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4.20.17
The presenters have nothing to disclose.
M7: Improving Clinical Flow ECHO
Kristin Batts
June Gillespie
Elizabeth Clewett
Roger Chaufournier
Kathy Reims
Overview of the Session
• Journey of an organization to improve efficiencies of care
• Change package and measures to improve clinical flow
• Project ECHO clinic simulation
• Alien abduction exercise
Table Introductions
• Name
• Organization
• One thing you hope to learn
• Report out themes of desired learning
4.20.17
The presenters have nothing to disclose.
Improving Clinical Flow ECHO: Cherry HealthKristin Batts, LMSW, HOTC Adult Site Manager
June Gillespie, RN BSN, Echo Project Manager
“Before”- Why Project ECHO? • Agency committed to Triple AimImproved Population Health
Improved Patient Experience
Reduced Health Systems Cost
• Chris Shea, CEO, saw Project ECHO as opportunity to answer question:How can we make systems more efficient so we can see more patients in cost
effective way?
• Video Vignette
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3 Cherry Health Sites chosen• Westside- largest Family Practice site
• 4.5 Provider FTE Family Practice (excluding PEDS),
• ~5800 Patient panel
• Cherry Street- 2nd largest Family practice site• 4.3 Provider FTE Family Practice (including PEDS)
• ~5700 Patient panel
• HOTC Adult- Internal Medicine, Strong interest in Quality Improvement. • 3.6 Provider FTE
• ~2900 Patient panel
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Improving Clinical FlowDriver diagram
Change PackageRoger ChaufournierKathy Reims
Aim: Create clinic work environment that supports:
Objectives:1.meeting patient care needs2.joy in work*3. optimization of resources
By: 7/31/2016
Improving Flow: an IHI Quality Improvement and Project ECHO Collaborative
Primary Drivers Change Concepts
Quality Improvement Strategy
Use a formal model
Empanelment
Establish/monitor metrics
Use panels and registries proactively
Assess supply and demand
Optimize the Care Team
Engaged Leadership
Develop culture for transformation Lead collective understanding
of business caseAssure sustainable change
Provide organizational support
Organized Relationship-Based Care
Identify and remove waste
Manage panel
Improve work flow
Listen to customers
Enable independent work
Function at top of skills
Process Measures Leadership Measures
Assign patients to provider panel
Patients as Partners
Manage patient expectations of care
Ensure patients see their assigned provider
Create standard work
Provide care in context of “what matters” to pt
Balance Measures
1. % state, ”I get what I want and need when I want and need it.”
2. % seen by PCP
3. % No Shows
* assessment in pre-work/end
Outcome Measures
3. average cycle time minutes
2. % empaneled
1. % state, “Does not waste my time.” 1. % colorectal cancer screening
2.% DM in control (A1c >9)
3. % persistent asthma on controller
4. # of days to 3rd next available
1. % visits per Provider FTE
2. cost per patient visit
3. net margin
Engaged Leadership
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Quality Improvement Strategy
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Empanelment13
Optimize the Care Team14
Organized, Relationship-based Care16
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Building Blocks Exercise• Instructions
• End Goal: Construct a visual structure for health center change.
• Each block must be labeled with a word from the Driver Diagram handout
• Use the dry erase marker to label blocks
• Be prepared to explain the rationale for your design
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An Overview of Project ECHO®(Extension for Community Health Outcomes)
Presented at the 18th Annual Summit on
Improving Patient Care in the Office Practice
and the Community: IHI Summit
Elizabeth Clewett, PhD, MBA
Path for this Conversation
• What is the ECHO model
• How was it used for this project?
• How to connect to an ECHO project near you
Supported by New Mexico Department of Health, Agency for Health Research and Quality, New Mexico Legislature, the Robert Wood Johnson Foundation, the GE Foundation and Helmsley Charitable Trust
At ECHO, our mission is to democratize medical knowledge and get best practice care to underserved people all over the
world. Our goal is to touch the lives of 1 billion people by 2025.
Problem (2003): 8 month wait in clinic to be treated for Hepatitis C
Estimated 28,000 in NM with Hep C
In 2004 less than 5% had been treated
No primary care physicians in the state would treat due to complex treatment with serious potential side effects
Few specialists available to see Hep C patients
Photo: Dr. Sanjeev Arora, Director and Founder of Project ECHO and the GI clinic at the University of New Mexico
Goal: A system that would
• Develop capacity to safely and effectively treat HCV in all areas of New Mexico and to monitor outcomes.
• Develop a model to treat complex diseases in rural locations and developing countries cost-effective way
Copyright 2015 Project ECHO®
Solution: ECHO Model – four pillars
Use Technology to leverage scarce resources
Sharing “best practices” to reduce disparities
Case based learning to master complexity
Web-based database to monitor outcomes
Copyright 2015 Project ECHO
Adults will learn only what they need to learn
Their learning is primarily problem-based rather than subject-based
They have a rich reservoir of experience to apply to their learning
They learn best in informal settings
They want guidance rather than instruction
ECHO AppliesAdult Learning Theory
Disease Selection
Common diseases
Management is complex
Evolving treatments and medicines
High societal impact (health and economic)
Serious outcomes of untreated disease
Improved outcomes with disease managementCopyright 2015 Project ECHO®
Successful Expansion into Multiple Diseases
Copyright 2016 Project ECHO®
Mon Tue Wed Thurs FriHepatitis C
• Arora• Thornton
Namibia HIV
• Struminger
IHS Navajo HIV
• Iandiorio
Hepatitis C in Prisons
• Thornton
Nurse Practitioners
• Van Roper
Rheumatology
• Bankhurst
Partners in Good Health and Wellness
• Struminger
Endocrinology & Diabetes
• Bouchonville
Chronic Pain and Headache
• Shelley
Integrated Addictions and
Psychiatry
• Komaromy
HIV
• Iandiorio
Bone Health
• Liewicki
Crisis Intervention for Community
Policing Agencies• Duhigg
Improving Clinical Flow• IHI
Tuberculosis
• Struminger
Complex Care
• Komaromy
Prison Peer Educator Training
• Thornton
Epilepsy
• Immerman
Cardiology
ECHO Replication Sites Worldwide:
Part 2:IHI-PROJECT ECHO COLLABORATIVE
Goal: To test whether the ECHO model can be used to support training for quality improvement and complex
systems redesign.
