Peer-to-Peer Webinar Series: Success Stories in EIDM October 19, 2017

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Funded by the Public Health Agency of Canada | Affiliated with McMaster UniversityProduction of this presentation has been made possible through a financial contribution from the Public Health Agency of Canada. The

views expressed here do not necessarily reflect the views of the Public Health Agency of Canada..

Peer-to-Peer Webinar: Success Stories in EIDM

Webinar 2 - Featuring:

Establishing a Community of Practice to Build Knowledge

and Skills in EIDM

Zsuzsi Rety, Amanda Harvey and Faye Parascandalo, City of Hamilton

Public Health Services

Applying the Access Improvement Measure Process

for Well-child Immunization

Sandy Phillips and Wendy Timmermans, Alberta Health Services

October 19, 2017 1:00 – 2:30 PM ET

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The EIDM Casebook

• Collection of success

stories in public health

• Available at

www.nccmt.ca/impact/

eidm-casebook

8

http://www.nccmt.ca/impact/eidm-casebook

Presented by:

ESTABLISHING A COMMUNITY OF PRACTICE TO BUILD KNOWLEDGE AND SKILLS IN

EVIDENCE-INFORMED DECISION MAKING WITHIN A PUBLIC HEALTH SETTING

City of Hamilton Public Health Services

October 19, 2017

Zsuzsi Rety

Public Health Nurse

Amanda Harvey

Competency Development Specialist

Suzanne Neumann

Public Health Nutritionist

Vicki Edwards

Public Health Nutritionist

Michelle Wawrzyniak

Public Health Nurse

Faye Parascandalo

Public Health Nurse

OBJECTIVES

• Illustrate how the City of Hamilton Public Health

Services is implementing Evidence-Informed

Decision-Making (EIDM)

• Discuss barriers to implementing EIDM initiatives

and how we overcame them

• Entice webinar participants to start or enhance their

EIDM strategy

BACKGROUND

• Participated in KB Mentoring Program at NCCMT

• Needed a way to build and practice new skills

• Started a Community of Practice (CoP)

• Established shared goals and objectives

• Supported by NCCMT mentor

• Participation grew over time

TERMS OF REFERENCE OBJECTIVES

1. To develop staff capacity to appraise relevant

public health research.

2. To develop staff capacity to apply validated EIDM

tools in practice.

3. To support program teams in their efforts to

appraise research and use EIDM.

