Welcome [] Welcome Laying the Groundwork for Meeting QI/QA Program Expectations in an HCH Setting Webinar: Lessons Learned from the San Francisco HCH Program March 6, 2012 We will

+ Welcome Laying the Groundwork for Meeting QI/QA Program

Expectations in an HCH Setting Webinar:

Lessons Learned from the San Francisco HCH Program

March 6, 2012 We will begin promptly @ 1 PM EST

Event Host Juli Hishida Technical Assistance Coordinator National HCH Council

This publication was supported by Grant/Cooperative Agreement Number U30CS09746-04-00 from the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA/BPHC.

Tech Support: Patrina Twilley

+ Presenter 2

Amy Petersen, MPH Healthcare Analyst, Quality Improvement

San Francisco Department of Public Health Community Oriented Primary Care

LAYING THE GROUNDWORK FOR MEETING QI/QA PROGRAM EXPECTATIONS IN AN HCH SETTING: CASE STUDIES FROM SAN FRANCISCO Amy Petersen, MPH Healthcare Analyst – San Francisco Department of Public Health

Learning Objectives

  Provide 2-3 examples for how 330(h) Program Expectations can be operationalized into day-to-day quality infrastructure

  Describe 2-3 ways health information technology and decision support tools can be used to report on HCH outcomes of interest

  Analyze and compare known and emerging QI approaches

  Formulate a business case for how HCH QI work is relevant to PCMH activities

330 Program Requirements

  Ongoing QI/QA Plan   Focused Responsibility for QI   Periodic Assessment of Service Use and

Quality

Health Center Program Reqs and PCMH (NCQA)

  Standard 6: Measure and Improve Performance: Use performance and patient experience data for continuous quality improvement  The practice uses performance and patient experience

data to continuously improve  The practice tracks utilization measures such as rates of

hospitalizations and ER visits  The practice identifies vulnerable patient populations  The practice demonstrates improved performance

Case Studies

SFDPH CHN Primary Care Clinics

Last Revised: 09/16/2009

Castro Mission Health Center (CMHC)

Potrero Hill Health Center (PHHC)

Silver Avenue Family Health Center (SAFHC)

Southeast Health Center (SEHC)

Tom Waddell Health Center (TWHC)

Chinatown Public Health Center (CPHC)

Ocean Park Health Center (OPHC)

Maxine Hall Health Center (MHHC)

Housing & Urban Health Clinic (HUHC)

Curry Senior Center

Community Oriented Primary Care Administration

CHPY Cole Street Clinic

CHPY Hip Hop to Health Clinic

CHPY Balboa Teen Health Center

CHPY Hawkins Clinic

CHPY Larkin Street Clinic

Medical Respite and Sobering Center (Fell St)

Special Programs for Youth (SPY)

Medical Respite and Sobering Center (Polk St)

San Francisco General Hospital Campus Clinics (SFGH PC)

•  TOTAL Patients •  7,500 homeless patients •  360,000 encounters •  5+% of visits with patients who are homeless

Ongoing QI/QA Plan

Dust off QI Plan or Find a New One

Focused Responsibility for Program

What is the Overall Purpose of a Quality Management Program?

  Form a sustainable quality infrastructure   Develop a performance measurement system   Initiate quality improvement activities   Involve consumers and their families

People Infrastructure

  Who?   How Often?   Ongoing training

Large Network

with multiple

sites

Single-site

Leaders Need to be Involved in all Areas of Improvement

Role Description

Data and Measurement

System Thinking

Developing Changes

Testing and Making Changes

Cooperation

Leader's Job: Generally: Creating a system in which change can be made and sustained

•  Clarify the aim

•  Constantly assess progress towards the aim

•  Help staff to improve

•  Overcome inertia in the present system

•  Provide the will for change

•  Find and present new knowledge and ideas for how it can be used

•  Encourage experimentation

•  Implement support structures

•  Offer consistent support to change

•  Develop / inculcate / reinforce a sense of common purpose

Source: Brooklyn Alliance Clinical Collaborative, 2003 Leading Improvement Slide from National Quality Center

Periodic Assessments

Reporting Infrastructure

  What are you reporting now?  HEDIS, UDS, Meaningful Use, local P4P

initiative   How accessible are your data?

