1. 1 Quality Improvement Series Session 5- FOCUS! Windy Stevenson lammersw@ohsu.edu

2. 2 Today’s Agenda

3. 3 Problem statement The DCH ambulatory clinic problem lists are incomplete and inaccurate

4. 4 Why do we care? Why?

5. 5 Last session’s “Ah-Ha!” moment  Residents are extremely busy  Residents are highly motivated to understand their patients  Residents are manually reviewing charts for fear of missing a major diagnosis…  And Residents won’t necessarily STOP this behavior just because we say our system is “fixed.”

6. 6 The Problem List “System”  Our current system is designed to produce chaos (failure in >80% attempts)  Even if we say we “fix” it, our culture is such that we won’t trust it unless we are very focused in WHAT we fix.

7. 7 Where do you start? Problem statement: The DCH ambulatory clinic problem lists are incomplete and inaccurate.

8. 8 Known resident preferences  The purpose of the problem list is generally not well understood  An “ID sentence” including chronic diagnoses is desirable  Documenting health maintenance (wcc) information doesn’t have the bang for the buck  There are varying opinions about the value of acute care info  Residents WANT this to work for providers and for patients  Can’t the system drive us toward success? Shouldn’t we be directed toward the list?

9. 9 Start somewhere…  Institutional or leadership priorities –Clinical –Fiscal  Safety risk  Most annoying (therefore most motivation to fix?)  Most easily solved  Most easily measured  Most meaningful to customers

10. 10 Being here today comes with POWER  Diagnosis Based? –All patients with asthma –All obese patients –All patients who have been seen by genetics –All former preemies  Age Based? –Start with all newborns –Target a certain WCC  Exclusion based? (The Sarah Green effect) –Should we focus on the kids who are normal??  Other ideas?

11. 11 How do you create a SMART aim?  Specific we are intentional and focused  Measurable we can prove we’ve had an impact  Actionable there are no known insurmountable barriers  Realistic it’s within our scope  Timely we’ll do it within a time frame

12. 12 Where to go from here  What do we want to do first? –Success begets success  What can we ACTUALLY accomplish? –What patient population(s) or problem type(s)? –To impact what time point (before the visit?)  What is our AIM?

13. 13 Take Home Points (review) Real (sustainable) change comes from changing systems, not changing within systems Be specific about what you want to accomplish, and why; be intentional Focus on patients Start before you think you are ready; don’t get paralyzed

14. 14 Challenges (ie barriers)  Time  Culture –Ownership  Definition of accuracy  Lack of natural error identification  Lack of natural rewards  Need for manual audits