In+Care Campaign,
Developing Process Diagrams, and
Tests of Change/PDSAs
Nanette Brey Magnani, EdD, HIVQUAL US
April 4, 2012
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HIVQUAL-US
Funded by HRSA
HIV/AIDS Bureau
• Participants
– Benjamin Harris – Erie FHS
– Mandy Kastner – ARC/W
– Shelton Kay – Crusader Health Center
– Bessie Akuomah - CDOH
– Alice Wightman – Heartland Health Outreach
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Check-in and Next Steps
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What can you do by our May 7th meeting?
Bessie – start with data; and enter it; 75%
Mandy – working on VL suppression
Benjamin – meet with case managers at
monthly meeting; Outreach worker and
care coordinator; identify reasons; fine
tune how to link back in to care;
Alice – pull team together; share/discuss
data; develop initial draft of process
diagram
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• Shelton – meet eCW consultant; access to
data; enter data into In+Care
– MH screening QI Project - Develop Mental health
screening process diagram
– Then when eCW data is ready; review results and
select QI focus
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Agenda
Welcome: Unmute lines, interactive webinar with discussion,
Q&A
Updates:
Next regional group meeting – Monday, May 7th; 9:30-12:30
at Erie Family Health Center; North Ave/ California (NE
corner of park)
In+Care Campaign progress
Review and discuss examples of process diagrams
Share some tests of change and team management tools
Next Steps
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Site Visits – week of May 7th
• Near North – OA; 2-4
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QI Project Steps
Step 1:
Step 2:
Step 3.
Step 4:
Step 5:
Step 6:
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Collect and Analyze Data.
Convene QI Project Team.
Investigate the Process
Implement PDSA(s)
Evaluate Results
Systematize Change
Step 1: Performance Measures and Data
In+Care Campaign Measures
• Gap in Care –% who did not have a medical visit with a provider
w prescribing privileges in the last 180 days
• Medical Frequency: % who had a medical visit w a provider w
prescribing privileges in each 6-month period of the 24-month
measurement period w/ a min. of 60 days between visits
• Patients Newly Enrolled in Care: % who were newly enrolled
with a medical provider w/ prescribing privileges and had a
medical visit in each of the 4-month periods of the
measurement year
• Viral Load Suppression: % of patients with a viral load less than
200 copies/ml at last VL test during the measurement year
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In+ Care Campaign Data Update March 15, 2012
• 11 Part C/D grantees are members of Greater
Chicago QM Group
• 4 submitted data for February, 2012
• 2 registered, no data entry
• 5 not registered in database
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Initial Data for 4 Submitting Programs:
Validate Data – Is it accurate?
Program
Gap in Care
Visit freq over
two years
#1 CCHC
Patient total
15.7%
223
53%
218 ?
#2 EFHS
Patient total
1.62%
185
92.7%
151
87.5%
8
84%
185
#3 HB
Patient total
18.6%
1590
58.5%
1538
59.8%
157
73.7%
1933
#4 Open Door
Patient total
3%
361
Not submitted
83.3%
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76%
423
*Nat’l -urban
Top 10%
Top 25%
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16.12%
103,259 – 163 org
67.4%
58,364 – 96 org
Newly enrolled VL suppression
in care
71%
267
59.4%
8,795 – 157 org
69%
119,656 – 157 org
3.6% - 3,852 -17 org 95.9%-7,928 –10org 99.2%-154-16 org 87.7% -5,371-16 org
5.4%--11,755-41 org 90.4%-10,651-24org 89.8%-1847-40 org 83.1%-17,478- 40 org
ARC/W:
gap: 3%
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new pts: 83% retention: 63%
VL supp: 74%
February Data for 4 Submitting Programs
MASSACHUSETTS – Part C
Program
Gap in Care
#1
Patient total
10.3%
146
#2
Patient total
4%
270
#3
Patient total
14.7%
157
#4
Patient total
10.9%
55
*Nat’l –programs
<500
Top 10%
Top 25%
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Visit freq over
two years
Newly enrolled VL suppression
in care
90%
146 (15 ?)