Clinical Flow in Primary Care Clinics
Focus
Effective and efficient Use of Provider Time
Optimizing Care Teams
Patient and Staff Satisfaction
Empanelment and Managing Case Loads
Removing waste
Using Data to Drive Changes
Spreading and Integrating Changes Over Time
Developing a Business Case for Changes
Overview of Project
Pre-work-organize improvement team + baseline assessment
Face to Face Learning Session
2 Virtual Learning Session
Monthly Data reporting
Monthly Leadership Calls
Weekly 2 hour teleECHO Clinics (10/22/15)
Video-conferencing Platform
Case based learning
Participants: 15 community clinics 1 year, 10 continued for additional 6 months
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15 FQHCs, Serving 134,061 Patients
Represent 7 CHCs
systems with a total of 68 FQHCs
Learning Session 1: Face to Face 41
Provider Cup full
RN, MA, front desk cups often
low
Exercise: distribution of tasks in the clinic
Anatomy of our weekly TeleECHO Clinic Sessions
Introductions
Case Presentation #1 by clinic team (30-40 minutes)
Clarifying questions (clinics, faculty)
Recommendations (round robin of teams)
Presenting team tells group what suggestions they are most likely to implement
Didactic (20-30 minutes) Interactive
Case Presentation #2 (30-40 minutes)
Clarifying questions (clinics, faculty)
Recommendations (round robin of teams if time)
Summary of discussion
5 minutes to fill out weekly survey
Post Clinic: recommendations sent to each presenting team
Data Transparency: key indicators shown regularly during case presentations and displayed in clinics
Measures—tracked at least monthly
Red indicates areas of overall improvement for participating sites
Outcome
1. Continuity
2. No shows
3.Patient
experience
Process1.Empanelment
2. Cycle time
3. % patients who say does not waste my time
Balance1.Colorectal screening
2.% DM in control (A1c >9)
3. % persistent asthma on controller
4. # of days to 3rd next available
Increase in Colorectal Screening: Possible Reasons Why
(Average from 31% to 41% over 18 months)
Greater awareness of data—shown each week in case templates.
1. Focus over 18 months on empanelment, care team coordination creating better relationship with patients
3. QI skills of PDSA testing, process mapping, and using data to refine systems of patient outreach and follow up
4. Copycat Effect: As saw teams focused on colorectal screening, focused didactics to use colo-rectal screening as an example for variety of topics, including engaging patients, developing a business case etc..
Weekly rhythm of teleECHO sessions helped drive quality improvement work into the daily and weekly workflow.
Making data visible: Embedding data (run charts) in weekly case templates helped create a culture of data transparency
QI skills (PDSA rapid cycle testing, process mapping etc..) seem to have become more embedded in work of staff.
Peer Learning: Importance of learning from other teams, hearing their struggles and what had tried
Some lessons learned
Overall
1. We believe ECHO is useful for QI learning and creating communities of QI learners (still in testing phase)
Next wave of testers: HealthInsight, QIOs, and NY State Dept of Health
2. We hypothesize that the ECHO model will provide a dramatically more efficient, cost-effective, and engaging way to teach QI methods to teams spread across large distances, compared to traditional collaborative and webinar models of learning3. Joy of work: Well run ECHO projects create communities of practice where participants want to come because they feel connected, engaged, and part of the community (not unusual to hear ‘this is the best hour of my week)4. Promote a culture of continual learning: ECHO projects create learning loops where participants who like on-going learning thrive.
Moving Knowledge Instead of Patients
ECHO Clinic
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HOTC Adult Presentation• Order Follow-up
• Update since presentation:• Process map done for Referral tracking
• Identified Gap in obtaining Scheduled date of referral/ diagnostic test (Still working on filling that gap)
• Have begun reporting % Completed for Diagnostic Tests and Referrals by Site and PCP monthly
• Working with Specialists- new relationships and opportunities for uninsured patients
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‘After’ Project ECHO• Video Vignette
• Continuing to use principles learned to test new Operational processes and new ideas
• Have a “ECHO Planning” Team that approves ‘new’ change ideas for testing. (Changes that may benefit multiple sites/programs, tie to Operational Plan, have baseline data and reasonable expectation of success
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Dashboard HOTC Adult (Kristin) ECHO Dashboard for Cherry_Heart as of January 21, 2017
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6. Percentage Empaneled
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7. Colorectal Cancer Screening
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9. Persistent Asthma on Controller
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10. Third Next Available Appointment
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Alien Abduction Table Exercise54
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