Ambulatory 401:
Building Improvement
Teams in Primary Care
WREN Conference
November 13, 2009
Dr. Sally Kraft
Stephanie Berkson
Workshop Overview
 The Problem
 Context
– UW Health
 The Solution
–
–
–
–
Physician-Manager Leadership teams
Ambulatory 401 Program
Key Concepts
Applied Learning
 The Results
 Lessons Learned
The Problem
Quality problems are everywhere,
affecting many patients. Between the
health care we have and the care we
could have lies not just a gap, but a
chasm.
IOM Crossing the Quality Chasm 2001
Urgent Need to Improve Our US
Health Care System







High costs
Rising costs
Disparities in care
Rising rates of uninsured
Medical errors
Growing physician dissatisfaction
Variable quality
Quality Improvement:
Building High Performing Frontline Teams
Level
A
“True North”
The experience of the patient and their
loved ones
B
Microsystems
Small units of care delivery
C
Organizations
The systems that supports small units of
delivery
D
Environment
Policy, payment, regulation,
accreditation: the factors that shape
behavior, interests and opportunities
Berwick. Health Affairs 2002
The quality of the microsystem is its ability to achieve
ever better care: safe, effective,patient-centered,
timely, efficient, and equitable. The quality of an
organization is its capacity to help microsystems do
that. And the quality of the environment—
finance, regulation, and professional education—is its
ability to support organizations that can help
microsystems to achieve those aims.
Berwick. Health Affairs 2002
Context: UW Health
University of Wisconsin Medical Foundation
• UW School of Medicine and Public
Health’s academic group practice plan
•1,090 physicians (~300 primary care
physicians)
• Wisconsin’s largest multi-specialty
medical group, one of the 10 largest
medical groups in the nation
• 48 practice locations
• Epic electronic health record
• Experience with quality
measurement, members of the WCHQ
• Experience with design and
administration of P4P
UW Health Driving Forces
 Organization complexity
– Multiple management structures within the same organization
 Physician dissatisfaction
– Not empowered to improve own practice environment
– Need for structures to support delivery of quality care
 High Primary Care physician turnover
– Recruitment difficulties
 Culture shift to local problem solving
– Desire to move away from top down solutions
– Desire to engage physicians in improvement efforts
– Desire to create local accountability
 Variable quality across primary care settings
Current UW Health Performance in
WCHQ
Size of the bubble is correlated to the number of
eligible patients at each organization
UW Health
ColorectalCancer
Cancer
UW Health
Colorectal
Screening Rates by Clinic
Screening Rates by Clinic
100%
WCHQ Colorectal Cancer Screening Rates
Measurement Period January - December 2008
UW Dane PCP (Clinics over 100 patients)
90%
80%
Screening Rate
70%
UW Overall Rate = 66.8%
60%
50%
40%
30%
20%
10%
0%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
UW Clinic
UWHC Clinics
UWMF Clinics
Size of the bubble is correlated to the number of eligible patients at each clinic
13
Failure to Build the System that makes it
Inescapably Easy to do the Right Thing
December 2008 UW Health WCHQ CRC Screening Rates
by Provider by Clinic
Screening Rate
100%
Size of Red Bubble Relative to # of Patients in CRC Denominator for that Provider; Blue
Dot = Clinic Average
(Providers with <50 pts in denominator excluded)
100%
90%
90%
80%
80%
70%
70%
60%
60%
50%
50%
40%
40%
30%
30%
20%
20%
10%
10%
0%
0%
Clinic #
The Solution
UW Health Strategy
 Establish new “lead physician” role at all clinics
– Pilot with Primary Care
 Develop clinic leadership team
– Partner lead physician with clinic manager
 Promote key principles
