Improving Quality of Care

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Improving Quality of Care

• The Experience of Community Health Clinic Ole,
  Napa

Robert Moore, MD MPH Medical Director
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Community Health Clinic Ole Vital Statistics

• 12,000 patients
• 32,000 encounters
• 5 physicians, 7 midlevel providers
• 55 Spanish speaking
• 70 Hispanic
• 60 with no regular health insurance
• 5 clinical sites

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Five Clinic Sites in Napa County

• Calistoga
• St. Helena
• Vintners Health Center
• Hope Center
• Napa Valley College

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Management Focus Controlling Costs versus
Improving Quality

• An example from the Government sector

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Problems we set out to solve

• How do we improve quality of care while
  maintaining fiscal strength of the organization?
• Old model of Quality Improvement was assigning
  blame for problems that occur.

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Quality Improvement At Clinic OleSolutions

• Electronic Health Record
• Staff Training
• Disease Tracking
• Re-engineering
• Creating a Culture of Quality

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Evolution in our Thinking about Quality
ImprovementStage I

• The more data for quality improvement, the better
  our quality of care will be
• Electronic Health Record
• Data Mining

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2 Year experiment with EHRBarriers and Obstacles

• Extensive search process
• Unable to justify full-functioning system (will
  explain later)
• Tested a low-cost internet-based solution for two
  years
• Product discontinued in 2002 back to paper
• Effect of system on quality and efficiency

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EHR Lessons Learned I

• True cost of implementation is at least three
  times the cost of the software, hardware,
  consultants, and external labor expenses
  including setup of templates, training etc.
• This is due to the hours needed by clinic staff
  to devote to the system to implement it.

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EHR Lessons Learned

• Even in the long term, EHRs do not inherently
  improve productivity, compared to paper medical
  record. The net effect on efficiency depends on
  the net effect of a number of possible features
  of an EHR.

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EHR features affecting efficiency

• Paperless (no duplicate paper record)
• Lab/Radiology/Hospital interface for results
• Variety of data entry modalities
• Order entry integration
• Integrated electronic prescriptions
• Well-designed templates
• Computers used in exam rooms
• Rapid sign-in with security
• System reliability (little/no downtime)
• Re-engineering other office processes

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EHR Lessons Learned

• The long-term success of any system change in
  Community Health Centers is related to the
  ability of this change to positively affect the
  bottom line of the health center.
• Critical for clinicians to understand this must
  understand the business implications for any
  quality improvement process
• Even the best EHR, by itself, usually decreases
  clinical productivity how to compensate for
  this?

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How to Sustain EHR

• Improved payer mix
• If favorable payer mix (High income per patient),
  and demand for more services may increase
  clinician hours
• Increased clinical efficiency (patients per hour)
  
• Sustained increase in grant/donation income

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Evolution in our Thinking about Quality
ImprovementStage 2

• Better education of providers and staff will
  improve quality
• System of formalized in-person trainings
• Ongoing email-based dissemination of clinical
  education
• Barriers/Obstacles and How Overcome
• Shortage of Trainer time
• Hesitation to take practitioners away from
  patient care time.
• Quantity of medical knowledge needed to stay
  current
• Translating new practitioner knowledge to changed
  behavior

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Evolution in our Thinking about Quality
ImprovementStage 3

• Chronic disease tracking will improve our quality
  of care across a broad range of clinical
  conditions

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Lessons Learned

• If the purpose of the Electronic Health Record is
  to improve quality of care, start by focusing on
  quality, rather than focusing on the Technology
  Solution.
• Poor business case for EHR at Clinic Ole
• Poor chronic disease tracking of most EHR
  systems, anyway
• Focus on biggest quality needs (based on
  individual business cases for these needs) look
  for system to meet these needs

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MediTracks implementation process

• Choose processes to track
• Use internal experts to define the
  current/ideal process in detail (flowchart
  helpful)
• Create the MediTracks tracking infrastructure
• Small scale roll-out of full tracking process
• Define barriers to full implementation correct
  barriers
• Clinic-wide implementation
• Continued evaluation and improvement (PDSA)

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Choosing Conditions to Track

• Divide all possible clinical quality projects
  into one of the following categories
• Projects that will improve clinic revenue
• Projects required due to regulatory mandates
• Projects that reduce risk of lawsuits
• Projects which will cost the clinic money
  (although they may save the patient/insurer
  money)
• Avoid category 4 projects unless they can be
  converted into category 1, through grants,
  quality bonus payments, etc.

