reports that direct the actions within RNS to move towards improvement and achievement of standards and excellence of care
Increase automation of data management within RNS
Level 3Level 2
Level 1
Foundation
Data is Power!!!
Conclusion
Remember and
spread the word
INDIVIDUALS AND FAMILIES
Improved clinical, functionaland population health outcomes
HEALTH CAREORGANIZATIONS
Informed,activated
individuals& families
Prepared, proactivepracticeteams
Activated communities &
prepared, proactivecommunity
partners
HealthyPublicPolicy
SupportiveEnvironments
CommunityAction
DeliverySystemDesign
ProviderDecisionSupport
InformationSystems
Productive interactions and relationships
PersonalSkills & Self-Management
Support
Ontario’s CDPM Framework
The Goals of CDPM• Activated Communities are collaborating across sectors and
with health care organization to identify and meet the needs of their populations. Individuals and families are linked to community resources
• Prepared Practice Teams at the time of the visit, they have the consumer information, decision support, people, equipment, and time required to deliver evidence-based clinical management, health promotion/prevention, and self-management support
• Informed Activated Individuals understand the disease process, are part of the care team, and realize his/her role as the daily self manager. Family and caregivers are engaged in the individual’s self-management. The provider is viewed as a guide on the side, not the sage on the stage.
We will achieve this through….
• Increased Self management• Strengthened Coordination• Risk Stratification Process• Enhanced IT system• Collection & Sharing of aggregate data• Increased communication• Increased Quality for patients and staff
The 5 C’s
• Communication• Collaboration• Coordination• Community• Change
Thanks for all your help
Being a contribution• “Naming oneself and others as a contribution
produces a shift away from self concern and engages us is a relationship with others that is an arena for making a difference. Rewards in contribution… are of a deep and enduring kind……”
Ben & Rosamund Zander - page 63
We give you all an “A”
“Giving an A”• “An A can be given to anyone in any walk of life.
When you give an A, you find yourself speaking to people not from a place of measuring how they stack up against your standards, but from a place of respect that gives them room to realize themselves.”
page 26 - “The Art of Possibility” by Ben & Rosamund Zander
You are all leaders
“Leading from Any Chair”• “A leader does not need a podium; she can be
sitting quietly on the edge of any chair, listening passionately, and with commitment, fully prepared to take up the baton”.
page 76 - “The Art of Possibility” by Ben & Rosamund Zander
Final thought to leave you with
“Patience and perseverance have a magical effect before which difficulties disappear and obstacles vanish.”John Quincy Adams
Recommended