 EHR timeline  Availability of canned reports  Disease registry

  Goals   Frequency of reporting

Set Goals

 National benchmarks for standard performance measures

 Relative improvement and thresholds  2-3 measures, no more than 5  Quarterly as standard, more frequently if

testing changes  Find your baseline, use run charts, set

goal lines

Evaluate Performance

  Dashboards   Provider Report Cards   Data Wall   Tracking a population of interest

Review Outcomes

Meeting Goals?

Action Planning

Document, Systematize,

Maintain

Clinic 2Primary Care DataWall

Who is in our active patient panel?Clinic 2

(COPC7 range) 0.05 TRUE # of active PCC panel patients 4265

3448-‐5574

# of active PCC panel patients 1250 per clinical FTE 1250-‐1300

% of active PCC panel patients 98.0 with PCP assignment 95-‐98

Panel data updated: 05/2011 Adjusted panel data updated: 05/2011

Age Groups

Age Group InformationClinic 2 COPC7

Range 0-‐98 0-‐99Average 45.1 44Median 47.5 48

The adjusted panel size for Clinic 2 is

4486This means that our 4265 patients have the expected number of visits of a panel that has 4486 patients. Expected visits are affected by demographics and health conditions.

0%

5%

10%

15%

20%

25%

30%

0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81+

COPC7 Comparisons include the 7 DPH Primary Care Clinics: Castro Mission, Chinatown, Maxine Hall, Ocean Park, Potrero Hill, Silver Avenue, and Southeast Health Centers.

Your Health Center is represented in blue. Data is for adult primary care patients 18 and older.

0%50%

100%

01/00 01/00 01/00

Clinic 2

COPC7

COPC Goal

Clinic 2

COPC7

Demographics data updated: 10/2010

Who came in for a medical visit at Clinic 2 from Jul 2010 to Jun 2010? * 3000 individual patients were * Top diagnoses were: seen by a medical provider 1. 401.9 HYPERTENSION NOS

2. 272.4 HYPERLIPIDEMIA NEC & NOS * 2.1 average medical visits 3. 250.00 DM2/NOS UNCOMP NSU per individual patient 4. 311 DEPRESSIVE DISORDER NEC

5. 250.02 DM2/NOS UNCOMP UNC * 500 patients were new to 6. 724.5 BACKACHE NOS Clinic 2 in the last 3 years 7. 278.00 OBESITY NOS

8. V65.40 COUNSELING NOS * Of these, 200 were new 9. V04.81 INFLUENZA VACCINE to any DPH clinic site 10. 305.1 TOBACCO USE DISORDER

57%

43%

31%

30%

21%

10%

7%

36%

19%

14%

14%

11%

5%

1%

0%

0%

0%

0% 10% 20% 30% 40% 50% 60% 70%

Female

Male

White

Black

Asian

Hispanic

Other

Healthy SF

Healthy Worker

Medi-Cal FFS

Uninsured

Medicare

Medi-Cal Cap

Commercial

Healthy Kids

Other

Healthy Family

Gender

Race

Financial Class

Access & OperationsClinic 2 patients waited 5 days for the next available appointment

Apr 2011 daysClinic 2 #N/A 5COPC7 #N/A 4

COPC7 min & max 4-‐5

Clinic 2 has 1250 patients per primary care provider FTEDec 2010 paid FTE panel/FTE