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MediTracks at Clinic OleUnderlying Business Cases

• Tracking Breast Cancer Screening
• Tracking Cervical Cancer Screening
• Tracking Vaccinations
• Tracking Subgroup of Patients with Diabetes
  Mellitus
• Tracking Patients with active and latent TB

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MediTracks ImplementationAnalyze process

• Local clinic experts review current and ideal
  process and make flowchart
• Process changes become evident
• Change based on PDSA small scale before rolling
  out to whole clinic

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Lessons Learned

• Once a clinic has MediTracks, the challenge to
  successful tracking is to consider each condition
  tracked as its own quality improvement project.
  Using the software is relatively straightforward.

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Barriers and Obstacles

• Developing and Nurturing Super-users
• Understanding how to harness power of the
  database to improve quality
• Efficiency of the System
• Useful mainly in clinical quality improvement,
  not other areas of quality improvement

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Clinical Efficiency of MediTracks

• Can be implemented with minimal provider effort
  no negative effect on productivity
• Requires support staff work need business case
  to support this ongoing expense
• Practice Management Interface essential to reduce
  support staff time needed for entering data.
• New lab interface reduces staff time needed for
  tracking that follows lab parameters

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Evolution in our Thinking about Quality
ImprovementStage 4

• Project teams re-design clinic processes
• Re-engineering of Patient Visit
• Group medical Visits
• Health Promoters
• Behavioral Health Integration
• Barriers and Obstacles
• Keeping projects moving forward
• Sustainability
• Local Expert Staff Turnover
• Maintaining leadership focus
• Lack of monitoring and feedback

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Evolution in our Thinking about Quality
ImprovementStage 5

• Developing an organization-wide culture of
  quality improvement

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Developing a Culture of Quality in Community
Health Centers

• Entire Management Team must embrace the goal
• Time commitment from management
• Willingness to allocate staff time to quality
  activities
• Need to think of quality in a broader sense
• Clinical quality
• Service quality
• Management quality
• Finance quality
• Quality of Human Resources Management
• Regulatory Quality

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Building a Culture of Quality

• Local QI leader needed
• Excellent leadership skills (Credibility
  throughout organization)
• Extensive training in quality improvement
  methodology
• Excellent management skills
• Deep understanding of how the clinic works
• Medical Director or Chief operating officer

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Implementing a Culture of Quality

• Quality Improvement Teams
• Every staff member assigned to a team
• Choosing team projects
• Choosing team leaders
• QI steering committee
• Train entire staff on principles of quality
  improvement
• Series of all-staff trainings
• More intensive trainings for QI team leaders

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Benefits of a Culture of Quality

• Improved job satisfaction
• Better working relationships
• More control over working environment
• Building of leadership/management skills in
  project team leaders
• Quality improvement spills over into personal
  lives of staff

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Barriers and Obstacles to Developing a Culture of
Quality

• Numerous pre-requisites
• Stability (Lack of crisis)
• Financial stability
• Adequate level of staffing
• Well trained staff
• No political crisis in the community
• Effective management team
• Mutual trust
• Shared commitment
• No major areas of weakness
• Wisdom coming from experience
• Local QI leader

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The Future? Balance

• Balanced Quality Improvement
• Technology Enhanced QI balanced with QI projects
  that dont require technology
• Maintain prior gains while moving forward in new
  areas, in all 5 stages of QI
• Electronic Health Record
• Training
• Tracking
• Process Re-design
• Culture of Quality

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Building a culture of quality as a Coalition

• Ensure that all clinics reach basic level of
  stability
• Build effective management teams
• Train management team members to be Quality
  Improvement leaders