1. Using PI Projects to Engage Residents in PCMH Transformation Kathleen Straubinger, RN, BSN Jeffrey Mathieu, MD STFM Practice Improvement November 2013

2. Objectives Define core curricular goals met though completion of PI projects Align resident PI projects with practice goals for achieving PCMH in continuity practice Help residents design and implement PI projects in their continuity practice

3. Lehigh Valley Family Health Center One of five Lehigh Valley Health Network Family Medicine Residency Continuity care sites Mixed care model –6 residents –1 CRNP –1 PA –4 half-time attendings –8 very part-time faculty 23,000 patient visits approx 6FTE

4. Lehigh Valley Family Health Center Re-recognized NCQA Level 3 PCMH 2011 Participant in academic and community practice learning collaboratives Primarily Safety Net Practice

5. LVFHC CCT* CCT CCT* CCT Practice Leadership Quality Council* Metrics Patients Residency Care Manager Case Manager Pharm Behav Med Non-CCT Staff

6. 2014 FM RC Requirements Residents are expected to systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement Residents should complete two scholarly activities, at least one of which should be a quality improvement project

7. LVFMR Curriculum Administrative and Leadership Portfolio –PCMH –PI –Lean –Project (portfolio comprehensive assessment)

8. Project Goals Leadership Demonstration Practice Alignment Sustainability

9. Process Idea Development Mentoring Team Discussion Project Proposal Form Quality Council Presentation Practice Education Pilot Evaluation Presentation

10. PI Process Checklist 1.Write and Clarify the project goal in context of creating a PCMH Goal: 2.Determine what metric will be used to measure success with approval by Quality Council Coaches Metric: 3.Request metric report from Metrics Committee Requested: 4.QA metric report Date QA Completed 5.Establish Threshold and incentives by Quality Council Threshold:

11. Project Assessment- Presentation Describe the clinical site Project rationale Project goals Activities of the improvement project Results/outcomes/evaluation If appropriate, a financial analysis.

12. Project Assessment - Content

14. Project Assessment - Presentation

15. Examples of Projects Med refill protocol BMI assessment Tickler file for diagnostic tests Pneumoccal vaccine for diabetics Dental varnish Osteoporosis screening HIV point of care testing Procedure room Lean organization Diabetic foot exams Nurse protocol for BP checks Hypertensive urgency protocol

16. POC HIV testing - 2012 Initiating an HIV point-of-care screening protocol in the continuity practice Resident –Obtained baseline metric for HIV screening –Researched protocol and obtained supplies for HIV screening –Piloted screening with 1 nurse Results….

17. POC HIV testing - 2012 Resident graduated immediately after pilot and screening was never generalized to rest of practice No follow-up champion Change not sustained

18. Pneumococcal Vaccine - 2013 Improve the FHC’s compliance with CDC recommendations regarding provision of the pneumococcal vaccine to diabetic patients Resident –Obtained baseline metric for pneumoccal vaccine rates –Personally reviewed and flagged charts to vaccinate at next visit –Reinforced standing order for pneumococcal vaccine with nursing staff Results….

19. Pneumococcal Vaccine - 2013 20% improvement in vaccine rates attributed to project Protocol archived for future reimplementation when metrics require Minimal practice transformation and lack of demonstration of leadership skills

20. Depression Screening - 2014 Improve practice screening rates for depression for diabetic patients Resident –Started project as PGY-2 –Obtained baseline metric for depression screening rates –Piloted project with team enlisting team nurses to administer PHQ2/PHQ9 –Generalized screening to practice –Required several PDSA cycles to adjust Results….

21. Depression Screening - 2014 45% improvement in depression screening rates Sustainable process as is integrated into practice workflow carried out by staff Opportunity to explore next steps including enlisting assistance from integrated behavioral health team

22. Sustainability Project must have either ongoing champion after resident graduates or by fully integrated into practice workflow Project must move past pilot phase if it is to survive Project must be aligned with practice goals

23. Learnings Don’t waste practice resources on projects just for the sake of education Start projects early – end of PGY-1/PGY -2 Resolve Research/PI Project confusion Focus resident on SMART projects (specific, measurable, attainable, relevant, time-bound) Resources are limited – don’t let resident fail as that can be a good lesson (practice/education tension) Make PI a practice function that the resident must integrate into, not just academic exercise

24. NCQA and Meaningful Use Practice Goals = Network Goals = Resident Goals Use PI projects to achieve process change not just quality measures Residents look first to clinical outcomes for projects – process not as sexy, but leads to developing a culture of practice PI Change for test or referral tracking, discharge reconciliation, medication reconciliation demonstrates true leadership – quality much easier