80.4%
163
89.5%
239
87.5%
8
94%
299
49.4%
77
100%
1
83%
71
16.1%
103,760 – 166 org
66.6%
58,990 – 99 org
59.62%
8,823 – 160 org
69%
120,577 – 160 org
3.7% - 3,852 -17 org
5.5%--12,057-42 org
96% - 7,978 -10 org 100% - 91 -16 org 88.5% - 5,588 -16
90.1%--10,792- 25
91%--1738-40 org org
org
83.7%--17,499-40
org
QI Project Steps
Step 1: Collect and report data. (QM Committee report on
performance measures.) (if no data, then develop a process
diagram; work flow)
Step 2: Convene QI Project Team (sub group), review data and set
improvement goal
Step 3: Investigate the cause: understand the process and causal
analysis (Flow chart/process diagram; drill down data)
Step 4: QI Project (PDSA)
Step 5: Evaluate with QM Committee and Stakeholders.
Step 6: Systematize changes.
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Step 2: Team Formation
Who is on your QI Project Team?
Do they need training? If so, can they be available for
team training and commit to the schedule?
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Step 3: Investigate the Process and Causal
Analysis
• Causal analysis tool
– Drill down your data
– Find out who is not meeting the measure
– Find out why
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Step 3: Investigate the Process
• Process Diagrams
– More deeply understand process improvement
• PDSA – change isolated vs clearly connected to process
– Promotes better decision making
•
•
•
•
Helps you to see your work at as a system, a whole
Gathers team’s thinking
Creates buy-in and consensus
Functions as a procedure and thus can be used to create
protocols and evaluate current ones
• Promotes wider understanding of process
Resources : HIVQUAL Workbook – flow chart
NQC: National Quality Academy Tutorials – flow chart
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Types of Processes in Health Care
Patient flow
Material flow
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Flowcharts
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Information flow
Clinical practice
What does a process
diagram look like?
Also called flow chart; work flow (Six Sigma)
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Process Diagram Definition
A process diagram or flow chart is a picture of the
steps of a process to:
– Understand the process
– Identify potential sources of problems – id underlying
causes
– Outline the ideal process steps and address the causes
– Enable communications with others
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Creating a Process Diagram and Next
Steps in Implementing PDSA
1.
2.
3.
4.
5.
6.
Agree on use and level of detail
Define starting and ending points
Document each step
Follow each branch to the end
Review and agree on the steps and diagram
Identify problem steps and list underlying
causes next to the step
7. Discuss tests of change (interventions) to
address key causes.
8. Develop a PDSA plan and implement.
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Flowcharts
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Most Commonly Used Process
Diagrams/Flowchart Symbols
Activity/step
Connecting lines
Start, end
Decision
yes, no
Wait symbol
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Flowcharts
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Improving Patient Retention
• Delta Regional Medical Center – Greenville,
MS
• Wright Primary Care Center – Scranton, PA
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DeD
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Improving VL Suppression Rates
• Arnot Ogden Medical Center, Elmira, NY
• St. Elizabeth’s, Utica, NY
• Brockton Neighborhood Health Center,
Brockton, MA
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Model of Hotspotters team activities – test new process
Collection of Data by QI Coordinator
(based on Excell spreadsheets, eMD and AIRS reporting)
Meeting of the Team (second Friday of
the month), review of the data
Patients on HAART with HIV viroload
over 100
Patients not seen in 6 months
Review most recent clinic and adherence
data for the client
Identify individual retention problems
Contact the patient with lab results
(NP)
□ Schedule f/u bloodwork
□ Schedule visit with NP to discuss
the lab results
□ Schedule appointment with
Treatment Adherence Counselor
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CM follows up with the patient
CM follows up with CBO
□ Schedule medical appointment with the provider
□ Schedule case management review with CM (if
needed, to follow up on patient’s issues)
□ Review outcome of interventions at the end of the month.