KEY RECOMMENDATIONS

1. Secure management support at the outset

2. Identify mentors for involvement

3. Encourage volunteer over mandated participation

4. Determine participant needs to drive the focus and goals for the CoP

5. Establish and adapt a Terms of Reference to continually meet

participant needs

6. Track participation

7. Empower staff to take turns leading the meetings

8. Encourage knowledge transfer to non-participants where relevant.

Lack of management

support

Lack of

mentors/expertise

Low participation rates Lack of visibility

Culture (learning culture) Resources (time) Staff buy-in Silos

Lack of ownership Not an organizational

priority

Lack of direction/

expectations

Burden on key staff

An add-on to typical workload of staff

SECURE MANAGEMENT SUPPORT AT

THE OUTSET

Lack of management

support

Lack of

mentors/expertise




priority

Lack of direction/

expectations

Burden on key staff


IDENTIFY MENTORS FOR INVOLVEMENT

Lack of management

support

Lack of

mentors/expertise




priority

Lack of direction/

expectations

Burden on key staff


ENCOURAGE VOLUNTEER OVER

MANDATED PARTICIPATION

Lack of management

support

Lack of

mentors/expertise




priority

Lack of direction/

expectations

Burden on key staff


DETERMINE PARTICIPANT NEEDS TO DRIVE

THE FOCUS AND GOALS FOR THE CoP

Lack of management

support

Lack of

mentors/expertise




priority

Lack of direction/

expectations

Burden on key staff


ESTABLISH AND ADAPT A TERMS OF

REFERENCE TO CONTINUALLY MEET

PARTICIPANT NEEDS

Lack of management

support

Lack of

mentors/expertise




priority

Lack of direction/

expectations

Burden on key staff


TRACK PARTICIPATION

Lack of management

support

Lack of

mentors/expertise




priority

Lack of direction/

expectations

Burden on key staff


EMPOWER STAFF TO TAKE TURNS

LEADING THE MEETINGS

Lack of management

support

Lack of

mentors/expertise




priority

Lack of direction/

expectations

Burden on key staff


ENCOURAGE KNOWLEDGE TRANSFER TO

NON-PARTICIPANTS WHERE RELEVANT

SINCE THE CASEBOOK

• CoP ongoing

• Organizational priority

• Trained 20 more people

• EIDM being embedded in processes

NEXT STEPS

• Training

• Evaluation

• Culture change

OBJECTIVES

• Illustrate how the City of Hamilton Public Health

Services is implementing EIDM

• Discuss barriers to implementing EIDM initiatives

and how we overcame them

• Entice participants to start or enhance their EIDM

strategy

COMMITMENT TO CHANGE

In the chat pod please tell us:

• What are your next steps?

• What will you bring back to your organization?

QUESTIONS AND DISCUSSION


Your Comments/Questions

• Use Chat to post comments

and/or questions



Chat

Participant Side

Panel in WebEx


Presenters

Wendy Timmermans, RN,

BScN, CCHN(c)

Alberta Health Services

Sandy Phillips, RN, BN, MN,

CCHN(c)

Alberta Health Services

ALBERTA AIMACCESS * IMPROVEMENT * MEASURES

THORNHILL COMMUNITY HEALTH CENTER

Well Child Immunization

October 19, 2017

The only person who likes

CHANGE is a baby in a wet

diaper! Anonymous

AIM helps healthcare teams to assess their process to improve client access

A collaborative model of learning for achieving high quality, team–based clinical care. The model was guided by expert facilitators but implemented at our local WC clinic (Thornhill)

Following processes were applied:

Team:Improvement teams represented all key roles in the clinic - "those who do the work must change the work.“ The team (a nurse, clerk and managers) met every 1-2 weeks in addition to 5 X 1 ½ day learning sessions.

Aim:Set specific, measurable goals for client access, office efficiency and clinical care.

Map:Built a flow map to understand all the elements of a client's visit through the clinic, and identified where challenges and constraints exist.

An All-Inclusive Resort…

Process Maps

Client phones into

CHC

Client selects from

phone tree options

(55 secs long)

Client presses

Option #3

Client greeted by

clerk on phone

Client Addressed

by Clerk

immediately

(Not placed on

Hold)

Client placed on

Hold

Client taken off

Hold and greeted

by Clerk

Client advised to

come to office to

complete New

Client Form and

bring Vaccination

History

Client arrives at

CHC Reception to

make Appointment

or Register

New Client Phones into CHC (From Outside Calgary Zone)

New Client Arrives at CHC (From Outside Calgary Zone)

Client arrives at or

calls into CHC

New Client To Thornhill CHC (From Within Calgary or Rural Area)

Clerk looks up

Vaccination History

in Phantim Reports

Clerk enters

Vaccination

History in

Phantim

Clerical

verifies

clerical data

entry

Determine if

client has an

AB PHN / ULI

#

Clerk requests AB

PHN (ULI #) from

client

Within

Calgary

and

Airdrie &

Cochrane

Urban +

Rural Area

excludes

Airdrie,

Cochrane

Rural

No

Yes

Existing Client in Phantim (Urban Calgary/Airdrie/Cochane)

Client

phones into

CHC

Client selects from

phone tree options

(55 secs long)

Client

presses

Option #3

Client greeted

by Clerk on

phone

Client taken off

hold and

greeted by

Clerk

Clerk looks

up client’s

info in

Phantim

Clerk verifies

client

vaccination

due /

demographics,

etc

Clerk goes

into Phantim

& changes

demographics

for baby

Clerk offers

appointment to

ClientYes

No

Clerk goes into

Phantim and

changes

demographics

for parents

Client specified

preference: am/

pm/evening clinic

& day of week

Clerk searches

for next available

appointment

Client

phones

into clinic

Client

enters

Phone

Tree

Client greeted by

Clerk on phone

(may be placed on

hold)