Clinic 2 3.83 1250COPC7 25.97 1300

COPC7 min & max 1250-‐1300COPC Goal 1125

Clinic 2 has a 90% appointment show rateMar 2011 total appts %

Clinic 2 1174 90.0COPC7 8609 95.0


0%

20%

40%

60%

80%

100%

04/10 04/11

0

300

600

900

1200

1500

04/10 04/11

0

10

20

30

40

50

04/10 04/11

90% of Clinic 2 patients saw their own provider at their most recent visitApr 2011 clinical hrs %

Clinic 2 #N/A 90.0COPC7 #N/A 95


90% of our patients would recommend us to a friend or family member

Apr 2011 # eligible %

Clinic 2 150 90

COPC7 150 95


90% of patients said they received timely after-‐hours medical advice


Clinic 2 150 90

COPC7 150 95


0%

20%

40%

60%

80%

100%

04/10 04/11

0%

20%

40%

60%

80%

100%

04/10 04/11

0%

20%

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60%

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100%

04/10 04/11

Quality of Care90% of diabetics at Clinic 2 had an A1c test last year


Clinic 2 520 90.0COPC7 3820 95.0

COPC7 min & max 90-‐90COPC Goal 90HEDIS-‐Medicaid 2009 80.6

90% of diabetics at Clinic 2 had an A1c value < 8 last yearApr 2011 # eligible %

Clinic 2 432 90COPC7 3293 95.0

COPC7 min & max 90-‐90HEDIS-‐Medicaid 2009 45.7

90% of diabetics at Clinic 2 had an LDL less than 100 last yearApr 2011 # eligible %

Clinic 2 395 90COPC7 3820 95.0

COPC7 min & max 90-‐90HEDIS-‐Medicaid 2009 33.5

90% of our patients had smoking status documented in the LCR last yearApr 2011 # eligible %

Clinic 2 4150 90.0COPC7 27675 95.0


0%

20%

40%

60%

80%

100%

04/10 04/11

0%

20%

40%

60%

80%

100%

04/10 04/11

0%

20%

40%

60%

80%

100%

04/10 04/11

0%

20%

40%

60%

80%

100%

04/10 04/11

Primary Care DataWall Mock-Up Actual scale is 3:1

•  San Francisco Community Clinic Consortium •  SF Department of Public Health – COPC •  Tom Waddell Health Center (SF)

Case Studies!

San Francisco Community Clinic Consortium

Case Study #1

QI/QA Plan


SFCCC – Opportunities for Infrastructure Enhancements

Performance Targets and Thresholds Adopted

2004-‐2006 2008

23 Core Indicators Finalized

2009

In depth Audit conducted (help from VISTA Program)

2010

2010 Indicators align with electronic reporHng goal

2011

Electronic Audit Loosely Defined Indicators for Assessing Quality

HCH Quality Measures

  Evaluated list of indicators from previous years against current guidelines and recommendations from a variety of organizations, including:   CDC   U.S. Preventive Services Task Force

  National Health Care for the Homeless Clinicians’ Network General Recommendations document

  San Francisco Department of Public Health

  And sought additional feedback from

  local practitioners and Medical Directors   clinic managers   clinic quality improvement staff

SFCCC– Core Set: HCH Indicators

  Emergency Contact   Living Conditions Assessment   Domestic Viol. Assessment   Sexual History Assessment   Sexual Health Education   Family Planning Services   HIV Testing Referral   Syphilis Screening   Cervical Cancer Screening

  Influenza Vaccination   Pneumococcal Vaccination   Td/Tdap Vaccination   Mental Health Screening   Mental Health Treatment   Drug & Alcohol Use Screening   Drug & Alcohol Abuse Treatment   Tobacco Use Screening   Tuberculosis Screening   Tuberculosis Chest X-Ray   Dental Assessment

SFCCC - High Hopes and Dashed Expectations: Quality Audit Teams

i2iTracks Disease Registry

  Registry is acceptable tool   Data entry/reporting known   Less time than manual review

Did you have a HCH Audit team at your clinic? (2010 Survey Results)

The HCH Audit provided a learning opportunity for our clinic.