□ Update viroload information and follow up on scheduled appointments
□ Review client’s chart in eMD for possible coordination of care needs.
Treatment Adherence for people with VL
Self-Assessment
Do they know which meds to take, how many, and
when?
Review Missed Doses
Are they missing doses of their medication?
Identify Barriers
Figure out how many doses missing and why?
Review Medication Guidelines
Are they taking it appropriately (i.e., with food,
without splitting, with other meds)?
Reassess for Readiness
Determine if client is ready to take medications
(confidence and importance).
Develop Care Plan
Set client-focused goals to overcome adherence
barriers (if client is agreeable).
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Medication Education
Provide medication and treatment education.
Resistance Testing
Determine if resistance has occurred and if a med
change needs to happen.
Overall Findings
• Start of the project – November
2011
- 60 clients on the list
- 25% no-shows
- 75% VL over 100
- 23% female/77% male
• Current data 2012
March
- 54 clients
- 13% no-shows
- 13% new clients
- 73% VL over 100
- 26% female/74%male
• 22 patient from November list remain on it in March
• 18%(4) no-shows/82%(18) VL over 100
• 32% female/68% male (note: higher number of women remaining on list for longer time)
• All of the clients remaining on the list were outreached to schedule an appointment,
repeat VL, run a resistance test and/or see Treatment Adherence Counselor.
• Patients with VL over 100: 61%(11) VL down, 28% (5) VL up, 2 – no change
• 2 clients restarted medications recently
• 5 clients with severe mental health problems – 4 enrolled in MH care
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client refusing care, 1 about to be closed (MIA).
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Team: Task/Next Steps to complete Step
3. Investigate the Process
• Draw a process diagram of your current process.
• Use flip chart paper, 8 ½ x 11” paper for each step
• Tape to a wall for others to see
• Could make it participatory by discussing with others to get
their input
• Circle key problem steps.
• Write causes of the problems next to each
problem step.
• Discuss and select interventions that can address
the key causes.
• Share with other members of team/clinic for
feedback.
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Step 4: PDSA
•
•
•
•
•
•
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What changes address key causes?
Develop a plan.
Try it out.
Measure. Did the change make a difference?
Why? Or why not?
Is there a need for another change?
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PDSA Examples
• HIV Patient Alert System (Arnot Ogden, St.
Elizabeth’s)
• Self management goal setting form (in
conjunction with individualized care plans)
• New Patient visit form (BHNC)
• Teach back tool for understanding importance
of taking medication (BMHC, St. Elizabeth’s)
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HIV Patient Alert System with Team
In combination with pt goal setting and individualized care plans
Red
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Yellow
Green
Lawndale Christian Health Center - Sonji
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Take Your HIV Medicine
On Time and Every Day
Educator name:
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HIVQUAL-US
Funded by HRSA
HIV/AIDS36
Bureau
The CD4 T cells in your body are your friends.
CD4-T
They are like a factory, making things that protect you from infection.
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But HIV is a clever virus.
HIV
CD4-T
It hijacks your good CD4 T cells, and turns them into an HIV factory.
Then
you get a lot of HIV (a big Viral Load).
HIVQUAL-US
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Your HIV medicines stop that HIV factory!
HIV
HIV Medicine
CD4T
When you swallow HIV pills, they go from your mouth to
your stomach, then into your blood to defend your CD4-T
cells.
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If you take your medicine ON TIME and EVERY DAY, you
keep enough medicine in your blood to defend you, and you will
usually feel better.
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Additional PDSAs
Wright Primary Care Center
• Improved review lists (measured by
comparing list of weekly scheduled
appointments)
• Scheduling appointments for patients by the
nurse and NP and given a card
Delta Regional Medical Center
• Involve District Social Worker after the first
letter is sent
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Team Management Tools
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Lancaster General Hospital. Comprehensive Care Center.
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