Clerk looks

up Client in

Phantim

Clerk verifies

Client

Vaccinations

due

Clerk verifies

Client

demographics and

contact

information

Client completes

New Client

Registration form

Clerk contacts

client to schedule

appointment

Clerk contacts

client to schedule

appointment

Client is then

treated as a new

client (see above)

Client provides

vaccination history

to clerk or faxes to

CHC

Yes

Vaccination History

received at CHC &

entered into PhantimClerk/Client completes and faxes

“Request for Vaccination History Form

to applicable site

Clerk photocopies

Vaccination History

and adds to client

chart

No

For clients without an

AB PHN (ULI#)

See Page 2

Go to “Making

Appointment” Map

Thornhill Community Health Center (Feb/Mar 2014)

Are Changes

Required

Is Client’s

Vaccination

History

available?

Where does

Client Live

Is Client in

Medipatient

System?

Is client placed

on hold?

Yes

No

Measure:

Collect and analyze data to understand performance and assess

the impact of changes (positive or negative improvements).

Ongoing measurement is essential to improve and maintain top

system performance.

Change:

Tests of change are applied using The Model for Improvement

PDSA (Plan-Do-Study-Act) cycles.

Sustain/Spread:

Sustain the gains, celebrate success and spread a culture of

improvement throughout the clinic and larger team or system.

AIM for Thornhill CHC

Reduce wait times from 65 days (Jan 2014) to 42

days by November 1/2014 With 2.0 FTE Augmentation and 100% Backfill, wait

times were at 6 days by May 26th, 2014.

Augmentation and full Backfill were discontinued

September 30th and wait times were back to 67 days

on October 13t, 2014 (as of Mar 13/15 - 72 days).

Office Efficiency Aim To increase process efficiency - amount of time that

the client can spend with the nurse in clinic is

maximized.

Decrease/address bottlenecks in the clinic process

from the time the client checks in.

Patient Survey Analysis

A total of 202 surveys were returned

Rated length of time spent with the nurse during the visit =

“Just Right”- 96% of time.

Rated the amount of information shared with them during their

appointment = “Correct Amount” – 95%.

Rated their visit = “Very Satisfactory” - 83%.

Areas for Improvement

Waited too long for an appointment.

Difficulty getting through on the phone to book an appointment.

Waited too long on hold on the phone.

Waited too long in the waiting room to see the nurse.

ENGAGE STAFF IN AIM BY:

Idea Parking Lot for staff to document their suggestions for

improvement/efficiencies with ongoing input of staff ideas.

PDSA Board in the staff room with up to date information on

planned/completed PDSAs with accompanying data.

Health Care Team Effectiveness Analysis completed by all staff

Designed to develop excellence in teamwork and collaboration.

Goal is to improve healthcare delivery through enhanced efficiency of

interdisciplinary teams.

Share AIM information at staff meetings.

All staff are involved in implementing the PDSAs and provide feedback.

Storyboard was created with up to date information (available in clinic and

presented at AIM Learning Sessions).

IDEAL SITUATION:

Demand matches Supply and matches Activity

D = S = A

DEMAND

Demand is the measure of “workload” generated (appointment demand)

Multiple ways to measure demand: yearly; daily basis; by panel size (number of clients in a practice); new appointments (new demand – 2 month visit); return appointments (return demand).

Demand is counted on the day it is generated - appointment requested on October 15th for November 20th. The Demand is counted on October 15th. (Done manually by the clerical when the client requests an appointment (phone and in person).

DEMAND – Anticipated Demand Outweighs Current Supply

Example #1

Birthrate of approximately 257/month with 2 monthers = 2 X 30 minute appointments 4, 6,12,18 monthers = 1 X 30 minute appointments REQUIRE: 4626 X 30 minute appointments/12 weeks

Staffing with NO augmentation provides 4302 appointments/12 weeks , therefore the clinic is short 324 appointments/12 weeks This doesn’t include vaccinating Preschoolers, Adults or In-Migration.