– Local ownership and accountability for clinical practice
within an academic context
– Team based delivery of care
 Enhance lines of communication
– Within site, across sites, across organization
 Provide new leadership teams with basic
improvement knowledge and skills
Ambulatory 401 Program:
Building Improvement Teams
Course Objectives
 Enhance and develop the physician-clinic manager leadership team
 Learn to improve clinic processes & services delivered to patients
 Review, learn and apply performance improvement techniques
 Provide understanding of the UW Health structures and metrics
Physician lead
and clinic
manager build the
leadership
team
Build the clinic team,
practice and learn
performance
improvement skills,
solve clinic problems
Build a network
of clinics
to share learnings
Ambulatory 401 Program Format
Attendees
 Clinic manager and clinic physician leader
Time line:
 Four, 2.5 hour sessions over 6 months
Didactic training topics (including action learning during sessions):
 Organizational overview & strategic priorities
 Metrics used to monitor efficiency and quality of care
 Clinic improvement team approach to change
 Process improvement concepts, tools and techniques
Applied training:
 Each clinic team completed an improvement project
 Project results presented and shared
Ambulatory 401 Classes:
 9 General Internal Medicine Clinics completed; May 2008
 11 Family Medicine Clinics completed; January 2009
 14 Family Medicine Clinics completed; June 2009
 8 Pediatrics Clinics in progress
Ambulatory 401:
Curriculum
 Leadership skills
– Overview of health care quality and the need to
improve
– Model for organizational improvement
– Understanding performance data
– Team development
– Effective meeting skills
– System-based thinking
 Performance improvement skills
– FOCUS PDCA model
Ambulatory 401
Why now?
The “good” old days
 Medical care was cheap
 Quality was not defined and
was not measured
 Physicians practiced
autonomously
 Insurance companies didn’t
exist
 Medical care was simple
 Medical care was an “art”
more than a science
Our current state
 Health care is expensive
 Quality is measured and
reported
 Physicians practice in large
groups, healthcare is
integrated in systems
 Insurance companies are
powerful
 Care is complicated
 Evidence and information
are plentiful
Level
A
“True North”
The experience of the patient
and their loved ones
B
Microsystems
Small units of care delivery
C
Organizations
The systems that supports small
units of delivery
D
Environment
Policy, payment, regulation,
accreditation: the factors that
shape behavior, interests and
opportunities
Berwick. Health Affairs 2002
Kotter. Harvard Business Review 2007
How do we get started?
Problem Identification
 What do we do that is valuable?
 What do we do that isn’t valuable?
 Lean Thinking (from Toyota improvement model):
Seeing and eliminating waste, i.e. eliminating anything
that doesn’t add value to the process
Keep
Eliminate
Value-Added
Non Value-Added
An activity that changes the form,
fit, or function of a product or
service; something the customer
would be willing to pay for.
Activities that do not add value to
the final product or service for the
customer. Given a choice,
customer’s won’t pay for it.
Value Stream Map
A tool to identify non-value added steps in a process.
This can be a good starting point to identify
problems and their causes.
Steps:
1. Define start and end points of the process
2. Identify all current steps in the process, with
stakeholders
3. Identify non-value steps (waiting, variation, rework)
4. Validate current state process
5. Create ideal value stream map (only value added
steps)
25
Brainstorming
A group exercise designed to generate lots of ideas.
This should be fun! Get everyone involved. Encourage
creativity.
Get excited!
Steps:

Review the topic with the whole group

Give people time to think silently about the topic

Each person writes down an idea on a card—one
idea per card (or write down all ideas on a flip
chart)

Post the cards or flip chart papers on the wall

Continue until all ideas have been recorded
Affinity Diagram
A tool to group large numbers of ideas into clusters so
that patterns and categories can be identified
Steps:
1. Ideas from your brainstorming session are posted
on cards on the walls
2. Silently members of the group move the cards into
distinct areas on the wall. Cards can be moved
multiple time, from cluster to cluster
3. After the cards have been grouped silently, the
entire team identifies “headers” for each cluster
Affinity Diagram
Multiple small improvement projects,
each one building from the earlier
project.
What do you
want in your clinic?
Clinic leaders keep
the improvement
efforts moving
forward toward the goal
Beginning of Amb 401,
Assess your current clinic
Ambulatory 401
Physician lead
and clinic manager
build the leadership
team.
Creating the vision
(brainstorming),
Assessing our
starting point
(SWOT analysis)
Build the clinic team,
solve problems
Cause and effect
(root cause analysis)
Small tests of change
(PDCA)
Build a network
of clinics
to share learnings
Share
our
learnings
The Results
Ambulatory 101/401 History
2007
UWMF Ops Committee endorsed primary care clinic
physician-manager leadership teams
Jan – May
2008
First Ambulatory 101 course taught to physician
leaders-managers at GIM clinics (9 clinics)
Sept 2008 –
Jan 2009
First ‘wave’ of DFM clinic leaders complete
Ambulatory 401 (11 clinics)
Feb-June 2009
Second ‘wave’ of DFM clinic leaders complete
Ambulatory 401 (14 clinics)
In Progress
Pediatrics clinic leaders participating in Ambulatory
401 (8 clinics)
Results:
Teams Made Improvements!
 January 2009 Family Medicine class
– 11 improvement projects completed
– 10 with data documenting improvements in care
 June 2009 Family Medicine class
– 10 improvement projects completed
– 9 with data documenting improvements in care
Project Example
Improving INR Result Times, Sun Prairie Clinic
Change Leader: Cindy Haase, Clinic Manager
Team Members: David Quoeff, MD, Joan Premo, RN, TL
Aim Statement:
We will improve timely communication
of INR results to the patient with a goal
of contacting the patient with the
results within 4 hours or less from the
time the lab results are reported for
95% of patients getting INR labs by
Jan 1, 2009 focusing on:
1. Developing and implementing a
protocol for RN’s to communicate med
changes to patients
2. IS changing Epic workflow: All INR
results going into both MD and RN
Results pools
Initial Findings:
From 47% to 90% contacted w/in 4 hrs
Follow-up Findings:
99% contacted w/in 4 hrs
Patients Contacted w/ INR Results in 4 hrs
100%
90%
99%
Jan 09
Feb 09
80%
60%
47%
40%
20%
0%
Nov 08
Results: Participants Found
Program Valuable
 88% of GIM respondents agreed that the information was
helpful to their role as a clinic leader
 95% of Family Medicine respondents agreed that participation
has or will lead to improvements in their clinic
 95% of Family Medicine respondents agreed that improvement
tools presented were useful
Results: Participants Found
Program Valuable
We have had QI improvement projects all along...but I
learned new techniques to discover how to evaluate the
current process and then to move on to designing a
new process. I think we are set and will continue using
the skills/methods we have learned and apply them to
future problem areas in the clinic. In this way it has
been helpful.
- Spring 2009 Ambulatory 401 Participant
Lessons Learned
Lessons Learned
 Selecting the right person is key
 Site participation in selection of the individual is important
 Video conferencing can work for some aspects but not
ideal particularly for project sharing
 Teams presentations are critical –teams learn quickly
from each other ---networking is enhanced
 Structured presentations allow for focus on work
accomplished
 Time and existing work loads are an issue
 Flexibility required –never ending conflicts for time
 Provides a strong foundation for all other improvement
activities
 Must be viewed as a long term investment –impact on
patient satisfaction, MD satisfaction, manager
satisfaction, staff / MD retention, practice efficiency ,
communication, ownership
Opportunities
 Bring in the Patient. Identify strategies to bring patient input
into improvement work.
 Anyone can be a Champion. Everyone within the clinic has the
potential to be a change leader; champions do not have to be
limited to physicians and clinic leadership.
 Share Improvements. Maximize e-communication tools to
share improvement work. Organize improvement projects by
topic i.e. results reporting, access, care management.
 Improve Together. Clinics with similar challenges and priorities
could work together to develop improved processes.
 Research. Critical evaluation to understand why improvement
interventions succeed or fail across a range of care settings.
Challenges
 Disseminating innovations and
improvements
 Sustaining improvements
 Aligning “top down” and “bottom up”
priorities
The Need to Improve….
Very seldom, under existing conditions,
does a patient receive the best care
which is possible to give with the
present state of medicine.
The Need to Improve is Historical
Very seldom, under existing conditions,
does a patient receive the best care
which is possible to give with the
present state of medicine.
The Flexner Report 1910
Very seldom, under existing conditions, does a patient
receive the best care which is possible to give with
the present state of medicine.
The time to improve is now.