San Francisco Department of Public Health

Case Study # 2

Focused Responsibility


  Community Oriented Primary Care  14 primary care clinics  42,000 patients  2011 Quality Culture Series  2012 Initiatives

 Team Based Care  Patient Experience  Staff Experience and Alignment

Risk Management Subcommittee

Risk Assessment Indicators

Unusual Occurrences

Medical Executive

Committee

Quality Council Nursing Executive

Committee

PERFORMANCE IMPROVEMENT & PATIENT SAFETY PROGRAM

Identified Issues Recommendations

Staff / Pt / Res Educ Clinical Practice Guidelines Priority Actions

GOVERNING BODY

Primary Care Quality Improvement Committee (PCQI)

Annual Reports and QI Plans

Clinical Practice Guidelines Priority Actions

Staff/ Pt/ Res Educ.

QI Task Forces Strategic Initiatives

Priority Actions Staff/Pt/Res Educ

Outcom

es

Outcom

es

Sentinel/ Significant

Events

Performance Improvement & Patient Safety (PIPS) Committee

COPC & SFGH Clinics

Data/Outcome Reporting

Other identified

risks

Primary Care QI Rep

  Leadership abilities   Good working knowledge of clinic   At least 70% FTE   Part of Management Team

SFDPH-COPC: Primary Care QI Toolkit

Template to describe services provided and management structure

QI Plan Template with section to name vision, goals,

& committee structure

Standard Reporting template and PPT

presentation

Display Improvement Data

Display Improvement Data

Tom Waddell Health Center

Case Study #3

Ongoing QI/QA Plan


“Use your mission to determine how you will do quality.”

“How do we do justice to the things that are unique about our work?”

On-going QI/QA Plan

  Outreach and retention in care efforts

  Focus on patients with assigned a primary care provider

  General health care measures allow QI program to develop

Measures Message

  Chronic Pain   TB Testing   HIV Testing   Flu Shot   BP Control   DM Control

1 X per Yr - Planning Meeting to Choose QI Priorities


  Align QI priorities with Management Team goals

  Performance Appraisals assess participation in QI work

  Training opportunities

QI Committee Accountability Structure

MD Admin Team (2)

Nurse Manager

Operations Manager

Social Worker

Health Workers

(2)

Clerk Asst MD

38

Population Characteristics

0

20

40

60

80

100

120

140

160

Num

ber

of P

atie

nts

Living Location

Where did HCH patients live during the measurement period

Case Studies Summary

THOUGHTS ABOUT IMPROVEMENT EFFORTS

  Before you try to solve a problem, define it.   Before you try to control a process, understand it.   Before trying to control everything, find out what is

important, and work on the most important or on that process having the biggest impact.

  Recognize that we can learn from failures, so respect “meaningful failures”

+ Questions & Answers 41

Amy Petersen, MPH Healthcare Analyst, Quality Improvement

San Francisco Department of Public Health Community Oriented Primary Care

+ 42 Resources   National HCH Council website www.nhchc.org

  National Quality Center http://www.nationalqualitycenter.org/

  HCH Clinicians' Network http://www.nhchc.org/resources/clinical/hch-clinicians-network/

  San Francisco Health Plan - Strength in Numbers http://www.sfhp.org/providers/quality_improvement/strengthinnumbers.aspx

  SFCCC Quality Measures - public reporting http://www.sfccc.org/programs/clinicalmeasures/Pub/Public%20Reporting%20SFCCC%2010%2012%2011.pdf

  SFCCC website www.sfccc.org

  SFDPH Community Oriented Primary Care - http://www.sfdph.org/dph/comupg/oservices/medSvs/hlthCtrs/

Health Care & Housing Are Human Rights

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Welcome [] Welcome Laying the Groundwork for Meeting QI/QA Program Expectations in an HCH Setting Webinar: Lessons Learned from the San Francisco HCH Program March 6, 2012 We will