Further, Preschoolers = 2628 children (upcoming year)= 606 appts/12 weeks. We are short 930 appts without considering Adults (10 minute appts)

or In-Migration. This is based on Preschoolers coming throughout the year versus our reality = a surge before the start of the school year.

Note: Birthrate has now increased to approx 275/month. Calgary Zone Population increase of 38,000 from 2013 to 2014.

SUPPLY

Is a measure of what could be done (in a perfect scenario).

Reflects the total number of minutes the provider can provide for appointments (captured in 10 minute increments with AIM).

It’s the number of available appointments and captures the planned work, not the actual work completed (e.g. clinic nurse away due to vacation/education etc. and not replaced).

Appointment length has an effect on the available appointments per day (10 minute, 30 minute and 60 minute appointments).

ACTIVITY

Activity is also called the “supply used” and is the actual

number of appointments seen.

It measures the time (in minutes) that the provider actually

spends with the client (those clients that show for their

appointments).

No Shows and Cancellations are NOT ACTIVITY – they count as

Demand but do not materialize as Activity

Activity can be greater or less than either Supply or Demand

HOW TO MEASURE Demand, Supply and Activity

This is performed daily

Supply: Took the number of nurses assigned to clinic in Phantim

to determine our Supply (each AM clinic, a nurse does 1x10, 1x60

and 4x30 min appointments).

Demand is measured by the number of requests that the clerical

receive for specific appointments. Demand is measured at the

time of the call, not the actual appointment date.

Variance – clerks may be busy and may not accurately track

the appointments.

Activity is measured/entered daily by Secretary through Phantim.

0

10

20

30

40

50

60

70

80

12-M

ay-1

4

19-M

ay-1

4

26-M

ay-1

4

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9-J

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-14

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6-O

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ct-

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ct-

14

Da

ys

Timeline

100% Clinic Backfilling for

vacation/sick time/leaves

ended Sept 30/14.

School nurses assigned

to clinic July 7 – Aug 15/14 = ↑Supply

Staggered Start

Times began

Oct 1/14

Augmented 570

extra appts May 12-

June 30/14

THIRD NEXT AVAILABLE APPOINTMENT

PDSA: New Phone Tree Message

Old Phone Tree

Takes 49 seconds to be transferred to a person

New Phone Tree

Takes 20 seconds to be transferred to a person

PDSA: Chart Verification

PDSA: Check In and Check Out Process

75%

0%

25%

0%

Not Working Well

Neutral

Working OK

Working Great

Pre PDSA: Clerk Satisfaction with Check

In Process

N 4

17%

33%

50%

0%

Not Working Well

Neutral

Working OK

Working Great

Post PDSA: Clerk Satisfaction with Check In

Process

N = 6

PDSA: Wait List Management

PDSA: Another Nurse Weighs Infant

PDSA: Undress Baby Before Appointment

PDSA: Bookmarks for each Age Group

www.jdennissn.wix.com/hphc

http://mail.albertahealthservices.ca/owa/redir.aspx?C=IOFQNZCg0ECN_mdZ6YAb1ZVA8f6ZM9JIcjC0OJE2iE9YJsqyyktCFozDCiSdswoqklFKkdOzyNA.&URL=http://www.jdennissn.wix.com/hphc

PDSA: Posting Cost of No Shows in Waiting Room

PDSA: No Shows

What do we want to put here?????

0%

2%

4%

6%

8%

10%

12%

12-M

ay-1

4

19-M

ay-1

4

26-M

ay-1

4

2-J

un-1

4

9-J

un-1

4

16-J

un

-14

23-J

un

-14

30-J

un

-14

7-J

ul-1

4

14-J

ul-

14

21-J

ul-

14

28-J

ul-

14

4-A

ug

-14

11-A

ug

-14

18-A

ug

-14

25-A

ug

-14

1-S

ep

-14

8-S

ep

-14

15-S

ep

-14

22-S

ep

-14

29-S

ep

-14

6-O

ct-

14

13-O

ct-

14

20-O

ct-

14

No

Sh

ow

Pe

rce

nta

ge

Timeline

No Show Chart

Clinic Average None None None

Weather aberation

affects attendance.

Calgary Stampede

Proposed schedule will ↓ the underutilized 10 min

appts and gain a 30 min appt for each nurse –

M,W,F (if you have 5 AM clinics each (M,W,F) = 15

additional 30 min appt per week. Will have 10 min

appt in Evenings and Tuesday & Thursday all clinics

PDSA: Increasing Supply with Appointment Schedule

May 23 - June 27th, 2014

Supply = 496 appts

Demand = 384 appts (77% used)

Activity = 343 appts (89% of the Demand)

Activity (69% of the Supply)

No Show = 39 appts (10.1%) 112 appts not booked

115 +39/496 appts were not used = 30.4%

September 02 – October 04, 2014Supply = 435 appts

Demand = 310 appts (77.42% used)

Activity = 277 appts (89% of the Demand)

Activity (64% of the Supply)

No Show = 32 appts (10.3%)157 appts not booked

157+32/435 appts were not used = 43.4%

Thinking

or

Stinking!

PROPOSED SCHEDULE (3 mornings/week)

↓Underutilized 10 minute appts = ↑30 min appts

TIME APPOINTMENT LENGTH

0820 – 0850 30 minutes

0850 – 0920 30 minutes

0920 – 0950 30 minutes

0950 – 1005 Coffee Break (15 mins)

Are 2 X 30 mins combined

1005 – 1105 60 minutes

1105 – 1135 30 minutes

1135 – 1205 30 minutes

1205 – 1220 Stocking Rooms

PDSA: Preschool Appointment Recall

Mail out monthly reminders to parents re: Preschooler’s

Vaccinations

@ 200 reminders/month to balance the Demand stream.

37% of 162 No Shows for July, 2014 were Preschoolers.

Re-evaluate this PDSA as there are plans to use the automated dialing

system to do this.

GOING FORWARD

Rolled out to Calgary Zone Community Health Centres:

Undress your baby poster

Bookmarks for HPHC Resource

Modification of the phone tree at various sites

Measurement of Demand, Supply & Activity

Wait list management process

At Thornhill we now have a QI committee (Clinic rooms,

Student anxiety, etc.)

Resources to Share

Resources to Share

How would you rate this wait?

Not Acceptable

At All

Not Very

Acceptable

Moderately

Acceptable Acceptable Very Acceptable

How would you rate the usual wait for an appointment when you (the patient) are sick

and call your medical clinic for an appointment?

Not Acceptable

At All

Not Very

Acceptable

Moderately


How would you rate getting this medical appointment fitting in with your schedule?

Very Easy Fairly Easy Neutral Not Very Easy Not At All Easy

How long did you wait for your appointment to start after you arrived?

Less than 5 minutes

5 to 10 minutes

11 to 20 minutes

21 to 30 minutes

More than 30 minutes

There was no set time for my appointment

How would you rate this wait?

Not Acceptable

At All

Not Very

Acceptable

Moderately


How would you rate the length of time spent with the healthcare provider you (the

patient) saw today?

Much too short Too short Just right Too long Much Too Long

How often do you leave the doctor’s office with unanswered questions?

Never Sometimes Often Always

THORNHILL CLERK SATISFACTION WITH NEW CHECK IN PROCESS (Pre PDSA)

Not Working Well Neutral Working OK Working Great

“Oh Geez” “Meh” “Yah Baby” “Awesome Dude”

Please check off which box applies.

Thank you!

QUESTIONS

For more information:

Sandy Phillips – [email protected]

Wendy Timmermans - [email protected]

mailto:[email protected]



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Date: November 15, 2017

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Register at: https://health-evidence.webex.com/health-

evidence/onstage/g.php?MTID=ef084d07d25268ba09bde5c40330205b2

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Funded by the Public Health Agency of Canada | Affiliated with McMaster UniversityProduction of this presentation has been made possible through a financial contribution from the Public Health Agency of Canada. The

views expressed here do not necessarily reflect the views of the Public Health Agency of Canada..

For more information about the National Collaborating Centre for Methods and Tools:NCCMT website www.nccmt.ca

Contact: [email protected]



Education

Peer-to-Peer Webinar Series: Success Stories in EIDM October 19, 2017